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An Anthropological Approach to mHealth: Health & Care in the Smartphone Age

alex.clegg3 March 2022

Open access image by Mohamed Hassan

Author: Charlotte Hawkins

As part of the ASSA project, we are currently working to publish a volume called: ‘An Anthropological Approach to mHealth: Health & Care in the Smartphone Age’. This volume consolidates insights from the team’s various anthropological initiatives in mobile health or ‘m-health’ – health-related uses of the phone – in diverse settings around the world. Drawing from an ethnographic perspective, we seek to contribute an anthropological understanding of mHealth, a growing industry often otherwise dictated by top-down priorities such as bespoke app creation. Instead, building from our own ethnographic insights about older people’s everyday uses of phones, and other studies stressing the evident importance of ‘informal mHealth’ (Hampshire et al., 2021), we illustrate a ‘smart-from-below’ approach which prioritises the everyday appropriation of phones and existing communicative apps for health purposes. We analyse the failures of conventional mHealth initiatives and the emergence of our alternative perspective, and how that led to several initiatives in which team members were themselves involved.

In this book, we offer a grounded ethnographic picture of mHealth in our various research contexts, with a view to broader global trends in population ageing, health and economic crises, the Covid-19 pandemic, declining public investment, increasing phone access, and global migration. This shows the potential of prioritising the everyday appropriation of mobile technologies in line with both social change and longer-standing care norms.. This is intended topromote an anthropological approach to support the relevance and effectiveness of mHealth going forward. We have already created a free online course (available here) for those interested in the topic but hope that the book will benefit other medical anthropologists and ethnographers interested in digital health, as well as digital health practitioners interested in social research around the design, implementation and evaluation of their work.

We have organised the book into three parts, reflecting what anthropology can offer for contextualizing, analysing and informing mHealth. Part one consists of three chapters concerned with contextualizing mHealth;

  • Xinyuan Wang on mHealth practice in mainland China;
  • Shireen Walton on visual digital communications about health during covid in Italy, and
  • Laura Haapio-Kirk on social self-tracking in Japan.

This is followed by contributions analysing mHealth:

  • Daniel Miller on googling for health in Ireland, and the ways it exacerbates existing disparities;
  • Patrick Awondo on the failures of various mHealth initiatives in Yaoundé, Cameroon; and
  • Pauline Garvey outlining the uses of phones to seek information and support around the menopause in Dublin, Ireland.

The volume concludes with three chapters informing specific mHealth initiatives:

  • Alfonso Otaegui’s recommendations for scaling the ‘nurse navigator’ model in public oncological clinics in Chile;
  • Marília Duque’s protocol for meal-logging and WhatsApp communications in Brazil; and
  • Charlotte Hawkin’s and John Mark Bwanika’s work on a digital mental health programme in Uganda.

Taken together, the volume seeks to provide a grounded ethnographic discussion on the challenges and opportunities of anthropology for mHealth, and of seeking health and care in the smartphone age. We aim for publication in 2022 with UCL Press, follow ASSA on Twitter, Instagram and Facebook to keep updated.

References

Hampshire et al. (2021). Informal mhealth at scale in Africa: Opportunities and challenges. World Development, 139:105257, 1-23

The ‘new sandwich generation’ in urban China

alex.clegg14 February 2022

Author: Xinyuan Wang

The recently released seventh national census in China shows that today’s China not only has one of the lowest fertility rates in the world (on average Chinese women are expected to have 1.3 children each throughout their lives, compared to the UK  where in 2020 it was 1.58), but also is facing ageing crisis where 149 Chinese cities are now classed as ‘deep ageing’. What do these figures mean to ordinary Chinese households? What does that mean to the very experience of ageing among older people in China?

As observed during my field work in Shanghai, a striking feature of this older generation in China is, what I call, a ‘new sandwich generation’. The concept of a sandwich generation used to refer to middle-aged people who are burdened by taking care of their young children and parents. But what is the new sandwich generation? To show what this means for ordinary Chinese people, I would like to introduce one of my key research participants Fangfang and her four-generation family.

Fangfang’s four generation household. Infographic by Xinyuan Wang

As shown on the chart, Fangfang is the second generation compared to her 89-year old mother, represented by the top bar. Fangfang’s daughter, the third bar from the top is 36, and has two young children, aged 9 and 2, who were born just after the thirty yearlong one-child policy was abolished in 2015.

Fangfang’s mother Hui was born in 1929 and belongs to the generation that suffered long periods of war and poverty. Hui fled into the former French concession in the city centre with her family to avoid shelling when Japan invaded Shanghai in 1937. During this period of time (from 1937 to 1949) the Sino-Japan war and civil war took place in China. For a brief period, life for Hui seemed to be less constrained as she married into a relatively well-off family, however, soon after the establishment of communist New China, the family business started to decline. All private businesses were cracked down on becoming state or collective owned and whole households were persecuted during various political struggles.

The second daughter in her family, Fangfang was born in 1949, just after the revolution. In the 1950s, the Party encouraged high fertility rates, as the population was regarded as the essential force of revolution and production, and women with many children were officially rewarded as ‘honourable mothers’ (guangrong mama). Despite limited life resources, Hui gave birth to seven children (from 1948 to 1965) and six of them survived to adulthood. During her childhood, Fangfang witnessed how her mother struggled to raise young children during a time of pervasive scarcity and uncertainty, and how her young brother, who suffered from congenital heart disease, only survived seven days due to the lack of medical treatment in 1950s.

Fangfang’s own life changed drastically when the Cultural Revolution started. All the schools closed, and urban youth nationwide were sent to the countryside to receive education from farmers. In 1966, when 17-year-old Fangfang said goodbye to her family in Shanghai, she did not expect she would be ‘stuck’ in the countryside for 12 years. In 1978, when Fangfang finally got transferred back to Shanghai, working in the factory where her father used to work, she was already 29 years old, she then married one of her former neighbours, and their daughter Lan was born in 1982.

Lan was the only child in the family, since the one-child policy had been enforced since 1979 in urban areas. Lan was born in a rather different era, when the egalitarianism that characterised the period of the planned economy had started to collapse because of the market-orientated economic reforms, which started in 1978. Fangfang clearly remembered how things were getting more competitive both at work and at Lan’s school.

When Fangfang’s granddaughter Joy was born in 2009, Lan only took half of her maternity leave and went back to work straight away to keep her promotion at work. At that time, Fangfang had just retired and in her words quite ‘naturally’ stepped into the role of being the mother of little Joy. In 2014, ‘only-child’ couples (meaning both the wife and the husband were the only children in their family) were allowed to have a second child in Shanghai and Lan gave birth to a boy in 2016. This time, Joy’s paternal grandmother (nai nai) had to come to help with raising the baby as Fangfang was too busy with taking care of the girl and her own mother.

According to ‘filial piety’ (xiao) principles found in Confucian ethics, adult children are supposed to take care of their old parents in order to pay back the ‘care debt’ they owe to their parents. Previously, in Chinese agricultural society, children were regarded as the ‘pension’ of the family. As the old Chinese saying goes ‘children are reared to provide support in old age’ (yang er fang lao). When Fangfang’s mother fell ill and needed intensive care, she made it clear that she did not want to be taken care of by non-kin so as not to ‘lose-face’, as that would suggest she raised ungrateful, or ‘unfilial’ (buxiao), children.

Therefore, Fangfang and her siblings, who are in their 60s and 70s have to take care of their mother in turns. Fangfang’s 70-year-old older brother fell ill himself because of the taxing labour of caregiving. He sighed,

‘You know in old days; I am already in the age of enjoying ‘filial piety’ from my children…but now I am still fulfilling ‘filial piety’ towards my mother. My mother is very fragile, but given medical treatments nowadays, she can easily live for another five years or longer…but I don’t know how long I can hold on…I am just emotionally and physically tired.’ 

According to Fangfang, all her siblings, including herself and her husband, can imagine themselves spending the last stages of their lives in a care home, being taken care of by care workers, so that their own children will be free of the ‘unbearable burden’ of elderly care.  They are pretty sure they will be the last generation in China to practice the traditional ‘in the way of providing actual elderly care labour. Another background fact is that, In China, the national pension scheme was first introduced in 1950s. In a way, retirement is an unprecedented life experience for the generations who lived in urban China.

‘We are struggling to take care of our mum, but at least we have siblings that we can share this burden with…it is 6 households with 12 people altogether, all taking care of one old person…our children are unlucky because they are part of the only-child generation…that is to say that at some stage, a couple with an only child will need to take care of old parents from both sides, which is four old persons. Can you imagine what kind of burden our generation will become to our children?’ Fangfang asked, rhetorically.

Furthermore, Fangfang thinks her daughter’s family could not even take care of their children without her support, not to mention their ability to support her in the future.

As Fangfang’s story shows, the new sandwich generation refers to retired people in their 50s to 70s who are simultaneously burdened with heavy care commitments for both their elderly parents and their grandchildren. This is partly a consequence of the extended life expectancy, the decades-long one-child policy, relatively early retirement, and the significantly improved health situation of older people. It is also an outcome of a multi-generational household strategy to deal with the intense social competition inherent in contemporary China. The situation of older people actively engaging with grandparenting is not unusual across the world as observed by the ASSA project, however, the heavy labour of care weighed on the shoulders of the older generation in urban China is rather pronounced. This is a vastly different situation from the connotations of ‘retirement’, which literally means ‘step back and rest’ in Chinese. In practice the experience is closer to the phrase ‘lean-in and be busy’, especially when taking care of both elderly parents and young grandchildren.