App-ography: A critical perspective on medical and health apps

All My Apps by alf eaton +
Anatomical Position by Connexions

I have been thinking and writing about mobile apps recently and how they are used for medical and health purposes. Millions of apps designed for smartphones, tablet computers and other mobile devices have been developed since their first appearance in 2008. Many of these are health and medical apps. In mid-2014 there were over 100,000 health and medical apps listed in the two major app stores, Apple App Store and Google Play, and new ones are being issued every day.

Several health and medical apps feature on Apple’s lists of popular apps, and download figures provided by Google Play show that some health and medical apps on their store have been downloaded hundreds of thousands or even millions of times. In late 2012 a Pew Research Center survey found that 85 per cent of American adults owned a mobile phone. Fifty-three per cent of these were smartphones, and one fifth of smartphone users had used their phone to download a health-related app. The most popular of these apps were related to monitoring exercise, diet and weight. A more recent market research study found that almost one-third of American smartphone users (equivalent to 46 million people) had used apps from the health and fitness category in January 2014Public health researchers have sought to evaluate their use in health promotion campaigns and gathering data on health-related practices. But few researchers have investigated the broader social, cultural, political and ethical dimensions of medical and health apps.

Healthcare practitioners and administrators are also increasingly using apps as part of their professional practice. Hundreds of apps have been developed by hospitals and other healthcare providers. A growing number of medical schools are now offering at least part of their education via apps and require their students to own a tablet computer. In one study that surveyed American doctors, more than two thirds said that they used apps as part of their work. Another survey of medical students and junior doctors in a UK healthcare region found that over half of both students and junior doctors had medical-related apps on smartphones, with apps for medical education purposes the most popular. The medical literature now often refers to ‘prescribing’ apps to patients.

Despite the ever-increasing popularity of apps, very little academic research focused on these devices has been carried out in the social sciences and humanities. Numerous market research reports and medical journal articles have been published that provide some quantitative data on their content, accuracy and use, but these are largely instrumental and descriptive rather than critical.

In recent years I have been interested in developing a research agenda in critical digital health studies, including research into medical and health-related apps. I adopt a sociomaterial perspective drawn from science and technology studies to investigate the digital health phenomenon. From this perspective, mobile apps, like all technologies, assume certain kinds of capacities, desires and embodiments; they also construct and configure them. Apps are new digital technology tools but they are also active participants that shape human bodies and selves as part of heterogeneous networks, creating new practices. Indeed apps may be viewed as sociocultural artefacts, the products of human decision-making, underpinned by tacit assumptions, norms and discourses already circulating in the social and cultural contexts in which they are generated, marketed and used. As they not only present information and health and medicine but also often invite users to generate and share digital data about themselves, apps participate as actors in the digital knowledge economy.

Various capabilities and responsibilities are produced via medical and health apps. They have enormous implications for the practice of medicine, the delivery of healthcare and public health work and the doctor-patient relationship. These apps have the potential to shape the ways in which the human body is understood, visualised and treated by healthcare workers and lay people alike. For example my study of sexuality and reproduction apps designed for people to use for self-tracking and monitoring purposes found that concepts of reproductive and sexual embodiment as they were represented in the apps were strongly gendered. Male sexuality was rendered as ideally high-performing and competitive, unrelated to reproduction. In contrast, few apps were designed for women to rank their sexual performance. However nearly all reproduction apps were targeted at women, centred on health and fertility.

Given that many medical apps are designed for medical education as well as to assist qualified practitioners in their daily work routines, they contain highly detailed and specialised medical information that previously was not available to lay people. This in itself is a major change in the ways in which medical information has been rendered open to access by lay people. Whether an app was designed for a medical practitioner or explicitly for lay users, it can be downloaded and used by anyone. This openness of access raises further questions about the maintenance of professional dominance and expertise for members of the medical profession. This is an issue I have been exploring in another app research project (with Annemarie Jutel) that focuses on medical diagnosis apps designed for both lay people and medical practitioners.

More research is needed that addresses the vested interests that might be involved in creating apps. Many stakeholders now jostle for lay people’s attention in the world of digital health information, including members of the medical profession and allied health professionals, health insurance companies, pharmaceutical and medical technology companies, hospitals, patient support associations, government agencies and digital device and software developers. My own app research, as well as my analysis of patient support websites, has revealed that it is not always apparent where such interests lie in digital health devices and platforms. Nor do users of digital health devices such as apps necessarily know how any personal data they may upload are used by the developers. Such information may be omitted, unclear or buried in the terms and conditions or privacy pages that require users to follow a hyperlink trail.

We know very few details about how health professionals such as medical practitioners, hospital administrators, public health professionals and health promoters are incorporating apps and associated mobile digital technologies into their working practices. Little knowledge is available on the working practices and assumptions of app developers and designers and the companies that commission apps. Nor do we know how lay people and healthcare and public health workers might be resisting or subverting these devices or creating their own. Analysis of the circulations, transformations and repurposing of the digital data that are generated by apps requires further attention, as do the topics of personal data security and privacy as the domains in which personal health and medical data are collected and used expand. Ethnographic and critical research that is able to elucidate the situated knowledges of apps offers immense potential for anthropologists and sociologists interested in health and medicine and in digital technologies.

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