When mHealth apps become unhealthy

You wake up in the morning and the first thing you see on your smartphone is how you slept that night. It is not you who determines that, but an app on your phone, which says you moved a lot while you were sleeping and which says your quality of sleep was not good enough. Then your app asks you how you feel today, are you happy? You get up, get a glass of water and make breakfast, while doing this you fill in all the ingredients in the mHealth-app you had this morning and you also see that you almost got two percent of the amount of steps you have to make today.

Of course here we are hypothetically speaking, but in this situation you would have already provided data on your mobile device about your sleep quality, your state of happiness, your eating habits and your body movement. These are four aspects of health that you allow to be determined by a smartphone app. Which already raises questions in terms of meaning about: what is happiness for you and when is your quality of sleep 'good enough'? We let this be determined by an app, which tells us what is the average we should live up to.

However, should we not determine that ourselves when something is ‘good enough’ or what happiness is? And where this situation described is a hypothetical situation, it is reality for more and more people.

Are we losing the human connection to our body by using self-monitoring health-apps?

The rise of the mHealth-apps

Mobile health or mHealth is a phenomenon which has been occurring increasingly in the last couple of years. Where in 2015 there were already 165.000 health apps available (IMS Healthcare institute for Healthcare Informatics, 2015), this number got doubled already in 2017 (IQvia Institute, 2017). Looking at this data it is not a surprise that the health and medical industry is in the top three of fields that has significantly grown in terms of using mobile devices (Statista, 2018).

mHealth apps give consumers the possibility to self-monitor several aspects of their health. Wellness, disease prevention and disease management can be monitored through these apps and it is important to give the people an active and informed role in their own healthcare. Mobile health is seen as a tool to improve the healthcare system by for example improving the communication, quality and costs for healthcare services (Statista, 2018).

Especially in a time  we are connected more and more in an online environment, this has added a new dimension to the production of knowledge by and about ourselves. The mHealth-apps give the consumer the opportunity to capture their data real-time - as they are -doing it. Which gives an immediate insight in their state of being in terms of health.

Many of the apps are for free which makes it even more interesting to download one and start using it. Dataveillance is used in order to immediately put the data provided by a user into action by connecting it back to healthcare providers (IMS Healthcare institute for Healthcare Informatics, 2015).

The information is purposed and repurposed as a part of the global digital knowledge economy (Lupton, 2016)

Lupton (2016) mentions how these apps are a concept of dataveillance, by providing you with several ways to share your information digitally, without you always knowing what your data is used for. The information is purposed and repurposed as a part of the global digital knowledge economy. Through this information healthcare providers can see for example whether practices of selfhood are conform to the cultural expectations

The worth of experience as knowledge and interpreting numbers

Thus where we nowadays monitor ourselves through our mobile devices, we used to do this in the past by connecting to our body and feeling when there was something wrong. You would not attach this to numbers provided by a mHealth app, but by feeling it yourself based on experiences by yourself or others.

Joan W. Scott wrote about experience as a form of knowledge in 1991. Experience as a form of knowledge can give you another dimension to a story or situation. Experience is personal and helps us to create our identity by interpreting information and getting interpreted by others. Therefor we can consider experiences as social constructions, which are partly made by our identity.

When using experience as a form of knowledge it is important to keep in mind various factors such as gender, ethnicity, language and age as well as the different ways information can be interpreted by different people. The way we perceive something can be very different in another culture or at another age. This also asks for interpretation of yourself and from others. Scott mentions in the article “What could be truer, after all, than a subject’s own account of what he or she has lived through?”(Scott, 1991, p.777), which makes it difficult to criticize knowledge based on experience. Also it should be kept in mind that experience is always political (Scott, 1991) there is for example no scientifical proof for the concept of race. The categories attached to this concept is based on social and historical ideas, which are political.

It is difficult to attach numbers to a subject like health.

These factors should not be only be put into consideration when using experience as knowledge, but also when using an application on your mobile device. Therefor it is difficult to attach numbers to a subject like health.

One example of something we attached a certain trustworthiness in numbers to is the need to walk 10.000 steps a day. This concept was created in Japan in the 1960s as a marketing campaign for a new pedometer. The nickname for the product was the ‘Manpo-kei’ which translates to ‘ten thousand steps meter’.

The 10.000 steps were based on the average amount of steps from people with various lifestyles in the 1960s (Y. Hatano, 2008). Thus adays this value which was set in the 1960s was a nickname for a pedometer and also here we should consider the different target groups. The amount of steps is for example too low for children and too high for older people (Y. Hatano, 2008). No need to say as well that the lifestyle of people in Japan in the 1960s might not be really relevant anymore for people in the 21st century globally.

In the Netherlands we had a campaign called ‘30minutenbewegen’ which started in 2007 and ended in 2010. The campaign by the ‘Kenniscentrum Sport’ was meant to make people aware to live a healthy lifestyle by having at least 30 minutes of movement a day (Alles over sport, 2018). The guidelines for how much you should move were determined by the so-called ‘Health Council’ (Gezondheidsraad), noticeable is that in the years after the campaign the guidelines changed compared to the guidelines used in the campaign in 2007-2010 (Alles over sport, 2018). Our lifestyle changed in the last couple of years because of new technologies in the digital age, thus it is important to keep on investigating the guidelines for several aspects of a healthy lifestyle.

When health-apps become unhealthy

The example of the origin of the ’10.000 steps a day’ which would be needed as a part of a healthy lifestyle shows how we cannot always rely on numbers given to us to live up to. Of course it is not wrong to want to live up to this number of steps a day, however it should not control your life. The BBC (2018) wrote an article about how people let an app control their life and shows how a health-app became unhealthy. The situation sketched in this news article is about Lara, a 29-year old who started tracking her steps and running. Which needed to result in a healthier lifestyle by increasing her physical activity.

The interviewee Lara describes how at first the app motivated her, but after a few weeks it made her competitive against her own produced data. She wanted to do better than the day before, day after day. Which resulted in bad habits in for example terms of sleep, because she did not go to bed when she did not reach her goal for that day yet (Davies, 2018). And this is not the only situation which you can think of in terms of using mHealth. The situation in the introduction was hypothetical, however it is not something unthinkable these days.

Promoting safer use

Thus how can we keep on benefitting from health-apps without them getting control over our lifestyle? Lewis & Wyatt (2014) wrote about the need for safer apps because “It is important that mobile medical apps used in health care settings are accurate and reliable, especially as health care professionals and patients may make critical decisions based on information from an app.” (p.1).

"It is important to promote safer use and create a risk assesment framework."

Health care professionals should have better knowledge about mHealth apps and patients should be better informed about the usage of the apps. A risk assessment framework should be available to see what the risks are from the usage of certain apps.

Because it is not only the provided data that is important, but also how algorithms react on that. When the algorithms make bad calculations it can lead to serious health problems (Lewis & Wyatt, 2014). Keeping in mind that many of the health-apps are for free and by this easy to install on your mobile device, it is even more important to promote safer use and create a risk assessment framework. Would it in some cases therefor be better to let people only use health-apps when prescribed, just as medicines?

Making health apps healthy

We started off in with the question in the introduction, whether people lose the human connection to their body because of mHealth and self-monitoring. Health-apps can help us in terms of health when used in a responsible way. More transparency and information about the apps could help people to be more responsible when using a health -app and by this not lose the human connection with their body.

Because what we experience ourselves and how we feel is more important than what an app tells us by using our data and drawing conclusions it by using algorithms.

Having more and better research about certain norms that are set in terms of health can also help to be more responsible. We should keep in mind that every individual is different, which means a certain norm can be applied for one person, however it can be different for the other person based on the cultural background, age, gender, etc.

The health-apps can be a way to improve the healthcare system by improving the communication with their patients and keep the costs lower for healthcare services. However this can only be done when health-apps are created together with the healthcare providers. Having over 160.000 health-apps in 2015, which already doubled in 2017, we can conclude that many of these apps will probably not be from good quality. Hot everyone is aware of this. Promoting safer use and having better quality from the apps, created together with healthcare providers, can be a way to keep health-apps healthy.

References

Alles over sport. (2018). Terugblik campagne 30 minuten bewegen.

Davies, A. (2018, May 29). Are health apps actually bad for your health? 

IMS Healthcare institute for Healthcare Informatics. (2015). Patient adoptation of mHealth: Use, Evidence and Remaining Barriers. Parsipanny USA: IMS Healthcare institute for Healthcare Informatics.

IQvia Institute. (2017). The Growing Value of Digital Health: Evidence and Impact on Human Health and the Healthcare System. Durham, USA: IQvia Institute.

Lupton, D. (2016). The diverse domains of quantified selves: selftracking modes and dataveillance. Economy and Society, 45:1, 101-122.

Scott, J. (1991). The evidence of experience. Critical inquiry, Vol. 17, No. 4 (Summer, 1991), 773-797.

Statista. (2018). mHealth - Statistics & Facts. 

Wyatt, T. L. (2014). mHealth and Mobile Medical Apps: A Framework to Assess Risk and Promote Safer Use. Journal of Medical Internet Research, 16(9): e210, 1-8.

Y. Hatano, M. K.-L. (2008). Revisiting "How many steps are enough?" . Medicine & Science in Sports & Exercise, pp. 537-543.