By Maeve O’Keeffe
Given the plethora of ways technology has infiltrated our lives, it is perhaps unsurprising that it is used more and more in a health-related capacity. Particularly since the Covid-19 pandemic, there has been an increasing reliance on online resources in healthcare, both in terms of treatment and tracking. We all were asked to download that garishly yellow Covid tracking app for the facilitation of contact tracing and the identification of close contacts during the height of the pandemic, and many have argued that the smooth system of contact tracing was reliant on access to mobile phones and the HSE website to register as a positive antigen case and notify close contacts. As well as that, the provision of many vital services remotely led to us all having to become used to phone and video consultations, even sending WhatsApp pictures for doctors to observe, rather than risk an in-person visit. Of course, the provision of services tending to our physical health were not the only things affected by lockdown, as therapeutic and counselling services also had to move onto online platforms.
Beyond counselling sessions being conducted online, there has been a burgeoning industry of online apps for mental and physical wellbeing, before ever covid-19 was an issue. In many regards, the proliferation of apps to promote user wellbeing and mental health is a good thing. While we strive to dismantle the stigma surrounding behavioural and/or mental health concerns, there are still many barriers that deter vulnerable people from seeking help, and online apps can help overcome some of these barriers. Mobile, largely inexpensive (if not free), and anonymous, it is not hard to see why the use of an app to help with mental health issues would be more accessible and less daunting to many people than traditional forms of therapy or visiting a healthcare professional. I spoke with Dr Samantha Dockray, senior lecturer in the School of Applied Psychology, about the development and use of apps in healthcare and wellbeing. “Apps are really terrific, and they offer people a relatively low-cost way to get help and guidance on how to improve their health, or psychological wellbeing,” she tells me; “It’s really wonderful to think how this can break down barriers to support people in areas that might be sensitive topics.”
However, when one delves a little deeper, it is apparent that despite the widespread availability of mental health apps, very few of these apps are scientifically informed, with many lacking rigorous evidence for their efficacy. In fact, a high volume of these apps lack any form of clinical expertise in their design and development, with some promoting strategies that are outdated or unsupported by evidence. Some apps actually incorporate approaches that are proven to be beneficial, such as cognitive behaviour therapy (CBT), guided meditation and mindfulness, and Acceptance Commitment Therapy (ACT). These may be helpful when used either alongside or as an alternative to traditional forms of therapy. But it would be misguided to assume that all apps are backed up by such proven therapeutic or behaviour change techniques.
The challenge for the consumer is distinguishing between which apps are supported by evidence, and which are simply attractive click-bait in the app store. “It’s difficult for anyone to quickly assess how much evidence and testing is behind the product that sells itself as a healthcare product. An app’s popularity is often based on its appearance, or if it has high ‘usability’, that is – it looks good and works smoothly,” says Dr Dockray. Considering how many of us rely on the average user ratings to decide which apps are worth our time, it is important to remember that user ratings are merely reflections of the app’s popularity, not necessarily its efficacy or usefulness. As well as this, many apps use impressive sounding psychobabble and jargon to create the illusion of a scientific base that can seem reassuring to the consumer, without having used randomised control trials and experiments to verify the app’s effectiveness during development. With this in mind, many mental health professionals are reluctant to promote the use of mental health apps instead of therapy among vulnerable people. Ultimately an ill-informed app design is no substitute for the benefits of the guidance and intervention of a professional who has dedicated years of their lives to becoming a competent counsellor, therapist, or coach.
What we need are more mHealth and eHealth apps developed by researchers in universities like our own. One such application is the MyUse app, which was recently developed by an interdisciplinary team with researchers from the schools of Applied Psychology, Business Information Systems, and Public Health, alongside the UCC Student Health Department. Dr Dockray was part of the “team of researchers and practitioners with high-level expertise in student health behaviours,” who “spent 3 years researching what works for students, for specific health behaviours and tailor-made it for college students.” The purpose of this app is to reduce the harm that can accompany the use of drugs, and was informed by extensive research into the factors that determine why third level students increase or decrease their drug use. Dr Dockray explains how, “It was also really important that we worked closely with UCC students and we got advice from students with a range of drug-use experiences, and representing the diversity of UCC students. These students advised us on the ‘real world’ of college life so we could make sure we were translating the research evidence into something that we are confident will work and be useful for students.” This marks a stark contrast to many of the apps purporting to be of use to vulnerable populations, when in reality, they lack any scientific grounding.
The Appstore is overflowing with sleek-looking apps, whether promising that you’ll get abs in three weeks, give up smoking for good, or calm your anxiety. Dr Dockray urges consumers to look beyond usability and appearance, however, to ascertain, “if it can have any effect on health, or help change your behaviour, you need to check out how the content was developed? Was a psychologist involved? Was a health practitioner part of the development team? Then you wonder – well, what’s their expertise in this area?” She advises consumers to “look up the research team – check their credentials,” remarking that, “it might take you ten minutes but that’s a better investment of time than downloading an app that has no research to back it up.” This makes sense, as the time spent investigating an app’s credentials is certainly more productive than time spent using an app with no proven benefits for health and wellbeing.
Regarding her work on the MyUse App, Dr Dockray is proud to use her expertise to develop apps with meaningful applications for users, in this case, students. “We gladly share our research so people can check that we are experts, and qualified and experienced in this particular area,” she tells me. Given the substantial body of published articles and research projects under her belt, she reiterates that, “it doesn’t take long to check the research evidence and credentials of an app , and everyone should invest that small bit of time making sure they’re getting what suits them best – and the best app for what they need!” We are fortunate that there is such a range of apps available to us, with more and more tailoring health programmes and information to your unique needs.
While the distinction between contact with a professional healthcare provider and the use of a healthcare app is typically clear, there is increasing investment in the development of artificial intelligence (AI) health coaches. An example of one such coach is on the MyLife app, developed by Irish Life insurance company. The app is described as a “personalised health and wellbeing app, that inspires people to live a healthier and more active life.” Irish Life customers can claim rewards from engagement with the app and its personalised AI health coach. Though many may find the idea of engaging with an AI health coach off-putting, this digitisation of wellbeing could be perceived as an innovative approach that incentivises people to be better informed and more attentive to their health. The element of concrete rewards for Irish Life customers based on improvements in their health score on the app is a sincere attempt to encourage people to improve their health-related behaviours, and illustrates scope in how technology and healthcare can interact. In providing information about health-related behaviours for app-users, apps like this may be seen as a bridge to accessible healthcare for individuals who face barriers to more traditional engagement with healthcare experts.
That said, engagement with healthcare apps need not necessarily be reliant on the potential to claim rewards. There are a host of other applications which use other techniques to encourage use and engagement. During lockdown, for instance, I became hooked on an app that tracked my runs. Each day, I would receive a notification with statistics about how I had improved the speed or duration of my run. Tracking my progress became addictively satisfying. It’s therefore unsurprising to see how many healthcare apps are focused simply on tracking health-related behaviours. Not only are there apps like Strava that track the user’s activity, but many women use apps like Flo to monitor their menstruation and fertility. There is also an abundance of sobriety trackers available for individuals seeking to change their substance-use patterns. And of course, one of the most ubiquitously used types of healthcare app is the calorie counter, where users can scan the barcodes of the food they consume to keep an eye on how many calories they consume every day. Many of these apps also give insight into macronutrient values, for those seeking in-depth knowledge into their diets. While these apps can of course be useful, they can also be perceived as a hindrance to users’ spontaneity and freedom when it comes to food.
Research conducted by Dr Dockray alongside her colleagues, Linehan and Ryan (2021) explored how people use tracking tools for weight loss, and investigated the implications that can inadvertently accompany use of such apps. She explains that “when an app isn’t evidence based, or not developed by people with expertise and then tested really well, there’s a risk of negative consequences.” Commonly used apps that track calorie intake, “can have unintended, unforeseen consequences,” for users, which may be amplified when they have not “been developed by teams who have research expertise combined with practitioner experience,” according to this recent research. She reminds readers therefore that “these are things to check for.”
Ultimately, apps can be amazing tools in promoting improved health and wellbeing. Apps allow for knowledge and information to be dispersed to more people with great ease. They can also allow users to learn more about issues that remain somewhat taboo, through community forums about health concerns, allowing individuals to discover what works for others suffering from the same or similar conditions. Healthcare apps have the potential not only to inform users, but also prompt palpable behavioural changes when it comes to health and wellbeing. Access to mental health services is arguably still inadequate, so the scope for apps to help people who are struggling cannot be underestimated. That said, when these apps are not informed by expertise and research, then the benefits of apps aimed at improving physical and mental health are entirely undermined.