Digitised Health, Medicine and Risk

Deborah Lupton

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781315447902
• Edition: 1
• Topic: Médecine
• Subtopic: Théorie, pratique et référence de la médecine

A prevailing excitement can be discerned in the medical and public health literature and popular media concerning the apparent 'disruptive' or 'revolutionary' potential of digital health technologies. Most of the wider social implications are often ignored or glossed over in such accounts. Critical approaches from within the social sciences that take a more measured perspective are important – including those that focus on risk. The contributors to this volume examine various dimensions of risk in the context of digital health. They identify that digital health devices and software offer the ability to configure new forms of risk, in concert with novel responsibilities. The contributions emphasise the sheer volume of detail about very personal and private elements of people's lives, emotions and bodies that contemporary digital technologies can collect. They show that apps and other internet tools and forums provide opportunities for health and medical risks to be identified, publicised or managed, but also for unvalidated new therapies to be championed. Most of the authors identify the neoliberal 'soft' politics of digital health, in which lay people are encouraged ('nudged') to engage in practices of identifying and managing health risk in their own interests, and the victim-blaming that may be part of these discourses.

This book was originally published as a special issue of Health, Risk and Society.

The gamification of risk: how health apps foster self-confidence and why this is not enough

Antonio Maturo^a,b and Francesca Setiffi^c

^aDepartment of Sociology and Business Law, University of Bologna, Bologna, Italy;^bSociology Department, Brown University, Providence, RI, USA; ^cDepartment of Political Science, Law and International Studies, University of Padova, Padova, Italy

Weight loss apps enable users to quantify many aspects of food consumption, beginning with calories intake. Users of weight loss apps can also participate in online forums that act as digital self-help groups. These apps also include several features related to game playing or gamification such as avatars, points and virtual awards. Gamification has the aim of strengthening motivation to carry out a (boring) task. We downloaded the 20 most popular free weight loss apps in Google Play. We analysed app descriptions provided by developers, comments about the selected apps in online forums and user reviews. We focused on four of these apps, since they had some special functions. We found that users’ risk management was based on a mixed method that combined quantification and gamification, that is, rationality and emotions. Quantification, which includes self-tracking, data analysis and graphic layout, provides the ‘rational’ basis for dietary regimes, while gamification provides the emotional support needed to maintain motivation and continue with the diet. Our analysis provides support for the emotion–risk assemblage theory and the in-between strategy. Our analysis reinforces the importance of emotions in risk management. However, these dieting apps are based on a reductionist approach to obesity and weight loss, as obesity is framed as an individual problem, while weight loss is seen as dependent on individual motivation. Such framing tends to conceal the social determinant of health and the social and political causes of obesity.

Introduction

In this article, we explore the ways in which weight loss apps frame the risks of obesity and structure individuals’ responses to being overweight. Using data from an analysis of the 20 most popular dieting apps in the Google Play store, we demonstrate that these apps frame obesity as an individual risk, downplaying the social determinants of health and how other aspects of biopolitics are marginalised in the digital health realm.

Health apps and risk

Health apps

The authors of the European Commission’s ‘Green Paper on mobile health’ (European Commission, 2014) outlined their high expectations for the potential of health apps. They noted that m-health could increase rates of early disease detection, reduce the cost of unnecessary consultations, increase prevention, contribute to a more sustainable and efficient health-care system and possibly foster patient empowerment. They also observed that almost 100,000 health- and well-being-related apps already exist. They called for further research in the areas of motivation and user engagement.

The development of m-health has been stimulated by the development of smartphones such as Apple’s iPhone over the past decade. These new phones have become a powerful tool for the self-tracking and measurement of a wide range of activities such as sport performance, physiological states, behaviours and feelings. They enable individuals to collect and carry out a statistical analysis of huge amounts of information about themselves and then share these data with a wide audience on social networks. This capacity to capture, analyse and share data on individual’s own behaviour, physiological states and performance has created a new culture of self-monitoring and personal analytics (Ruckenstein, 2014) that is supported and encouraged by online communication through digital platforms and social networks.

These new technological opportunities have stimulated a consumer-centred model of health, based on self-determination and ‘the central role of patients in making decisions about the course of the care’ (Guseva, 2013, p. 1). As the sources of medical information shift from those controlled by doctors such as medical records and specialist journals to interactive websites and online communities, it is easier for individuals and patients to find information, get support and share their illness experiences with others with the same conditions (Light & Maturo, 2015). These changes, among other factors, have also contributed to increasing expectations of health self-management and patient health literacy – though the information individuals may access online may not be subject to the same level of scrutiny and quality control as, for example, the findings reported in peer-reviewed journals.

This emphasis on individual or self-led healthcare is reflected in health apps that seek to tap into and enhance user motivation. These apps provide facilities for, inter alia, the keeping of digital diaries and the sharing of results with one’s online community of ‘friends’. Some features of apps are based on cognitive psychology approaches, such as the Transtheoretical Model of Health Behavior Change (Prochaska & Velicer, 1997), for behavioural changes such as quitting smoking or stopping drinking.

While the new technologies embedded in apps make it possible to monitor virtually any aspect of life, also work productivity for example, bodily functions remain the privileged target for self-tracking (Lupton, 2013b). This privileging is reflected in the large number of apps for losing weight – obesity is indeed increasingly labelled as one the most dangerous health problems in the world. For example, two-thirds of Americans are obese or overweight (Flegal, Graubard, Williamson, & Gail, 2005). In the last 40 years, the number of obese people has tripled, while the number of overweight people has not changed (Sullivan, 2010). Given the wide array of weight loss-focused apps and the prevalence of overweight and obesity, we have focused our research on apps aimed at weight loss.

In our analysis, we focus on quantification; a social phenomenon that is growing in social life and as such should be studied through sociological concepts. The force of numbers in and of themselves has been of little interest to sociology in the past, possibly because quantification was so ubiquitous as to be taken for granted by laypeople and researchers alike. Health apps allow people to quantify any kind of experience and to create personal analytics. Alongside quantification, we will also discuss gamification, a technique intended to foster productivity and achieve goals by transforming work into a game. Most health apps (and many marketing strategies) are based on this strategy. Moreover, through their managerial language and graphics, these apps depict the user as a self-entrepreneur who works on herself as if she were an enterprise with the mission of increasing physical, cognitive and emotional ‘productivity’.

The algorithmic body and the quantified self

Espeland and Stevens call for a sociology of quantification, claiming that quantification should be taken into consideration as a sociological phenomenon:

Quantification is a constitutive feature of modern science and social organization, yet sociologists have generally been reluctant to investigate it as a sociological phenomenon in its own right. (Espeland & Stevens, 2008, p. 402)

Although there has been sociological interest in quantification, most of the discussion has focused mainly on the epistemological aspects of quantitative methods of social research (Bryman, 1984; Cipolla & De Lillo, 2004; Olsen & Morgan, 2005), rather than on the consequences of the extension of a culture of quantification into everyday life. There are some exceptions: Mackenzie (2014) draws from a sociology of algorithms in order to explain how mathematical models shape markets; under a more ethnomethodological perspective, Suchman (2011) has investigated how instruments have material effects in the construction of scientific facts, while Mackenzie (2013) has analysed the practices by which synthetic biology constructs its legitimisation in society. From a more classic sociological stance, in his theory of communicative action, Habermas (1985) warned against the progressive colonisation of the lifeworld by the system and its instrumental rationality – yet he did not explicitly investigate quantification as a tool of instrumental rationality.

It may be that this lack of interest in quantification is due to the fact that ‘In a world saturated with numbers, it is easy to take the work of quantification for granted’ (Espeland & Stevens, 2008, p. 411) and that ‘Counting may seem like a simple act, but doing it on a large scale requires well-funded bureaucracies with highly trained administrators’ (Espeland & Stevens, 2008, p. 411). The lack of attention to the impact of quantification on everyday life has a historical dimension. The development of technology means that quantification no longer requires the support of a large bureaucracy. In contemporary society, individuals can organise their domestic activities, even their sexual lives (Lupton, 2014b), using the same principles and methodologies of large-scale commercial organisations. Technology such as smartphones enables individuals to undertake intensive self-tracking. Individuals can collect and store an enormous amount of life data, such as the number of steps they take each day, time spent in rapid eye movement (REM) sleep or the miles they run. Individuals can also track their own heart rate, body temperature, blood sugar, menstruation cycle and caloric intake. In fact, individuals can record a wide range of everyday activities, form the money they spend, the drinks they drink to the number of cigarettes they smoke. Through the construction of ‘personal analytics’, individuals can also bring fine-grained statistical analysis to bear on the data they collect and develop precise graphical representations. Among the visualisation types, the most common are line charts, followed by bar charts and calendars (Choe, Lee, Bongshin, & Kientz, 2014). In short, digital quantification and self-tracking aim to reconnect what Weber argued modernity had separated. For Weber:

the modern rational organization of the capitalistic enterprise would not have been possible without two other important factors in its development: the separation of business from the household, which completely dominates modern economic life, and closely connected with it, rational book-keeping. (Weber, 1992, p. 35)

Self-tracking re-establishes the link between the private household and the public sphere of business creating the ‘quantified self’, a concept first identified by Gary Wolf and Kevin Kelly, two editors from Wired magazine in 2008 (Wolf, 2010). Wolf and Kelly created a site, www.quantifiedself.com, on which people fond of self-tracking can exchange information, discuss their achievements and reflect on the effectiveness of such tracking for changing one’s habits. The site has acted as a hub for an impressive number of social activities. There are more than 100 ‘quantified selfer’ associations spread all over the world, which hold workshops every week and have an annual conference. The slogan of the site is revealing: ‘self-knowledge through numbers’ (see the site The Quantified Self, http://quantifiedself.com/2011/03/what-is-the-quatified-self/). Wolf described the main characteristics of the ‘philosophy’ of quantified selfers in a (now) famous article in the New York Times (2010). Its title is particularly appropriate: The Data-Driven Life. Wolf stressed the importance of collecting data related to our everyday life activities. He claimed that if individuals collect detailed information on themselves, as it is done by the R&D departments of big corporations, they could become more conscious of their errors, improve their habits and be more productive. In short, quantification would allow individuals to become better human beings. Hence, for many quantified selfers, self-tracking is a tool of human enhancement (Maturo, 2012).

The strong emphasis ‘on numbers in the discourse and technologies associated with digital self-tracking’ (Lupton, 2015, p. 7) is especially interesting. According to Wolf (2010), individuals tolerate this ‘dry and mechanical’ kind of knowledge because the results can be so powerful. Wolf argued that:

Numbering things allows tests, comparisons, experiments. Numbers make problems less resonant emotionally but more tractable intellectually. In science, in business and in the more reasonable sectors of government, numbers have won fair and square. (Wolf, 2010, p. 2)

Lupton (2014a) also observed that numbers render subjective experiences apparently objective. The body can be represented mathematically as a set of values, numbers and algorithms, which seem to be easily comparable across individuals.

Furthermore, this way of representing (and knowing) the body can easily be shared on social networks, shifting these previously private elements into the public sphere (Lupton, 2012). According to van Manen, social networks have been encouraging ‘the privatization of the public and the publicization of the private’ (Van Manen, 2010, p. 1024). Also, charming graphs and bright histograms make the quantifications appear more real and true. Indeed, visualisation is at the core of the scientific-like discourse constructed by these apps. This is particularly evident in healthcare and medicine, where magnetic resonance imaging has moved from being a valuable diagnostic tool to being an authoritative source of knowledge (Joyce, 2008) so that the primary diagnostic tool is no longer ‘touch’ but has become ‘sight’.

Apps can be seen as ‘technologies of the self’ (Foucault, 1977) that shape a body which is increasingly healthy and productive. This ‘disciplined’ body emerges as a result of adherence to a specific regime made up of targets, rewards and punishments. Yet, the punishment is not a ‘pastoral’ one (one inflicted by the good shepherd), nor is it a juridical one. It is more similar to a missed bonus in a video game or losing points in a game we play on our smart phones. Indeed, one of the main features of the self-tracking experience is gamification.

The gamification of health

Gamification can be viewed as a process by which non-game activities are represented in a game-like form (Morford, Witts, & Killingsworth, 2014). Some researchers use the term ludification, which is a broader concept incorporating gamification. According to Lupton and Thomas, ludification:

is used in the academic literature on gaming… to refer to elements of games reading into other aspects beyond leisure pursuits. (Lupton & Thomas, 2015, p.1)

Gamification has been used extensively in education programmes to promote improved learning motivation and outcomes. Currently, gamification is considered one of the most innovative and promising marketing tools (McGonigal, 2011). The idea of a reward is at the core of gamification practices, framing behavioural change in terms ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Citation Information
• Notes on Contributors
• Introduction: Digitised health, medicine and risk
• 1. The gamification of risk: how health apps foster self-confidence and why this is not enough
• 2. Threats and thrills: pregnancy apps, risk and consumption
• 3. Asthma on the move: how mobile apps remediate risk for disease management
• 4. Digital ‘solutions’ to unhealthy lifestyle ‘problems’: the construction of social and personal risks in the development of eCoaches
• 5. Digitalised health, risk and motherhood: politics of infant feeding in post-colonial Hong Kong
• 6. ‘Holy shit, didn’t realise my drinking was high risk’: an analysis of the way risk is enacted through an online alcohol and drug screening intervention
• 7. Stem cell miracles or Russian roulette?: patients’ use of digital media to campaign for access to clinically unproven treatments
• 8. Biosensing: how citizens’ views illuminate emerging health and social risks
• Index