Activity trackers, smart watches, health apps, personal heart rate monitors. These new technologies promise to transform health, health literacy and health care.
But to date, these wearable health technologies have been largely marketed towards those who have been dubbed ‘the white, the worried and the well’.
What might they mean for culturally and linguistically diverse communities and the health workforce that supports them – and who should be involved in shaping the research around that?
These issues will be explored at a symposium in Melbourne this Thursday, hosted by the Centre for Culture, Ethnicity and Health (CEH), in partnership with the Research Unit in Public Cultures (RUPC) at the School of Culture and Communication at the University of Melbourne and the Better Health Channel.
The main speakers include:
- Suneel Jethani, from the University of Melbourne’s School of Culture and Communication
- Janette Gogler, Chief Nursing Information Officer, Bendigo Health
- Sean McClowry, Partner with Deloitte Digital.
The event has been organised by Dr Ruth De Souza, CEH Stream Leader in Research, Policy and Evaluation, who is tweeting this week at @WePublicHealth and talks about the aims of the symposium in this interview (below).
In the post below, De Souza also provides an excellent wrap of the many issues (including clinical, technical, and ethical) posed by wearable technologies for individuals, communities, the health workforce and researchers – it is republished with permission from her blog.
See the bottom of the post for preview interviews with researcher Dr Danny Butt about the political and policy implications of the new kinds of ‘publics’ that are being generated by wearable technologies and with North Richmond Community Health and CEH Director Demos Krouskos about the unique Melbourne health community that is hosting and shaping this research agenda.
There you can also see extracts from some of the early discussions that have begun at #wearablesCEH on Twitter.
Sensing horizontality: I bought a wearable device to monitor my sleep
Ruth De Souza writes:
Are you a night owl or an early bird? Or do you fall in between? I succumbed and bought a wearable device because I thought it could be useful to track my sleep. I spend a few nights in the city every week and I notice that I feel less rested than when I am ‘home’.
It seems the right time to buy a wearable device, I am co-organising a Wearables seminar on July 28 2016 at the Centre for Culture, Ethnicity and Health. I’ve also been invited by Croakey to guest tweet on @WePublicHealth and I want to explore how the concepts of consumer participation, health literacy and cultural competence are changing with technologisation in health care. (Check out this interview with Marie McInerney from Croakey if you are interested in the seminar). I’ve also just started a course at QUT on Social media and data analytics as an entry point into beginning to understand what kinds of data are being generated and what can be done with that.
Wearable health technologies are growing in social acceptance and use, especially for people interested in fitness and health monitoring as a form of preventative medicine.
As sensors become cheaper and smaller, many kinds of health-related data that previously relied upon clinical equipment are becoming available for continuous self-monitoring by patients and consumers.
In effect, these technologies are turning the body into media, so that a health consumer can become their own 24 hour news channel focused entirely on the real-time representation of wellbeing.
Wearable technology platforms have been dominated by the English-speaking middle-classes, (‘the wealthy, worried and well’ as Michael Paasche-Orlow suggests), limiting the community benefits of enhanced participation and health. Barbara Feder Ostrov notes:
But Fitbits aren’t particularly useful if you’re homeless, and the nutrition app won’t mean much to someone who struggles to pay for groceries. Same for emailing your doctor if you don’t have a doctor or reliable Internet access.”
The diffusion of mobile phones (that can also be used as health monitoring devices) indicates that these technologies will only expand to a wider range of users.
What are wearables?
Wearable devices or “wearable technology” and “wearables” refer to electronic technologies or computers that are incorporated into clothing and accessories and worn on the body. They can include smart watches, fitness trackers, head mounted displays, smart clothing and jewellery.
They do many things that mobile phones and laptop computers do, but some also have features not seen in mobile and laptop devices. Sensory and scanning features can provide biofeedback and track physiological function. There are also more invasive devices which can implanted such as micro-chips, smart tattoos, pumps.
Why is everyone talking about wearables now?
The world of health information is undergoing significant transformation in the digital era. New media channels such as the Internet allow access to on-demand health information outside of authoritative channels; and new technologies such as fitness trackers and wearables produce a wide range of personal health information.
Several trends have increased attention on technologies in health, including the democratising role of the internet, leading to the emergence of more intensively informed health consumers who expect more precise and individualised care; the ubiquity and mobility of network communications, allowing the immediate bidirectional transfer of information between individuals and systems; the role of social media in providing networks for sharing both personal data and health experiences; and the increasing cost of health care and the potential for technology to make health management more efficient.
What are the benefits?
Traditionally, much clinical interaction relies on self-reporting by consumers, which is then interpreted by researchers and published for incorporation into practice by health practitioners.Along the way, much important information is “lost in translation”.
New consumer healthcare technologies are brokering a shared informational interface between caregivers, clinicians, communities and researchers, allowing practitioners to access richer and more detailed empirical data on health consumer activity and their participation in health-seeking activities.
Consumer health technologies offer potential for care to be more equitable and patient-centred. In turn, the impacts of these technologies on health service education, planning and policy are far-reaching. More about benefits.
Could wearables enhance independence and participation?
Advances in health mean that residents of industrialised countries live longer, but with multiple, often complex, health conditions. Health technologies can expand the capabilities of the health care system by extending its range into the community, improving diagnostics and monitoring, and maximizing the independence and participation of individuals (Patel, Park, Bonato, Chan and Rodgers, 2012).
The United Kingdom’s National Health Service (NHS) is giving millions of patients free health apps & connected health devices in a bid to promote self-management of chronic diseases.
Wearable sensors also have diagnostic and monitoring applications, which can sense physiological, biochemical and motion changes. Monitoring could help with the diagnosis and ongoing treatment of people with neurological, cardiovascular and pulmonary diseases including seizures, hypertension, dysrhythmias, and asthma.
Home-based motion sensing might assist in falls prevention and help maximize an individual’s independence and community participation.
What are the concerns about wearables?
The technological promise also brings concerns, including the impact on the patient-provider relationship; and the appropriate use and validation of technologies. Technologies are also developed with particular service-users in mind, and rarely designed with the participation of people from structurally and culturally marginalised communities.
Despite the ubiquity and access to apps, wearables and websites, the lack of science might preclude behaviour change (e.g. no set of standards) and the “average person” could struggle to choose an app that is effective at changing health behaviour.
There’s concern about whether we can trust the scientific rigour of the apps we are using, for example the accuracy of the heart rate tracker of the Fitbit and concerns about security.
What impact will technologies have on health professional roles?
Health professionals will have to consider how they work with clients in the context of these technologies.
The capacity to review and share healthcare experiences is already available. Technologies will require changes in rules, business models, workflow and roles.
The advent of authoritative websites like the Better Health Channel means that health professionals may no longer be the ultimate gate-keepers of knowledge – their role might shift to being health coaches who empower clients to monitor and improve their health by using their own data.
They might have a larger role in care coordination and managing care transitions through the use of mobile health apps. They could play a greater role in research at the point of care through data gathering in research projects. They could play a greater role in evaluating the quality and appropriateness of particular apps.
Technology could also free up time to care. Nurses often spend more time collecting information than looking after patients. One study showed 60 per cent of the nurse’s/midwife’s time was spent collecting information and only 15 per cent caring for their patients. ePrescription systems in Sweden, the US and Denmark increased health provider productivity per prescription by over 50 per cent. eReferrals in Europe reduced the average time spent on referrals by 97 per cent.
So there is potential for the enhancement of health system design: workflow and the coordination of care. There will also need to be better support for innovation as this post from The Medical Startup notes:
How can you innovate where your environment is slow to respond to change, and, despite best intentions, has trouble understanding the few (or many) employees who want to do more, but can’t articulate their feelings? How can you innovate when you risk being penalised or even kicked out of a specialty college that you’ve worked so hard to enter?”
Health professionals will also need data management or data analytic skills in order to best use the data wearable health technologies generate.
The data will range from public health intelligence (for example tracking outbreaks); using data as a diagnostic tool; to follow up treatment plans; to provide access to the personas, problems, goals and preferences which can then improve the care plan through tailored information and also improve engagement and activation.
Health professionals will also need to find ways to prepare patients better for their appointments so that the time they spend is better used.
What kinds of workforce preparation will be necessary for using technologies effectively?
The Digital Skills for Health Professionals Committee of the European Health Parliament surveyed over 200 health professionals about their experience with digital health solutions, and a large majority reported to have received no training, or insufficient training, in digital health technology.
The committee recommended continuous education of health professionals in the knowledge, use and application of digital health technology.
Curricula will need to be updated to prepare health professionals for using mobile apps/diagnostic and data monitoring tools to nurses’ repertoire of skills and competencies and larger focus on patient-centred care and consumer engagement in health promotion and maintenance activities.
Will there be new roles for ‘informaticians’ whose job is to help download apps, set it up, teach patients how to use it to make health messages more understandable?
Educators will need to consider how they teach students to use technology and integrate the use of mobile technology into learning experiences and clinical practice. They’ll need to consider how to use technology such as texts, mobile telephones, or video for health promotion and disease prevention.
They will also need an understanding of informatics and how health data are stored, transmitted, and used, as well as the use of the electronic health record in patient-centered care planning (Kennedy, Androwich, Mannone, & Mercier, 2014).
Could benefits be realised for people from CALD backgrounds?
Victoria is one of the most culturally diverse communities in the world, which accounts for around one-third of migrant settlement in Australia. The number of Victorians born overseas have grown by 29 per cent from 2001 to 2011—from just below 1.1 million people to 1.4 million (VARG, 2014).
The Auditor General notes in the VARG report (2014) that:
Migrants, particularly those with low English proficiency or poor literacy in their own language, and refugees and asylum seekers are among our most vulnerable members of the community. This is because they often have complex needs, particularly in relation to health, welfare and language services. A whole-of-government approach to the broader area of multicultural affairs should improve integration, reduce duplication and better identify gaps in services.”
Evidence is growing that the greater the health literacy of an individual, the greater the likelihood of health maintenance and promotion.
Low health literacy is associated with more adverse health outcomes (people with low levels of individual health literacy are between 1.5 and 3 times more likely to experience an adverse health outcome (DeWalt et al. 2004 cited in ACSQHC 2013c).
People from refugee and migrant backgrounds may be disadvantaged in the health system because they are in the process of developing their health literacy and capital.
Access to and through health care is a significant aspect of feeling a sense of belonging and worth, so improvements in health participation will also have a significant impact on broader social inclusion. We need to explore how low health literacy/data literacy affect the use of health information, merely having access to information in apps is no guarantee that you can use the information.
It’s going to be interesting seeing what data comes out of the Jawbone app. Having had it for two days I can see that it provides useful data about the type of sleep I’ve had. What I do with the information will be one of the questions I grapple with next.
Health Literacy and Consumer-Facing Technology: Workshop Summary
By Roundtable on Health Literacy, Board on Population Health and Public Health Practice, Institute of Medicine, National Academies of Sciences, Engineering, and Medicine.
Research based in the community
Marie McInerney writes:
The Centre for Culture Ethnicity and Health (CEH) in inner city Melbourne is thought to be the only Australian research centre of its kind that is based within a community health service.
And its host, the North Richmond Community Health, is in itself unique, based in the grounds of Victoria’s largest public housing estate.
It’s a diverse cultural community that has undergone dramatic demographic change in recent decades, with gentrification and the loss of local industry, which has really cut job opportunities for men particularly.
CEH’s role is to develop services and resources to support communities and organisations in cultural competence, health literacy and consumer participation.
In this video below, North Richmond Community Health and CEH Director Demos Krouskos says it’s important to have a research centre like CEH surrounded by the sorts of issues relating to inclusion and equitable access to health services that it is trying to deal with on a state and national level. He says:
We deal with these issues in the other part of our organisation, North Richmond Community Health, everyday, so it’s a great learning environment for everybody at CEH to be able to understand how to change our practice and be able to address those issues of access and inclusion.”
Talking about why CEH is hosting the wearables technology symposium, he says it’s instructive to know that one of the first services established in refugee camps across the world now is a mobile phone tower. He says:
It’s extraordinary how many of our clients, they might arrive in Australia with very little else, (but) they have a smart phone.
That provides us with a unique opportunity to think about how we might be innovative in a very creative way, not just in communication strategies but our ways of building relationships of trust with our communities.”
Bringing together the experts to shape the research agenda
Dr Danny Butt is a Research Fellow in Participatory Public Space at the Research Unit in Public Cultures at the University of Melbourne.
In the interview below, he talks about his interest in the political and policy implications of the new kinds of ‘publics’ that are being generated by devices like wearable technologies, including how they are creating communities that are not subject to the same policy controls or levers that we expect in more traditional public spaces from governments or councils or hospitals or other agencies.
Butt’s colleague Suneel Jethani, from the University of Melbourne’s School of Culture and Communication, will be one of three main speakers. He has just submitted his PhD on related issues and will talk about the routes to technical innovation and markets for wearables and the problems of regulation and governance associated with the production, sharing and access of personal health data.
Butt says the symposium is seeking to develop a research agenda by bringing together experts from many fields together to find out, before the research begins, what are the important questions to consider across a range of issues: clinical, technical, policy, governance, community etc.
This is what community health is about: it’s about understanding that knowledge is no longer only held in the expert individual who reads the book: that knowledge is out there in the world.
I think this brings about an important methodological kind of question for us in the university sector: if we want to be engaged out there, where these things are happening…then that’s absolutely incumbent on us to co-design these research programs with the people who we expect to benefit from it and the people who are going to use it.”
Early #wearablesCEH discussions on Twitter