The Social Epidemiology of the Digital Health Divide: Mixed-Methods Evidence from Community Health Workers in an Aspirational District of India

Background/Objectives: This study examines the social epidemiology of digital health adoption and the determinants of the digital divide among Community Health Workers (CHWs), including Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), Auxiliary Nurse Midwives (ANMs), and their supervisors in Muzaffarpur, Bihar, India’s most populous aspirational district, with a focus on inequities across cadres, departments, and rural and urban contexts. Methods: An exploratory sequential mixed methods design was used. The quantitative phase included a cross-sectional survey of 95 CHWs across four blocks spanning urban, semi-urban, rural, and flood-prone areas. The qualitative phase comprised 32 in-depth interviews with CHWs, and block-level officers and six focus group discussions stratified by cadre and setting. Research tools were grounded in the behavior model. Quantitative data were analyzed using Jamovi software, and qualitative data with ATLAS.ti. Results: Urban, higher-income, and better-educated cadres reported greater use of digital applications, while limited device functionality, lower education, and rural flood-affected location constrained digital engagement. ANMs experienced app fatigue from multiple platforms, while AWWs and ASHA faced persistent device failures and financial burdens from personal smartphone use. Block-level officers and CHWs highlighted ongoing barriers, including technical failures, fragmented systems, workload, and reliance on informal support. Conclusions: The digital divide is shaped by intersecting social and structural factors across cadres, departments, and geography. Bridging this gap requires equitable infrastructure, continuous training, integrated user-centered systems, and supportive policy to ensure digital health reforms advance health equity in low-resource settings.