The cultural specificity of digital health technologies

Digital health technologies configure a certain type of practising medicine and public health, a certain type of patient or lay person and a specific perspective on the human body. The techno-utopian approach to using digital health technologies tends to assume that these tacit norms and assumptions are shared and accepted by all the actors involved, and that they are acting on a universal human body. Yet a cursory examination of surveys of digital health technology use demonstrates that social structural factors such as age, gender, education level, occupation and race/ethnicity, as well as people’s state of health and their geographical location play a major role in influencing how such technologies are taken up among lay people or the extent to which they are able to access the technologies.

An American study of the use of some digital health technologies using representative data collected by the National Cancer Institute in 2012, for example, found no evidence of differences by race or ethnicity, but significant differences for gender, age and socioeconomic status (Kontos et al. 2014). Female respondents were more likely to use online technologies for health-related information, as were younger people (under less than 65) and those of higher socioeconomic status. People of low socioeconomic status were less likely to go online to look for a healthcare provider, use email or the internet to connect with a doctor, track their personal health information online, using a website to track to help track diet, weight or physical activity or download health information to a mobile device. However they were more likely to use social media sites to access or share health information. Women were more likely than men to engage in all of these activities.

While there is little academic research on how different social groups use apps, market research reports have generated some insights. One report showed that women install 40 per cent more apps than men and buy 17 per cent more paid apps. Men use health and fitness apps slightly more (10 per cent) than women (Koetsier 2013). A Nielsen market report on the use of wearable devices found that while men and women used fitness activity bands in equal numbers, women were more likely to use diet and calorie counter apps (Nielsen 2014).

As these findings suggest, gender is one important characteristic that structures the use of digital health technologies. The digital technology culture is generally male-dominated: most technology designers, developers and entrepreneurs are male. As a result, a certain blindness to the needs of women can be evident. For example, when the Apple Health app was announced in 2014, destined to be included as part of a suite of apps on the Apple Watch, it did not include a function for the tracking of menstrual cycles (Eveleth 2014). Gender stereotypes are routinely reproduced in devices such as health and medical apps. As I noted in my study of sexuality and reproduction self-tracking apps, the sexuality apps tend to focus on documenting and celebrating male sexual performance, with little acknowledgement of women’s sexuality, while reproduction apps emphasise women’s over men’s fertility.

App designers and those who develop many other digital technologies for medical and health-related purposes often fail to recognise the social and cultural differences that may influence how people interact with them. Just as cultural beliefs about health and illness vary from culture to culture, so too do responses to the cultural artefacts that are digital health technologies. Aboriginal people living in a remote region of Australia, for example, have very different notions of embodiment, health and disease from those that tend to feature in the health literacy apps that have been developed for mainstream white Australian culture (Christie and Verran 2014). It is therefore not surprising that a review of the efficacy of a number of social media and apps developed for health promotion interventions targeted at Aboriginal Australians found no evidence of their effectiveness or benefit to this population (Brusse et al. 2014).

Few other analyses have sought to highlight the cultural differences in which people respond to and use digital health technologies. This kind of research is surely imperative to challenge existing assumptions about ‘the user’ of these technologies and provide greater insights into their benefits and limitations.

New project on fitness self-tracking apps and websites

My colleague Glen Fuller and I have started a new project on people’s use of fitness self-tracking apps and platforms (such as Strava and RunKeeper). We are interviewing people who are active users of these devices, seeking to identify why they have chosen to take up these practices, what apps and platforms they use, how they use them and what they do with the personal data that are generated from these technologies. We are interested in exploring issues around identity and self-representation, concepts of health, fitness and the body, privacy, surveillance and data practices and cultures.

The city in which we live and work, Canberra, is an ideal place to conduct this project, as there are many ardent cyclists and runners living here.

See here for our project’s website and further details of the study.

Some thoughts on public health ethics

Yesterday I attended a symposium on public health ethics held at my university. It was an interesting experience, as like most sociologists I am not very familiar with the literature on public health ethics, although I have drawn upon some of  it from time to time. However I am very interested in the moral, political — and yes, sometimes the ethical dimensions — of public health, and a great deal of my research has focused on these issues (for example, Lupton, 1995, 2012; Petersen and Lupton, 1997).

When listening to the presentations defining public health ethics, and later following up some of the literature mentioned in the symposium, it was apparent to me that academics writing in the public health ethics field also do not appear to read sociological analyses of public health (or if they do, they not cite them very often). So neither field is currently engaging with the other to any great extent. Why this lack of interaction, given that there are clear overlaps between the critical sociology of public health and public health ethics? The approach known as ‘critical public health ethics’ is especially close to the concerns of the critical sociology of public health as it tends to focus to a greater extent on the politics and power relations inherent in public health (Callaghan and Jennings, 2002). Both critical public health ethics and the critical sociology of public health are interested in how public health strategies and models affect individuals and populations; both want to engage in a critique of the taken-for-granted assumptions that pervade public health; both pay attention to the potential for injustice, excessive paternalism and constraint of freedom within public health approaches; both address the issue of why certain issues are identified as ‘public health problems’ and why others are ignored; and both draw attention to the focus on individuals’ health-related behaviours in public health and the need to highlight the broader social, cultural and political causes of ill-health and disease.

Probably the main reason for the lack of recognition of the literature on both sides is the different histories of public health ethics and the critical sociology of public health. Public health ethics is a very new field that grew from bioethics, a type of applied ethics. Public health ethics and bioethics are based very strongly on the underpinnings of traditional moral and political philosophy (Carter et al., 2012). As a result a lot of writing in public health ethics is preoccupied with distinguishing between the various philosophical approaches that can be used to evaluate public health strategies:  for example, what insights a utilitarian, libertarian, human rights or distributive justice perspective may offer. Public health ethicists weigh up these various perspectives when evaluating the claims of public health and make decisions on what is the most ethical action based on their reasoning. They tend to publish their work in mainstream journals of public health or in specialist medical or public health ethics journals.

The critical sociology of public health has less of an applied focus than public health ethics, tending to focus more on the social structural features underpinning public health approaches and engaging in a more overtly political critique. Sociologists writing in this area usually position themselves outside of public health, while in contrast public health ethicists often position themselves inside public health as part of their role of attempting to advise on the best course of action. While sociologists may often refer to ‘ethics’, they are not generally concerned with comparing different ethical perspectives and evaluating them. They tend to have a far more relativist approach to ethics, and indeed may engage in an analysis of medical or public health ethical discourse itself as a socially constructed phenomenon (see, for example, Jallinoja, 2002).

Further, while the critical sociology of public health is also informed by philosophy, sociologists have taken up different theorists to conduct their analyses, drawn largely from what is often termed ‘grand theory’. In particular sociologists have employed the political economy approach influenced by Marxism and more recently the writings of Foucault on biopolitics, biopower, governmentality and the care of the self. The critical sociology of public health also has somewhat of a longer history than critical public health ethics. It has been in existence for some decades, as found particularly in articles published in the journal Critical Public Health, established in 1979 under the original title of Radical Community Medicine, but also in several other sociology journals. Sociologists of public health and public health ethicists therefore tend to publish in very different journals and as a result do not tend to routinely see each other’s work.

Despite their major differences (and perhaps because of these differences) it would be interesting to see how each field could gain from a greater engagement with and acknowledgement of each other’s work. It is intriguing to think about what synergies may be generated by such an engagement. I hope that this post represents one small step in this direction.

References

Callaghan, D. and Jennings, B. (2002) Ethics and public health: forging a strong relationship. American Journal of Public Health, 92, 169—76.

Carter, S., Kerridge, I., Sainsbury, P. and Letts, J. (2012) Public health ethics: informing better public health practice. NSW Public Health Bulletin, 23(5-6), 101—6.

Jallinoja, P. (2002) Ethics of clinical genetics: the spirit of the profession and trials of suitability from 1970s to 2000. Critical Public Health, 12(2), 103—118.

Lupton, D. (1995) The Imperative of Health: Public Health and the Regulated Body. London: Sage.

Lupton, D. (2012) Fat. London: Routledge.

Petersen, A. and Lupton. D. (1997) The New Public Health: Health and Self in the Age of Risk. London: Sage.

My new book ‘Fat’


My latest book Fat has just been published as part of Routledge’s Shortcuts series.

In contemporary western societies the fat body has become a focus of stigmatizing discourses and practices aimed at disciplining, regulating and containing it. Despite the fact that in many western countries fat bodies outnumber those that are thin, fat people are still socially marginalized and treated with derision and even repulsion. Medical and public health experts insist that an ‘obesity epidemic’ exists and that fatness is a pathological condition which should be prevented and controlled.

Fat is a book about why the fat body has become so reviled and viewed as diseased, the target of such intense discussion and debate about ways to reduce its size down to socially and medically acceptable dimensions. It is also about the lived experience of fat embodiment: how does it feel to be fat in a fat-phobic society? Deborah Lupton explores fat as a cultural artefact: a bodily substance or body shape that is given meaning by complex and shifting systems of ideas, practices, emotions, material objects and interpersonal relationships.

Fat reviews current scholarship and research into obesity discourse and politics, drawing upon critical perspectives offered in the humanities and social sciences and by fat activism and the size acceptance movement. It will be an engaging introduction for the interested general reader, as well as for students across the humanities and social sciences.