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Read this before developing an mHealth app: tips on saving time and money by walking in other people’s shoes

Marilia Duque E S15 September 2020

An example of a desire path, a consequence of erosion due to people walking on it rather than taking the pre-designed path. Photo licensed under the Creative Commons Attribution 2.0 Generic license

A few weeks ago, I was invited to mentor a startup. They used the term mentorship, but it was more like an informal talk. They are developing an app to help relatives coordinate the care of their elderly parents. Their motivation for this is genuine. The founders are three siblings who had a hard time when they found themselves having to take care of their mother, who had dementia, for several years. They believe they have learned a lot from their experience and they could help other families by combining all the resources they needed as caregivers into a single app. They did a great job. The app is a combination of a calendar for medication and doctor’s appointments, a chat feature the family can use to talk, a channel for checking health information, another channel that can be used to connect with doctors and caregivers and a function that provides reliable, trustworthy information and medical guidance. They also invited one of the most respected researchers on health and ageing to support them with the development of this tool. So, why do I think this app might fail?

During the ASSA project, I conducted a 16-month ethnography with older people in Sao Paulo. At the beginning of fieldwork, I was expecting to find people using apps specifically designed for health and care. Instead, I found people using WhatsApp to create groups to coordinate the care of relatives and to get medical guidance from friends. WhatsApp is the main means of communication among Brazilians who own a smartphone, so the decision to place conversations addressing health and care onto the platform seems natural, especially among older people, as sometimes, WhatsApp is the only app they feel comfortable with. Centralising multiple tasks on WhatsApp means they don’t have to install a new app. This is relevant because, due to many older people using a second-hand device, mobile phone memory can be a problem. Moreover, the process of downloading an app is itself one of the things that they find can make them feel like they have got stuck. Even if they succeed in downloading a new app, they may face constraints related to the adoption of new technology. As one of my research participants said: “you don’t change a winning game”. They just feel like they are at home when they are using WhatsApp.

That is not the case of the three startup founders I am talking about. They are young and technology is not a barrier to them. However, most of the siblings I met who were taking care of elderly parents were middle-aged. This demands an exercise of empathy, which is not just about identifying what caregivers need. It is crucial to consider where they would like to find what they need. It is important to learn how and where (in which app) they get things done. The eureka moment should then come when developers understand how to improve and add value to the choices the users have already made. Katrien Pype called this ‘smartness from below’[1].

In my research, I work with the term “desire path”[2]. In a park, for example, the desire path is the path users create by choosing a route that is different from the one designed by planners. The desire path is the materialisation of the free will. It can be seen as a kind of disobedience, but there is something really valuable about this unpredictable preference. Observing the desire path is an opportunity to learn what users feel is more appropriate for the experience they want. In that sense, taking the desire path into account can save resources and time and might be a good short cut to succeeding in the challenge of designing an app people are actually willing to use.

Because the app they are planning to develop contains an in-built calendar, one of the questions I asked the startup’s founders was whether they would normally use a calendar other than Google. They said they wouldn’t. So why assume their users would use something different to what they are used to? It is easier to integrate the schedule that caregivers need to keep track of the care they provide (sometimes across multiple family members) into the calendar they already use in their day to day life, rather than persuading them to adopt a new one. In that case, Google Calendar is the desire path and app developers are the ones who should adapt their journey to the use of it. The same occurs with WhatsApp. Based on this experience as well as my observations during fieldwork in Sao Paulo, investigating how doctors, clinics and insurance health plans in the city were using WhatsApp for health purposes, I developed a series of protocols for clinics and hospitals showing how WhatsApp can be used to facilitate their communication with patients when it comes to patient triage, the provision of medical care and patient education. These protocols were published under the title “Learning from WhatsApp: Best Practices for Health” (you can download this for free here). In the 150 pages of the book, I haven’t invented anything. It is just simple and pure WhatsApp. My work was to learn with people and systemise the steps.

Figure 1: Example of how WhatsApp might be used to coordinate remote care. In this case, the nurse in charge of interacting with patients via Whatsapp uses the ‘star message’ function to indicate that the patient’s query is pending, so she can go back to the patient after the image is seen by the doctor. Source: ‘Learning from Whatsapp: Best Practices for Health’, by Marilia Duque.

I also published another book called “WhatsApp for Nutritionists” (the book was only published in Portuguese and it is available here). The book is a result of a project I worked on where my challenge was to rebuild the kind of food diary[3] a bespoke m-Health app provides but using only WhatsApp features. The intervention’s effectiveness was tested by having older people assisted by the UNIFESP Medical School in Sao Paulo trial the new method. Participants were invited to take a picture of everything they ate and drank every day and shared this with the nutritionist via WhatsApp. They didn’t have to learn anything new and neither did the nutritionist, as both were already WhatsApp users. This way, the medical school didn’t have to develop an additional app in order to create a reliable method for assessing dietary requirements and needs. It was a successful and cost-effective intervention.

Figure 2 and 3: Examples of how Whatsapp can be used for nutrition purposes – the user sends the nutritionist a photo of all of their meals, thus creating a visual log of their nutritional intake for the day. These are examples of how nutritionists can visualise a patient’s food diary on their mobile and on WhatsApp Web. Source: WhatsApp® Aplicado à Nutrição, by Marilia Duque.

I do think the app I was invited to talk about is far better than WhatsApp, and it should be, as it was designed specifically for health purposes by people who have experience in the problem they want to solve. My point is that there is no guarantee people will use it. That is why my advice is to observe, learn and respect the desire paths taken by potential users before developing something new. They are the choices people have already made.

 

[1] Pype, Katrien. “Smartness from Below: Variations on Technology and Creativity in Contemporary Kinshasa.” What Do Science, Technology, and Innovation Mean from Africa?, edited by Clapperton Chakanetsa Mavhunga, The MIT Press, 2017, pp. 97–115.
[2] https://www.theguardian.com/cities/2018/oct/05/desire-paths-the-illicit-trails-that-defy-the-urban-planners
[3] RUCKENSTEIN, M. (2015). Uncovering Everyday Rhythms and Patterns: Food tracking and new forms of visibility and temporality in health care. Techno-Anthropology in Health Informatics: Methodologies for Improving Human-Technology Relations, 215, 28-40.

 

No “pãodemia” for older people

Marilia Duque E S25 June 2020

“Pãodemia” is the expression used to describe the phenomenon of people baking bread (bread is “pão” in Portuguese), cakes and cookies during the quarantine that was imposed during the COVID-19 pandemic in Brazil. The expression, created by the Portuguese chef Filipa Gomes, went viral when she shared a video on her Instagram with a tutorial on how to make bread at home using just four ingredients. She named the recipe “Pãodemia”[1]. During these months of isolation, a cooking craze spread like a fever in Brazil and in other places in the world[2] as a way of avoiding leaving home, occupying one’s free time and alleviating stress. As a consequence, other than the huge rise in demand for flour in Brazil, Google registered an increase in searches for bread recipes in the country. At the end of March 2020, the number of search terms used to find bread recipes had quadrupled compared to any period in 2019[3].

Filipa Gomes’s “Pãodemia” tutorial on Instagram. Screengrab taken by the author.

The idea of turning every recipe into a pleasant activity also gained visibility on social media. People who before COVID-19 had no time to be at home or cook now share pictures of their homemade recipes, competing for distinction among peers. On my social media channels, I could see many friends my age who were chefs sharing their bread, cakes and other homemade dishes. I was also invited to a WhatsApp group called “Pandemic Kitchen”, where friends were challenged to share their creativity in cooking during the quarantine.

Directly from the oven to social media feeds. Screengrab of post shared on my Facebook timeline.

However, I observed that none of the older people I met during my 16-month ethnography in Sao Paulo were sharing any bread or cake photos. Instead, they kept sharing information they considered relevant to their peers together with all kinds of opportunities to learn new things or engage in new activities, all of which were now restricted to the online. What’s more, I also noticed they were creating many of these new opportunities.

One of the groups I studied during my research is organised around the purpose of developing new alternatives to work in old age, with the added challenge that these alternatives should combine pleasure and financial gains. To my surprise, they quickly migrated their face-to-face weekly meeting to Zoom, where they now have meetings and activities every day. Before coronavirus started, I guess like most of us, they didn’t know about Zoom. Their online activities were mainly concentrated on their Whatsapp group as well as the WhatsApp Broadcast list they use to keep the group up to date about the schedule of face-to-face activities. Although the group is focused on working and entrepreneurship, a recent survey conducted by one of the members revealed that 72% of them joined the group’s meetings to improve their sociability. This result confirmed something they already knew. Their biggest mission, as a group, is to make older people leave their homes, fighting isolation and offering a collective opportunity for them to be productive and useful. Most of the time, members make their skills available to the group and most of their initiatives address problems they face in everyday life. In other words, they are working for themselves, to improve their own experience of ageing.

When the face to face meetings were suspended, they had to move fast to avoid letting the group die. And so they did. With a professional background in collecting data through surveys, one of the members created a questionnaire using Google Docs with a portfolio of ideas for things they could do together, even at distance. The ideas people showed more interest in were transformed into their own dedicated WhatsApp groups and the respondents were automatically included according to their preferences. The most popular initiative existed even before COVID-19 – it was the “Demystifying Smartphones” workshop, created by Sergio Grinberg, aged 69. Grinberg uses his professional background working with computers to help older people to feel comfortable with their smartphones and especially with WhatsApp. However, with coronavirus, the workshop addressed what became older people’s first priority: learning how to use Zoom platform[4]. And they succeeded. As shown in their weekly schedule below, they now have activities on Zoom from Monday to Saturday.

Trabalho 60+ weekly agenda of activities on Zoom

Last Sunday, I invited the team responsible for organising these activities to a Zoom meeting, where I could get to know what they were metaphorically “cooking” better. I started by asking whether they had baked any bread, as I thought I could have missed something. They explained they had thought about an activity where they would all bake bread according to the same recipe and then donate all of it to a charity but people didn’t stick to the initiative. One of the explanations for this is that they are all focused on solving their own problems first, creating opportunities for older people to be connected and empowered. The second one is a kind of a been-there-done-that explanation. To put it in their words:

“For us, cooking became a pain in the ass. Now we are confined to being home again. But we don’t post what we are doing alone. We cook together. That is fun.”

Zoom meeting with the “Trabalho 60+” group members. Screengrab taken by the author.

Keeping doing things together – that is their spirit. In that vein, instead of posting what they consider domestic affairs, they created the Zoom event “Cooking with Friends”. Every Friday, they get online on Zoom to cook the same recipe. Each week, a different person is responsible for sharing the recipe with the ingredients and instructions, so they have time to organise themselves and get the ingredients together. During the meeting, the person sharing the recipe is also “the chef” who will guide the friends through making the recipe.

All set for the activity “Cooking with Friends”. Photo: @Eduardo Meyer

Outside the kitchen, the group is also engaged in other activities, such as organising a virtual library where they share the eBooks they have. They also have a “Janelas para o Mundo” (“Windows to the world” in Portuguese) initiative, during which they have discussions related to literature, following a dynamic similar to the one used in the “Cooking with Friends” initiative. A selected text is shared with the group and they get together once a week to have a guided discussion. People can also practice facial gym exercises on Tuesdays (they have now opened a second class, as there was huge demand for it) or join the Happy Hour meeting every Friday evening when they also celebrate the birthdays of the week. They have a choice of around 18 activities to join during the week. As there are plenty of options, people started advertising their own initiatives as they are competing for their friends’ attention. To help them, the workshop “Demystifying Smartphones” is also teaching people how to manage other applications such as Canva[5], a graphic design platform that can help them create posts for Facebook and Instagram, videos and presentations, as seen in the examples below.

Card shared on WhatsApp to promote the event “Windows to the World”. As seen on the left side on the top, the initiative even has a logo.

Card shared on WhatsApp to promote the event “Cooking with friends”.

With creativity and a pinch of professionalism, this group of older people are refusing to be confined at home. They were once confined at home, far before COVID-19 started, when they retired. Since then, they have fought hard to conquer new spaces and visibilities. Therefore, they can be confined to the online now but they are not particularly interested in bread. Instead, they are performing their miracles to multiply the opportunities they have to stay connected as a group, being productive while at the same time, sharing some of life’s pleasures together.

To get a taste of how the group “Trabalho 60+” is using Zoom platform to keep together during the quarantine, watch the video below and enjoy the experience of cooking with friends. It is mouthwatering, to say the least.

Video produced by “chef” Conrado when the taught other members of the group how to prepare the cauliflower pie.

 

[1] https://www.noticiasaominuto.com/fama/1453284/paodemia-a-receita-de-filipa-gomes-que-se-tornou-viral-no-instagram

[2] https://brasil.elpais.com/brasil/2020-04-09/todo-mundo-em-busca-de-receitas-de-pao-caseiro-para-amenizar-a-quarentena.html

[3] https://saude.estadao.com.br/noticias/geral,na-quarentena-assar-pao-e-bolo-ganha-espaco-e-aumenta-procura-por-farinha,70003261439

[4] https://br.vida-estilo.yahoo.com/inspiracoes-terceira-idade-sergio-grinberg-091843876.html?soc_src=community&soc_trk=fb

[5] https://www.canva.com/