One of the biggest challenges facing the healthcare system in Japan today is a rapidly ageing, rapidly shrinking, population. One-quarter of the population of 127 million are over the age of 65 – the world’s highest proportion – and this is predicted to rise to 30% by 2025 (National Institute of Population & Social Security Research [NIPSSR], 2012). According to the World Health Organization, Japan ranks first in the world for the highest age to which a person can expect to enjoy good health: 74.5 years old. Only about 12% of the elderly (those aged 75+) population require long-term care, of which about 4.3% are institutionalised, while the rest live at home and receive care from family and health professionals (Thang, 2011). The healthcare system in Japan is covered by a national health insurance plan focused on preventative medicine through the practice of annual health check-ups. Since the early 2000s, health checks have been delivered for all age groups, and age-appropriate tests are performed for each age category.

In my ethnography of a rural health check in Tosa-cho, Kōchi Prefecture, the patients were generally very positive about their experience of coming to the health check every year, and said that it helped them feel motivated to stay healthy by giving them goals. Each patient brought with them a personal booklet which the doctor would write their notes in, as well as affixing a photograph of the patient with the doctor (which you can see in the video above). These booklets helped the patients to track any differences in their test results year on year, and to help them know which areas they had to work harder to improve such as though dietary modifications. Self-tracking in this case was low-tech, but its motivational power was clear.

The video above is narrated by Dr Kimura Yumi from Osaka University, one of the doctors who co-ordinate this health check for over 75s which has been running for 15 years. The health check was established when the town’s head councillor wanted to improve the health of ageing residents through preventative medicine. He invited doctors and researchers from different universities around Japan with the aim to identify key factors affecting the health of elderly people. This type of community “field medicine” (フィールド医学) is a relatively new practice in Japan, and inviting researchers to the Kochi health check up was the first such attempt among geriatric people both domestically and internationally (Matsubayashi and Okumiya, 2010). The annual community-based health check in Tosa-cho appears to have been successful in terms of reducing medical costs for geriatric care. The medical expenses for the elderly there between 2004 and 2007 were reduced, compared with Motoyama-cho, a neighbouring, similar sized and similar environmental control town, as well as compared with Kochi City and with the average medical expenses of 35 towns in Kochi Prefecture.

After my participation in the health check I returned to this community regularly over the subsequent eight months in order to get a better understanding of people’s lives and wider attitudes to health and wellbeing. My long-term ethnographic research in the community found that people continually emphasised the importance of food and social connection for maintaining health. Indeed many said that they came to the health check each year precisely because of the opportunity to catch up with friends. This finding led to the development of a digital health project in partnership with Dr Kimura and Sasaki Lise which is still ongoing. This project was designed to see if participating in chat groups via the messaging application LINE could improve quality of life among elderly participants.

Because of the coronavirus pandemic, the health check did not run in 2020. However, the crisis prompted innovation: the local town hall were inspired by our digital health project to create their own version in which they connected residents via LINE (the most popular messaging app in Japan). Residents who signed up to the buddy scheme via LINE were then rewarded with a meal at the town hall with their chosen ‘buddy’ – all in a socially distanced and covid-safe manner. Even though digital forms of care are only just emerging among elderly people in this rural town, it is already clear that they are going to be integral to how care is organised in the future, well beyond the pandemic.

National Institute of Population and Social Security Research [NIPSSR], (2012). Nihon no shorai suitei jinko [Population projection for Japan] Accessed 01.08.2018 <http://www.ipss.go.jp/site-ad/index_english/esuikei/gh2401e.asp>

Matsubayashi, K., & Okumiya, K. (2012). Field medicine: a new paradigm of geriatric medicine. Geriatrics & gerontology international, 12(1), 5-15.

Thang, L. L. (2011). Aging and social welfare in Japan. Routledge handbook of Japanese culture and society, 172-85.

(@Jornal do Sudoeste: http://www.jornaldosudoeste.com.br/noticia.php?codigo=105255)

In Portuguese, the term “gambiarra” is used to describe someone fraudulently tapping into the electricity supply. In everyday life, the word also refers to an improvised solution that was achieved with limited resources. In that sense, “gambiarra” is an exercise of creativity. I have previously talked about my experience teaching old adults in a WhatsApp course aimed at the third age in Sao Paulo, where I conducted my fieldwork. In this post, I will address how I taught them to do a “gambiarra” on WhatsApp. My goal was to turn WhatsApp into a diary that could help them in their daily tasks, from shopping to managing their intake of medication. This idea came from my observation that students usually bring pen and paper in order to take notes and systematise what they learned. Their notes were basically step-by-step lists that conveyed the information they received that day in the more linear way of thinking they were more familiar with. Moreover, writing things down was also a strategy they used in order to remember what they learned.  During the course, I noticed that they used this strategy not only for the WhatsApp classes but also to help them to remember what they have to do, where they have to go and how to get there.

I could have taught them to use an app designed for that purpose, such as Note or even Calendar. However, among these students and among my research participants in general, WhatsApp is the app they feel most comfortable with, as this is where their conversations with family and friends take place. Therefore, the choice to build a diary on WhatsApp would avoid any constraint related to the adoption of a new app. In other words, the diary on WhatsApp would be ready-to-use, as my students were already basic Whatsapp users. Whatsapp doesn’t have a diary functionality, so we then started our “gambiarra”. The idea was that each student would add their own contact on WhatsApp, so they could start a conversation with themselves (which would be enhanced by features like audio messages and photos). There are two ways to do this and no guarantee as to whether which of them will work, as it depends on the device students have. The first way to do this is to add yourself as a contact by saving your own phone number under ‘Contacts’ and then search for the name you have given to this contact and to start a conversation with yourself. When this option fails, you can ask someone to share your contact with you on a conversation or on a group on WhatsApp you have access to. You will then have the option to click on “message” and you will be able to start a conversation with yourself.

Option 1 (left) and Option 2 (right): starting a conversation ‘with yourself’.

I also gave students a bonus. After the “gambiarra” was done, I taught them to “pin” this chat on the top of the WhatsApp conversations list, so they could easily access their diaries.

The diaries on WhatsApp could help them in multiple ways. They could create their shopping list directly on the app. They could do so by typing the items, they could use the audio to record them and they could also take a picture of the list they had on paper.

Examples of a shopping list on WhatsApp Diary: text message, audio message or picture

Taking pictures is a powerful resource for registering, organising and accessing information they come across during their daily routines. Like any of us, older people may also use the WhatsApp camera to record a particular street name they want to remember for later reference, the bus they intend to take or the useful phone number they might want to use later to have pizza or even medication delivered.

WhatsApp Diary used to remember a street name or a location.

WhatsApp Diary used to register information about public transport.

WhatsApp Diary used to take note of a useful telephone number.

Keeping diaries on WhatsApp can also be used for self-care. Older people can type or use voice messages to register a particular symptom or event they want to report to their doctors, like a day when they felt dizzy, for example. WhatsApp can help them make a note of these events, plus the app automatically registers the date and time when the event was reported.

This functionality can also help older people manage their medicine intake. My mother’s case is one example of how this works. She is in her late sixties and has to take a pill to manage a chronic condition every day, as soon as she wakes up. This allows her to then start her day. The problem was that sometimes, she was not sure whether she had already taken the pill or not. Together, we decided to do a “gambiarra” on her WhatsApp, so she could have her own diary to manage her pills. Since then, as soon as she takes her pill, she sends a message to herself. The message (“okay”) is registered there on her WhatsApp diary together with information about the time and date, which she can access anytime she is not sure whether she has taken her pills that day.

In that sense, the use of WhatsApp for health purposes can itself be seen as a “gambiarra”. WhatsApp was not designed for health purposes, but its functionalities can be used to deliver and improve care. This requires improvisation and creativity, but also a pinch of empathy. Especially among older people, exploring the apps they are already comfortable with can save them time and effort in adopting new technology.

WhatsApp can actually be a time-saving and low-cost tool whatever the target audience and objective is. That is why the use of WhatsApp for health can become more than a “gambiarra”, that is spontaneously adopted due to a constraint on resources. Indeed, as I observed in the Brazilian health landscape, there is a shift in Whatsapp use from informality to formality, as it is also used by doctors, clinics, hospitals and health insurance plans as their institutional channel to communicate with patients. You can read more about these examples in my book “Learning with Whatsapp: Best Practices for Health”, where I describe different uses of WhatsApp for Health based on what I observed during my ethnography in São Paulo. You can find out more about the book here, and download it free here.