Multilevel drivers of digital transformation in long-term elderly care services: evidence from the Qinghai-Tibet Plateau, a high-altitude and resource-limited region of China

Objective This study examines the multilevel drivers influencing the digital transformation of long-term elderly care services in the Qinghai-Tibet Plateau, a high-altitude and resource-constrained region of China. It aims to clarify the causal influence, hierarchical structure and system roles of environmental, organizational, technological and individual drivers. Methods A multi-method analysis was conducted using expert assessments from government officials, institutional managers and academic experts. Potential drivers were identified through a literature review and a two-round expert consultation. The DEMATEL, ISM and MICMAC methods were applied to analyze causal relationships, delineate hierarchical pathways and classify system roles. Results Environmental drivers, particularly economic development and policy support, demonstrated the strongest causal influence and formed the foundational layer of the transformation system. The hierarchical model revealed a three-level structure in which environmental drivers occupied the deepest level. Organizational and technological drivers formed the intermediate layer, which was dominated by technological drivers, while the surface layer was primarily shaped by organizational drivers, with individual drivers distributed across both layers. The MICMAC classification further indicated that environmental drivers functioned as independent system drivers, whereas organizational and technological drivers showed high dependence. The absence of linkage factors suggests that digital transformation in the Qinghai-Tibet Plateau remains at an early stage and is characterized by a predominantly top-down pattern of implementation. Conclusion Digital transformation in long-term elderly care services in the Qinghai-Tibet Plateau is driven by a multilevel system anchored in macro-environmental conditions. Strengthening policy support and fiscal capacity is essential to facilitate progress. Enhancing organizational capability, improving technological infrastructure and advancing the digital competencies of frontline staff are necessary to convert enabling conditions into effective service delivery. These findings provide evidence to inform context-sensitive digital health and long-term care strategies in remote and underserved regions.