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Applying ethnography to digital health aims; challenges and opportunities

charlotte.hawkins.1710 August 2019

Author: Charlotte Hawkins

Photo (CC BY) Charlotte Hawkins

How can a holistic ethnographic understanding of ageing experiences, particularly related to health mobile phone engagement, contribute to an mHealth initiative and improve the accessibility of health services and information through mobile phones? This applied challenge in the ASSA project has initiated partnerships with digital health practitioners in most of our fieldsites – in particular, with collaborators working within existing phone practices. This aligned with our early finding across the fieldsites, that mobile phones are commonly used for health purposes, but through communication on apps evidently most popularly used, such as calls, Facebook and WhatsApp. In Kampala, I worked with The Medical Concierge Group (TMCG), a medical call centre founded by Ugandan medics to improve the accessibility, affordability and quality of healthcare. They offer a 24-hour toll-free phone line, SMS, WhatsApp and Facebook access to a team of doctors and pharmacists and have 50,000 interactions each month. At the time of fieldwork, they were in the process of researching the development a psychiatric call line, or ‘telepsychiatry’. This early stage of service development meant that TMCG were interested in and able to accommodate holistic ethnographic insight in their considerations.

Ethnographic insights included systematic information on 50 low income research participants’ existing mobile phone and mobile health practices as relevant to accessing TMCG services. For example, access to airtime and data is intermittent, with a tendency towards regular low-cost subscriptions. This suggests that calling or using the internet could be inaccessible to users at least once a day. Furthermore, 54% of participants had made health-related calls in the last month, and 27% of their previous three remittances were for health purposes, which confirmed an existing propensity to use mobile phones to support family health – but only across their own network of friends and relatives. Interviews with 50 respondents encountered during the wider ethnography also offered TMCG feedback on mental health perceptions, experiences and help-seeking preferences. These interviews were predominantly with older people, mostly older women, who would not typically opt to engage with research on mental health, and yet who represent an advisory position within their family or community. This also included interviews with health workers, including psychiatric clinicians at the local government hospital, and private health clinicians within the fieldsite. Research showed that treatment for mental illness was perceived to be unavailable, costly, or stigmatised. Often respondents said they prefer to handle mental health problems through prayer or counselling within their community, with hospital treatment sought only once problems become severe. This suggested that optional, confidential, accessible or community-based mental health services could be useful for low-income people in Kampala, if advertised accordingly.

Initially, the wide-reaching interview responses were considered thematically, from causality to treatment seeking, and condensed into representative quotes for presentation back to the team. More recently, alongside the team, these themes have been expanded to inform a draft publication in psychiatric journals, which TMCG hope to use seek further funding. We also hope to further disseminate findings in accessible formats amongst other digital and mental health service providers in Kampala. As familiar to many applied medical anthropologists, translating interpretive, subjective and relativist ethnographic information within positivist, objective and universalist medical paradigms brings challenges, such as risking that complex human experiences and perceptions are reduced into ‘practical’ or digestible concepts (Kleinman, 1982; Scheper-Hughes, 1990). However, this assumes that the health practitioners and their discipline are not open to understanding their patient’s everyday realities, which has not been the case in this instance, perhaps reflecting a particular affinity between anthropology of digital health – appropriation of phone based health services is entirely dependent on their relevance and usefulness for their target populations.

The on-going collaborative process has also highlighted what anthropology might learn from the research and writing processes of health disciplines, for example: ensuring findings are widely disseminated and thus accessibly written; avoiding anecdotal, emotive or biased claims; and ensuring that quantitative statements, “many people said xxx”, are qualified and backed-up. The collaboration has  also confirmed that the flexibility of anthropological research and richness of qualitative insight potentially has much to offer health programmes, to ensure their contextual relevance. In ethnographic research, we have the privilege of time, which comes with in-depth insight, and familiarity with the community – time and understanding which we can offer usefully to other audiences. The data provided can perhaps confirm a hunch of a practitioner from the area but can also surprise them. When documented and publicised, the data encourages practitioners to both tailor their approach, but also allows them to share the specific requirements of their target population, encouraging others to do the same – or hopefully even to offer funding to support them.

 

REFERENCES

Scheper-Hughes, N. Three Propositions for a Critically Applied Medical Anthropology. (1990) Social Science & Medicine 30 (2): 189-97.

Kleinman A. The teaching of clinically applied medical anthropology on a psychiatric consultation-laison service. In Clinically Applied Anthropo1ogy: Anthropologists in Health Science Settings (Edited by Crisman N. and Maretzki T.) Reidel. Dordrecht, 1982.

 

“Blame the phone!” UI design and elderly smartphone users

Alfonso Otaegui12 August 2018

Photo (CC BY) J Stimp.

As I mentioned in my previous post, a first step in my ethnography of the experience of ageing and the use of smartphones involved volunteering at a cultural center in the working-class neighborhood where I am living in Santiago de Chile. For a couple of months, I have been a teacher’s assistant in two workshops on the usage of smartphones aimed at elderly people. In these workshops lasting for four weeks, enthusiastic grey-haired students learn the basics of smartphones settings (unblocking the phone, connecting to Wi-Fi, turning on and off the GPS, flight mode and the like), how to use the Camera app, Whatsapp and Google Maps.

In addition, for a couple of weeks, I have been giving a complementary workshop by myself, for those who have already finished the main workshop. This complementary workshop focuses on repetition and exercising: students have the opportunity to practice in more extended periods of time what they have learnt in the first workshop, and to go step-by-step over and over again. This complementary workshop has given me the opportunity to be in more frequent contact with the students, and to become more familiar with their struggles and their success in mastering this nowadays pervasive new device. Many of the difficulties I noticed have been also spotted by my colleague Marilia Pereira in her field site in Brazil.

One of the most common feelings expressed by the students at the beginning is frustration: the phone doesn’t do what the teacher has just shown, the screen goes off all of a sudden, or cryptic warnings pop up, among other things. In my short experience so far, the most common —yet invisible— difficulty lies in the touch interface. Many elderly students find it difficult to distinguish between a ‘tap’ and a ‘long press’, and they tend to do a ‘long press’ when a ‘tap’ is required. I believe it is related to the lack of self-confidence when using the smartphone: they press the button long enough to be sure they are pressing it (as with a door bell). The problem though, is that the long press is a different input and therefore produces a result other than the expected one. Another difficulty lies in hitting the exact right spot on the screen, as, again, a slight miss has a different outcome (e.g. on Android’s Whatsapp’s chats menu, hitting the contact picture will show you that picture, hitting just a little to the right will open the chat), contributing to the general feeling of frustration.

Another common experience is the feeling of being overwhelmed by the vast array of menus, gestures, and different ways to do the same things on the smartphone. Having shared many classes with these elderly students, I started to grasp the experience from their point of view. Considering the difficulties of the touch UI, the diversity of Android iterations, manufacturer’s software skins, etc., I can see how complex and overwhelming this experience might be. All the functions of the phone seem chaotic to me now: there is no clear logical hierarchy in the arrangement of apps and functions. Most of the students do not recognise the difference between the home screens and the app drawer (the majority have Android devices), especially when the wallpaper in the app drawer is the same as on the home screens (but, adding to the confusion, this does not happen with every phone). One old man did this to access the camera: instead of tapping the camera icon on the home screen, he would tap the app drawer icon, and then the camera icon inside the app drawer. Furthermore, as the teacher of the main workshop pointed out, they expect to learn the ‘one way’ to do something on the phone, while multiple ways are possible (and sometimes these are needed, when one of the ways does not work).

In these situations of frustration, they tend to blame themselves (“I don’t understand technology” or “my head is not good for this”) as they judge themselves unable of learning the intricacies of this device, which seem evident for their grandchildren (who don’t have the time nor the patience to teach them). Having experienced this frustration myself when trying to teach a simple procedure to a new student whose specific smartphone model I have never used, I wish they would allow themselves to blame the phone now and then (I certainly do). Sometimes the interface is not as intuitive as it should be, sometimes too many shortcuts stay in the way and sometimes there is no visual cue on where to tap (the flat design of previous years has made this worse). However, I must say that they blame the phone sometimes, but in the most radical way: ‘this phone does not work’ (therefore, it must be changed). This has happened when they had accidentally left the phone in flight mode or silent mode, and they were unable to either receive phone calls or hear them, respectively. It is as if they could see the problem only in themselves or in the hardware (the phone as a device), while the software (and UI design) remains a blind spot. The interface is there, yet it goes unnoticed.

All in all, this is just the beginning of a long path for these new old beginners. It will be interesting to see if, as the workshop progresses, these engaged learners build up more self-confidence and make their way through the garden of forking paths of mobile UI.