mHealth and pandemic communication in the Global South: A culture-centered study of India’s community health workers’ meanings of smartphones during the COVID-19 pandemic

Abstract

Mobile health (mHealth) initiatives gained prominence during the COVID-19 pandemic, often relying on community health workers (CHWs) to implement digital tools. Such initiatives are, however, typically top-down and expert-driven, overlooking the voices and structural realities of marginalized CHWs in the Global South. Guided by the culture-centered approach (CCA), this study co-creates insights with India’s CHWs known as Accredited Social Health Activists (ASHAs)—an all-female health workforce from the communities they serve—on the meaning of smartphones during the pandemic. ASHAs faced coercive pressures to procure smartphones to document COVID-19 work, despite lacking financial means or infrastructural support. This introduced what the study terms digital burden—the compounding of labor, surveillance, and moral obligation without enabling resources. While earlier literature celebrates mHealth efficiency, this study critiques such narratives by highlighting how imposed digital expectations can reproduce infrastructural violence. Despite these constraints, ASHAs drew on cultural and relational resources—such as family and community support—to navigate structural barriers. The findings offer a global critique of neoliberal health governance, cautioning that mHealth initiatives disconnected from local realities risk deepening inequality rather than addressing it.

Keywords

Community health workers COVID-19 pandemic culture-centered approach mHealth

During the COVID-19 pandemic, community health workers (CHWs) in countries such as India played a pivotal role in frontline response and community-level pandemic mitigation (Niyati and Mandela, 2020). CHWs are typically recruited from the underserved communities they serve, bringing localized, culturally grounded approaches to healthcare (World Health Organization, 1978). In India, this model was institutionalized through the National Rural Health Mission (NRHM) in 2005, which introduced the role of Accredited Social Health Activists (ASHAs)—rural women tasked with facilitating access to primary health services in low-resource settings (National Health Mission, n.d.). The pandemic significantly expanded their responsibilities to include contact tracing, symptom monitoring, and public awareness campaigns (Niyati and Nelson Mandela, 2020), reinforcing their centrality in India’s public health response.

One major shift during this period was the increased reliance on mobile health (mHealth) tools globally, including in India. ASHAs across several states were expected to use personal smartphones to upload evidence of their COVID-19 work (Brar Singh, 2020; Hindustan Times, 2020). Although positioned as innovative, these mHealth initiatives often emerged from top-down mandates that excluded frontline workers from decision-making (Dutta et al., 2018; Kumar and Anderson, 2015). The dominant techno-optimistic discourse around mHealth—focused on efficiency and scalability—frequently overlook the everyday struggles and systemic exclusions faced by CHWs in the Global South.

This oversight is particularly striking given the multiple layers of marginality ASHAs navigate. Drawn from economically disadvantaged rural communities, they work without formal employment status, receive minimal compensation, and lack institutional safeguards (Closser and Shekhawat, 2022). As women embedded in patriarchal contexts, they must juggle household duties with professional responsibilities, often under intense pressure and without adequate support (Raj, 2022). Despite being praised as “COVID-19 warriors,” ASHAs remain structurally vulnerable—subjected to overwork, surveillance, and community stigma during the pandemic (Ramanathan and Chakravarthy, 2021).

This study adopts the culture-centered approach (CCA) to foreground ASHAs’ perspectives on the imposition of digital technologies during the pandemic. The CCA critiques health interventions that exclude the voices of those they target, arguing such exclusions reproduce structural inequities (Dutta et al., 2018). By co-constructing “voice infrastructures,” the CCA collaborates with marginalized communities to surface their experiences and challenge dominant, expert-led narratives. This research, therefore, centers the voices of healthcare workers at the margins of the Global South, illuminating their agentive responses to digital mHealth solutions imposed under the guise of innovation.

Literature review

This section is organized into five parts: it first examines India’s cultural dynamics and the digital divide, then reviews mHealth literature with a focus on CHWs. It next outlines the structural barriers CHWs face in mHealth implementation and the cultural resources they draw on to navigate them, concluding with an overview of the CCA, the study’s guiding framework.

Cultural dynamics and digital divide in India

In India, Internet access has expanded due to improved infrastructure and affordable mobile phones (GSMA, 2024). Internet penetration rose from 14.9% in 2015 to 43% in 2022 (Basuroy, 2023). By 2024, rural India had 90 million more internet users than urban India (IAMAI-KANTAR, 2024), with 1.2 billion mobile subscribers, including 600 million smartphone users (Anand, 2022).

Despite this growth, India’s Internet penetration remains lower than in developed nations—91% in the U.S., 95% in the U.K., 90% in Australia, and 92% in New Zealand (The World Bank, n.d.). Even with the world’s cheapest data plans, many low-income Indians struggle to afford smartphones, which cost twice the average monthly salary (Gill, 2020). Socio-economic disparities persist, disproportionately affecting rural and lower-income populations.

Digital access is shaped by urban-rural divides, gender norms, and caste hierarchies, often reinforcing inequalities. Although rural Internet use is growing, 63% of rural Indians remain offline (IAMAI-KANTAR, 2024) due to poor infrastructure, unreliable electricity, weak mobile networks, high costs, and a lack of local-language digital tools. The intersection of rurality and the gender digital divide is particularly pronounced in developing countries (Wyche and Olson, 2018). Rural women, including ASHAs, face additional barriers due to affordability, gender norms, education, and limited digital skills (Treuthart, 2020). A study in the Southern Indian state of Tamil Nadu, for instance, found that lower-income rural men saw Facebook as a threat to young unmarried women, fearing exposure to online dating, while men of all backgrounds joined the platform earlier (Venkatraman, 2017). Another study in central India found women’s household responsibilities further limited phone use (Scott et al., 2021). Caste and class disparities worsen digital exclusion, as lower-caste and economically disadvantaged individuals, including ASHAs, struggle to afford smartphones and Internet access (Manzar et al., 2016).

Despite these challenges, cultural resilience mitigates digital divides. Rural women navigate barriers through familial and community networks, leveraging collective strategies rooted in cultural norms (Venkatraman, 2017). In low- and middle-income countries like Bangladesh, Pakistan, India, and parts of Africa, collectivism fosters shared technology access within families and communities, challenging narratives that equate digital exclusion solely with a lack of resources (Sambasivan et al., 2018; Sultana et al., 2018).

mHealth and CHWs: a critical review

mHealth (or Mobile Health) refers to the use of mobile phones to deliver healthcare services and health-related information (World Health Organization, 2018). A critical distinction in mHealth discourse is between the general use of mobile phones for healthcare and the specific role of smartphones in digitalizing health services. Basic mobile phones allow voice calls and SMS-based interventions, whereas smartphones enable Internet-based applications, including teleconsultations, data collection, and instant messaging via platforms like WhatsApp (Krishnan, 2022; Scott et al., 2022). The increasing penetration of mobile devices has led to growing enthusiasm for mHealth interventions, with studies highlighting their potential benefits, such as improved healthcare access, treatment adherence, and cost reduction (Aranda-Jan et al., 2014; Chow et al., 2016). The COVID-19 pandemic accelerated the adoption of mHealth technologies worldwide, particularly in areas such as telemedicine, contact tracing, and digital surveillance (Krishnan, 2022; Scott et al., 2022). Despite the optimism surrounding these interventions, the effectiveness and scalability of mHealth, however, remain contentious, particularly in resource-limited countries of the Global South. While studies suggest that mHealth can enhance healthcare delivery, much of the existing research is dominated by randomized controlled trials (RCTs), which, despite demonstrating short-term success, often fail to translate into sustainable, community-driven solutions (Chib et al., 2015).

Structural challenges in CHWs’ adoption of mHealth technologies

mHealth interventions are often implemented by CHWs, whose engagement with mobile technology is shaped not only by technological affordances but also by economic, infrastructural, and sociocultural factors influencing access and usability. While RCTs suggest that mobile phones can reduce CHWs’ workload, minimize travel, and enhance data collection, coordination, and supervision—findings supported by studies in Nepal, India, and Zambia (Biemba et al., 2017; Meyers et al., 2016; Modi et al., 2016)—these controlled settings often overlook structural barriers that hinder real-world implementation.

Some studies highlight that mobile phones can provide CHWs with personal benefits, such as autonomy and empowerment (Ismail and Kumar, 2019; Pal et al., 2017). However, these advantages are unevenly distributed and heavily dependent on broader socio-economic conditions. Despite the growing push for digital health solutions, affordability remains a significant barrier, particularly for CHWs like ASHAs, who come from marginalized backgrounds and earn meager wages (Ismail and Kumar, 2019). Many prioritize household expenses, such as their children’s education, over personal smartphone access (Ismail and Kumar, 2019). Cultural norms may also restrict women from owning phones or may favor face-to-face communication over mobile-based health interactions (Ahmed et al., 2014).

In addition, infrastructural constraints—including poor network coverage, unreliable Internet, frequent power outages, and the financial burden of mobile data or airtime—limit the effectiveness of mHealth tools, particularly in top-down initiatives (Ismail and Kumar, 2019). These challenges are not unique to India but are prevalent in other low- and middle-income countries, such as Bangladesh, Pakistan, Ghana, and Uganda (Ahmed et al., 2014; Aranda-Jan et al., 2014; Tariq and Durrani, 2018). This further challenges the dominant techno-deterministic narrative that equates mobile phone penetration with universal accessibility and usability.

Limitations of top-down mHealth initiatives

Framed by a techno-deterministic narrative, the rise of mHealth technologies has prioritized expert-driven health promotion and surveillance, often sidelining frontline workers like ASHAs (Dutta et al., 2018; Kumar and Anderson, 2015). In several states, ASHAs were required to use smartphones for data collection without adequate consultation, training, or support—issues echoed in media reports (Brar Singh, 2020; Hindustan Times, 2020). The rigid hierarchical structure and top-down approach within the public health system that suppresses the voices of ASHAs has been documented in prior research (Mishra, 2014) and reflected in state-level press releases that frame monthly meetings as performance monitoring rather than collaborative decision-making. Similar dynamics exist in other developing countries, where CHWs are seen as volunteers, limiting their role in shaping health policy (Vaughan et al., 2015).

This top-down approach within the mHealth sphere assumes that digital tools automatically translate into improved health outcomes, ignoring the structural constraints that marginalize CHWs and the communities they serve (Vaughan and Tinker, 2009). By privileging technocratic and “expert” knowledge, such initiatives perpetuate a neoliberal logic that shifts responsibility onto low-paid, overburdened workers while erasing their voices from decision-making (Dutta, 2021).

The inefficacy of these interventions is evident in cases like in rural Uttar Pradesh, an Indian state, where ASHAs were provided with low-cost mobile phones that were inadequate for their tasks, leading to underutilization and frustration (Kumar and Anderson, 2015). This failure was not due to a lack of digital literacy among CHWs but rather the deliberate exclusion of their needs from policy discussions, reinforcing a paternalistic approach that prioritizes top-down efficiency over grassroots realities.

CHWs’ agency and adaptation strategies

Despite the structural constraints imposed by top-down mHealth initiatives, CHWs actively exercise agency by developing adaptive strategies to navigate technological barriers. Rather than passively accepting inadequate infrastructure, CHWs demonstrate resourcefulness by using multiple SIM cards to mitigate poor network connectivity (Ismail and Kumar, 2019) and leveraging family members’ smartphones in collectivist cultural settings across India, Pakistan, Bangladesh, and parts of Africa for work-related communication on platforms such as WhatsApp (Krishnan, 2022; Scott et al., 2022). These improvisations challenge the dominant narrative that technological access alone determines mHealth efficacy, underscoring the need for interventions that account for the lived realities of CHWs. However, such workarounds also highlight the inequitable burden placed on CHWs, who must compensate for systemic failures by mobilizing personal and familial resources.

Contribution of this research

While existing mHealth literature often highlights benefits and barriers, it largely adopts a top-down, quantitative lens that overlooks the lived experiences of CHWs. These studies tend to focus narrowly on access and adoption, neglecting the broader structural and gendered challenges that shape CHWs’ everyday realities—especially during health crises like COVID-19, when digital initiatives intensify without adequate support.

This study centers India’s ASHAs, a distinctly marginalized group of female CHWs embedded in rural, patriarchal contexts. Despite being essential to public health delivery, their labor remains under-recognized and poorly supported. Exploring how ASHAs engaged with mHealth during the pandemic offers critical insights into how digital technologies often exacerbate, rather than alleviate, precarity.

Although COVID-19 has become routinized, its long-term impacts on public health infrastructures and digital governance remain significant. In a globalized world, such large-scale health crises are likely to recur, making it imperative to understand how frontline workers like ASHAs negotiate crisis-driven digital transformations.

This study fills this gap by drawing on the CCA, a meta-theoretical framework designed specifically to foreground marginalized voices, to critically examine ASHAs’ negotiations with mHealth, particularly in crisis situation. By situating their narratives within the three tenets of CCA—culture, structure, and agency—it offers a grounded perspective on digital health from the “margins of the margins.” The next section introduces CCA, the theoretical lens guiding this analysis.

The Culture-Centered Approach

The CCA, a well-established meta-theoretical framework, provides a necessary counterpoint to the dominant techno-optimistic discourse in mHealth, which assumes that digital technologies inherently empower marginalized communities. Within this discourse, CHWs, such as ASHAs, are frequently reduced to mere implementers of top-down mHealth initiatives, with little attention given to their lived realities. While existing literature celebrates mHealth’s potential benefits, it inadequately addresses the structural and cultural constraints that shape CHWs’ experiences.

CCA challenges this reductionist framing by foregrounding culture, structure, and agency as interdependent forces shaping health communication (Dutta et al., 2018). Culture encompasses the shared beliefs and practices that inform local meanings, structure refers to the material conditions—such as institutional policies—that enable or constrain action, and agency reflects individuals’ capacity to navigate and resist these constraints. Unlike mainstream health communication and mHealth frameworks, which reinforce power hierarchies by privileging expert-driven knowledge, CCA actively centers subaltern voices to challenge hegemonic narratives (Dutta, 2014).

Prior research using CCA has demonstrated how marginalized communities repurpose digital technologies in ways that defy dominant frameworks. For instance, low-income migrant workers in Singapore used mobile phones to document workplace deaths, countering state narratives (Dutta et al., 2018). These cases highlight the agentic capacity of marginalized groups to appropriate technology on their own terms. However, existing CCA research on digital technology has largely focused on non-pandemic contexts or migrant populations during pandemics (Dutta et al., 2018; Zapata, 2015), leaving a gap in understanding how CHWs navigate digital health directives during crises.

This study extends that work by examining CHWs’ mHealth experiences during the COVID-19 crisis, posing two critical questions:

How do India’s CHWs make meaning of top-down mHealth directives during the pandemic?

How do they navigate structural barriers while negotiating these directives?

Method

This study employs the CCA to foreground the voices of ASHA workers, contextualizing their narratives within culture, structure, and agency. Culture refers to shared community beliefs (Dutta et al., 2018), structure encompasses material conditions such as institutional policies (Zapata, 2015), and agency denotes individuals’ ability to navigate barriers (Dutta et al., 2018). The study received ethics approval from Massey University’s Human Ethics Committee.

Initially, ASHAs declined to participate without formal approval, prompting the first author to secure permission from the Chief District Medical Officer (CDMO). The local ASHA coordinator then assisted in recruitment, either directly or via a provided list. Participants were recruited from 30 out of 121 villages, ensuring diverse experiences by recruiting at least one ASHA from each village. Note here that the selection criterion was that participants must be ASHA workers engaged in COVID-19 duties, aligning with the research’s focus on their pandemic experiences. The study did not exclusively target ASHAs with mobile phones, as its goal was to explore diverse meanings related to technology, including those without access, in a real-world context. The participants were from villages served by the Mendhasala Community Health Centre (CHC) in Bhubaneswar Block, Khordha district, Odisha, an eastern state in India. Khordha district, home to both urban centers like Bhubaneswar and underdeveloped rural areas, is one of Odisha’s most economically diverse regions. While Bhubaneswar city is a hub for education, healthcare, and IT, the surrounding villages face significant challenges in healthcare, digital access, and infrastructure.

Mendhasala CHC, located at the intersection of urban and rural areas, serves as a critical healthcare provider for villages lacking adequate medical infrastructure. Despite its proximity to Bhubaneswar, the center highlights the urban-rural divide in healthcare access, making it an ideal site for studying digital exclusion, as these villages face barriers to digital technology despite their proximity to urban resources. The first author’s existing local contacts facilitated trust-building with participants.

Power dynamics in the hierarchical public health system were addressed through voluntary participation, verbal consent, and private interviews. As an Odia woman with cultural and linguistic ties to the region, the first author built trust with participants. Reflexivity was maintained through field notes and discussions with the second author. Semi-structured interviews began with informal conversations, easing participants into topics such as pandemic-related challenges. When smartphone access emerged as a concern, follow-up questions explored barriers and coping strategies. An iterative analysis approach refined questions based on emerging themes.

Data were collected through in-person interviews between October and December 2022 until saturation was reached. Interviews, lasting 1–1.5 hours, were conducted in Odia, the official language of the state of Odisha, with verbal consent. The first author transcribed and translated the interviews, cross-checking meanings with participants during follow-up interactions. An iterative analysis approach refined questions based on emerging themes. The three phases of analysis, aligning with Constructivist Grounded Theory (Charmaz, 2006), involved open coding to identify concepts and categories from within the data (open coding), axial coding to explore the relationship between categories, and selective coding to identify a “story line” that covered all relevant categories. Coding was performed by the first author and reviewed by the second author to ensure inter-coder reliability.

Findings

The dominant themes that emerged from dialogues with ASHA workers include (a) structural inaccessibility to smartphones, particularly financial insecurity as a key barrier; (b) disempowerment and cultural dislocation amid structural constraints, encompassing both digital dependency and the fracturing of social ties; and (c) expressions of individual and collective agency in navigating these challenges.

Structural in-access to smartphones

During fieldwork in October 2022, only 7 of the 30 ASHAs interviewed owned personal smartphones. Most relied on basic mobile phones costing around Rs. 500 (approx. $6 USD), yet still effectively carried out key COVID-19 tasks such as referral coordination and quarantine support. Despite this, all ASHAs reported facing top-down pressure to document their work via smartphone photos sent on WhatsApp—ranging from posting quarantine stickers to distributing medicine kits. This imposed digital requirement, disconnected from their material realities, placed them in a coercive bind, highlighting the disconnect between technological mandates and ground-level infrastructural access, as discussed below.

Financial insecurity as a structural barrier

Financial insecurity emerged as a key structural barrier to smartphone ownership among participants. While it may seem like a matter of individual affordability, their narratives reveal how this issue is embedded in broader systemic forces—persistent economic precarity, institutional neglect, and top-down digital health requirements imposed without adequate support.

At the heart of this structural constraint lies the institutional exploitation of ASHAs’ labor. Recruited from socioeconomically disadvantaged communities, ASHAs are designated as “volunteers,” which excludes them from formal employment benefits or job security. In Odisha, they receive Rs. 3500 monthly for routine tasks, with a temporary Rs. 1000 monthly incentives during the COVID-19 crisis. These performance-based payments are often delayed and insufficient. Participants consistently linked their inability to purchase smartphones with their limited earnings. As ASHA 22 explained, “We don’t even get Rs. 5000 every month. A big phone costs around Rs. 15,000 to 16,000. How can I afford one when I also have household expenses to cover?”

Despite this, ASHAs were expected to use smartphones for pandemic-related documentation—photographing quarantine stickers, distributing medicines, and sending updates via WhatsApp. No devices were provided. The Odisha government later introduced a Rs. 250/- mobile allowance, but only for those who already owned smartphones, effectively excluding those most in need. As one ASHA remarked, “The government only gave money for Internet recharge to those with big phones—but how can we buy one when our income is so low?”

For many, the push to meet digital requirements came at the cost of basic necessities. ASHA 17 recalled how an ANM worker suggested saving 2 months’ salary to buy a smartphone, “ANM didi (elder sister) did not realise that my two months’ salary is only 4–6 K. If I save up all that money, how will I feed my family?” This highlights how the expectation to stay digitally connected was not only financially burdensome but also affected ASHAs’ health and well-being. As many became sole earners during the pandemic—while male family members lost informal jobs due to lockdowns—ASHAs faced intensified pressure to balance caregiving with stretched incomes. ASHA 24’s experience reflects the compounding strain of these roles:

During the pandemic, we sold grains to buy a big phone for my elder son, and then took a loan to buy one for my younger son, so they could attend online classes. I bought two phones for my sons, so how could I afford one for myself?

She even skipped meals to ensure her children’s education—viewed as a “ticket out of poverty.” Yet, she remained excluded from digital participation in her own professional role. “If I had more money,” she added, “I could have bought a big phone for myself and not relied on my husband and sons for my work.” Her account reflects the double bind faced by working-class women—expected to sustain public health systems and domestic life, yet systematically denied the resources to do either effectively. In this context, digital exclusion becomes not just a technical gap, but a form of structural violence.

Disempowerment and cultural dislocation amid structural challenges

A key theme that emerged was the impact of smartphone inaccessibility on ASHA workers’ personal and professional lives. Beyond being a technological barrier, it reflected deeper structural inequalities—leading to disempowerment, emotional distress, and a breakdown of long-standing cultural norms of respect.

Disempowerment and dependency in a digital ecosystem

As digital tools became central to ASHAs’ everyday work—facilitating data sharing, photo documentation, and communication—participants associated smartphone access with autonomy and efficiency. Younger ASHAs with smartphones could work independently, but those without became dependent on family or community support, hindering their efficiency and self-esteem. As ASHA 15 noted, “If I have to send any photo or information on WhatsApp, I have to wait for my son to return from work. Now, I am completely dependent on my son for my work.” This sense of helplessness was amplified by institutional pressures to meet strict deadlines, despite the lack of infrastructure. When family members grew impatient or refused to help, tensions within the household surfaced. ASHA 16’s experience illustrates this strain:

I ask my son for help, but he is usually occupied with his work. If I ask him repeatedly, he says, “why don’t you buy your own phone?” When I ask my husband, he says, “why don’t you ask your supervisors to give you a phone.”

These responses reveal a gendered burden, where women are expected to meet professional duties without institutional support, often facing dismissal at home. The absence of basic tools like smartphones shifted healthcare responsibilities to families and communities, straining relationships and causing psychological stress.

Fracturing of cultural and social ties

In rural India, ASHAs hold a unique social position, often based on kinship and cultural affiliation, with many being selected as daughters-in-law of the village, reflecting traditional Hindu norms that prioritize women who are “settled” in their husband’s villages. This role traditionally grants them respect and cooperation from the community, reinforced by collectivist values and long-term interpersonal ties.

However, the pandemic disrupted these dynamics. ASHAs, once trusted kin and caregivers, were stigmatized and ostracized due to fears surrounding COVID-19. ASHA 8 noted, “Normally, as the daughter-in-law of the village, people cooperate with me and show me respect. But during the pandemic, everything changed. People treated us terribly.” Her comment highlights how panic and suspicion—fueled by misinformation, poor communication, and distrust in government—destabilized a once-secure sense of belonging in an information-scarce rural setting. For instance, ASHA 2 described the disbelief that spread in her area:

When I urged them to get tested, the villagers dismissed COVID-19’s existence, alleging that the government orchestrated the situation for financial gain, claiming officials received payment for each admission to quarantine centers. When I refuted this, they accused me of being biased since I work for the government.

Similar distrust was observed regarding the COVID-19 vaccine. ASHA 18 narrated:

The villagers said, “The government is conducting research on us. God knows if we’ll live or die after getting that vaccine?” They’d seen all sorts of rumors on their TVs and phones, so they were scared.

These quotes highlight a strong sense of distrust toward the government. ASHAs—who were once perceived as part of the community due to kinship and cultural ties—were now seen as extensions of the state.

In this context, ASHAs who once drew upon communal relationships for assistance—such as having someone take a photo on their behalf—faced humiliation and rejection. ASHA 17 recounted:

During COVID-19, when I sought help from some people with taking photos, they thought I would pass on the virus to them. They said, “You are getting paid for this, why should we help you?” I cried almost daily during the pandemic.

The transactional framing of ASHAs’ labor—as merely paid work—stripped away recognition of their emotional and physical commitment to community care. Their requests for help were no longer viewed as part of a reciprocal social contract but rather as unwelcome impositions.

This rupture in relational trust reflects how state neglect fractures social solidarity. The cultural ethos of seva (service) gave way to suspicion and resentment, as institutional failures eroded respect for frontline workers. As ASHA 17 noted, “I went on door-to-door COVID-19 surveys for three months. People can help take a photo for one or two days, but they won’t do it for months, right?” Her words underscore the unsustainability of prolonged, unsupported dependency, revealing the emotional toll, cultural dislocation, and loss of dignity faced by ASHAs.

Enactment of individual and collective agency

This section documents how ASHAs enacted agency both at the individual level—through communicative resistance to authority—and at the collective level—by mobilizing familial and community support systems to navigate smartphone-related barriers.

Individual agency: communicative resistance within hierarchical structures

Despite their lower positioning within the hierarchical public health system, several ASHAs actively created communicative spaces to articulate their challenges and advocate for their needs. These acts of voice reflect their agentic efforts to be heard within a system not built to listen. For instance, ASHA 22, who owned a basic keypad phone, boldly raised her concerns with her immediate supervisor, “We told our supervisors that if you expect us to use a big phone (smartphone), why not provide one?” Similarly, ASHA 17, who was the primary breadwinner for her family due to her husband’s mental illness, took the initiative to directly explain her financial constraints—first to her block supervisor and then to the ANM,

I explained to my block supervisor and then to ANM didi—I am the only earning member in my family. My husband is unwell and cannot work. My sons are studying, and the youngest is still in school. In this situation, how can I afford a smartphone? If I spend two months’ salary to buy one, what will my children eat? I want to do the work, but I need support to do it.

These narratives demonstrate how ASHAs, despite the deeply hierarchical structures surrounding them, exercised voice and courage to negotiate the conditions under which they were asked to perform digital tasks. They actively attempted to draw attention to their lived realities, financial precarity, and the unfeasibility of expectations thrust upon them.

However, these self-advocacy efforts were met with indifference or deflected responsibility. ASHA 17’s request for support was dismissed by the ANM, who told her to save 2 months’ salary for a phone—an unrealistic suggestion. ASHA 6 was told to “borrow a smartphone” and keep working because “the work must be done at all costs.” Such responses reveal the absence of meaningful upward communication, with supervisors enforcing top-down directives rather than offering support, rendering ASHAs’ agency largely symbolic.

Collective agency: leveraging familial and community networks

In the absence of institutional support, ASHAs relied heavily on cultural and communal resources to perform their digital tasks. This form of collective agency draws from the collectivist ethos and strong familial ties prevalent in rural India (Chadda and Deb, 2013). For instance, ASHA 15 explained how her son became her technological conduit,

When my supervisors need to send any important information, they send it to my son’s WhatsApp number. If I need to take a photo, I rely on my son to take it and send it to my supervisor.

Similarly, joint family structures often enabled ASHAs to access support from sisters-in-law, spouses, and children, with younger members mediating digital access. These narratives also reflect a subtle reversal of caregiving roles, as children assisted their mothers in professional tasks.

ASHAs also extended this collective reliance to the broader community. ASHA 29 shared:

When I visited a COVID-19 patient’s house in the village, I often requested their family members to take my photo and send it to my supervisor. Or, I approached any young person I spotted with a smartphone in the village to do the same. Everyone in my village knows me, we all live together, so they readily help me.

This sense of communal ease is deeply embedded in rural kinship networks. ASHA 8’s identity as a daughter-in-law of the village enabled similar trust and cooperation, “I am regarded as the daughter-in-law of this village, so my community members heed my advice and immediately approach me when they face any health issues.” In such collectivist settings, a daughter-in-law or daughter is seen as a relational identity extending to the whole village, reinforcing shared responsibility. Yet, this reliance came at a cost, particularly during the heightened fear of the early pandemic phase. Several participants reported verbal abuse and social stigma when repeatedly seeking help with technology.

Discussion

At the heart of this discussion lies a critical interrogation of dominant mHealth narratives through the lens of ASHAs’ lived experiences during the COVID-19 crisis. While mHealth is often celebrated for enhancing healthcare access and efficiency, this study introduces the concept of digital burden to highlight how top-down digital interventions—when implemented without infrastructural support—can exacerbate precarity, surveillance, and emotional distress for CHWs.

In doing so, the study contributes to the growing body of CCA research by being the first to center CHWs’ voices on mHealth in the context of a global health crisis. It extends CCA by theorizing how digital infrastructures intensify the intersections of structure, culture, and agency—revealing how smartphones, far from being neutral tools, often reinforce structural inequalities and deepen the gendered vulnerabilities of CHWs in rural India. By foregrounding meaning-making from the “margins of the margins” (Dutta et al., 2018), this work reimagines mHealth not merely as a technological fix, but as a contested terrain shaped by power, labor, and voice.

Exposing digital burden and challenging dominant mHealth narratives

Dominant mHealth narratives often celebrate digital tools as empowering and efficient for CHWs. However, such accounts overlook the lived realities of frontline workers like ASHAs, for whom mHealth technologies often introduce digital burdens rather than relief. In this study, the pressure to procure and maintain smartphones—compounded by demands to submit photographic evidence of COVID-19 duties—exemplifies how digital interventions exacerbate existing structural inequalities. Rather than reducing workloads or health risks, as often claimed (Meyers et al., 2016; Modi et al., 2016), these technologies add layers of unpaid, undocumented labor.

This overload is multifaceted. ASHAs face the financial strain of buying smartphones—costing over Rs. 4500—while earning only about Rs. 3500 monthly. They must travel to specific sites for photo documentation, increasing time, effort, and exposure. These requirements come without institutional support, widening the gap between policy and practice. Engaging with digital tools is not only logistically demanding but also materially and emotionally taxing, embedding new forms of surveillance under the rhetoric of empowerment.

By centering ASHAs’ voices, this study challenges the techno-optimism that dominates mHealth discourse. Much of the existing literature, often based on randomized trials and quantitative metrics (e.g. Aranda-Jan et al., 2014; Chow et al., 2016; Pal et al., 2017), assumes mobile access and digital literacy as universal. These assumptions erase the socio-economic precarity shaping ASHAs’ engagement with technology. In this context, digital tools are far from neutral; they act as instruments of control and extraction, intensifying labor in the name of innovation.

Surveillance and the individualization of responsibility

A striking theme that emerged is the individualization of digital responsibility—the expectation that ASHAs bear the cost of smartphones and mobile data themselves. This aligns with a broader neoliberal logic, where the state withdraws from responsibility and instead positions marginalized individuals as entrepreneurial agents who must solve structural problems through personal investment (Watkins et al., 2018). Despite promises of digital empowerment, ASHAs received no financial assistance to procure smartphones. While the Odisha government provided mobile data allowances (Government of Odisha, 2023), the responsibility for hardware remained personal. This reinforces Hampshire et al.’s (2017) observation that mHealth initiatives often shift risk to the most vulnerable.

In addition, the requirement to send photographic evidence of pandemic-related work reflects a surveillance apparatus embedded in mHealth. This surveillance, under the guise of documentation, functions not to improve care delivery but to discipline labor. Unlike community-led documentation practices observed in bottom-up models, the photographic requirement in this case served more to monitor than support CHWs, increasing both infection risk and time commitment without commensurate compensation.

Parental responsibility and digital trade-offs

ASHAs’ narratives reveal how parental responsibilities and professional caregiving roles collided during the pandemic, generating difficult trade-offs within already resource-constrained households. On one hand, they were expected to serve as frontline CHWs, meeting intensified demands through mHealth initiatives that required constant digital engagement. On the other, they were caregivers at home, responsible for ensuring their children’s continued education as schools shifted online. These overlapping caregiving responsibilities were further strained by financial precarity—many ASHAs had become the sole earners after their husbands, employed in the informal sector, lost their jobs during the lockdowns.

In households with limited or single smartphone access, ASHAs often prioritized their children’s educational needs over their own professional requirements. This decision reflects more than maternal instinct; it speaks to a deeply held sense of parental duty to fulfill their children’s basic rights, including access to education. At the same time, it demonstrates strategic agency. Smartphones were not just tools of immediate necessity—they were seen as vehicles of long-term educational and social mobility. Even amid economic hardship, ASHAs found purpose in investing in their children’s future, embodying culturally rooted values of care, sacrifice, and resilience, as also found in another study conducted with ASHAs in Delhi in non-pandemic context (Ismail and Kumar, 2019). The pandemic, however, amplified these tensions, particularly as digital health interventions failed to account for the familial and emotional labor embedded in ASHAs’ lives, calling for a more intersectional understanding of care, technology, and agency in frontline health work.

Implications for privacy, policy, and theory

A key but often overlooked aspect of mHealth is data privacy, which emerged prominently in this study conducted in a marginalized setting where privacy is routinely compromised. Many ASHAs reported being required to send patient-related COVID-19 information—including names and health conditions—via others’ smartphones or shared WhatsApp accounts, as they did not have personal access to smartphones. Despite this, they received no structural support; instead, they were instructed by their seniors to use someone else’s device. The absence of a clear data protection framework not only reflects systemic indifference to ethical data handling but also reveals a significant breach of privacy in contexts already marked by vulnerability.

Furthermore, the state’s failure to engage ASHAs in the design of digital interventions highlights a broader democratic deficit in public health governance. Rather than being treated as active stakeholders, ASHAs were reduced to passive implementers of top-down technologies—contradicting the participatory principles advocated by the CCA (Dutta et al., 2018).

Cultural rupture, persistent digital divide, and disempowerment

The narratives of ASHAs illustrate how the digital turn in public health governance—particularly the rollout of mHealth initiatives during the pandemic—produced new forms of marginalization. Access to smartphones became a marker of professional recognition, yet the lack of structural support meant that many ASHAs, especially older or economically disadvantaged ones, could not meet these expectations. Those with smartphones were able to promptly share visual evidence of their work, gaining praise and validation, while others were left unseen and unacknowledged.

This structural inequality was compounded by cultural rupture—ASHAs without phones had to rely on husbands, sons, or neighbors for access, leading to feelings of frustration, dependency, and even humiliation. These experiences challenge celebratory narratives around digital inclusion and highlight how top-down technological interventions—when imposed without addressing pre-existing inequities—can reinforce disempowerment. The so-called “digital divide” is not just about access to devices; rather, it is a persistent and evolving gap, where outdated tools and lack of autonomy keep ASHAs at the margins of digital transformation.

Culture and agency

Within an overwhelmingly disempowering digital landscape, ASHAs enacted forms of agency that complicate dominant narratives of marginality as passivity. Despite systemic digital exclusion, they made strategic choices—borrowing phones, coordinating shared access, and mobilizing familial and community networks—to fulfill their roles. These actions, while shaped by constraint, reflect not mere coping but a critical negotiation with structural limitations and institutional neglect.

This agency is culturally situated, rooted in collectivist values and social ties that become vital assets in navigating precarity. While such dependence on kinship networks is often problematically framed as a deficit, especially when it leads to strain or rupture—as it did during the pandemic due to prolonged dependency and fear—these networks emerged as key infrastructures of survival in the absence of state support. Rather than romanticizing resilience, the findings foreground how ASHAs’ culturally grounded agency is continually tested and stretched by structural violence. This aligns with prior research (Ismail and Kumar, 2019; Krishnan, 2022) and affirms the CCA’s insistence on locating agency within the dynamic interplay of culture, structure, and power.

Summary

Overall, this study offers a critical intervention in mHealth scholarship by theorizing how top-down digital health initiatives, when disconnected from the lived realities of marginalized communities, risk reinforcing and deepening structural inequalities. While prior research emphasizes the efficiency of mobile technologies in healthcare delivery (Meyers et al., 2016; Modi et al., 2016), this study challenges such techno-optimism by introducing the concept of digital burden—where digital tools amplify the workload, stress, and precarity of frontline workers. This burden often reflects infrastructural violence, where digital demands are imposed without adequate infrastructure, access, or support. Extending the CCA, the study shows how mHealth systems can function as instruments of coercion and surveillance, framed more as moral duties to the state than tools of care.

These findings have global relevance. As mHealth platforms expand across the Global South in the name of innovation, this study calls for participatory, equity-focused frameworks that center the structural constraints and cultural contexts shaping frontline workers’ engagement with technology. It contributes to a growing body of literature that urges critical scrutiny of digital health and insists on grounding interventions in the lived experiences of those most affected.

Footnotes

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Samiksha Pattanaik

Author biographies

Samiksha Pattanaik is a PhD student at Massey University in New Zealand, with a diverse academic and professional background. She has worked as a community researcher at the Center for Culture-Centered Approach to Research and Evaluation (CARE), Massey University. She has over 6 years of professional experience working at various media organizations in India, UK, and New Zealand. Currently, she is working at the New Zealand Herald newspaper, where she continues to apply her expertise in media research and analysis.

Mohan J Dutta is Dean’s Chair Professor of Communication, and Director, Center for Culture-Centered Approach to Research & Evaluation (CARE) at Massey University. Mohan Dutta’s research examines marginalization in contemporary healthcare, health care inequalities, the intersections of poverty and health, political economy of global health policies, the meanings of health in the realms of marginalized experiences in underserved communities in the Global South, and the ways in which participatory culture-centered processes and strategies are organized in marginalized contexts to bring about social change. Based on his work on healthcare among indigenous communities, sex workers, migrant workers, and rural communities, he has developed an approach called the culture-centered approach that outlines culturally-based participatory strategies for addressing unequal healthcare policies and global disparities.

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