Abstract
Expansion of India’s national Ayushman Bharat Digital Mission (ABDM) without evidence on population-level mobile health (mHealth) utilization risks exacerbating inequities in universal health coverage. The COVID-19 vaccination drive, India’s first mandatory nationwide digital health intervention, provided a natural setting to assess the digital competencies and role of socio-demography and awareness in equitable utilization of mHealth. This institutional cross-sectional study surveyed 1,160 smartphone users and 215 non-users in Western India. Competencies required for utilization (scheduling online appointment or downloading certificate) were mapped to the DigComp 2.1 framework. Determinants of equitable awareness and utilization were assessed using Cochrane’s PROGRESS-plus equity framework. Bivariate analysis and multivariable logistic regression were used to identify factors associated smartphone ownership, awareness and utilization, followed by mediation analysis to evaluate the role of awareness in utilization. Only 615 (53%) smartphone users utilized vaccination platforms; 398 (34.3%) booked slots and 489 (42.2%) downloaded certificates independently (level 3 proficiency); 138 (64.2%) of non-users relied on on-site registration and appointments. Essential competence domains were information and data literacy, communication and collaboration, and safety. Males (aOR=1.58), younger age (aOR=1.03), higher education (aOR=4.51), professional occupation (aOR=2) and students (aOR=2.36) had higher odds of awareness. Awareness was the strongest predictor of utilization (aOR=29.9). It fully mediated the association of gender and education, and partially mediated the association of age and occupation, with utilization. Significant inequities exist in mobile health utilization. Future digital strategies must prioritize awareness campaigns and provide non-digital alternatives to access, to ensure universal health coverage.