Wi-Fi, smartphones, and all associated phenomena have permeated lives all around the globe. We are just seeing the first generation of humans to grow up with these things – the first of the ‘digital natives’. The health implications of virtual information and communication technologies have recently been questioned by academics, with forecasts of growing inequalities in health due to differential population access to virtual technologies (1), along with unequal distributions of the literacy skills and ability to find and use high-quality online information. June of 2014 brought about a shift in the digital market, whereby average daily use of health and fitness apps grew by 62%, outpacing the use of apps overall, at only 33% growth (2).
PLOS Public Health Perspectives is pleased to welcome Priya Kumar to discuss these issues on the blog. Kumar is a nearly finished doctoral candidate in the School of Oriental and African Studies at the University of London. Her doctoral research questions the impact of the World Wide Web in fostering online and offline connections between migrant communities around the globe. She is an expert in digital research methods and online content analysis.
This piece will be conducted in two parts, check back on Thursday, 16th October for Part 2.
LK: Why are the growth of mobile apps and the data they produce interesting to you?
PK: As a researcher of virtual phenomena, I find that mobile apps are an interesting area now that mobile devices are outselling personal laptops. The largest area of mobile app growth is in health and fitness, which will have ramifications in terms of the dissemination of health information, individual behaviors, and health care delivery. There are also questions about the governance and ethics surrounding the vast amounts of cloud-based personal health data that are being generated, such as in the health apps embedded within the Apple and Android operating systems.
Given the recent data leakage scandals surrounding the cloud, privacy is of primary concern for everyone involved (3). And ‘everyone’ is a lot of people: individuals, as both consumers of digital apps and patients within health care systems, also the producers of the apps, and health care providers themselves.
Mobile health apps raise big questions for health ethics in the future. On the positive side, as researchers, we can now look at more long-term and specialized data for certain diseases that can be collected through these apps that we could not look at previously.
LK: What does the recent growth of the mobile health (mHealth) and digital health wearables market mean for how we ‘consume’ health and fitness?
PK: Mobile apps are interesting because they are available across countries. By 2017, 85% of the world’s population is expected to be covered by a commercial mobile signal (4). That transcends state borders, and in that way, mobile apps bring about a lot interesting questions for anyone studying regulatory frameworks and state-based policy.
For me, the word, ‘consume’ is interesting as it identifies a new type of health ‘consumer’ that wasn’t there prior to the introduction of mobile health apps. There are at least three different broad uses of health apps: for personal fitness and well being, for clinical and care-enhancing tools, and for health research. The first usage, fitness and well being, most directly relates to ideas of consumption. On this side, we will continue to see increasing types of consumer benefits with these apps over time as more and more are produced. A potential target on both of the clinical and health research sides is the ability to track health behaviors through these apps over long-term periods. Still, we have to consider that the majority of health care delivery services are through health practitioners. And although we can define these broad uses, the output targets are not well defined.
We don’t really know what will happen in terms of the ‘consumption’ of health, or whether health is something that should be ‘consumed’.
LK: In that case, are mHealth apps a flashy feature or a real tool?
PK: To even question the idea of apps being ‘flashy features’ versus being real transformative tools, we have to look at the online-offline nexus. What that means is the effects that health apps are having in the ‘real’ world. Understanding these phenomena on the research side of things will require mixed qualitative and quantitative methods. We need to see a lot more collaboration across disciplines in order to characterize ‘hand-held health’, to really understand the health, health care, marketing, and creative sides of apps, and the idea of the patient as a mobile consumer. We need to tap into more collaborative relationships to gain a sense of how effective apps are in improving population health. For example, a 2013 study by the IMS Institute for Healthcare Informatics analyzed over 40,000 health apps to investigate how beneficial mHealth is to healthcare (5). Just over 16,000 health apps were for patients to help enhance their healthcare, 7,000 were directed at health care professionals themselves, and over 20,000 were not actually related to health care (5). Clearly, a minority of apps is targeted at improving patient experience in health care at the moment. The image below shows findings from the IMS report.
The phenomenon of ‘hand-held health’ is complex. With Apple’s HealthKit and the other health tracking apps embedded in Android software, it’s becoming the norm to track health. For those of us above the age of 25, these are cool features, but we have to consider younger generations, the ‘digital natives’ who will be growing up with pre-existing social and digital norms surrounding these things. Behavioral changes in health care consumption stimulated by apps may lead to changing norms surrounding health care in the future. And maybe even the ethics surrounding sharing of personal health data will change, if we don’t view it as being so private in the future. But, we really don’t know these things. Health apps have really only been around for about four years, that’s not a lot of time.
LK: Who uses mobile health apps?
PK: Usually they are targeted demographics. In general, the users of the ‘flashy features’ such as tracking running, heart rate, and counting steps are termed ‘fitness fanatics’. These people are typically women between the ages of 24 and 54 and come from relatively privileged backgrounds (2). In North America and in western European countries, it appears that the market emphasis is on these types of complementary apps for leisure-based users.
Health behaviors become more visible through social media, such as uploading running distance to Facebook through the Nike app. However, this visibility doesn’t necessarily mean that these apps are efficacious in improving health.
The second trend, beyond western societies, is in developing countries. Usually, these countries end up ‘leap-frogging’ technologies. What that means is that in the African continent, for example, most of the virtual technology that is used comes from hand-held smartphone devices rather than from laptops, which have been in large part bypassed. One of the most notable cases is with Samsung. Within this year, all Samsung mobile devices distributed in the African continent will be embedded with a free app called ‘Smart Health’. The app is claimed to be ‘the first ever Pan-African Mobile Health Delivery Network’, and was launched by Mobilium Global in seven countries: Nigeria, Kenya, South Africa, Angola, Ghana, Tanzania, and Senegal (6). It’s been heralded as a comprehensive app with real-time information on three pandemics, HIV/AIDS, tuberculosis, and malaria, along with approved symptom checkers for each disease (6).
The app provides access to information that individuals may not easily get from their governments or public health authorities. The app builds a health-related institution, which functions across state boundaries and allows for more civic engagement with health issues. In this context, the app could be very beneficial and now that it is built into Samsung technology, it becomes the standard through which users are questioning their health. Maybe this level of accessibility is something that we in the western world take for granted. However, when something is built into your phone without you even asking for it, it becomes an unquestioned part of your language, something that’s not taboo and something that you can discuss.
Check back on Thursday, 16th October for Part 2 of this piece, covering the ethics and governance of mobile health apps and risks of their use.
- Viswanath K, Nagler RH, Bigman-Galimore CA, McCauley MP, Jung M, Ramanadhan S. The communications revolution and health inequalities in the 21st century: implications for cancer control. Cancer Epidemiol Biomarkers Prev. 2012;21(10):1071-8.
- Khalaf S. Health and fitness apps finally take off, fueled by fitness fanatics. Flurry Insights. http://www.flurry.com/blog/flurry-insights/health-and-fitness-apps-finally-take-fueled-fitness-fanatics#.VDlXESldV5k (accessed 11 October 2014).
- BBC. FBI investigates ‘Cloud’ celebrity picture leaks. BBC. 2 September 2014. http://www.bbc.co.uk/news/technology-29011850 (accessed 11 October 2014).
- Savitz E. Ericsson: 85% global 3G coverage by 2017; 50% for 4G. Forbes. 6 May 2012 (accessed 12 October 2014).
- IMS Institute for Healthcare Informatics. Patient apps for improved healthcare: from novelty to mainstream. IMS Institute for Healthcare Informatics. 2013.
- Mobilium Global Limited. Mobilium announces launch of breakthrough mobile health App ‘Smart Health’. http://mobilium.com/about-us/october-2013-mobilium-smart-health-app/ (accessed 12 October 2014).