Adoption, digital health literacy, and patient satisfaction of Ayushman Bharat Digital Mission: an analytical cross-sectional study among outpatient department attendees

The Ayushman Bharat Digital Mission (ABDM) is India’s ambitious effort to establish a complete digital health ecosystem. However, evidence on real-world adoption, user experiences, and barriers among target populations remains limited. To estimate the adoption of ABHA ID registration services among outpatient department (OPD) attendees in tertiary care hospitals, and to assess patient satisfaction, digital health literacy levels, and identify barriers, gaps, and limitations in accessing healthcare through ABDM. A hospital-based cross-sectional study was conducted among 425 outpatient department (OPD) attendees across three tertiary care hospitals in Agra using multistage random sampling from September 2024 to April 2025. ABHA ID registrations adoption rates were calculated from hospital records over eight months in comparison with conventional OPD registration (non-digital paper based). Digital health literacy was assessed using the validated 21-item Digital Health Literacy Instrument (DHLI). Patient satisfaction was measured using a structured 10-item Likert scale questionnaire. Barriers, gaps, and limitations were evaluated through structured interviews. Data were analysed using descriptive and inferential statistics. The study was conducted among 425 outpatient department (OPD) attendees. In which 537,278 total OPD visits, 129,007 completed ABHA ID registrations with a below average monthly adoption rate of 23.96%. Overall digital health literacy was moderate (mean DHLI score: 2.94 ± 0.72) among 425 OPD attendees, with males scoring significantly higher than females (U = 15,922, p < .001). Education showed the strongest positive correlation with DHLI scores (ρ = 0.480, p < .001) while age showed a weak negative correlation (ρ=-0.230, p < .001). Participants demonstrated better operational skills (2.38 ± 0.64) but weaker abilities in evaluating reliability (2.18 ± 0.66) and protecting privacy (2.22 ± 0.65). Patient satisfaction was high with over 80% agreeing that ABDM made registration easier and was user-friendly. However, only 55% felt comfortable with data privacy protection. Major barriers included preference for in-person healthcare (85.6%), high data plan costs (81.9%), difficulty using health apps (65.6%), language difficulties (64.0%) and hesitation to share one time password (OTP) (60.0%). Notably, 88% expressed need for training and support, while 58.6% lacked adequate knowledge about ABDM despite visiting participating facilities. While ABDM demonstrates operational efficiency and moderate patient user satisfaction, adoption of ABHA registration remains limited in comparison to conventional OPD registrations, with significant barriers related to digital literacy, awareness, economic constraints, and privacy concerns. Substantial gender, age, and educational disparities exist in digital health literacy. To achieve equitable and sustainable adoption, targeted interventions are essential, including community-based digital literacy programs, simplified multilingual interfaces, strengthened privacy safeguards, subsidized data access, and on-site support through trained facilitators particularly for vulnerable populations including women, older adults, and those with lower educational attainment.