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

By alex.clegg, on 3 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

What lies in store for WhatsApp?

By Georgiana Murariu, on 26 March 2021

Fig. 1. A smartphone displaying WhatsApp’s logo. Photo by AARN GIRI via Unsplash

Since I joined the ASSA project as a public dissemination officer in late 2019, I’ve spent a lot of time discussing WhatsApp with the researchers in the group. Unsurprisingly, a lot of this discussion was actually on WhatsApp. The messaging service is probably the main way you communicate with your parents, siblings, and friends too, that is unless you live in China or the US, where the messaging app is not yet dominant. More than a quarter of the world uses WhatsApp, in fact – a few months ago, the Economist reported that the app was used by nearly 3 billion people. This is likely to continue going up as a result of COVID-19 moving more communications online.

WhatsApp is a key component of the stories, theories, and analysis contained in the monographs that will come out of the ASSA project, simply because it has become absolutely essential to communication between family members and is sometimes the primary reason for buying a smartphone in the first place, especially among those who are first-time smartphone users.

It is, as the ‘Global Smartphone’ book suggests, the heart of the smartphone alongside LINE and WeChat which are the dominant apps used in Japan and China respectively.

In this post, I want to reflect on some of the things I have learned about the messaging service through the first-hand ethnographic evidence coming out of this project and discuss its future direction of travel a bit, especially in light of two recent developments: attempts to better monetise the app, and the perceptions that the privacy of its users is becoming compromised.

Monetising WhatsApp

A few months ago, our colleague Marilia Duque forwarded us an article in the NYT that suggested that changes being made to WhatsApp by its owner, the Facebook corporation, could be an important hint as to the direction the internet was going in.

WhatsApp was purchased by social media giant Facebook in 2014, two years after it completed its purchase of photo sharing app Instagram. Since Instagram has become Facebook-owned, it has, over the years, introduced pretty radical measures for extracting revenue out of the app. Inextricably tied to influencer culture, the app has also recently placed the ‘shops’ feature front and centre and is generally known for favouring beautifully-designed, professional looking accounts in its algorithm. WhatsApp, however, is a challenge for Facebook, because in and of itself, the app does not make a lot of money (its initial £0.69 annual cost was dropped in 2015). WhatsApp operates without ads, in contrast to platforms like Instagram and Facebook. In many of the markets it operates in, especially if we are talking about countries where many mobile phone users have cheap, constant access to data, it has all but rendered SMS services redundant.

As it stands, Facebook owns a gigantic messaging service that a large part of the world’s population uses, which gives it a lot of potential power. However, it also owns a service that it can’t technically monetise in the classical sense. The goal was initially to have Whatsapp users communicate with banks, airlines and other businesses, and for WhatsApp to charge these businesses a certain fee to provide customer service infrastructure for them.

There have been attempts, here and there, to extract more revenue out of the app, including ‘WhatsApp Business’, a version that helps businesses interact with customers via chat, like in the example below, from the WhatsApp website. Although this feature is used in Brazil and India, it is not exactly globally successful (even if Brazil and India are big markets), and certainly not how the majority of customers would think to communicate with a business they’re buying from.

Fig 2. An example of how WhatsApp Business works. Photo credit: WhatsApp website.

This does not mean that the concept would not work if scaled up, or that users would reject it – indeed, the ASSA project found that in many fieldsites, WhatsApp use went well beyond communication with family and friends, and was used in very diverse settings, from setting up care for a relative, to helping oncology nurses in Chile orient patients and give them the information they needed to cope with the complexity of navigating oncology treatment.

Marília Duque, our researcher who did 16 months of fieldwork São Paulo, Brazil, has written about the potential of the messaging app to be used in healthcare settings – both between healthcare professionals, and healthcare professionals and patients. What she proposes is a response to the reality that in many countries, doctors already use WhatsApp in hospital and clinical settings, though not always openly. This has been happening in the UK for a number of years – WhatsApp is seen as a seamless way to get information across, eliminating the need to communicate through what are sometimes seen as ‘archaic’ NHS systems, though for now, this question is still surrounded by data-sharing concerns, especially because it involves patient data.

When it comes to businesses featuring on the platform in a more professional capacity, many are likely going to be treading carefully (although again, this varies country by country). The reason for this is that WhatsApp is already a large number of users’ people’s preferred app because there are no ads on it and for some, because it is end-to-end encrypted (though I am not suggesting everyone cares about this) and therefore its message contents fairly private. Being in this intimate space and meeting the user ‘where they are’ in an era in which people are increasingly less likely to visit a company website is desirable for many organisations/businesses, but it has to be well-calibrated to users’ preferences, and there is good reason to believe many WhatsApp users are resistant to advertising. While one might prefer to resolve an internet issue with a customer service agent over WhatsApp, certain commercial services might not be as ‘wanted’ in the same space where one shares news and details about their life with their family and friends.

Meeting users where they are and privacy concerns

There is another factor that influences people being on WhatsApp – at a certain point, it is no longer solely about the app’s features or how intuitive its user interface is, but about the momentum of mass adoption. In business terms, an sms-style app has the potential to make money through exponential growth: one person vouches for the app so the rest of the members of the group download it to keep in touch with that person. This then keeps happening until the app becomes indispensable to its base of users. In more ethnographic terms, the ASSA team often found that some research participants were more or less forced to get the app – whether due to family pressure, or because everyone else was using it, or because their friends simply wouldn’t invite them to things as often if they weren’t on WhatsApp. This happened across several fieldsites. It has been common in the recent history of media for companies to first focus on growth prior to finding a route to commercial success.

WhatsApp has become a conduit to more intimate, private conversations, having become the platform of choice for both those who are tech-savvy, as well as those who are just getting used to their first smartphone. In some cases (including personal anecdotes I’ve been privy to), WhatsApp extends digital literacy to people who are not necessarily very good with email: it is not uncommon for a recent smartphone user to say they will WhatsApp something, while at the same time finding attaching it to an email difficult. But is this because the app is particularly user-friendly to use? Or is it because, forced by circumstance, for example if working or living in different countries, users were forced to be on it because most of their friends were on there, which has imposed a sort of digital literacy on them? And what happens when media reports surrounding the new terms and conditions proposed by WhatsApp causes a significant drop in users, so much so that the company has been forced to postpone their implementation due to backlash? Although Whatsapp has said that the contents of its messages will remain end-to-end encrypted, many users have interpreted the prompt on their phones asking them to accept the new terms as a sign that parent company Facebook will be able to access the content of those messages. What WhatsApp will be able to collect, however, is meta-data about its users: who they message, how frequently, and at what time (but without having access to the content of those messages). Alternative messaging apps such as Signal and Telegram are perceived as having benefitted from the fact that users tend to be more suspicious of WhatsApp due to it being owned by Facebook, as well as due to a general atmosphere of suspicion towards Big Tech.

As much as there is some talk of users moving to apps like Signal or Telegram (both plagued by their own problems, related to potentially being used by extremist political groups to organise), WhatsApp has become the medium through which a large proportion of the world communicates privately. This encompasses not just messages that set up meetings between friends or help people keep in touch with family members, but much more than that. WhatsApp chats have been used in court to present evidence (and such evidence is precious when the accuser/victim has not backed up their claims via another, more official channel, like email), to organise shifts in professional settings (sometimes disadvantaging those not using the platform), and even to provide the members of political groups with a place to organise operations.

It is hard to predict the future, but at the same time, it is difficult to believe that in a short space of time, users whose lives are effectively currently stored on WhatsApp will make the move to alternative apps (that is, if they even care about what data is collected about them in the first place). Adopting a new communication channel, if the mass momentum isn’t there – is just not worth it. As it stands, I currently have two friends on Signal and if I were to choose to move away from WhatsApp, I would have to persuade my entire family to join me. As we know, getting large amounts of users, not all of whom are tech-savvy, to download and install a new app is not without its hurdles.

You can download a list of the sources I linked to in this blog post here.