2025/09/03 by Tina D Purnat, Elisabeth Wilhelm, Becky K White +4 · 1 voice · 2 citations
Health Professions · Psychology · #COVID-19 and Mental Health #Health Literacy and Information Accessibility #Mobile Health and mHealth Applications
paper · pdf · doi:10.1093/heapro/daaf166
openalex publication_date 2025/09/03 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/31
Forty years ago, the Ottawa Charter for Health Promotion reframed health as a resource for everyday life and called for action across five domains: building healthy public policy, creating supportive environments, strengthening community action, developing personal skills, and reorienting health services (World Health Organization 1986). That framework was transformative, establishing a new public health through a socio-ecological lens. Its principles still resonate, but the world has changed. The Charter recognized the importance of health information for health and well-being, which later evolved into the concept of health literacy: the ability to access, evaluate, and use health information, now even more essential in today’s digital world (Liu et al. 2020, Muscat et al. 2022). Four decades later, the information environment has become central to public health. It is the dynamic system of all information, agents, and processes, spanning individuals, organizations, technologies, and their interactions, that shape how people create, share, and engage with meaning (The Royal Society et al. 2020). Once dominated by one-way communication through newspapers, radio, and television, with health professionals as the main conduits of health messages, it is now instant, interactive, and algorithmically curated through search engines, social media, wearables, and artificial intelligence (AI) assistants. The information environment no longer just delivers messages but determines which are seen, trusted, and acted upon in shaping opinion, decisions, and health behaviors. Marking the Charter’s anniversary (Thomas et al. 2025) means retooling its tenets for the world we live in now. Public health must name the information environment as a determinant of health and confront the ways digitalization, platformization, and profit-driven design reshape health decisions and health promotion practice (Kickbusch 2021, Palmer and Gorman 2025, Wardle and Scales 2025). When the Ottawa Charter was adopted in 1986, the internet, barely born in 1983, was not part of everyday life. It was seen as a tool for exchanging information, not a global infrastructure shaping politics, culture, and health. Yet, concerns about how information and marketing influence health were already present. The International Code of Marketing of Breast-milk Substitutes warned against commercial promotion undermining breastfeeding (World Health Organization 1981). By 1997, the World Health Assembly adopted a resolution on cross-border advertising and sales of medical products online, cautioning that unregulated marketing could threaten patients and public health (World Health Organization 1997). These early debates foreshadowed today’s challenges with the digital marketing of unhealthy products (Ashtari and Taylor 2023). By the late 1990s, the internet entered households. Search engines organized the growing web, messengers connected people in real time, and Google quickly became the dominant gateway to knowledge. A BMJ editorial described “information epidemics,” warning that misinformation could spread online with epidemic force, exacerbating inequities (Coiera 1998). The internet soon shifted from a digital library to an ecosystem designed to monetize attention, engagement, and personal data. With social media, users became both producers and consumers of content, while platform design and algorithms curated what people saw, shaping opinions, interests, and decision-making. The health consequences are now visible in every area of life. Parents increasingly double-check pediatric advice against Google searches or parenting forums (Frey et al. 2022). Social media influencers promote medical tests and supplements, contributing to overdiagnosis, anxiety, and unnecessary interventions (Nickel et al. 2025). Many young people consume health information from uncredentialed voices and believe “doing their own research” rivals medical expertise while also regretting health decisions influenced by misinformation (Edelmann Trust Barometer 2025). Healthcare professionals describe patients arriving with expectations shaped by online content, from cosmetic procedures inspired by filtered images (Veras et al. 2025), to requests for unnecessary diagnostic tests (Lu and Schulz 2024). Some describe the current moment as Web 5.0: an internet defined by immersion, ubiquity, and intimacy (Mbunge et al. 2022, Gomes 2024). AI companions, predictive algorithms, wearables, and immersive platforms now weave themselves into daily routines. Information ecosystems are inherently intertwined with almost every aspect of everyday life and blur the line between “online” and “offline” decision-making in health. Health topics as diverse as nutrition, fertility, mental health, chronic disease, sexual health, or cancer prevention, have been reshaped. Yet, health promotion continues to struggle to make its voice heard in an information environment where platform design, monetization, and weak regulation outweigh public health goals. Traditional public health strategies assumed that better knowledge led to better decisions. In today’s digital ecosystem, accurate and health-promoting information is systematically disadvantaged. The information environment is not just a collection of messages between producers and consumers, but an infrastructure made up of algorithms, business models, and design choices that determine what people see, believe, and do (The Royal Society et al. 2020, Wardle and Scales 2025). Platforms are built for engagement and profit, not accuracy and equity. A sensational video about a fad diet can eclipse official dietary guidance because it attracts more clicks and revenue (Prybutok et al. 2024, Diyab et al. 2025). Fertility clinics advertise costly add-on IVF services with misleading claims shaping patient decisions (Lensen et al. 2021, Stein and Harper 2021). Meanwhile, social media exposure to e-cigarette marketing and influencer content has been linked to underestimation of risk and increased vaping among youth (Lee et al. 2021). Monetization, not accuracy, determines what information users see online. The inequities in health and health information in today’s information environment are shaped by the social determinants of health. Evidence from Australia shows that people with lower education, limited English proficiency, lower digital and health literacy, and lower trust in government and authorities were more susceptible to COVID-19 misinformation (Pickles et al. 2021). Low-income youth are heavily exposed to digital marketing of unhealthy food and alcohol (Potvin Kent et al. 2024). Children encounter ads that exploit emotional cues and influencer promotions often in poorly regulated spaces (Guo et al. 2025). Older adults report high exposure to misleading health content and difficulty judging credibility when headlines are sensational or images are emotionally charged (Brashier and Schacter 2020, Zhou et al. 2022). The information environment is not neutral: it generates exposures that deepen health disparities and erode trust. The influence goes beyond exposure to false claims. The information environment reshapes norms, trust, and identity. Corrective health information often loses impact once people return to their usual feeds. This “washout effect” shows that changes in knowledge or attitudes fade without sustained exposure to alternative information. In an experiment with Fox News viewers in the USA, attitude shifts persisted only while participants consumed different media, then reversed when they returned to their usual environment (Broockman and Kalla 2025). The lasting force lies not in individual messages but in the broader information environment. Similarly, research on acculturation shows that migrants’ information diets and health behaviors shift because they adapt to prevailing informational and cultural context, not because of isolated choices (Lee and Tse 1994). Communities organized around contested illnesses, such as Lyme disease and long COVID, further illustrate how online forums create parallel systems of knowledge. In these spaces, lived experience can outweigh institutional expertise, mainstream advice may be rejected, and unproven treatments embraced (Day 2022, Kopsco et al. 2023). The risk stems not from single pieces of information people receive, but from entire discursive worlds where standards of evidence fragment and trust in health institutions erodes. This dynamic forces health promotion to contend with a new reality. Traditional strategies that assume that accurate, tailored messages alone will shape behavior fail in an information environment influenced by profit. In this system, health-promoting information is rarely positioned to achieve impact. If the Ottawa Charter taught us that health is created where people live, work, pray, play, study, and gather, today this must also include the digital spaces, architectures, feeds, and algorithms that shape those lives. Health promotion must not only prevent and mitigate risk but actively build healthier information environments, support health professionals as they navigate digital conversations with their patients, clients, and communities, and champion digital design choices that privilege health and well-being over profit. In doing so, it can help ensure that the digital age expands rather than erodes opportunities for equitable and thriving communities. Public policy has long shaped health through regulation, from seat belt laws to tobacco advertising bans and alcohol taxation. In 1986, the Ottawa Charter urged governments to embed health into all policy domains. In 2025, this mandate must extend to algorithms, data governance, and platform accountability (Sui et al. 2023, Golbeck 2025). Governments should consider regulating the use of data from health wearables and apps, algorithmic health advertising, and addictive design features while demanding transparency from commercial actors. Just as the tobacco industry was brought under public health regulation once shown to be addictive and harmful to health, the platform economy must be reshaped to support health equity and well-being (Milano et al. 2020, Valentine et al. 2022). Supportive environments once meant safe schools, healthy workplaces, and clean neighborhoods. Today, they must also mean safe information ecosystems. A supportive information environment, considering the social and commercial determinants of health, would elevate trusted health voices, reduce manipulative design, and curb predatory marketing, increasing equity in information exchange. Achieving this requires re-engineering algorithms with health outcomes in mind, building infrastructures not dependent on monetization, and protecting vulnerable groups. As smoke-free laws reshaped public spaces, digital spaces must now be redesigned for health (Bickmore et al. 2018, Purba et al. 2023). Health promotion is uniquely positioned to lead this work, drawing on systems approaches that address social, commercial, and political determinants (White et al. 2025). The Charter emphasized empowerment of communities to define priorities and act. In today’s digital era, mobilization often happens online. Communities validate, contest, and amplify what is meaningful to them and counts as credible (Wardle and Scales 2025). Health promotion must support communities with resources to document harms, build resilience, and advocate for systemic change. Tools to measure resistance to misinformation can help identify vulnerabilities and guide action (Rosário et al. 2025). Sustained and trusted engagement can ensure communities are equipped not only to navigate but to reshape digital environments in ways that promote health. In 1986, developing personal skills meant teaching health literacy, coping strategies, and informed decision-making. In 2025, these skills must include digital and health literacy and influence literacy (Senft and Greenfield 2023, White et al. 2023). Influence literacy means recognizing how online appeals to identity and belonging can shape health choices. It requires awareness of how memes, hashtags, challenges, and viral videos generate trust through affect rather than evidence. Education systems should help young people distinguish peer experience from manipulation, while adults must learn to resist persuasive but misleading content. Health promotion should equip both the public and health professionals with skills to live in environments where influence and emotion can shape health decisions as powerfully as facts. The Charter urged a shift from cure to prevention and from institutions to communities. In the digital age, this means acknowledging that individuals’ experiences are shaped long before they engage with health professionals or the health system. Many form expectations and anxieties molded by Google searches, TikTok videos, online forums, or AI assistants. Health systems must therefore integrate the information environment and digital trust-building into care and public health programs, and recognizing the new tasks for different health professional profiles. For example, from a healthcare worker’s perspective, this involves: taking a digital exposure history (What did you see? From whom? How did it make you feel?); practicing empathetic debunking and values-based counseling that acknowledges why content felt trustworthy; co-creating accurate materials with community leaders and creators; triaging algorithm-driven demand, from unnecessary testing to anxiety triggered by viral trends; absorbing the new emotional labor of repairing trust; and addressing gendered burdens, as women providers face disproportionate harassment and counseling workloads. Institutions should recognize these as “work,” and provide training, compensation, and resources so health professionals and communities can meet the challenges of the information environment (Wilhelm et al. 2025). Preventive care should include digital literacy and resilience training. Health systems must advocate for healthier information environments as core infrastructure for prevention and equity, just as sanitation, housing reform, or clean water. The Ottawa Charter’s action areas remain relevant but need to expand to reflect today’s information environment. Frameworks, tools, and standards need revision. Many existing tools do not reflect digital realities. For example, digital health information quality criteria once emphasized website text’s authorship and readability, but people now encounter health content through search optimization, influencer feeds, or AI-generated summaries. Updated frameworks must consider how information is ranked, surfaced, and reframed, since visibility, searchability, and context shape impact as much as accuracy of content. Resilience metrics also require updating. Rather than asking if individuals can spot ‘true’ or “false” claims, assessments should capture how communities withstand sustained exposure to persuasive narratives and maintain trust in shared norms. Frameworks must also address gendered impacts, where women face pressure around pregnancy, fertility, and body image, and men are targeted with performance-enhancing supplements and hyper-masculine ideals. Health services must manage demand shaped by digital narratives, from requests for unnecessary scans to interest in alternative therapies promoted online. At the same time, older adults and other groups who remain offline risk exclusion from services increasingly mediated by digital tools. Ensuring equity requires adapting both health promotion and service delivery to these realities. As we mark 40 years of the Ottawa Charter, the challenge is clear: health promotion must recognize the information environment as a determinant of health and adapt its frameworks to the realities of 2025. This means regulating platforms and algorithms and implementing ethical standards; creating supportive digital information environments designed around health rather than profit; empowering communities not only to consume health information but also to monitor and advocate; fostering digital and influence literacy across the life course; and reorienting health services to engage constructively with patients’ digital exposures. “Health Promotion International” invites contributions that advance this agenda, such as updating information quality standards for the AI era, developing resilience metrics, documenting digital harms, evaluating engagement strategies, and proposing governance solutions. Just as the Ottawa Charter once expanded our vision of health to include housing, education, and equity, it must now expand again to include digital architectures, online communities, algorithmic feeds, and immersive platforms. Health promotion can build on decades of work to meet these challenges head-on. The Ottawa Charter provides a framework to meet people where life unfolds: not only where we live, work, pray, play, and gather, but also where we scroll, search, stream, and connect. T.D.P. holds the position of advisor to the Editorial Board; R.R. is a member of the Editorial Board, and O.O. is an Associate Editor for “Health Promotion International”. All authors contributed to the writing and critical revision of the manuscript. None declared. Not applicable.