When Enabling Factors Become Constraints: A Qualitative Case Study of Sustainability and Temporal System Dynamics in an Equity-Oriented Digital Intervention for Sexually Transmitted Infection Testing

When Enabling Factors Become Constraints: A Qualitative Case Study of Sustainability and Temporal System Dynamics in an Equity-Oriented Digital Intervention for Sexually Transmitted Infection Testing | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article When Enabling Factors Become Constraints: A Qualitative Case Study of Sustainability and Temporal System Dynamics in an Equity-Oriented Digital Intervention for Sexually Transmitted Infection Testing Ihoghosa Iyamu, Devon Haag, Sofia Bartlett, Catherine Worthington, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9227568/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Background Digital interventions designed to expand access to sexually transmitted and blood-borne infection (STBBI) testing are promoted to advance equitable health services. Yet many remain pilot projects, limiting their population-level impact. We examined factors influencing the sustainability of GetCheckedOnline, British Columbia’s digital STBBI testing service and described how these factors interact over time during transition beyond piloting and into routine operations. Methods We conducted a qualitative instrumental case study guided by the Dynamic Sustainability Framework. Purposive sampling captured perspectives across intervention, organizational, and system levels. Semi-structured interviews and one focus group were conducted with 28 health systems partners between February and June 2025. Reflexive thematic analysis was used, with attention to temporal shifts across pilot, scale-up, and ongoing operations. Results Four interconnected themes characterized GetCheckedOnline’s sustainability from pilot to scale, demonstrating how early enabling conditions became constraining as post-COVID testing demand increased, laboratory costs rose, and fiscal pressures intensified. First, values-driven urgency acted as both catalyst and constraint: an equity mandate fueled rapid expansion but limited planning for governance, infrastructure, and funding, and early design choices (e.g., manual results entry to support non-nominal testing) created operational complexity. Second, early implementation through flexible governance structures became misaligned at scale, where clearer ownership and accountability mechanisms were required to support system integration. Third, informal relational supports and team resilience were critical to early success, as these enabled progress through trusted partnerships and individual commitment; yet, these placed hidden burdens on staff to manage processes that were not considered as standard operations. Finally, ambiguous system structures which allowed early flexibility became constraints, as reliance on a single laboratory partner able to meet privacy requirements, project-based funding pathways, and limited mechanisms for transitioning pilots into operations impeded full integration despite the service’s demonstrated value. Conclusion GetCheckedOnline’s evolution highlights a patterned inversion during scale up, when early enabling conditions became structural constraints when lacking formal transition mechanisms. For equity-oriented digital services, deliberate pause points and institutionalization of governance, funding, and technical systems are critical for scale. By articulating this inversion dynamic, the study contributes to implementation science and offers insights for jurisdictions scaling similar innovations. Digital Health Sustainability Implementation Science Health systems STBBIs Figures Figure 1 Contributions to the literature This study addresses implementation science gaps in understanding how digital health interventions transition from pilot to sustained operation within publicly funded health systems. We identify a patterned temporal inversion during scale-up, in which early enabling conditions can become structural constraints when governance, funding, and infrastructure mechanisms do not evolve alongside intervention growth. We suggest that this inversion dynamic may be anticipated under conditions of absent transition planning, offering practical signals for earlier system-level alignment. We ground “pilotitis” and “valley of death” concepts in concrete governance and organizational processes, extending sustainability scholarship beyond uptake and effectiveness outcomes. Introduction Digital health interventions are increasingly promoted as ways to expand equitable access to care and modernize public health systems across diverse settings while ensuring efficient resource utilization [1–4]. Yet, significant challenges impede systems’ ability to transition from early pilot success to stable, integrated, and sustainably resourced programs, even when interventions demonstrate clear early benefits [5–7]. This persistent implementation gap limits the population-level impact of digital interventions and often results in resource wastage across health systems [8, 9]. Recent implementation and translational science literature has described related patterns as “pilotitis” and the “valley of death,” highlighting how promising innovations often demonstrate early success but struggle to transition into sustained, system-level integration [5–7, 10–12]. Similar concerns have been noted in Canada, where strong innovation and pilot activity have not consistently translated into system-wide implementation and scale [5, 10]. This challenge is particularly salient in efforts to address the rising burden of sexually transmitted and blood-borne infections (STBBIs). Digital testing interventions can potentially reduce longstanding access barriers, especially for people facing stigma, geographic isolation, or limited engagement with clinic-based care [13–17]. Global and national strategies increasingly position digital interventions as key enablers of low-barrier, person-centred approaches to STBBI testing and care [16, 17]. Yet most digital STBBI interventions have been implemented as isolated pilot projects with temporary funding, limiting their ability to become stable components of public health systems [14, 18]. The difficulty of sustaining and integrating these digital models threatens progress toward global goals of expanding stigma-free testing options and embedding equitable sexual health services within primary care [16, 17]. Growing interest in sustainability within health services research has generated a shift toward recognizing sustainability as a dynamic process, in which beneficial outcomes are maintained through ongoing adaptation to evolving multilevel contexts [19–21]. While this dynamic framing has advanced theoretical debate, it remains underexamined in digital health contexts, particularly for equity-oriented interventions implemented within publicly funded systems. The predominance of short-term digital pilots further limits opportunities to observe how sustainability processes unfold over time or how interventions negotiate changing organizational, technological, and policy conditions [9, 14]. Practice-based evidence is needed to inform planning, adaptation, and scale-up strategies that enhance long-term sustainability and better support efforts to reduce disparities in STBBI outcomes [22]. GetCheckedOnline is a digital STBBI testing service developed by the BC Centre for Disease Control (BCCDC) and the BC Public Health Laboratory (BCPHL; located at the BCCDC). It was introduced as a pilot in 2014 and underwent initial scale-up in 2016 [23, 24]. Designed as a low-barrier, equity-oriented alternative to clinic-based testing, the service aims to reduce access barriers for populations underserved through conventional pathways while enabling clinical resources to be redirected to more complex care needs [23, 24]. Users create accounts, complete a risk assessment, and receive tailored test recommendations with a laboratory requisition [23]. Specimens are collected at participating laboratory sites. Results are released to users online under clinical oversight, with nurse-led follow-up and linkage to care for positive tests. Its long-standing integration within the provincial public health system and sequential expansion across nine communities offer a unique opportunity to observe sustainability processes as they unfold in practice [24, 25]. GetCheckedOnline’s longevity provides an empirical basis for a temporal exploration of how interventional, relational, organizational, and system-level factors evolve and interact across project phases in publicly funded systems [19, 20, 26]. Study Purpose This study examined multilevel factors influencing the long-term sustainability of digital health interventions as they move from pilot to scale within publicly funded systems. We analyzed how the intervention, its organizational, and system dynamics evolved over time to support or constrain sustained delivery of an equity-oriented digital service. Methods Study Design and Theoretical Framework We conducted a qualitative instrumental case study of GetCheckedOnline, conceptualized as a bounded digital health intervention within British Columbia’s publicly funded health system [27, 28]. Guided by a constructivist orientation, the case study approach enabled an in-depth, contextually grounded exploration of sustainability within a complex health system [29]. We drew on the Dynamic Sustainability Framework (DSF), which describes sustainability as an ongoing process requiring the evolving fit between an intervention, its organizational setting, and the broader ecological system [19]. DSF was used to inform sampling across multiple system levels, guide the development of interview prompts focusing on adaptation and contextual change, and focus the analysis on temporal shifts across pilot implementation, scale-up, and ongoing operations [19, 20]. The DSF also informed interpretation of findings through attention to changing intervention–context interactions over time. The case was bounded by the organizational structures responsible for GetCheckedOnline (the BCCDC and the BCPHL), their provincial partners (including Provincial Laboratory Medicine Services (PLMS), regional health authorities (RHAs), and the Ministry of Health (MoH)), and the period from initial pilot planning in 2012 through scale-up, adaptation and sustainability planning activities up to 2025. The case was also intentionally bounded to provincial-level implementation partners to focus on system-level governance and sustainability dynamics. Perspectives from RHAs is planned for subsequent work. Study procedures adhered to the COREQ criteria for qualitative reporting [30]. Study setting and context GetCheckedOnline operates within British Columbia’s publicly funded health system, where responsibility for STBBI services is distributed across several interconnected agencies, including the MoH, BCCDC, the BCPHL, and RHAs [23]. Each has distinct operational and population priorities that have influenced the intervention’s development over time. GetCheckedOnline is situated at the BCCDC, which oversees program design, clinical governance, and day-to-day operations, while the BCPHL provides diagnostic testing and supports the laboratory workflows required for online ordering and result management [23, 31]. Program delivery is coordinated across multiple groups: the core program team, surveillance staff, clinicians at the BCCDC STI Clinic, laboratory personnel, provincial digital infrastructure groups, and specimen-collection sites operated through a single contracted private laboratory system [23]. The service runs within the Provincial Health Services Authority’s (PHSA) digital infrastructure and must adhere to its technical, privacy, and security requirements. Clinically, GetCheckedOnline is fully integrated with the BCCDC STI Clinic, which provides medical oversight, facilitates treatment referrals, and supports follow-up for clients who test positive [23]. GetCheckedOnline currently offers testing for chlamydia, gonorrhea, syphilis, HIV, and hepatitis C. Available in nine urban, suburban, and rural communities across the province, the service conducts more than 30,000 tests annually and accounted for over 7.5% of all STBBI tests in participating BC regions based on 2021 estimates [25]. Participants and sampling We used stratified purposive sampling to ensure representation across the three levels of the DSF: the intervention (GetCheckedOnline core team), the practice setting (BCCDC clinical and operational leads), and the broader ecological system (MoH, BCPHL, PHSA’s other agencies: Provincial Laboratory Medicine Services (PLMS), and Provincial Digital Health and Information Services (PDHIS)). Sampling reflected the distributed nature of governance and implementation responsibilities relevant to GetCheckedOnline’s long-term sustainability. A list of potential participants was developed with the GetCheckedOnline team and included individuals who currently or recently (within the past year) held strategic, operational, clinical, laboratory, or digital infrastructure roles connected to the service. Initial invitations were sent through the program to introduce the study, followed by direct coordination and scheduling by the lead researcher (II). Snowball sampling was used to identify additional informants [32]. Recruitment continued until adequate information power was achieved across organizational levels and no additional eligible participants remained. Of the 31 individuals approached, three did not respond and no one actively declined, representing a 90% response rate [33]. Data Collection We conducted individual interviews and one focus group, including members of the BCCDC Indigenous Public Health program, between February and June 2025. Data were analyzed iteratively to allow exploration of emerging ideas. Interview and focus group guides were informed by constructs from the DSF (Appendix 1) and explored sustainability, system fit, governance, and adaptation across GetCheckedOnline’s lifespan [19]. Data collection was conducted virtually on Microsoft Teams by the first author (II), a physician and health systems researcher experienced in qualitative inquiry. Although embedded within the broader organizational context, II was independent of the GetCheckedOnline implementation team. No non-participants were present during interviews. Participants completed a brief demographic and role survey prior to their session. Interviews were semi-structured and averaged 58 minutes in length, and the focus group lasted 85 minutes. With participant consent, sessions were audio-recorded and transcribed using automated transcription software, except for one interview in which detailed field notes were taken instead of recording. All transcripts were reviewed and corrected against the audio for accuracy. The first author also took detailed field notes during and immediately after each session to support reflexive and analytic interpretation. All data were stored securely on BCCDC servers with access restricted to the study team. Data analysis All transcripts, field notes, and reference documents were imported into NVivo 15 for management and analysis [34]. We conducted a reflexive thematic analysis guided by Braun and Clarke, characterized by iterative engagement with the data, acknowledgement of researcher subjectivity, and the development of interpretive rather than purely descriptive themes [35, 36]. This was a focused secondary analysis of data pertaining to pilot identity, governance processes, organizational integration, and sustainability. Analysis began with repeated readings of transcripts and inductive coding by the first author (II). Codes captured patterns related to governance structures, organizational roles, legacy design choices, and system dynamics across the lifespan of GetCheckedOnline. Coding proceeded iteratively, supported by analytic memos that documented early insights and informed refinement of the coding structure over time. A temporal lens was applied to distinguish historical conditions from contemporary dynamics, which allowed examination of how system, organizational, and relational contexts shifted across phases of pilot development, scale-up, and operational integration [19]. As themes were identified, the DSF was incorporated as a sensitizing framework to support interpretive depth, particularly when exploring narratives about the evolving fit between the intervention, its practice setting, and the broader ecological system [19, 20]. Candidate themes were reviewed and refined through reflexive reviews with the research team. Thick description was used to contextualize findings and support transferability. Reflecting on our positionality, the first author and several members of the team have longstanding experience implementing digital and STBBI-related public health interventions in BC, including varying degrees of involvement with GetCheckedOnline. These positionalities provided historical and contextual insight but also held potential to influence interpretation. To address this, we adopted a constructivist stance and used reflexive journaling, memoing, and team-based dialogue to examine how our assumptions, professional roles, and program familiarity influenced analytic decisions [29]. Ethics This study received approval from the University of British Columbia Behavioural Research Ethics Board (H24-01575) and was conducted in accordance with the Declaration of Helsinki. All participants received written information at least 24 hours before their session to allow time for consideration and provided informed consent prior to participation. Participation was voluntary, with the option to withdraw at any time. Given the small and interconnected health-system context, transcripts were fully de-identified, and quotations are reported at unit level to reduce risk of deductive disclosure. Results A total of 28 participants contributed to the study, representing the BCCDC, BCPHL, broader PHSA agencies (outside of BCCDC) and the MoH (Table 1). Participants held strategic, operational, digital, and laboratory positions, with 4 months to 14 years of experience related to the service, providing perspectives across intervention, organizational, and system levels. We identified four interconnected themes that reflect the intervention’s evolution over time. Participants described an early phase marked by values-driven urgency, negotiated flexibility, and strong relational commitment that enabled rapid expansion despite limited formal infrastructure. As testing demand increased post-COVID-19 and inflationary pressures intensified laboratory costs, these same features became increasingly strained, revealing governance ambiguity, deferred system integration, and reliance on invisible labor. The themes below trace how early enablers gradually became constraints as the intervention scaled with illustrative quotations as appropriate (Table 2). Table 1: Participants in the 2025 GetCheckedOnline Sustainability Study (N=28) Characteristic n % Organization Ministry of Health (MoH) 4 14% Provincial Health Services Authority (PHSA; outside BCCDC) 7 25% BC Centre for Disease Control (BCCDC) * 17 61% Primary Role Category BCCDC GetCheckedOnline Team 4 14% BCCDC Clinical Operations 6 21% BC Public Health Laboratory (BCPHL) 2 7% PHSA Provincial Laboratory Medicine Services 5 18% Ministry of Health 4 14% PHSA Provincial Digital Health Services 2 7% BCCDC Indigenous Public Health Program¹ 5 18% Years in Current Role 0-2 years 7 25% 3–5 years 12 43% 6–10 years 6 21% >10 years 3 11% 1 Five participants from the Indigenous public health program took part in a single focus group but are counted individually in the table. * Includes BC Public Health Laboatory staff collocated at the BCCDC. BCCDC is a program of the broader PHSA organization. Theme 1: Values-driven urgency as a catalyst and a constraint in the transition from pilot to scale Participants consistently situated GetCheckedOnline’s equity mandate as a central driver of early momentum. Reducing barriers to STBBI services for people facing stigma or structural exclusion was described as a moral imperative motivating the team during the transition from pilot to early regional expansion. Many referenced direct encounters with clients unable to safely access clinic-based care, and senior leaders framed the service as a response to longstanding inequities in STBBI testing. This values-driven urgency helped sustain progress even when formal system supports were limited. Although website development and system configuration could have been completed relatively quickly, participants recalled spending years navigating approvals with digital, privacy, and security teams to enable a patient-facing portal (further described in theme 4). Early expansion was characterised by excitement and support across partners, relational work, and a sense that the window of opportunity was limited, prompting efforts to extend the service to additional regions while enthusiasm remained strong. “So yeah, I feel like looking at it as a pilot, and people just really got stuck on it as a pilot. In my mind, the pilot ended when we expanded to other health authorities. We just didn't officially say that. And in retrospect, maybe that we should have actually… Instead of diving into the expansion and kind of really there was a lot of excitement within the health authorities and a lot of momentum and we didn't want to lose that. So, like, yes, let's come up with an expansion plan before we even launch GetCheckedOnline pilot. But you know, in retrospect, maybe we should have paused and said, ‘OK, …are, are we going ahead with this? And on a long-term goal and or long-term plan and if we are going ahead what are the key sustainability things we need to think about?’” – BCCDC GetCheckedOnline Team As implementation progressed, participants noted this urgency often displaced attention to foundational infrastructure and transition planning. Expansion continued without a clear end-of-pilot milestone or a deliberate pause to consider long term operational requirements. Several participants reflected that design choices appropriate for the pilot context (particularly manual results-entry workflows introduced to protect privacy and maximise accessibility through non-nominal testing) became increasingly challenging as volumes grew and as provincial digital infrastructure evolved. Participants identified post-COVID-19 demand increases and inflationary pressures affecting laboratory costs as external shocks that marked an inversion point, where system constraints became apparent as demand grew. In hindsight, some described a missed opportunity for structured planning around governance, funding, and integration before scaling. These early patterns contributed to later misalignment between the intervention and a system context that was changing more rapidly than the service architecture itself (Table 2). Theme 2: Negotiated governance flexibility and the emergence of accountability gaps during scale up Participants described GetCheckedOnline as operating within a negotiated, semi-formal governance arrangement involving the core program team, BCCDC clinical operations, the public health laboratory, and regional health authorities. While participation agreements enabled collaboration, they did not clearly codify program ownership or accountability. This structure was considered an asset during the pilot and early regional expansion because partners could contribute based on their strengths and facilitate nimble decision making. Values alignment around the service’s equity goals supported collaboration even without formal governance mechanisms. With service growth, the limitations of this flexible model became more apparent. Participants across agencies noted persistent uncertainty about program ownership. One participant described difficulty determining where a business case should land within the Ministry, as it moved between units without finding a clear home. “We don't even know who owns the program… Let's start there. When, and this is just based on my experience when we were working on, you know, supporting the business case that Doctor [Name] and the team were working on. We couldn't even figure out where it would land in in the ministry.” – PHSA Lab Services Administration Others recalled that RHAs initially covered specimen collection costs through a shared cost model but later negotiated withdrawal of funding responsibilities as testing volumes increased, leaving BCCDC to assume these expenses without dedicated funding, reinforcing the perceived widening gap between rhetorical support and the allocation of material responsibility. “ One of my first questions when I started working with the team was oh my goodness, how are you gonna do this longer term?... There’s many models existing within the health authorities, where there's a shared cost model and one of the comments that came back was in I think in 2020 or 2021 (so not that long ago) up until that point we were in a cost sharing model with some of the health authorities, or maybe all of them…” – BCCDC Clinical operations Participants also described navigating parallel approval pathways across BCCDC, PLMS, contracted private laboratory partners (responsible for specimen collection) and the Ministry, which often did not align. One participant referred to cross agency decision processes as difficult to navigate and noted that long term funding and ownership questions frequently fell to the GetCheckedOnline operations team who were not positioned to resolve them. “It's a bit of a bit of a black box to me how we get the leadership in Ministry of Health and PLMS to talk to the leadership at BCCDC and PHSA to hash that [funding] out… It's feeling very much like confidence on our small team to work that out, and… that's not the appropriate level for that to be discussed.” – BCCDC GetCheckedOnline Team This absence of clear structures for shared accountability contributed to fragmented responsibility during scale up and complicated efforts to secure stable funding and system alignment over time. Theme 3: Informal Relational Supports and Team Resilience as Substitutes for Institutional Mechanisms Relationships were consistently described as central to GetCheckedOnline’s early success and continued operation. In the initial phases, dedicated medical and executive leaders “stood behind” the program, using their influence to resolve operational bottlenecks and maintain legitimacy across partner organisations. Champions in the health system were credited with navigating difficult decisions and sustaining momentum when formal supports were limited. “The public health laboratory functions under a global budget, which means that we have a fixed budget and it doesn't matter whether we have more tests coming in or less tests coming in. We have to function within that and if we go over budget, we have to find savings within… So that was why in the early days this created a significant risk to the public health laboratory and created a lot of friction with operational accountability and pressures. And so, the “medical director basically says this is an important program that needs to be supported. We're gonna figure out the funding later”” – BCPHL The GetCheckedOnline operational team was also widely recognised for its vision, commitment to equity and skill. Partners described the team as having achieved “exceptional work with very limited resources,” noting that their combined expertise in clinical care, laboratory processes, digital systems, and surveillance enabled them to succeed despite funding limitations. Trust developed over years of collaboration facilitated direct communication, rapid problem solving, and the ability to “vouch” for each other’s intentions and capabilities when questions arose. As GetCheckedOnline expanded, however, participants acknowledged the limits of these relational strengths. Reliance on individual effort and informal networks placed disproportionate and often invisible burdens on team members, giving a sense of an under-resourced program. “You know [name], who I respect and absolutely adore so much, so I will always say yes to [them]. You know, [they’ll] just reach out and say, hey, we have this consultant, we have a few program evaluation questions, can you help? … Like it's a lot of work. It's a lot of work… And so, if you're putting like a 0.3 [FTE] analyst on this, you have to define what you want them to do because that won't be enough if you're trying to do 10 objectives.” – BCCDC Clinical Operations Decisions such as absorbing additional laboratory costs from RHAs or continuing manual processes were perceived as driven by personal commitment rather than through deliberate planning or resourced structures. Some participants expressed concern that strategic questions about GetCheckedOnline’s future were being negotiated at the level of the frontline operational team rather than through coordinated system channels, leaving the team with responsibility that exceeded their formal authority. Therefore, while relational coordination and team resilience were essential for sustaining the service during early uncertainty, reliance on these informal supports proved insufficient to replace the institutional mechanisms required for scale and longer-term integration. Theme 4: Ambiguous System Structures That Enabled Pilots but Constrained Integration Participants described GetCheckedOnline operating within a provincial system that was evolving in its approach to digital health. In early years, several recalled resistance to a public-facing portal for sensitive test results. Considerable time was spent working with privacy, security, and information management teams to explain the model and address concerns. As one participant noted: “You could rebuild it in like a few months for sure it, but it took us years to build it and a lot of that was just like [name] and I spent a lot of time talking to people like [IT services] and privacy and security and like, like getting them to like onboard even less like introducing them to the idea of what it would be and like convincing them that we could actually have a website that was externally facing that like patients could use and see their own health care information. Things are a little bit different now. I think there's more appetite for that kind of thing now. Then there was like back then, but a lot of our efforts were just on, like, essentially like getting people to accept it and support it”. – BCCDC GetCheckedOnline Team Over time, participants perceived a shift in the provincial ecosystem, with growing appetite for digital tools and a stronger focus on coordinated digital health strategies. However, they noted that GetCheckedOnline’s architecture remained heavily influenced by earlier conditions. Legacy design choices, such as non-nominal workflows and associated workarounds like special naming conventions and manual result entry on the website, continued to support equitable testing access but limited interoperability with registries, reimbursement systems, and other clinical platforms. These constraints required ongoing manual work by clinical, surveillance, and digital health staff. Laboratory contracting structures restricted to a single geographically limited private laboratory partner and rigid funding arrangements made it difficult to adjust budgets or service agreements as testing demand increased. Participants also emphasised the absence of clear provincial mechanisms for transitioning digital pilots into stable operational programs. They reported no established process through which a proven intervention like GetCheckedOnline would be assessed for long term adoption with dedicated funding envelopes, an institutional home, and defined accountability: “Well, it's something that we don't do well. So, when we think about a project, to stand up a program and I was involved in the digital [name] project when we left. That's great. You know, like we go out, we get one time funding for, for to stand to, to do a project and that's how I understand GetCheckedOnline started… But what we don't do is we don't have often the ability to transition that program or that project into operations. It's that ongoing funding that doesn't exist and you know in a in a perfect world, it would be amazing if somehow, whether it be the ministry or PHSA or whomever, BCCDC, recognized that, OK. Well, we're doing this great work. I mean we either need to start building in a transition to operations plan or we need to acknowledge there's going to be a hard stop until we get there.” – PHSA Lab Services Administration Instead, they described the service as occupying an “in between” position: valued and routinely used, yet still dependent on project-based resources and ad hoc decisions. Therefore, ambiguous system structures that once enabled innovation later constrained adaptation and fuller integration as the provincial digital, political and fiscal landscape evolved. Table 2: Early Enablers and Later Constraints in GetCheckedOnline’s Sustainability Trajectory Themes Development and Pilot Phase: Enabling Conditions Scale-Up and Sustained Operation: Emerging Constraints Theme 1: Values-Driven Urgency and Equity Mandate • Rapid adoption • Ability to bypass bureaucratic bottlenecks • Political and early funding support • Limited infrastructure development for scale • Persistence of manual workflows • Operational strain as demand increased Theme 2: Semi Formal Governance and Negotiated Flexibility • Flexible, rapid decision making across agencies • Shared commitment without binding structures • Ambiguity in ownership and accountability • Lack of formalized cost-sharing mechanisms • Governance misalignment as financial exposure increased Theme 3: Informal Relational Supports and Team Resilience • Trust-based collaboration • Executive-led problem solving • Champion navigation of system barriers • Reliance on informal labor • Hidden burdens on staff • Substitution for absent institutional mechanisms Theme 4: Ambiguous System Structures • System openness to experimentation • Flexibility within early digital context • Dependence on a single laboratory partner • Project-based funding pathways • Limited mechanisms for transition to routine operations Note: Transition from pilot to scale-up marked by external pressures, including post-COVID-19 demand increases and rising laboratory costs, intensified financial exposure and accelerated the shift from enabling conditions to structural constraints. Discussion Summary of Findings This study used GetCheckedOnline as an instrumental case to examine the multilevel factors shaping the long-term sustainability of digital health interventions as they move from pilot to scale. Guided by the DSF, we identified four interrelated themes that explain both early enabling conditions and later constraints. First, values-driven urgency and an equity mandate catalyzed expansion but displaced attention from the governance, infrastructure, and funding arrangements required for scale. Second, semi-formal governance and negotiated flexibility supported rapid piloting yet produced accountability gaps as financial exposure increased. Third, informal relational supports and team resilience functioned as compensatory infrastructure, sustaining operations while masking institutional deficits that became more visible with growth. Finally, ambiguous system structures that initially enabled experimentation lacked mechanisms to transition the service into stable, fully integrated operations. Overall, findings conceptualize sustainability as a dynamic process in which early enablers can become structural constraints when organizational and system adaptation does not keep pace with intervention scale. Figure 1: Temporal inversion during scale-up: mapping early enabling conditions and emergent constraints in the GetCheckedOnline case Comparison With Existing Literature Findings from our study align with previous work showing that digital health interventions often remain in “perpetual pilot” status because of unclear governance, unstable funding, and limited integration pathways [5, 6, 9, 37]. Similar challenges have been described regarding privacy, contracting, and interoperability, particularly for digital interventions that sit between public health and clinical systems [9, 37]. However, most analyses of digital STBBI testing focus on early development and feasibility rather than long-term scale-up [14, 38]. By examining narratives spanning a decade, our analysis foregrounds sustainability as a temporal process, demonstrating how early enabling conditions can invert into structural constraints when governance, infrastructure, and system arrangements fail to evolve alongside intervention scale. Inversion was frequently triggered by service growth, cost escalation, and heightened perceptions of organizational risk given post-COVID-19 fiscal constraints (Figure 1). In particular, our case suggests that equity-oriented design creates both significant opportunity and unintended risk [39–42]. Design choices that improved access for underserved communities, including non-nominal workflows and manual result entry processes, were central to operationalizing GetCheckedOnline’s equity objectives. This supports emerging work on digital health equity, and extends it by highlighting the need for early, parallel investment in scalable infrastructure, rather than treating equity as a pilot phase consideration and scalability as a later technical problem [43, 44]. Our findings also refine existing accounts of the role of relationships and champions in implementation [43, 45, 46]. Relational work within and across organizations was indispensable in navigating early resistance, maintaining legitimacy, and solving problems when formal mechanisms were not yet in place. However, relational infrastructure acted as a compensatory mechanism for structural gaps. By sustaining operations through champions and informal networks, the team inadvertently masked institutional deficits and reduced the impetus for governance and resource reforms [37]. This suggests that while relationships are rightly recognized as early implementation enablers, relying solely on relational work is unsustainable given that it normalizes under-resourcing by promoting overperformance [22, 47]. Finally, our case adds empirical depth to work on “pilotitis” and the innovation “valley of death” by illustrating what it means, in a public health context, for a digital service to remain in a liminal space, unable to transition from pilot to fully integrated program [12, 48]. System structures allowed early experimentation, but without clear mechanisms to transition GetCheckedOnline into a defined operational home with stable funding and shared accountability [49, 50]. Overall, our themes suggest that sustainability challenges are not simply a technical or administrative oversight. Instead, it reflects how risk averse health systems can create structural spaces where innovations are encouraged to demonstrate value yet are not readily absorbed into routine operations [37, 49]. This has implications for equity-focused interventions, which may be simultaneously valued and structurally precarious. Explanation of Findings Through DSF GetCheckedOnline’s trajectory demonstrates how an intervention’s fit with its context can shift over time, affecting its sustainability [19, 20]. During its early phase, alignment between the intervention’s equity goals, team expertise, and system willingness to support piloting created strong initial fit. However, as the service expanded, the contextual conditions around it changed. Governance roles became more ambiguous, operational demands exceeded available capacity, and system structures proved inflexible to the adaptations needed for integration. Figure 1 emphasizes these temporal dynamics. It maps the point at which factors that initially enabled piloting, such as values driven urgency, flexible governance, and relational work, began to function as constraints once testing volumes, expectations, and system conditions changed. The figure is not intended as a new theoretical model. Rather, it extends DSF’s emphasis on dynamic fit by identifying a patterned inversion point during scale up, in which pilot phase governance and funding arrangements become misaligned with the structural demands of sustained operation, resulting in prolonged institutional liminality. In GetCheckedOnline’s case, the absence of dedicated transition structures meant that adaptation occurred largely within the core team, while organizational and system level adaptation lagged behind [19, 20]. Therefore, these findings support the DSF proposition that sustainability depends not only on the intervention’s capacity to adapt, but also on the system’s ability to accommodate and institutionalize those adaptations [19, 20]. Our case study suggests that for digital health services, this includes explicit attention to transition points, where early enabling conditions need to be deliberately converted into formal governance, infrastructure, and resourcing arrangements to avoid patterns in which valued services remain structurally vulnerable on the margins of routine practice [5, 10]. Implications for Practice, Public Health, and Equity Our findings suggest important considerations for scaling equity-oriented digital health interventions. First, equity-focused design needs to be accompanied by early planning for scalable infrastructure [37, 42]. Features that improve access, such as flexible workflows or non-nominal testing options, require long-term investment in automation and integration to remain sustainable as demand grows [37]. Equity and scalability should be developed together rather than treated as separate phases [26]. Purposeful pauses to assess readiness for scale and align governance, funding, and technical systems can support smoother transitions from pilot to routine operations and reduce reliance on informal workarounds (Figure 1). Second, as digital interventions grow, flexible governance structures need to shift toward formal arrangements, including memoranda of understanding that define ownership, roles, and resource commitments [10, 20, 37]. These agreements should anticipate different growth scenarios and specify the supports required to maintain fit as scale increases. While early flexibility enabled piloting, sustained operation requires clearer accountability mechanisms than were available during GetCheckedOnline’s expansion. Third, relational work was essential in sustaining the service, but reliance on informal coordination is inherently time limited [37, 47]. Health systems should develop formal implementation and integration roles that distribute responsibility more evenly and reduce dependence on individual champions, recognizing that team resilience cannot substitute for institutional support. Finally, our findings highlight the need for intentional system-level mechanisms to transition digital pilots into fully integrated public health services [5, 10]. We have previously identified the need for centralized digital public health resources within institutions that support mechanisms for more adaptable contracting processes, integration-ready digital infrastructure, and funding pathways that extend beyond time-limited project envelopes [51]. Without these structural supports, even well-established and highly valued digital services may remain peripheral to routine operations. Grant funders must also consider sustainability design as a condition for funding late-stage pilots. Strengths and Limitations Findings from this study should be considered alongside its strengths and limitations. Strengths include candid and reflective insights of participants with deep historical knowledge spanning over a decade, multi-agency sampling across multiple system levels, high response rates, and the use of an established theoretical framework to guide interpretation. Prolonged engagement, reflexive practice, and member checking also support the credibility of the analysis. Limitations include the study’s focus on a single provincial health system and limited direct participation from RHAs given the study scope. Their perspectives were explored indirectly through participants who worked closely with them. While transferability should be approached with caution, the mechanisms identified align with broader digital health and implementation science literature and are likely relevant to other equity-oriented digital health interventions. More research is needed to explore whether identified themes can be extended across the BC health systems and beyond. Conclusions GetCheckedOnline’s evolution illustrates how digital health interventions can demonstrate sustained public health value yet struggle to transition into routine operations without parallel evolution in governance, infrastructure, and system support. In this case, early enabling conditions, including equity commitments, flexible semi formal governance, relational coordination, and evolving openness to digital innovation, were essential for piloting but did not mature into the formal structures required for long term integration. As scale intensified demand and financial exposure, these early strengths became structural constraints. More broadly, this analysis contributes to implementation science by identifying a patterned inversion point during scale up, in which pilot phase arrangements become misaligned in the absence of deliberate transition mechanisms. It reframes sustainability as a time sensitive process requiring purposeful institutionalization of governance, funding, and technical systems as interventions mature. These insights provide practical guidance for jurisdictions seeking to scale and sustain equity-oriented digital interventions in public health. Abbreviations Abbreviation Meaning BC British Columbia BCCDC BC Centre for Disease Control BCPHL BC Public Health Laboratory COREQ Consolidated criteria for reporting qualitative research CPS Clinical Prevention Services COVID Coronavirus disease DSF Dynamic Sustainability Framework FTE Full time equivalent HIV Human immunodeficiency virus IMITS Information Management and Information Technology Services MoH Ministry of Health NVivo NVivo qualitative data analysis software PDHIS Provincial Digital Health Information Services PHL Public Health Laboratory PHSA Provincial Health Services Authority PLMS Provincial Laboratory Medicine Services RHA Regional health authority STBBI Sexually transmitted and blood borne infection STI Sexually transmitted infection Declarations Ethical Approval and Consent to Participate This study received approval from the University of British Columbia Behavioural Research Ethics Board (H24-01575) and was conducted in accordance with the Declaration of Helsinki. All participants received written information at least 24 hours before their session to allow time for consideration and provided informed consent prior to participation. Participation was voluntary, with the option to withdraw at any time. Given the small and interconnected health-system context, transcripts were fully de-identified, and quotations are reported at unit level to reduce risk of deductive disclosure. Competing Interests None declared Funding II is supported by a Canadian Institutes for Health Research (CIHR) Health Systems Impact Fellowship (Award number 521442), a Michael Smith Health Research BC Trainee Award (Award number – HSIF-2024-04465) and a CIHR Canadian HIV Trials Network (CTN+) post-doctoral fellowship. This study was funded through II’s fellowship. MG reports a CIHR Applied Public Health Chair (PP6-170676). DG reports a Canada Research Chair in Sexual and Gender Minority health. Authors’ Contributions II conceptualized the study, led study design, conducted data collection, led analysis, and drafted the manuscript. DH contributed to study design, interpretation of findings, and critically revised the manuscript. SB contributed to data interpretation and manuscript revision. CW contributed to conceptual framing, interpretation of findings, and manuscript revision. DG contributed to interpretation and critical manuscript revision. MG contributed to study conceptualization, supervision, interpretation of findings, and critical revision of the manuscript. All authors read and approved the final manuscript. Acknowledgements We sincerely thank the study participants for generously sharing their time and insights. We are grateful to Heather Pedersen and Ashley Bentley for their guidance and thoughtful input throughout the project. We also acknowledge the members of the GetCheckedOnline Provincial Sustainment Working Group for their ongoing engagement and for helping ground this study in health system realities. We thank members of the BCCDC Clinical Prevention Services team for their support and collaboration. Finally, we acknowledge the users of GetCheckedOnline, whose engagement with the service and efforts to access testing shaped the broader context in which this study was conducted. Use of Artificial Intelligence Portions of manuscript drafting and editing were supported using GPT-5.2 (OpenAI) to assist with language refinement and structural clarity. All intellectual content, interpretation of findings, and final editorial decisions were made by the authors. The authors take full responsibility for the accuracy and integrity of the work. Availability of data and materials The datasets analyzed in this study were generated as part of organizational quality improvement and implementation activities within the British Columbia Centre for Disease Control and are not publicly available due to institutional and privacy restrictions. Data may be made available from the corresponding author upon reasonable request and with permission from the British Columbia Centre for Disease Control. Consent to Publish Not applicable. References Budd J, Miller BS, Manning EM, et al. Digital technologies in the public-health response to COVID-19. Nature medicine 2020; 26: 1183–1192. Gunasekeran DV, Tham Y-C, Ting DSW, et al. Digital health during COVID-19: lessons from operationalising new models of care in ophthalmology. The Lancet Digital Health 2021; 3: e124–e134. Iyamu I, Xu AXT, Gómez-Ramírez O, et al. Defining Digital Public Health and the Role of Digitization, Digitalization, and Digital Transformation: Scoping Review. 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Evaluating the Impact of the COVID-19–Related Public Health Restrictions on Access to Digital Sexually Transmitted and Blood-Borne Infection Testing in British Columbia, Canada: An Interrupted Time Series Analysis. Sexual Trans Dis 2023; 50: 595–602. Gomez-Ramirez O, Gilbert, M, Grace, D. Beyond initial implementation: barriers and facilitators to the scale-up, adaptation, maintenance, and sustainability of GetChecedOnline . Digital Sexual Health Initiative, 2021. Yin RK, Campbell DT. Case study research and applications: design and methods . Sixth. Thousand Oaks, California: SAGE Publications, Inc, https://ebooks.umu.ac.ug/librarian/books-file/Case%20Study%20Research%20and%20Applications.pdf (2018). Priya A. Case Study Methodology of Qualitative Research: Key Attributes and Navigating the Conundrums in Its Application. Sociological Bulletin 2021; 70: 94–110. Charmaz K. Chapter 8 - Grounded Theory: Objectivist and Constructivist Methods. 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A critical review of the reporting of reflexive thematic analysis in Health Promotion International. Health Promotion International 2024; 39: daae049. Braun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qualitative Research in Psychology 2021; 18: 328–352. Greenhalgh T, Wherton J, Papoutsi C, et al. Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies. J Med Internet Res 2017; 19: e367. Rapid Response Service. A review of internet-based testing services for HIV and sexually transmitted infections (STIs) . Toronto, Ontario: The Ontario HIV Treatment Network, https://www.ohtn.on.ca/wp-content/uploads/2022/03/RR168_STI-online-testing.pdf (March 2022, accessed 20 September 2022). Lyles CR, Wachter RM, Sarkar U. Focusing on Digital Health Equity. JAMA 2021; 326: 1795. Rodriguez JA, Lyles CR. Strengthening digital health equity by balancing techno-optimism and techno-skepticism through implementation science. npj Digit Med 2023; 6: 203. Lee EW, McCloud RF, Viswanath K. Designing Effective eHealth Interventions for Underserved Groups: Five Lessons From a Decade of eHealth Intervention Design and Deployment. J Med Internet Res 2022; 24: e25419. Gómez-Ramírez O, Iyamu I, Ablona A, et al. On the imperative of thinking through the ethical, health equity, and social justice possibilities and limits of digital technologies in public health. Canadian Journal of Public Health 2021; 112: 412–416. Iyamu I, Kassam R, Worthington C, et al. Missed opportunities to provide sexually transmitted and blood-borne infections testing in British Columbia: An interpretive description of users’ experiences of Get Checked Online’s design and implementation. DIGITAL HEALTH ; 10. Epub ahead of print 2024. DOI: 10.1177/20552076241277653. Crawford A, Serhal E. Digital Health Equity and COVID-19: The Innovation Curve Cannot Reinforce the Social Gradient of Health. Journal of medical Internet research 2020; 22: e19361. Lyles CR, Nguyen OK, Khoong EC, et al. Multilevel Determinants of Digital Health Equity: A Literature Synthesis to Advance the Field. Annu Rev Public Health 2023; 44: 383–405. Rodriguez JA, Clark CR, Bates DW. Digital Health Equity as a Necessity in the 21st Century Cures Act Era. JAMA 2020; 323: 2381–2382. May CR, Mair F, Finch T, et al. Development of a theory of implementation and integration: Normalization Process Theory. Implementation Sci 2009; 4: 29. Seyhan AA. Lost in translation: the valley of death across preclinical and clinical divide – identification of problems and overcoming obstacles. transl med commun 2019; 4: 18. Labrique AB, Wadhwani C, Williams KA, et al. Best practices in scaling digital health in low and middle income countries. Globalization and Health 2018; 14: 1–8. Labrique A, Vasudevan L, Weiss W, et al. Establishing Standards to Evaluate the Impact of Integrating Digital Health into Health Systems. Glob Health Sci Pract 2018; 6: S5–S17. Iyamu I, Haag D, Carson A, et al. Opportunities and Challenges for an Organizational Digital Public Health Strategy in a Provincial Public Health Program in Canada: Qualitative Description of Practitioner Perspectives. JMIR Public Health Surveill 2025; 11: e72588–e72588. Additional Declarations No competing interests reported. Supplementary Files Appendices.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 04 May, 2026 Reviewers agreed at journal 15 Apr, 2026 Reviewers invited by journal 10 Apr, 2026 Editor assigned by journal 08 Apr, 2026 Submission checks completed at journal 26 Mar, 2026 First submitted to journal 25 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9227568","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":623897103,"identity":"7c328113-1f1b-4a39-9746-24b3e6e2786c","order_by":0,"name":"Ihoghosa 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case\u003c/p\u003e","description":"","filename":"Fig1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-9227568/v1/3515b7cb46a8f6813457e2d4.jpg"},{"id":107487198,"identity":"1a149e0b-e7f9-4b69-b63d-7c8e1afb2d51","added_by":"auto","created_at":"2026-04-22 02:40:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5058587,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9227568/v1/b9f49287-69cf-459e-a11c-18a3a4556497.pdf"},{"id":107376932,"identity":"4a679752-4c77-4ff9-9530-7e7a0c66c8a2","added_by":"auto","created_at":"2026-04-21 01:23:11","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24045,"visible":true,"origin":"","legend":"","description":"","filename":"Appendices.docx","url":"https://assets-eu.researchsquare.com/files/rs-9227568/v1/e87f351e600c41f5da6cfbb4.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"When Enabling Factors Become Constraints: A Qualitative Case Study of Sustainability and Temporal System Dynamics in an Equity-Oriented Digital Intervention for Sexually Transmitted Infection Testing","fulltext":[{"header":"Contributions to the literature","content":"\u003cul\u003e\n \u003cli\u003eThis study addresses implementation science gaps in understanding how digital health interventions transition from pilot to sustained operation within publicly funded health systems.\u003c/li\u003e\n \u003cli\u003eWe identify a patterned temporal inversion during scale-up, in which early enabling conditions can become structural constraints when governance, funding, and infrastructure mechanisms do not evolve alongside intervention growth.\u003c/li\u003e\n \u003cli\u003eWe suggest that this inversion dynamic may be anticipated under conditions of absent transition planning, offering practical signals for earlier system-level alignment.\u003c/li\u003e\n \u003cli\u003eWe ground “pilotitis” and “valley of death” concepts in concrete governance and organizational processes, extending sustainability scholarship beyond uptake and effectiveness outcomes.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003eDigital health interventions are increasingly promoted as ways to expand equitable access to care and modernize public health systems across diverse settings while ensuring efficient resource utilization\u0026nbsp;[1–4]. Yet, significant challenges impede systems’ ability to transition from early pilot success to stable, integrated, and sustainably resourced programs, even when interventions demonstrate clear early benefits\u0026nbsp;[5–7]. This persistent implementation gap limits the population-level impact of digital interventions and often results in resource wastage across health systems [8, 9]. Recent implementation and translational science literature has described related patterns as “pilotitis” and the “valley of death,” highlighting how promising innovations often demonstrate early success but struggle to transition into sustained, system-level integration\u0026nbsp;[5–7, 10–12]. Similar concerns have been noted in Canada, where strong innovation and pilot activity have not consistently translated into system-wide implementation and scale\u0026nbsp;[5, 10].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis challenge is particularly salient in efforts to address the rising burden of sexually transmitted and blood-borne infections (STBBIs). Digital testing interventions can potentially reduce longstanding access barriers, especially for people facing stigma, geographic isolation, or limited engagement with clinic-based care\u0026nbsp;[13–17]. Global and national strategies increasingly position digital interventions as key enablers of low-barrier, person-centred approaches to STBBI testing and care [16, 17]. Yet most digital STBBI interventions have been implemented as isolated pilot projects with temporary funding, limiting their ability to become stable components of public health systems [14, 18]. The difficulty of sustaining and integrating these digital models threatens progress toward global goals of expanding stigma-free testing options and embedding equitable sexual health services within primary care [16, 17].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGrowing interest in sustainability within health services research has generated a shift toward recognizing sustainability as a dynamic process, in which beneficial outcomes are maintained through ongoing adaptation to evolving multilevel contexts\u0026nbsp;[19–21]. While this dynamic framing has advanced theoretical debate, it remains underexamined in digital health contexts, particularly for equity-oriented interventions implemented within publicly funded systems. The predominance of short-term digital pilots further limits opportunities to observe how sustainability processes unfold over time or how interventions negotiate changing organizational, technological, and policy conditions [9, 14]. Practice-based evidence is needed to inform planning, adaptation, and scale-up strategies that enhance long-term sustainability and better support efforts to reduce disparities in STBBI outcomes [22].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGetCheckedOnline is a digital STBBI testing service developed by the BC Centre for Disease Control (BCCDC) and the BC Public Health Laboratory (BCPHL; located at the BCCDC). It was introduced as a pilot in 2014 and underwent initial scale-up in 2016 [23, 24]. Designed as a low-barrier, equity-oriented alternative to clinic-based testing, the service aims to reduce access barriers for populations underserved through conventional pathways while enabling clinical resources to be redirected to more complex care needs [23, 24]. Users create accounts, complete a risk assessment, and receive tailored test recommendations with a laboratory requisition [23]. Specimens are collected at participating laboratory sites. Results are released to users online under clinical oversight, with nurse-led follow-up and linkage to care for positive tests. Its long-standing integration within the provincial public health system and sequential expansion across nine communities offer a unique opportunity to observe sustainability processes as they unfold in practice [24, 25]. GetCheckedOnline’s longevity provides an empirical basis for a temporal exploration of how interventional, relational, organizational, and system-level factors evolve and interact across project phases in publicly funded systems [19, 20, 26].\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eStudy Purpose\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThis study examined multilevel factors influencing the long-term sustainability of digital health interventions as they move from pilot to scale within publicly funded systems. We analyzed how the intervention, its organizational, and system dynamics evolved over time to support or constrain sustained delivery of an equity-oriented digital service.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch2\u003e\u003cem\u003eStudy Design and Theoretical Framework\u0026nbsp;\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eWe conducted a qualitative instrumental case study of GetCheckedOnline, conceptualized as a bounded digital health intervention within British Columbia’s publicly funded health system [27, 28]. Guided by a constructivist orientation, the case study approach enabled an in-depth, contextually grounded exploration of sustainability within a complex health system [29]. We drew on the Dynamic Sustainability Framework (DSF), which describes sustainability as an ongoing process requiring the evolving fit between an intervention, its organizational setting, and the broader ecological system [19]. DSF was used to inform sampling across multiple system levels, guide the development of interview prompts focusing on adaptation and contextual change, and focus the analysis on temporal shifts across pilot implementation, scale-up, and ongoing operations [19, 20]. The DSF also informed interpretation of findings through attention to changing intervention–context interactions over time. The case was bounded by the organizational structures responsible for GetCheckedOnline (the BCCDC and the BCPHL), their provincial partners (including Provincial Laboratory Medicine Services (PLMS), regional health authorities (RHAs), and the Ministry of Health (MoH)), and the period from initial pilot planning in 2012 through scale-up, adaptation and sustainability planning activities up to 2025. The case was also intentionally bounded to provincial-level implementation partners to focus on system-level governance and sustainability dynamics. Perspectives from RHAs is planned for subsequent work. Study procedures adhered to the COREQ criteria for qualitative reporting [30]. \u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eStudy setting and context\u0026nbsp;\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eGetCheckedOnline operates within British Columbia’s publicly funded health system, where responsibility for STBBI services is distributed across several interconnected agencies, including the MoH, BCCDC, the BCPHL, and RHAs [23]. Each has distinct operational and population priorities that have influenced the intervention’s development over time. GetCheckedOnline is situated at the BCCDC, which oversees program design, clinical governance, and day-to-day operations, while the BCPHL provides diagnostic testing and supports the laboratory workflows required for online ordering and result management [23, 31]. Program delivery is coordinated across multiple groups: the core program team, surveillance staff, clinicians at the BCCDC STI Clinic, laboratory personnel, provincial digital infrastructure groups, and specimen-collection sites operated through a single contracted private laboratory system [23]. The service runs within the Provincial Health Services Authority’s (PHSA) digital infrastructure and must adhere to its technical, privacy, and security requirements. Clinically, GetCheckedOnline is fully integrated with the BCCDC STI Clinic, which provides medical oversight, facilitates treatment referrals, and supports follow-up for clients who test positive [23]. GetCheckedOnline currently offers testing for chlamydia, gonorrhea, syphilis, HIV, and hepatitis C. Available in nine urban, suburban, and rural communities across the province, the service conducts more than 30,000 tests annually and accounted for over 7.5% of all STBBI tests in participating BC regions based on 2021 estimates [25].\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eParticipants and sampling\u0026nbsp;\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eWe used stratified purposive sampling to ensure representation across the three levels of the DSF: the intervention (GetCheckedOnline core team), the practice setting (BCCDC clinical and operational leads), and the broader ecological system (MoH, BCPHL, PHSA’s other agencies: Provincial Laboratory Medicine Services (PLMS), and Provincial Digital Health and Information Services (PDHIS)). Sampling reflected the distributed nature of governance and implementation responsibilities relevant to GetCheckedOnline’s long-term sustainability. A list of potential participants was developed with the GetCheckedOnline team and included individuals who currently or recently (within the past year) held strategic, operational, clinical, laboratory, or digital infrastructure roles connected to the service. Initial invitations were sent through the program to introduce the study, followed by direct coordination and scheduling by the lead researcher (II). Snowball sampling was used to identify additional informants [32]. Recruitment continued until adequate information power was achieved across organizational levels and no additional eligible participants remained. Of the 31 individuals approached, three did not respond and no one actively declined, representing a 90% response rate [33].\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eData Collection\u0026nbsp;\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eWe conducted individual interviews and one focus group, including members of the BCCDC Indigenous Public Health program, between February and June 2025. Data were analyzed iteratively to allow exploration of emerging ideas. Interview and focus group guides were informed by constructs from the DSF (Appendix 1) and explored sustainability, system fit, governance, and adaptation across GetCheckedOnline’s lifespan [19]. Data collection was conducted virtually on Microsoft Teams by the first author (II), a physician and health systems researcher experienced in qualitative inquiry. Although embedded within the broader organizational context, II was independent of the GetCheckedOnline implementation team. No non-participants were present during interviews. Participants completed a brief demographic and role survey prior to their session. Interviews were semi-structured and averaged 58 minutes in length, and the focus group lasted 85 minutes. With participant consent, sessions were audio-recorded and transcribed using automated transcription software, except for one interview in which detailed field notes were taken instead of recording. All transcripts were reviewed and corrected against the audio for accuracy. The first author also took detailed field notes during and immediately after each session to support reflexive and analytic interpretation. All data were stored securely on BCCDC servers with access restricted to the study team.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eData analysis\u0026nbsp;\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eAll transcripts, field notes, and reference documents were imported into NVivo 15 for management and analysis [34]. We conducted a reflexive thematic analysis guided by Braun and Clarke, characterized by iterative engagement with the data, acknowledgement of researcher subjectivity, and the development of interpretive rather than purely descriptive themes [35, 36]. This was a focused secondary analysis of data pertaining to pilot identity, governance processes, organizational integration, and sustainability. Analysis began with repeated readings of transcripts and inductive coding by the first author (II). Codes captured patterns related to governance structures, organizational roles, legacy design choices, and system dynamics across the lifespan of GetCheckedOnline. Coding proceeded iteratively, supported by analytic memos that documented early insights and informed refinement of the coding structure over time. A temporal lens was applied to distinguish historical conditions from contemporary dynamics, which allowed examination of how system, organizational, and relational contexts shifted across phases of pilot development, scale-up, and operational integration [19]. As themes were identified, the DSF was incorporated as a sensitizing framework to support interpretive depth, particularly when exploring narratives about the evolving fit between the intervention, its practice setting, and the broader ecological system [19, 20]. Candidate themes were reviewed and refined through reflexive reviews with the research team. Thick description was used to contextualize findings and support transferability. Reflecting on our positionality, the first author and several members of the team have longstanding experience implementing digital and STBBI-related public health interventions in BC, including varying degrees of involvement with GetCheckedOnline. These positionalities provided historical and contextual insight but also held potential to influence interpretation. To address this, we adopted a constructivist stance and used reflexive journaling, memoing, and team-based dialogue to examine how our assumptions, professional roles, and program familiarity influenced analytic decisions [29].\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eEthics\u0026nbsp;\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThis study received approval from the University of British Columbia Behavioural Research Ethics Board (H24-01575) and was conducted in accordance with the Declaration of Helsinki. All participants received written information at least 24 hours before their session to allow time for consideration and provided informed consent prior to participation. Participation was voluntary, with the option to withdraw at any time. Given the small and interconnected health-system context, transcripts were fully de-identified, and quotations are reported at unit level to reduce risk of deductive disclosure.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 28 participants contributed to the study, representing the BCCDC, BCPHL, broader PHSA agencies (outside of BCCDC) and the MoH (Table 1). Participants held strategic, operational, digital, and laboratory positions, with 4 months to 14 years of experience related to the service, providing perspectives across intervention, organizational, and system levels. We identified four interconnected themes that reflect the intervention\u0026rsquo;s evolution over time. Participants described an early phase marked by values-driven urgency, negotiated flexibility, and strong relational commitment that enabled rapid expansion despite limited formal infrastructure. As testing demand increased post-COVID-19 and inflationary pressures intensified laboratory costs, these same features became increasingly strained, revealing governance ambiguity, deferred system integration, and reliance on invisible labor. The themes below trace how early enablers gradually became constraints as the intervention scaled with illustrative quotations as appropriate (Table 2).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1: Participants in the 2025 GetCheckedOnline Sustainability Study (N=28)\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"624\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristic\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOrganization\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003eMinistry of Health (MoH)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003eProvincial Health Services Authority (PHSA; outside BCCDC)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003eBC Centre for Disease Control (BCCDC)\u003csup\u003e*\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e61%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrimary Role Category\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003eBCCDC GetCheckedOnline Team\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003eBCCDC Clinical Operations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003eBC Public Health Laboratory (BCPHL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003ePHSA Provincial Laboratory Medicine Services \u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e18%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003eMinistry of Health\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e14%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003ePHSA Provincial Digital Health Services\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003eBCCDC Indigenous Public Health Program\u0026sup1;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e18%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eYears in Current Role\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003e0-2 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e25%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003e3\u0026ndash;5 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e43%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e21%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 483px;\"\u003e\n \u003cp\u003e\u0026gt;10 years\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd nowrap=\"\" valign=\"bottom\" style=\"width: 70px;\"\u003e\n \u003cp\u003e11%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd nowrap=\"\" colspan=\"3\" style=\"width: 624px;\"\u003e\n \u003cp\u003e\u003csup\u003e1\u003c/sup\u003eFive participants from the Indigenous public health program took part in a single focus group but are counted individually in the table. \u003csup\u003e*\u003c/sup\u003eIncludes BC Public Health Laboatory staff collocated at the BCCDC. BCCDC is a program of the broader PHSA organization.\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003ch2\u003e\u003cem\u003eTheme 1: Values-driven urgency as a catalyst and a constraint in the transition from pilot to scale\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eParticipants consistently situated GetCheckedOnline\u0026rsquo;s equity mandate as a central driver of early momentum. Reducing barriers to STBBI services for people facing stigma or structural exclusion was described as a moral imperative motivating the team during the transition from pilot to early regional expansion. Many referenced direct encounters with clients unable to safely access clinic-based care, and senior leaders framed the service as a response to longstanding inequities in STBBI testing. This values-driven urgency helped sustain progress even when formal system supports were limited. Although website development and system configuration could have been completed relatively quickly, participants recalled spending years navigating approvals with digital, privacy, and security teams to enable a patient-facing portal (further described in theme 4). Early expansion was characterised by excitement and support across partners, relational work, and a sense that the window of opportunity was limited, prompting efforts to extend the service to additional regions while enthusiasm remained strong.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;So yeah, I feel like looking at it as a pilot, and people just really got stuck on it as a pilot. In my mind, the pilot ended when we expanded to other health authorities. We just didn\u0026apos;t officially say that. And in retrospect, maybe that we should have actually\u0026hellip; Instead of diving into the expansion and kind of really there was a lot of excitement within the health authorities and a lot of momentum and we didn\u0026apos;t want to lose that. So, like, yes, let\u0026apos;s come up with an expansion plan before we even launch GetCheckedOnline pilot. But you know, in retrospect, maybe we should have paused and said, \u0026lsquo;OK, \u0026hellip;are, are we going ahead with this? And on a long-term goal and or long-term plan and if we are going ahead what are the key sustainability things we need to think about?\u0026rsquo;\u0026rdquo;\u003c/em\u003e \u0026ndash; BCCDC GetCheckedOnline Team\u003c/p\u003e\n\u003cp\u003eAs implementation progressed, participants noted this urgency often displaced attention to foundational infrastructure and transition planning. Expansion continued without a clear end-of-pilot milestone or a deliberate pause to consider long term operational requirements. Several participants reflected that design choices appropriate for the pilot context (particularly manual results-entry workflows introduced to protect privacy and maximise accessibility through non-nominal testing) became increasingly challenging as volumes grew and as provincial digital infrastructure evolved. Participants identified post-COVID-19 demand increases and inflationary pressures affecting laboratory costs as external shocks that marked an inversion point, where system constraints became apparent as demand grew. In hindsight, some described a missed opportunity for structured planning around governance, funding, and integration before scaling. These early patterns contributed to later misalignment between the intervention and a system context that was changing more rapidly than the service architecture itself (Table 2).\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eTheme 2: Negotiated governance flexibility and the emergence of accountability gaps during scale up\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eParticipants described GetCheckedOnline as operating within a negotiated, semi-formal governance arrangement involving the core program team, BCCDC clinical operations, the public health laboratory, and regional health authorities. While participation agreements enabled collaboration, they did not clearly codify program ownership or accountability. This structure was considered an asset during the pilot and early regional expansion because partners could contribute based on their strengths and facilitate nimble decision making. Values alignment around the service\u0026rsquo;s equity goals supported collaboration even without formal governance mechanisms. With service growth, the limitations of this flexible model became more apparent. Participants across agencies noted persistent uncertainty about program ownership. One participant described difficulty determining where a business case should land within the Ministry, as it moved between units without finding a clear home.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;We don\u0026apos;t even know who owns the program\u0026hellip; Let\u0026apos;s start there. When, and this is just based on my experience when we were working on, you know, supporting the business case that Doctor [Name] and the team were working on. We couldn\u0026apos;t even figure out where it would land in in the ministry.\u0026rdquo;\u003c/em\u003e \u0026ndash; PHSA Lab Services Administration\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOthers recalled that RHAs initially covered specimen collection costs through a shared cost model but later negotiated withdrawal of funding responsibilities as testing volumes increased, leaving BCCDC to assume these expenses without dedicated funding, reinforcing the perceived widening gap between rhetorical support and the allocation of material responsibility.\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003eOne of my first questions when I started working with the team was oh my goodness, how are you gonna do this longer term?... There\u0026rsquo;s many models existing within the health authorities, where there\u0026apos;s a shared cost model and one of the comments that came back was in I think in 2020 or 2021 (so not that long ago) up until that point we were in a cost sharing model with some of the health authorities, or maybe all of them\u0026hellip;\u0026rdquo;\u003c/em\u003e \u0026ndash; BCCDC Clinical operations\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eParticipants also described navigating parallel approval pathways across BCCDC, PLMS, contracted private laboratory partners (responsible for specimen collection) and the Ministry, which often did not align. One participant referred to cross agency decision processes as difficult to navigate and noted that long term funding and ownership questions frequently fell to the GetCheckedOnline operations team who were not positioned to resolve them.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;It\u0026apos;s a bit of a bit of a black box to me how we get the leadership in Ministry of Health and PLMS to talk to the leadership at BCCDC and PHSA to hash that [funding] out\u0026hellip; It\u0026apos;s feeling very much like confidence on our small team to work that out, and\u0026hellip; that\u0026apos;s not the appropriate level for that to be discussed.\u0026rdquo;\u003c/em\u003e \u0026ndash; BCCDC GetCheckedOnline Team\u003c/p\u003e\n\u003cp\u003eThis absence of clear structures for shared accountability contributed to fragmented responsibility during scale up and complicated efforts to secure stable funding and system alignment over time.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eTheme 3: Informal Relational Supports and Team Resilience as Substitutes for Institutional Mechanisms\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eRelationships were consistently described as central to GetCheckedOnline\u0026rsquo;s early success and continued operation. In the initial phases, dedicated medical and executive leaders \u0026ldquo;stood behind\u0026rdquo; the program, using their influence to resolve operational bottlenecks and maintain legitimacy across partner organisations. Champions in the health system were credited with navigating difficult decisions and sustaining momentum when formal supports were limited.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;The public health laboratory functions under a global budget, which means that we have a fixed budget and it doesn\u0026apos;t matter whether we have more tests coming in or less tests coming in. We have to function within that and if we go over budget, we have to find savings within\u0026hellip; So that was why in the early days this created a significant risk to the public health laboratory and created a lot of friction with operational accountability and pressures. And so, the \u0026ldquo;medical director basically says this is an important program that needs to be supported. We\u0026apos;re gonna figure out the funding later\u0026rdquo;\u0026rdquo;\u003c/em\u003e \u0026ndash; BCPHL\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe GetCheckedOnline operational team was also widely recognised for its vision, commitment to equity and skill. Partners described the team as having achieved \u0026ldquo;exceptional work with very limited resources,\u0026rdquo; noting that their combined expertise in clinical care, laboratory processes, digital systems, and surveillance enabled them to succeed despite funding limitations. Trust developed over years of collaboration facilitated direct communication, rapid problem solving, and the ability to \u0026ldquo;vouch\u0026rdquo; for each other\u0026rsquo;s intentions and capabilities when questions arose.\u003c/p\u003e\n\u003cp\u003eAs GetCheckedOnline expanded, however, participants acknowledged the limits of these relational strengths. Reliance on individual effort and informal networks placed disproportionate and often invisible burdens on team members, giving a sense of an under-resourced program.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You know [name], who I respect and absolutely adore so much, so I will always say yes to [them]. You know, [they\u0026rsquo;ll] just reach out and say, hey, we have this consultant, we have a few program evaluation questions, can you help? \u0026hellip; Like it\u0026apos;s a lot of work. It\u0026apos;s a lot of work\u0026hellip; And so, if you\u0026apos;re putting like a 0.3 [FTE] analyst on this, you have to define what you want them to do because that won\u0026apos;t be enough if you\u0026apos;re trying to do 10 objectives.\u0026rdquo;\u003c/em\u003e \u0026ndash; BCCDC Clinical Operations\u003c/p\u003e\n\u003cp\u003eDecisions such as absorbing additional laboratory costs from RHAs or continuing manual processes were perceived as driven by personal commitment rather than through deliberate planning or resourced structures. Some participants expressed concern that strategic questions about GetCheckedOnline\u0026rsquo;s future were being negotiated at the level of the frontline operational team rather than through coordinated system channels, leaving the team with responsibility that exceeded their formal authority. Therefore, while relational coordination and team resilience were essential for sustaining the service during early uncertainty, reliance on these informal supports proved insufficient to replace the institutional mechanisms required for scale and longer-term integration.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eTheme 4: Ambiguous System Structures That Enabled Pilots but Constrained Integration\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eParticipants described GetCheckedOnline operating within a provincial system that was evolving in its approach to digital health. In early years, several recalled resistance to a public-facing portal for sensitive test results. Considerable time was spent working with privacy, security, and information management teams to explain the model and address concerns. As one participant noted:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;You could rebuild it in like a few months for sure it, but it took us years to build it and a lot of that was just like [name] and I spent a lot of time talking to people like [IT services] and privacy and security and like, like getting them to like onboard even less like introducing them to the idea of what it would be and like convincing them that we could actually have a website that was externally facing that like patients could use and see their own health care information. Things are a little bit different now. I think there\u0026apos;s more appetite for that kind of thing now. Then there was like back then, but a lot of our efforts were just on, like, essentially like getting people to accept it and support it\u0026rdquo;.\u003c/em\u003e \u0026ndash; BCCDC GetCheckedOnline Team\u003c/p\u003e\n\u003cp\u003eOver time, participants perceived a shift in the provincial ecosystem, with growing appetite for digital tools and a stronger focus on coordinated digital health strategies. However, they noted that GetCheckedOnline\u0026rsquo;s architecture remained heavily influenced by earlier conditions. Legacy design choices, such as non-nominal workflows and associated workarounds like special naming conventions and manual result entry on the website, continued to support equitable testing access but limited interoperability with registries, reimbursement systems, and other clinical platforms. These constraints required ongoing manual work by clinical, surveillance, and digital health staff. Laboratory contracting structures restricted to a single geographically limited private laboratory partner and rigid funding arrangements made it difficult to adjust budgets or service agreements as testing demand increased. Participants also emphasised the absence of clear provincial mechanisms for transitioning digital pilots into stable operational programs. They reported no established process through which a proven intervention like GetCheckedOnline would be assessed for long term adoption with dedicated funding envelopes, an institutional home, and defined accountability:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Well, it\u0026apos;s something that we don\u0026apos;t do well. So, when we think about a project, to stand up a program and I was involved in the digital [name] project when we left. That\u0026apos;s great. You know, like we go out, we get one time funding for, for to stand to, to do a project and that\u0026apos;s how I understand GetCheckedOnline started\u0026hellip; But what we don\u0026apos;t do is we don\u0026apos;t have often the ability to transition that program or that project into operations. It\u0026apos;s that ongoing funding that doesn\u0026apos;t exist and you know in a in a perfect world, it would be amazing if somehow, whether it be the ministry or PHSA or whomever, BCCDC, recognized that, OK. Well, we\u0026apos;re doing this great work. I mean we either need to start building in a transition to operations plan or we need to acknowledge there\u0026apos;s going to be a hard stop until we get there.\u0026rdquo; \u0026ndash;\u0026nbsp;\u003c/em\u003ePHSA Lab Services Administration\u003c/p\u003e\n\u003cp\u003eInstead, they described the service as occupying an \u0026ldquo;in between\u0026rdquo; position: valued and routinely used, yet still dependent on project-based resources and ad hoc decisions. Therefore, ambiguous system structures that once enabled innovation later constrained adaptation and fuller integration as the provincial digital, political and fiscal landscape evolved.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2: Early Enablers and Later Constraints in GetCheckedOnline\u0026rsquo;s Sustainability Trajectory\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eThemes\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDevelopment and Pilot Phase: Enabling Conditions\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eScale-Up and Sustained Operation: Emerging Constraints\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 1: Values-Driven Urgency and Equity Mandate\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e\u0026bull; Rapid adoption\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Ability to bypass bureaucratic bottlenecks \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Political and early funding support\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u0026bull; Limited infrastructure development for scale \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Persistence of manual workflows \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Operational strain as demand increased\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 2: Semi Formal Governance and Negotiated Flexibility\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e\u0026bull; Flexible, rapid decision making across agencies \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Shared commitment without binding structures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u0026bull; Ambiguity in ownership and accountability\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Lack of formalized cost-sharing mechanisms \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Governance misalignment as financial exposure increased\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 3: Informal Relational Supports and Team Resilience\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e\u0026bull; Trust-based collaboration \u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Executive-led problem solving \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Champion navigation of system barriers\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u0026bull; Reliance on informal labor \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Hidden burdens on staff \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Substitution for absent institutional mechanisms\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 214px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTheme 4: Ambiguous System Structures\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 194px;\"\u003e\n \u003cp\u003e\u0026bull; System openness to experimentation \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Flexibility within early digital context\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u0026bull; Dependence on a single laboratory partner \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Project-based funding pathways \u0026nbsp;\u0026nbsp;\u003cbr\u003e\u0026nbsp;\u0026bull; Limited mechanisms for transition to routine operations\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e Transition from pilot to scale-up marked by external pressures, including post-COVID-19 demand increases and rising laboratory costs, intensified financial exposure and accelerated the shift from enabling conditions to structural constraints.\u003c/p\u003e"},{"header":"Discussion","content":"\u003ch2\u003e\u003cem\u003eSummary of Findings\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eThis study used GetCheckedOnline as an instrumental case to examine the multilevel factors shaping the long-term sustainability of digital health interventions as they move from pilot to scale. Guided by the DSF, we identified four interrelated themes that explain both early enabling conditions and later constraints. First, values-driven urgency and an equity mandate catalyzed expansion but displaced attention from the governance, infrastructure, and funding arrangements required for scale. Second, semi-formal governance and negotiated flexibility supported rapid piloting yet produced accountability gaps as financial exposure increased. Third, informal relational supports and team resilience functioned as compensatory infrastructure, sustaining operations while masking institutional deficits that became more visible with growth. Finally, ambiguous system structures that initially enabled experimentation lacked mechanisms to transition the service into stable, fully integrated operations. Overall, findings conceptualize sustainability as a dynamic process in which early enablers can become structural constraints when organizational and system adaptation does not keep pace with intervention scale.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1:\u003c/strong\u003e Temporal inversion during scale-up: mapping early enabling conditions and emergent constraints in the GetCheckedOnline case\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eComparison With Existing Literature\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eFindings from our study align with previous work showing that digital health interventions often remain in \u0026ldquo;perpetual pilot\u0026rdquo; status because of unclear governance, unstable funding, and limited integration pathways [5, 6, 9, 37]. Similar challenges have been described regarding privacy, contracting, and interoperability, particularly for digital interventions that sit between public health and clinical systems [9, 37]. However, most analyses of digital STBBI testing focus on early development and feasibility rather than long-term scale-up [14, 38]. By examining narratives spanning a decade, our analysis foregrounds sustainability as a temporal process, demonstrating how early enabling conditions can invert into structural constraints when governance, infrastructure, and system arrangements fail to evolve alongside intervention scale. Inversion was frequently triggered by service growth, cost escalation, and heightened perceptions of organizational risk given post-COVID-19 fiscal constraints (Figure 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn particular, our case suggests that equity-oriented design creates both significant opportunity and unintended risk\u0026nbsp;[39\u0026ndash;42]. Design choices that improved access for underserved communities, including non-nominal workflows and manual result entry processes, were central to operationalizing GetCheckedOnline\u0026rsquo;s equity objectives. This supports emerging work on digital health equity, and extends it by highlighting the need for early, parallel investment in scalable infrastructure, rather than treating equity as a pilot phase consideration and scalability as a later technical problem [43, 44]. Our findings also refine existing accounts of the role of relationships and champions in implementation\u0026nbsp;[43, 45, 46]. Relational work within and across organizations was indispensable in navigating early resistance, maintaining legitimacy, and solving problems when formal mechanisms were not yet in place. However, relational infrastructure acted as a compensatory mechanism for structural gaps. By sustaining operations through champions and informal networks, the team inadvertently masked institutional deficits and reduced the impetus for governance and resource reforms\u0026nbsp;[37]. This suggests that while relationships are rightly recognized as early implementation enablers, relying solely on relational work is unsustainable given that it normalizes under-resourcing by promoting overperformance\u0026nbsp;[22, 47].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFinally, our case adds empirical depth to work on \u0026ldquo;pilotitis\u0026rdquo; and the innovation \u0026ldquo;valley of death\u0026rdquo; by illustrating what it means, in a public health context, for a digital service to remain in a liminal space, unable to transition from pilot to fully integrated program [12, 48]. System structures allowed early experimentation, but without clear mechanisms to transition GetCheckedOnline into a defined operational home with stable funding and shared accountability [49, 50]. Overall, our themes suggest that sustainability challenges are not simply a technical or administrative oversight. Instead, it reflects how risk averse health systems can create structural spaces where innovations are encouraged to demonstrate value yet are not readily absorbed into routine operations [37, 49]. This has implications for equity-focused interventions, which may be simultaneously valued and structurally precarious.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eExplanation of Findings Through DSF\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eGetCheckedOnline\u0026rsquo;s trajectory demonstrates how an intervention\u0026rsquo;s fit with its context can shift over time, affecting its sustainability [19, 20]. During its early phase, alignment between the intervention\u0026rsquo;s equity goals, team expertise, and system willingness to support piloting created strong initial fit. However, as the service expanded, the contextual conditions around it changed. Governance roles became more ambiguous, operational demands exceeded available capacity, and system structures proved inflexible to the adaptations needed for integration. Figure 1 emphasizes these temporal dynamics. It maps the point at which factors that initially enabled piloting, such as values driven urgency, flexible governance, and relational work, began to function as constraints once testing volumes, expectations, and system conditions changed. The figure is not intended as a new theoretical model. Rather, it extends DSF\u0026rsquo;s emphasis on dynamic fit by identifying a patterned inversion point during scale up, in which pilot phase governance and funding arrangements become misaligned with the structural demands of sustained operation, resulting in prolonged institutional liminality. In GetCheckedOnline\u0026rsquo;s case, the absence of dedicated transition structures meant that adaptation occurred largely within the core team, while organizational and system level adaptation lagged behind [19, 20]. Therefore, these findings support the DSF proposition that sustainability depends not only on the intervention\u0026rsquo;s capacity to adapt, but also on the system\u0026rsquo;s ability to accommodate and institutionalize those adaptations [19, 20]. Our case study suggests that for digital health services, this includes explicit attention to transition points, where early enabling conditions need to be deliberately converted into formal governance, infrastructure, and resourcing arrangements to avoid patterns in which valued services remain structurally vulnerable on the margins of routine practice [5, 10].\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eImplications for Practice, Public Health, and Equity\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eOur findings suggest important considerations for scaling equity-oriented digital health interventions. First, equity-focused design needs to be accompanied by early planning for scalable infrastructure [37, 42]. Features that improve access, such as flexible workflows or non-nominal testing options, require long-term investment in automation and integration to remain sustainable as demand grows [37]. Equity and scalability should be developed together rather than treated as separate phases [26]. Purposeful pauses to assess readiness for scale and align governance, funding, and technical systems can support smoother transitions from pilot to routine operations and reduce reliance on informal workarounds (Figure 1). Second, as digital interventions grow, flexible governance structures need to shift toward formal arrangements, including memoranda of understanding that define ownership, roles, and resource commitments [10, 20, 37]. These agreements should anticipate different growth scenarios and specify the supports required to maintain fit as scale increases. While early flexibility enabled piloting, sustained operation requires clearer accountability mechanisms than were available during GetCheckedOnline\u0026rsquo;s expansion.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThird, relational work was essential in sustaining the service, but reliance on informal coordination is inherently time limited [37, 47]. Health systems should develop formal implementation and integration roles that distribute responsibility more evenly and reduce dependence on individual champions, recognizing that team resilience cannot substitute for institutional support. Finally, our findings highlight the need for intentional system-level mechanisms to transition digital pilots into fully integrated public health services [5, 10]. We have previously identified the need for centralized digital public health resources within institutions that support mechanisms for more adaptable contracting processes, integration-ready digital infrastructure, and funding pathways that extend beyond time-limited project envelopes [51]. Without these structural supports, even well-established and highly valued digital services may remain peripheral to routine operations. Grant funders must also consider sustainability design as a condition for funding late-stage pilots.\u003c/p\u003e\n\u003ch2\u003e\u003cem\u003eStrengths and Limitations\u003c/em\u003e\u003c/h2\u003e\n\u003cp\u003eFindings from this study should be considered alongside its strengths and limitations. Strengths include candid and reflective insights of participants with deep historical knowledge spanning over a decade, multi-agency sampling across multiple system levels, high response rates, and the use of an established theoretical framework to guide interpretation. Prolonged engagement, reflexive practice, and member checking also support the credibility of the analysis. Limitations include the study\u0026rsquo;s focus on a single provincial health system and limited direct participation from RHAs given the study scope. Their perspectives were explored indirectly through participants who worked closely with them. While transferability should be approached with caution, the mechanisms identified align with broader digital health and implementation science literature and are likely relevant to other equity-oriented digital health interventions. More research is needed to explore whether identified themes can be extended across the BC health systems and beyond.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eGetCheckedOnline’s evolution illustrates how digital health interventions can demonstrate sustained public health value yet struggle to transition into routine operations without parallel evolution in governance, infrastructure, and system support. In this case, early enabling conditions, including equity commitments, flexible semi formal governance, relational coordination, and evolving openness to digital innovation, were essential for piloting but did not mature into the formal structures required for long term integration. As scale intensified demand and financial exposure, these early strengths became structural constraints. More broadly, this analysis contributes to implementation science by identifying a patterned inversion point during scale up, in which pilot phase arrangements become misaligned in the absence of deliberate transition mechanisms. It reframes sustainability as a time sensitive process requiring purposeful institutionalization of governance, funding, and technical systems as interventions mature. These insights provide practical guidance for jurisdictions seeking to scale and sustain equity-oriented digital interventions in public health.\u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u003cstrong\u003eMeaning\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;British Columbia\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBCCDC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;BC Centre for Disease Control\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eBCPHL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;BC Public Health Laboratory\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCOREQ\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Consolidated criteria for reporting qualitative research\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCPS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Clinical Prevention Services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCOVID\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Coronavirus disease\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eDSF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Dynamic Sustainability Framework\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFTE\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Full time equivalent\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHIV\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Human immunodeficiency virus\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIMITS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Information Management and Information Technology Services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eMoH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Ministry of Health\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eNVivo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;NVivo qualitative data analysis software\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePDHIS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Provincial Digital Health Information Services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePHL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Public Health Laboratory\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePHSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Provincial Health Services Authority\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003ePLMS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Provincial Laboratory Medicine Services\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRHA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Regional health authority\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSTBBI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Sexually transmitted and blood borne infection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSTI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003e\u0026nbsp;Sexually transmitted infection\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval and Consent to Participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study received approval from the University of British Columbia Behavioural Research Ethics Board (H24-01575) and was conducted in accordance with the Declaration of Helsinki. All participants received written information at least 24 hours before their session to allow time for consideration and provided informed consent prior to participation. Participation was voluntary, with the option to withdraw at any time. Given the small and interconnected health-system context, transcripts were fully de-identified, and quotations are reported at unit level to reduce risk of deductive disclosure.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNone declared\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eII is supported by a Canadian Institutes for Health Research (CIHR) Health Systems Impact Fellowship (Award number 521442), a Michael Smith Health Research BC Trainee Award (Award number \u0026ndash; HSIF-2024-04465) and a CIHR Canadian HIV Trials Network (CTN+) post-doctoral fellowship. This study was funded through II\u0026rsquo;s fellowship. MG reports a CIHR Applied Public Health Chair (PP6-170676). DG reports a Canada Research Chair in Sexual and Gender Minority health.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eII conceptualized the study, led study design, conducted data collection, led analysis, and drafted the manuscript. DH contributed to study design, interpretation of findings, and critically revised the manuscript. SB contributed to data interpretation and manuscript revision. CW contributed to conceptual framing, interpretation of findings, and manuscript revision. DG contributed to interpretation and critical manuscript revision. MG contributed to study conceptualization, supervision, interpretation of findings, and critical revision of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe sincerely thank the study participants for generously sharing their time and insights. We are grateful to Heather Pedersen and Ashley Bentley for their guidance and thoughtful input throughout the project. We also acknowledge the members of the GetCheckedOnline Provincial Sustainment Working Group for their ongoing engagement and for helping ground this study in health system realities. We thank members of the BCCDC Clinical Prevention Services team for their support and collaboration. Finally, we acknowledge the users of GetCheckedOnline, whose engagement with the service and efforts to access testing shaped the broader context in which this study was conducted.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eUse of Artificial Intelligence\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePortions of manuscript drafting and editing were supported using GPT-5.2 (OpenAI) to assist with language refinement and structural clarity. All intellectual content, interpretation of findings, and final editorial decisions were made by the authors. The authors take full responsibility for the accuracy and integrity of the work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets analyzed in this study were generated as part of organizational quality improvement and implementation activities within the British Columbia Centre for Disease Control and are not publicly available due to institutional and privacy restrictions. Data may be made available from the corresponding author upon reasonable request and with permission from the British Columbia Centre for Disease Control.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eBudd J, Miller BS, Manning EM, et al. 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Multilevel Determinants of Digital Health Equity: A Literature Synthesis to Advance the Field. \u003cem\u003eAnnu Rev Public Health\u003c/em\u003e 2023; 44: 383\u0026ndash;405.\u003c/li\u003e\n\u003cli\u003eRodriguez JA, Clark CR, Bates DW. Digital Health Equity as a Necessity in the 21st Century Cures Act Era. \u003cem\u003eJAMA\u003c/em\u003e 2020; 323: 2381\u0026ndash;2382.\u003c/li\u003e\n\u003cli\u003eMay CR, Mair F, Finch T, et al. Development of a theory of implementation and integration: Normalization Process Theory. \u003cem\u003eImplementation Sci\u003c/em\u003e 2009; 4: 29.\u003c/li\u003e\n\u003cli\u003eSeyhan AA. Lost in translation: the valley of death across preclinical and clinical divide \u0026ndash; identification of problems and overcoming obstacles. \u003cem\u003etransl med commun\u003c/em\u003e 2019; 4: 18.\u003c/li\u003e\n\u003cli\u003eLabrique AB, Wadhwani C, Williams KA, et al. Best practices in scaling digital health in low and middle income countries. \u003cem\u003eGlobalization and Health\u003c/em\u003e 2018; 14: 1\u0026ndash;8.\u003c/li\u003e\n\u003cli\u003eLabrique A, Vasudevan L, Weiss W, et al. Establishing Standards to Evaluate the Impact of Integrating Digital Health into Health Systems. \u003cem\u003eGlob Health Sci Pract\u003c/em\u003e 2018; 6: S5\u0026ndash;S17.\u003c/li\u003e\n\u003cli\u003eIyamu I, Haag D, Carson A, et al. Opportunities and Challenges for an Organizational Digital Public Health Strategy in a Provincial Public Health Program in Canada: Qualitative Description of Practitioner Perspectives. \u003cem\u003eJMIR Public Health Surveill\u003c/em\u003e 2025; 11: e72588\u0026ndash;e72588.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Digital Health, Sustainability, Implementation Science, Health systems, STBBIs","lastPublishedDoi":"10.21203/rs.3.rs-9227568/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9227568/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eDigital interventions designed to expand access to sexually transmitted and blood-borne infection (STBBI) testing are promoted to advance equitable health services. Yet many remain pilot projects, limiting their population-level impact. We examined factors influencing the sustainability of GetCheckedOnline, British Columbia\u0026rsquo;s digital STBBI testing service and described how these factors interact over time during transition beyond piloting and into routine operations.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003e We conducted a qualitative instrumental case study guided by the Dynamic Sustainability Framework. Purposive sampling captured perspectives across intervention, organizational, and system levels. Semi-structured interviews and one focus group were conducted with 28 health systems partners between February and June 2025. Reflexive thematic analysis was used, with attention to temporal shifts across pilot, scale-up, and ongoing operations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eFour interconnected themes characterized GetCheckedOnline\u0026rsquo;s sustainability from pilot to scale, demonstrating how early enabling conditions became constraining as post-COVID testing demand increased, laboratory costs rose, and fiscal pressures intensified. First, values-driven urgency acted as both catalyst and constraint: an equity mandate fueled rapid expansion but limited planning for governance, infrastructure, and funding, and early design choices (e.g., manual results entry to support non-nominal testing) created operational complexity. Second, early implementation through flexible governance structures became misaligned at scale, where clearer ownership and accountability mechanisms were required to support system integration. Third, informal relational supports and team resilience were critical to early success, as these enabled progress through trusted partnerships and individual commitment; yet, these placed hidden burdens on staff to manage processes that were not considered as standard operations. Finally, ambiguous system structures which allowed early flexibility became constraints, as reliance on a single laboratory partner able to meet privacy requirements, project-based funding pathways, and limited mechanisms for transitioning pilots into operations impeded full integration despite the service\u0026rsquo;s demonstrated value.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eGetCheckedOnline\u0026rsquo;s evolution highlights a patterned inversion during scale up, when early enabling conditions became structural constraints when lacking formal transition mechanisms. For equity-oriented digital services, deliberate pause points and institutionalization of governance, funding, and technical systems are critical for scale. By articulating this inversion dynamic, the study contributes to implementation science and offers insights for jurisdictions scaling similar innovations.\u003c/p\u003e","manuscriptTitle":"When Enabling Factors Become Constraints: A Qualitative Case Study of Sustainability and Temporal System Dynamics in an Equity-Oriented Digital Intervention for Sexually Transmitted Infection Testing","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-21 01:23:02","doi":"10.21203/rs.3.rs-9227568/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"258634977742005009362030853752001894133","date":"2026-05-04T10:22:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"325553351672387141939566023463250190742","date":"2026-04-15T22:13:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-10T08:35:27+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-08T05:02:45+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-26T23:51:24+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2026-03-25T23:48:29+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"105ec586-4f22-4580-990f-650426e0fd61","owner":[],"postedDate":"April 21st, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"258634977742005009362030853752001894133","date":"2026-05-04T10:22:52+00:00","index":33,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-21T01:23:03+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-21 01:23:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9227568","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9227568","identity":"rs-9227568","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}