'Personal Health Surveillance': The Use of mHealth in Healthcare Responsibilisation

Users' Perceptions and Trust in AI in Direct-to-Consumer mHealth: Qualitative Interview Study

BACKGROUND

The increasing use of direct-to-consumer artificial intelligence (AI)-enabled mobile health (AI-mHealth) apps presents an opportunity for more effective health management and monitoring and expanded mobile health (mHealth) capabilities. However, AI's early developmental stage has prompted concerns related to trust, privacy, informed consent, and bias, among others. While some of these concerns have been explored in early stakeholder research related to AI-mHealth, the broader landscape of considerations that hold ethical significance to users remains underexplored.

OBJECTIVE

Our aim was to document and explore the perspectives of individuals who reported previous experience using mHealth apps and their attitudes and ethically salient considerations regarding direct-to-consumer AI-mHealth apps.

METHODS

As part of a larger study, we conducted semistructured interviews via Zoom with self-reported users of mHealth apps (N=21). Interviews consisted of a series of open-ended questions concerning participants' experiences, attitudes, and values relating to AI-mHealth apps and were conducted until topic saturation was reached. We collaboratively reviewed the interview transcripts and developed a codebook consisting of 37 codes describing recurring or otherwise noteworthy sentiments that inductively arose from the data. A single coder coded all transcripts, and the entire team contributed to conventional qualitative analysis.

RESULTS

Our qualitative analysis yielded 3 major categories and 9 subcategories encompassing participants' perspectives. Participants described attitudes toward the impact of AI-mHealth on users' health and personal data (ie, influences on health awareness and management, value for mental vs physical health use cases, and the inevitability of data sharing), influences on their trust in AI-mHealth (ie, endorsements and guidance from health professionals or health or regulatory organizations, attitudes toward technology companies, and reasonable but not necessarily explainable output), and their preferences relating to the amount and type of information that is shared by AI-mHealth apps (ie, the types of data that are collected, future uses of user data, and the accessibility of information).

CONCLUSIONS

This paper provides additional context relating to a number of concerns previously posited or identified in the AI-mHealth literature, including trust, explainability, and information sharing, and revealed additional considerations that have not been previously documented, that is, users' differentiation between the value of AI-mHealth for physical and mental health use cases and their willingness to extend empathy to nonexplainable AI. To the best of our knowledge, this study is the first to apply an open-ended, qualitative descriptive approach to explore the perspectives of end users of direct-to-consumer AI-mHealth apps.

Developing Digital Mental Health Tools With Culturally Diverse Parents and Young People: Qualitative User-Centered Design Study

BACKGROUND

Approximately 39% of young people (aged 16-24 y) experience mental ill health, but only 23% seek professional help. Early intervention is essential for reducing the impacts of mental illness, but young people, particularly those from culturally diverse communities, report experiencing shame and stigma, which can deter them from engaging with face-to-face services. Digital mental health (DMH) tools promise to increase access, but there is a lack of literature exploring the suitability of DMH tools for culturally diverse populations.

OBJECTIVE

The project was conducted in partnership with a large-scale national DMH organization that promotes evidence-based early intervention, treatment, and support of mental health in young people and their families. The organization wanted to develop a self-directed web-based platform for parents and young people that integrates psychological assessments and intervention pathways via a web-based "check-in" tool. Our project explored the views of culturally diverse parents and young people on the opportunities and barriers to engagement with a web-based DMH screening tool.

METHODS

We conducted a 2-phase qualitative study aiming to identify potential issues faced by culturally diverse communities when engaging with DMH tools designed for the Australian public. We worked with 18 culturally diverse participants (parents: n=8, 44%; young people: n=10, 56%) in a series of design-led workshops drawing on methods from speculative design and user experience to understand the opportunities and barriers that organizations might face when implementing population-level DMH tools with culturally diverse communities. NVivo was used to conduct thematic analyses of the audio-recorded and transcribed workshop data.

RESULTS

Five themes were constructed from the workshops: (1) trust in the use and application of a DMH tool, (2) data management and sharing, (3) sociocultural influences on mental health, (4) generational differences in mental health and digital literacy, and (5) stigma and culturally based discrimination in mental health support.

CONCLUSIONS

The emergent themes have important considerations for researchers wishing to develop more inclusive DMH tools. The study found that healthy parent-child relationships will increase engagement in mental health support for young persons from culturally diverse backgrounds. Barriers to engagement with DMH tools included culturally based discrimination, the influence of culture on mental health support, and the potential impact of a diagnostic label on help seeking. The study's findings suggest a need for culturally safe psychoeducation for culturally diverse end users that fosters self-determination with tailored resources. They also highlight important key challenges when working with culturally diverse populations.

Negotiating uncertainties: care-seeking in an algorithmic society

This article examines how different layers of health-related uncertainties emerge and intersect in an algorithmic society. We aim to understand how people's self-care practices co-evolve with digitalised health systems. Sweden stands out among Western countries due to the population's high digital consumption of medical and health products. We conceptualise health-related uncertainties as inherent in care-seeking. The uncertainties are embedded in an algorithmic society and hinge on what we term algorithmised medicine. Methods used are open-ended questionnaires and semistructured interviews with Swedish residents. We identify: First, people are aware of algorithm-embedded digital infrastructure and its impact on information access in everyday life. Second, people oscillate on a trust-distrust nexus in different contexts. And third, lived experiences of the body compete with medical advice and online information. We conclude that while formal health systems strive to be robust, access to medicines remains an uncertain practice at the interplay of medicine, algorithms and bodily experiences of sickness. This study contributes to the field of medical humanities by showing that the digital arena is a porous and emergent entity, with inseparable links to people's lived experiences.

The impact of digital health technologies on moral responsibility: a scoping review

Recent publications on digital health technologies highlight the importance of 'responsible' use. References to the concept of responsibility are, however, frequently made without providing clear definitions of responsibility, thus leaving room for ambiguities. Addressing these uncertainties is critical since they might lead to misunderstandings, impacting the quality and safety of healthcare delivery. Therefore, this study investigates how responsibility is interpreted in the context of using digital health technologies, including artificial intelligence (AI), telemonitoring, wearables and mobile apps. We conducted a scoping review with a systematic search in PubMed, Web of Science, Embase, CINAHL and Philosopher's Index. A total of 34 articles were included and categorized using a theoretical framework of responsibility aspects, and revealed two main findings. First, we found that digital health technologies can expand and shift existing 'role responsibilities' among caregivers, patients and technology. Second, moral responsibility is often equated with liability or accountability, without clear justification. Articles describe new ways in which physicians can be held accountable, particularly in the context of AI, and discuss the emergence of a 'responsibility gap' where no-one can be fully responsible for AI-generated outcomes. The literature also shows that m-Health technologies can increase patients' accountability for their own health. However, there was limited discussion in the reviewed literature on whether these attributions of accountability are appropriate. We conclude with implications for practice and suggestions for expanding the theoretical framework of moral responsibility, recommending further study on responsibility of collectives and artificial entities, and on the role of virtue in digital health.

Critical design decisions and user demographics in enhancing real-time digital mental health interventions: A systematic review

Background

Real-time digital mental health interventions, primarily enabled by smartphone technology offer continuous, personalised support, that adapts in response to the changing needs of individuals. Despite being prominently explored in populations with psychiatric disorders, there remains a notable gap in the systematic analysis of demographic characteristics, as well as the foundational design decisions or rules that underpin the personalisation of these interventions.

Objectives

(a) Identifying the prevalent design decisions to enable personalisation within real-time digital mental health interventions, (b) the influence of these design decisions on the clinical outcomes of the interventions, and (c) the demographic characteristics of populations with psychiatric disorders targeted by real-time digital health interventions.

Methods

Following PRISMA (preferred reporting items for systematic reviews and meta-analyses) guidelines, a systematic literature review was conducted of peer-reviewed literature focusing on real-time digital interventions in populations with clinically diagnosed psychiatric disorders. We undertook a narrative synthesis to derive the demographics and personalisation design decisions of the interventions and conducted a pooled meta-analysis to evaluate clinical outcomes.

Results

Interventions predominantly targeted female and Caucasian demographics, yielding modest clinical improvements. Our analysis identified nine critical personalisation design decisions concerning measurement, intervention, and interactions with health professional with varying influence on clinical outcomes.

Conclusion

Understanding the complex nuances of design decisions that shape real-time digital health interventions, as well as identifying which patient demographics benefit most, is fundamental for their effective clinical impact and safe use.

Prospero Registration

PROSPERO CRD42020161663.

Digital rights and mobile health in Southeast Asia: A scoping review

Objective

Digital technology has the potential to support or infringe upon human rights. The ubiquity of mobile technology in low- and middle-income countries (LMICs) presents an opportunity to leverage mobile health (mHealth) interventions to reach remote populations and enable them to exercise human rights. Yet, simultaneously, the proliferation of mHealth results in expanding sensitive datasets and data processing, which risks endangering rights. The promotion of digital health often centers on its role in enhancing rights and health equity, particularly in LMICs. However, the interplay between mHealth in LMICs and digital rights is underexplored. The objective of this scoping review is to bridge this gap and identify digital rights topics in the 2022 literature on mHealth in Southeast Asian LMICs. Furthermore, it aims to highlight the importance of patient empowerment and data protection in mHealth and related policies in LMICs.

Methods

This review follows Arksey and O'Malley's framework for scoping reviews. Search results are reported using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) checklist. Frequency and content analyses were applied to summarize and interpret the data.

Results

Three key findings emerge from this review. First, the digital rights topics covered in the literature are sparse, sporadic, and unsystematic. Second, despite significant concerns surrounding data privacy in Southeast Asian LMICs, no article in this review explores challenges to data privacy. Third, all included articles state or allude to the role of mHealth in advancing the right to health.

Conclusions

Engagement in digital rights topics in the literature on mHealth in Southeast Asian mHealth is limited and irregular. Researchers and practitioners lack guidance, collective understanding, and shared language to proactively examine and communicate digital rights topics in mHealth in LMIC research. A systematic method for engaging with digital rights in this context is required going forward.

Healthiness as a Virtue: The Healthism of mHealth and the Challenges to Public Health

Mobile health (mHealth) technologies for self-monitoring health-relevant parameters such as heart frequency, sleeping patterns or exercise regimes aim at fostering healthy behavior change and increasing the individual users to promote and maintain their health. We argue that this aspect of mHealth supports healthism, the increasing shift from institutional responsibility for public health toward individual engagement in maintaining health as well as mitigating health risks. Moreover, this healthist paradigm leads to a shift from understanding health as the absence of illness to regarding health as the performance of certain rituals in order to project healthiness. By drawing from the analogy between healthiness and traditional virtues, we evaluate the promises made by proponents of mHealth technologies for self-monitoring. We argue that the implementation and use of mHealth risk entrenching existing inequalities and, more particularly, tend to exclude populations situated at the losing end of those inequalities from participating in the quasi-virtue of healthiness. Consequently, the implementation and use of mHealth technologies not only present challenges for social justice but also undermine their primary societal goal-to promote public health. Finally, we offer several suggestions on how to realize the potential benefit of mHealth.

The 5 K run in popular fiction: Reading about parkrun and couch to 5 K

Recent years have witnessed great interest in mass-participation running events (1), and organisations such as parkrun and fitness programmes like Couch to 5 K, have been instrumental in enabling participation for inexperienced runners. Concomitant with this has been a number of fictional works which centre on the 5 K run. I contend that exploring fictional texts can offer a fresh take on how movements such as parkrun and Couch to 5 K have entered the popular imagination. The four texts explored are Wake's Saturday Morning Park Run (2020), Park's A Run in the Park (2019), Boleyn's Coming Home to Cariad Cove (2022), and James's I Follow You (2020). The analysis is arranged thematically around the categories of health promotion, individual transformation, and community building. I argue that these texts frequently operate as health promotion tools and can help familiarise would-be runners with how parkrun and Couch to 5 K work.

Commercial mHealth Apps and Unjust Value Trade-offs: A Public Health Perspective

Mobile health (mHealth) apps for self-monitoring increasingly gain relevance for public health. As a mobile technology, they promote individual participation in health monitoring with the aim of disease prevention and the mitigation of health risks. In this paper, I argue that users of mHealth apps must engage in value trade-offs concerning their fundamental dimensions of well-being when using mobile health apps for the self-monitoring of health parameters. I particularly focus on trade-offs regarding the user's self-determination as well as their capacity to form personal attachments. Depending on the user's level of advantage or disadvantage, value trade-offs can pose a threat to the users' sufficient fulfillment of the dimensions of well-being. As such, value trade-offs can entrench existing structural injustices and prevent disadvantaged users to benefit from this technology. I argue that value trade-offs are, to some, a type of injustice that can drive disadvantaged users away from a sufficiency threshold of well-being, risk users to fall below the threshold, or have an accumulative effect on different dimensions of the user's well-being.