By Robyn Kalda
At the end of April I went to the Apps for Health conference in Hamilton.
From a health promotion perspective as well as from a technological perspective, the entire field of apps for health and wearable technology is fascinating, albeit rather larval. There is a lot going on, but not in sync -- it's a rather cacophonous space at the moment, with no standards and very little interoperability. Everyone is working alone to invent new kinds of wheels. It reminds me of the early days of personal computing. Now, we know ctrl-s (or its equivalent) will probably save your work in most computer-related things we encounter, but it wasn't always so. I remember pointing out the "save" icon in Word to someone in the early 90s, back when the icon was meant to look like a floppy disk (remember those?), and the person said "Oh, the tv icon? I always wondered what that was for!" To be fair, it did kind of look like a TV.
That's kind of where health apps and wearable tech are now: figuring out tiny pieces of a big field, throwing a lot of ideas at the wall (in isolation) and seeing what sticks. At the moment there are many ways to represent respiration, for example, or calories or sleep time or stress/emotion. You could spend your whole day counting and reporting things in many single-purpose apps or devices that don't talk to each other (or to anything else).
What does this have to do with health promotion?
Quite a bit. If we look to the Ottawa Charter's action areas in health promotion (build healthy public policy, create supportive environments for health, strengthen community action for health, develop personal skills, and re-orient health services) and its three health promotion basic strategies (to enable, mediate, and advocate), it's clear health promoters need to be paying attention to the possibilities and issues with technology and health.
I'll divide my comments among the stragegies.
As we move from pure data collection to apps and wearables that can help make decisions and recommendations, health promoters need to have a say in what these decisions might be. Are they healthy decisions overall, for the person and for society? Who is creating the app or wearable and what is their agenda?
There are some excellent apps and wearables being produced right now. For example, at Apps for Health I was particularly impressed with BrainFX, an app produced by several Occupational Therapists for the assessment of mild to moderate brain dysfunctions. Not only does it speed up the assessment process, it removes potential delivery bias, delivers a report immediately, and allows users to contribute their de-identified data for research. OTs benefit from spending two hours to assess someone and get a report instead of twenty hours. Patients benefit from a report that's immediately available and so can see the specifics of their issues and begin therapy immediately instead of having to wait weeks or months for a hand-written report. Researchers benefit from a steadily increasing collection of nicely anonymous data. Win-win-win.
In the fitness realm, Zombies, Run! and The Walk, both by Six to Start (The Walk was co-produced with the UK's NHS), are excellent examples of how to add a game layer to workouts for extra fun and reward.
On the other hand, virtually all health-related apps and wearables focus on lifestyle issues, which we know are not the major contributors to health. How can health promoters enable the kind of bigger-picture thinking that could lead to apps and wearables that consider health beyond steps and calories?
There are many apps and wearables that aim to help develop personal skills. These are of widely varying quality, and health promoters could help guide people to more credible, reliable, practical apps and to use them in a healthy way. Is it healthy to quantify exactly how many peas your baby ate for lunch and his/her sleep to the nearest second? Or is it healthier to put down the phone and interact with the baby instead? Do we put the might of our words behind self-driving cars, which might reduce injuries, or do we help guide society away from car dependence altogether? Some apps "gamify" health by providing connections to other users based on data sharing -- how can we help people disentangle their thoughts about privacy vs. the benefits of access to support? Technology needs health promoters to help mediate the larger issues.
Privacy issues in health apps and in wearables are far, far from resolved. At Apps for Health, Ontario's previous Information and Privacy Commissioner gave an impassioned keynote advocating Privacy By Design. That is, in her opinion (and mine), technology should by default protect the user's privacy. If they choose to share their information, it should be clear what data is being shared, who it's being shared with, and why. The corporatization of data and data mining are, I think we can all agree, concerning from a health promotion point of view, and advocating for transparency and Privacy By Design is something health promoters can do.
Security is also something health promoters can draw attention to. I am not at all sure I want my heart rate monitor, my baby monitor, my drug infusion pump or my house (or the power grid, for that matter) attached to the hackable Internet of Things just yet. We need to do some deeper thinking about the implications of the risks involved in connecting everything to the Internet.
Issues of equality and discrimination are key, as well, and health promoters can keep these in the public eye. Whose data is being collected from all these wearables? Well, data from people who can afford smartphones and wearables, so these people are probably from the wealthier end of society. If we're going to be making policy choices based on collected data -- for example, the City of Toronto has created a cycling app to collect information about where people ride to help future infrastructure decisions -- we need to spend much more time considering who is included and who is not.
This is evident even from looking at the images that are used of wearable technology in action: wearables are almost always shown on white male bodies. When female bodies are shown at all they are shown either as billboards, wearing high heels and tight dresses displaying the technology in question on their chests or skirts, or they are wearing revealing workout gear. Women's bodies are depicted somewhat more often in apps addresing mood or stress. In all contexts, however, the women all have long hair and (with few exceptions) are white. What does this mean about whose needs are being attended to with this technology? What kinds of bodies are being considered "normal" and what does this mean on a societal level?
This is very early days, and health promoters have a wonderful opportunity to help guide technology in ways that will be healthy at all levels from the individual to the societal. Feel free to explore my public "wearabletech" tagged bookmarks and "apps" tagged bookmarks and, of course, any other sources that appeal to you. I encourage all health promoters to keep a weather eye on health apps and wearable technology and to speak up whenever you can.