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Nurse navigators and WhatsApp: an example of smartness from below

AlfonsoOtaegui8 December 2018

Photo by Alfonso Otaegui

Within the scope of the project Anthropology of Smartphones and Smart Ageing (ASSA), we are committed to work collaboratively with a local mHealth initiative, or any initiative that will improve the access to healthcare or the wellbeing of the populations among whom we are carrying our fieldwork.

At the beginning, before even starting my fieldwork, I envisioned this initiative as the creation and implementation of a bespoke mHealth app, which would respond to a necessity observed in the field. This approach implied spotting a gap in the site –a need not yet addressed but noticed by the ethnographer– and creating an app which would fill that gap. It was certainly a top-down implementation approach: I would give the users something they needed but were not aware they needed.

After a couple of months, I realized it would be wiser to simply describe an app people already used in a creative way, and bring this local idea to another place, where this idea could be helpful. This approach, which could be described as ‘bottom-up’, implies acknowledging the creativity of local populations in the adoption of communication technologies, what Pype (2017) names ‘smartness from below’. With the same aim of bringing good ideas from one place to another, we have also started in our team to build up a list of ‘best practices’ in healthcare throughout all of our field sites.

With this aim in mind, I will spend the last six months of my fieldwork in Santiago doing ethnography at an oncological center in a public hospital. This particular hospital is the only public one in Santiago having implemented a ‘nurse navigator’ model of healthcare (Devine 2017).

The navigator nurses work as mediators between oncological patients and the medical and bureaucratical system of a public hospital in a low-income area. Cancer treatments mean two complexities for the patient: the medical complexity of the treatment and the bureaucracy of the public health system. Different cancer treatments can have several effects on different systems of the body, so managing the treatment implies handling a lot of information. The treatment is based on a series of procedures (image exams, chemotherapy sessions, blood tests, etc.) which require prescriptions and appointments, and have to be carried out in a specific order, and in certain amount of time (otherwise the probabilities of success decline). Navigator nurses actually manage the treatment for the patient, as they have the expertise to deal with both kind of complexities.

According to oncologist Bruno Nervi, president of the foundation Chile sin Cancer (‘Chile without cancer’), there are around 100 oncologists in Chile, when 400 are needed (55.000 people are diagnosed with cancer every year) (‘La Fundación Chile sin cáncer (…)’ 2018). Given the high number of patients, oncologists do not have the time to explain all the details of the treatment. The nurses working at the chemotherapy room face the same problem, as they try to fit in as many patients on a day as possible. The nurse navigators then, fill in this gap by educating the patient on the details of the disease and its treatment and mediate between the patient and the complex bureaucratical system of public healthcare in Chile. They make all the appointments for exams, blood tests and the like –which requires a lot of paperwork– and stay in touch with patient in case this has any doubt or question. These dedicated nurses constitute a human factor in healthcare that no app can replace. The nurse navigators, however, do use an app that is the most commonly used messaging app amongst patients: WhatsApp. According to the navigator nurses, WhatsApp gives them the chance to use various means of communication depending on the particularities and necessities of every patient: some prefer a phone call, some other need to see the info written in a text message, other will be reassured if they see a picture of the prescription or an exam order, some need an audio message they can listen to several times in order to understand the meaning (most of the patients are low-income people with low levels of education). Besides, nurse navigators are available for the patients for any doubt or question they might have. These nurses are there for them, to answer their questions and to comfort them, as the treatment and this relation of distant care can last for years.

Daniel Miller, principal investigator of the ASSA project, recommended in his last book ‘The Comfort of People’ on hospice patients and the use of new media, that it would important to create a patient/carer charter of new media use (2017: 218). The usage of WhatsApp by these nurse navigators actually follows a protocol which developed out of their experience in the last couple of years. I will attempt to describe this protocol and app usage and build up a model. I really hope it will be possible to bring this locally developed good idea to other public hospitals in Chile.

References

Devine, A. (2017, April 3). The Nurse Navigator: A Patient’s Compass On The Healthcare Journey. Retrieved from https://nurse.org/articles/nurse-navigator-career-path-salary-job-description/

La Fundación Chile sin cáncer y su contribución para cambiar la historia del cáncer en Chile. (2018, October 15). Retrieved from https://www.uc.cl/es/la-universidad/noticias/31765-la-fundacion-chilesincancer-y-su-contribucion-para-cambiar-la-historia-del-cancer-en-chile

Miller, D. (2017). The Comfort of People. Cambridge: Polity Press.

Pype, K. (2017). Smartness from Below: Variations on Technology and Creativity in Contemporary Kinshasa. In C. C. Mavhunga (Ed.), What Do Science, Technology, and Innovation Mean from Africa? (pp. 97–115). Cambridge, Massachussetts: The MIT Press.

Living alone vs. loneliness: Notes from a Milanese neighbourhood

ShireenWalton1 September 2018

Photo (CC BY) Shireen Walton

One of the key features of living in Milan are the characteristic apartment buildings (pictured below). Built in the early 20th century, these buildings, known as ‘palazzo’ (palazzi pl.), have housed generations of families, groups and individuals over the decades; Italian and non-Italian, working and middle-class.

Typical apartment buildings in the Milan fieldsite. Photo (CC BY) Shireen Walton

Photo (CC BY) Shireen Walton.

Living here, in an inner-city, multi-ethnic neighbourhood in Milan, I am struck by how many people I have come to know who live by themselves. My findings reflect official figures on single-person households, which are increasing exponentially within Europe [1] (a majority being in northern European countries), as well as globally, as witnessed in countries such as Japan, China, and Brazil [2]. In 2016 in the EU, single-person households accounted for almost one third (32.5 %) of private households, with a higher proportion of women (18.4 %) living alone than men (14.1 %) [3]. In Italy, the national average for people living alone is 31%, while in Milan, 52% of households consist of one person [4]. Among a number of explanations for people living alone through choice and/or circumstance are; a number of socio-economic changes over the last 60 years, shifts in work and lifestyle patterns, higher separation and divorce rates, evolving gender roles, and a potent legacy of 1970s Italian Feminism in challenging normative expectations of nuclear family models.

In light of this increasing trend, ethnography can help question some common assumptions about people who live alone – namely, that such people are alone in their lives. In her monograph (2015) on the subject of Italian women above the age of 45 living alone in Milan, Sociologist Graziella Civenti, based on a sociological study of 250 women, found that through a variety of collective ties, practices, and networks, such women establish intricate care and exchange networks that carry out many of the social and economic functions traditionally carried out within and by the nuclear family structure. In so doing, they are able to establish a functional sharing economy that is mutually sustaining and nurturing based on the premise of solidarity, mutual assistance, and attending to common problems [5].

Civenti’s findings resonate with my own unfolding research here in Milan, on ageing and smartphones amongst Italians and migrants, where among my informants who live alone, there is a similarly strong emphasis on the role of networks, of various kinds, on- and offline, in offering care, comfort, and physical/virtual participation in various contexts. To take two brief examples to illustrate:

Claudia (Italian) is 54. She originally moved to Milan from a nearby northern Italian town to study, work and to ‘escape her family and close-knit life’. Claudia lives alone in a palazzo building in a central part of the neighbourhood. She is separated from her husband, and has no children. She works full time at an administrate job in the city. Her Mother (late 70s), who she duly visits every weekend, lives in another northern Italian city. Claudia’s next-door neighbour is a female widow, Clara (84) whose two children live in other cities across Italy, and who she sees infrequently due to their busy lives. What once started out as a co-sharing of responsibility of watering each other’s pot plants on the balcony of the floor in which they live, eventually blossomed into a friendship over the 15 years the women have lived side-by-side. Claudia describes Clara as her ‘go to person’ for many things:

“If one day I was to have a fall, or pass out on the floor, it would be Clara who would notice first. She would notice my absence; my leaving for work in the morning, my coming home at night… family/friends wouldn’t notice for days, even weeks. Clara would go around to check on me. I’ve given here a key of course. I also have hers.”

The relationship between the two women now constitutes a kind Mother-daughter one; one that has been gradually crafted through a mix of neighbourly goodwill, as well as a cross-generational female bond nurtured through mutual care giving and receiving.

For other women in the neighbourhood, such as those living alone away from their home country, the issue takes on different dimensions.

Zaina (35) is from Tanzania. She lives alone with her two-year old daughter in a small apartment obtained through the help of social services. Zaina left her country two years ago in the hope of what she envisaged to be better economic opportunities in Europe. Her husband (also Tanzanian) is currently working in another African country. She is in contact with him, and her Mother back home, via WhatsApp. As an outsider to many of the social and ethnic groups here in Milan (most of the Tanzanian people she knows in Italy are in Naples – she is connected with them via a WhatsApp group), Zaina explained how she can feels lonely sometimes. With a young daughter that she has been told is too young to attend some of the local nurseries, searching for a job proves challenging. However, due to various on– and offline practices, Zaina described how she is ‘never really alone’. Her smartphone, providing she has credit on it, keeps her company. It connects her to family back in Tanzania, and to siblings living in other European countries. From time-to-time, Zaina attends community events at the public school in the park near to her apartment, where she can be around other Mothers, celebrate festivals such as Eid, and connect with the wider community, including attending Italian language classes. Unlike Claudia, for Zaina, it is not the apartment building space that provides the community feeling she finds so comforting, but the exact opposite – it is through her reaching out beyond the confinement of the apartment – to wider spaces in the community, and online to social media – that she feels she and her daughter are present and to varying degrees, cared for, both in Milan and back home in Tanzania.

Photo (CC BY) Shireen Walton

There therefore seems to be a complex sociological relationship between living alone and loneliness that I am exploring through my ethnography. I am beginning to see how in various spaces (social, geographical and digital) of/for care, people who live by themselves co-construct wellbeing through everyday acts, through which they craft themselves into social worlds, on- and offline – from the next-door-neighbour chats, to family/culture-linked WhatsApp groups, and beyond. At a time in history when an increasing number of people are living alone, (digital) anthropological findings that emphasise everyday lives lived can help unpack societal prejudices and assumptions, such as the hyper-individualism of such people, or that living alone infers a person’s loneliness and/or alterity in society. Challenging these ideas may prove difficult in the societies themselves, but nuancing the issue further by taking into account a range of individual lives and practices, can have a number of implications for social policymakers, particularly when it comes to ageing populations such as Italy, with 28% of the population over 60, and 31% living da sola/o.

References:

[1] Eurostat, 2017: https://ec.europa.eu/eurostat/web/products-eurostat-news/-/DDN-20180706-1?inheritRedirect=true

[2] Civenti, G. (2015). Una Casa Tutta Per Sé. Indagine Sulle Donne Che Vivono Da Sole. FrancoAngeli, Edizioni.

[3] Eurostat, 2016 report: https://ec.europa.eu/eurostat/statistics-explained/index.php?title=People_in_the_EU_-_statistics_on_household_and_family_structures#Single-person_households

[4] Civenti, G. (2015). (Ibid.)

[5] Civenti, G. (2015). (Ibid).

[6] United Nations 2015 World Population Ageing Report