Text: Interview by Erik Freudenreich
Photo: Heidi Diaz - Service d'appui multimédia (SAM)

"Points and icons are not enough to change our behaviour"

Psychologist Maria del Rio Carral studies the impact of smart devices on health. For this issue of In Vivo, she talks about issues surrounding these technologies.

Today, over 300,000 applications related to health—whether in terms of diet, sleep, sex, or exercise—can be downloaded to your phone. The market is predicted to be worth 151 billion Swiss francs by 2025 according to a study by Grand View Research. Aside from these astronomical numbers, what is the real impact of these tools on users’ health? Can they help solve current public health challenges? Maria del Rio Carral, a researcher in health psychology, published a series of scientific articles that analyse the phenomenon, which has grown exponentially in the past decade. In her interview, she details the hopes and fears raised by the quantified self.

What exactly is a smart device?

In healthcare, it refers to the use of a smartphone to collect physiological indicators about the body, which are then turned into digital data that are processed by an application. The application uses algorithms to provide immediate feedback about the user's health while also comparing him or her to other users. By calculating the number of steps the user takes in a day, the amount of calories consumed, and the quality of his or sleep, this tool raises all sorts of questions, including the sometimes murky divide between health and sickness. Should a person be considered “unhealthy” if he or she isn't physically active and doesn’t use a food tracking app on a regular basis?

These technologies are still too recent to understand their societal impact and their effect on the definition of health and disease. What is clear is that these data are creating a norm.

Insurance companies are often the most vocal advocates for these kinds of applications.

Some insurance companies have started treating smart devices like guardians and guarantors of "good health". However, I don't think these technologies are sufficient to meet the complex health needs of today’s society.

The underlying logic of these devices is based on a purely individualistic motivation.

They use the same reward and self-efficiency systems that have long been used in health psychology through an approach aimed at changing an individual’s behaviour. For example, if you think you are capable of stopping smoking, you are more likely to succeed. However, these models treat behaviours as if they could be isolated from other social practices, which always take place within a specific context. Smoking also makes us want to drink a glass of wine—a habit that can in turn make us want to watch a film instead of exercise. Some specialists think it would be more effective to target social practices instead of empowering individuals.

What is the most surprising finding that has come out of your research so far?

Two-thirds of the people who participated in one of our surveys reported they did not own a smart device or wanted to use one in the future. This was even more surprising given that we had conducted the survey during a Planète Santé trade show, which focuses on digital health. Some people reported they would be willing to use one if they were sick and had been prescribed one by their doctor. Clearly, it is very difficult to promote health in our society.

People often wait until they are sick or at risk before they change their attitude.

This points to humanity’s complexity. Individuals’ behaviours are inevitably social and anchored within a culture, a moment in time, and their own personal history. That’s something that technology has not yet been able to take into account.

Who is using these kinds of tools today?

There are four main categories of users. The first includes patients who use these devices to manage a chronic disease and monitor their symptoms and vitals on a daily basis due to the state of their health. The second is made up of athletes, who use the data to measure their performance. The third is made up of "average Joes" who, out of curiosity, want to change a specific behaviour or improve their performance. Finally, there are the followers of the quantified self movement, a practice that consists of collecting as much data about yourself as possible in order to optimise your day-to-day life and improve your understanding of yourself.

In Switzerland, as part of the survey we conducted at Planète Santé, around 50% of users we spoke with indicated they used smart devices to measure their physical activity. Twenty-three percent used them to manage their diet, 11% to monitor a chronic disease, and 16% for other reasons, which included contraception, measuring their blood-alcohol level, or sleep.

A large percentage of users stop tracking their data after a few months. Why is that?

The promoters of these objects and other stakeholders in the healthcare industry believe these new technologies will revolutionise our lives. However, our behaviour cannot be easily changed when points and icons are our rewards. It’s a great idea to count your calories, but how will you navigate that next invitation to a restaurant or a dinner at a friend’s house? As part of a study on women using an application to lose weight, we noticed that some were deciding to not use it on the weekends. Others chose to use it in secret by not showing others that they were using it every day or by not sharing their data with the virtual community. We also noted that the devices were being used in a wide variety of ways. When they were experiencing a temporary bout of depression, for example, people tended to store the device in a drawer instead of using it.

You reviewed what the scientific literature had to say about smart devices . What did you find?

Right now, most scientific authors in the field are enthusiastic about these devices. They hope the technology will offer a solution to major public health challenges, especially by reducing costs by encouraging people to manage their health themselves.

The existing literature tends to posit that we will use these devices in the future to share more about who we are and understand ourselves more thoroughly.

This idea assumes that people want to change their behaviour and improve their health. However, a minority of researchers from the fields of sociology, philosophy, anthropology, and sometimes psychology are more critical of these technologies and their ability to infringe on private life. By giving our data to major companies like Apple, we are working for them in a sense. Some of these authors criticise how these devices standardise our behaviour. Could this normalisation create a risk of exclusion or even lead to higher insurance premiums for those who refuse to track their data?

Some authors denounce society's obsession with "healthism". Why do they mean by that?

This term, which was coined by the American economist Robert Crawford, refers to the importance we place on being healthy—to the detriment of other aspects and activities of daily life. As a result, anyone who doesn't make health the focal point of their life is considered abnormal in today's society. Health, which should be the choice of each individual, has become everyone’s business. We are constantly bombarded by messages telling us we should eat well and stay healthy.

Some authors believe this push towards "healthism" can provoke the opposite response. Some people will continue to smoke their daily pack of cigarettes to repudiate these rules.

Are we at risk of creating a "wellness dictatorship"?

Absolutely. Several recent psychology studies have shown the impact of social media platforms like Facebook and Instagram on dietary norms and the idea of the "perfect" body, depending on gender, especially among young adolescents, who are potentially even more vulnerable.

How do smart devices affect doctors?

Technology can certainly help advance the "4P" (personalised, preventative, predictive, and participatory) approach to medicine. However, doctors must introduce these technologies to patients as part of a gradual education and socialisation process, in the same way they would explain a medicine’s secondary effects. Over the past few years, the use of medical implants has grown. These technologies are used to constantly monitor patients with diabetes or heart risks, for example. One of the many unanswered questions about these technologies is whether or not doctors will have enough time to study the data of all their at-risk patients. My goal is to explore this topic through an upcoming research project on cardiovascular disease.



Maria del Rio Carral holds a doctorate in psychology and is the author of several studies on the use of digital technologies in healthcare.
The young Swiss-Mexican researcher is currently a lecturer at the Psychology Institute at the University of Lausanne.