Our self-tracking movement and health literacy: are we really making every moment count?

Abstract

There is a growing movement related to self-tracking in the quest for better health. Why do so many people like to use ‘intelligent tools’ like shiny sensors or mobile apps to keep an eye on every move? Do they really help us drive sustained healthy behavioral changes? Despite technological advances and product promises, we must remember that technology alone does not facilitate change to optimize health benefits. The purpose of the commentary is to pose the question: How ‘health literate’ do we have to be to reap the actionable health benefits of self-tracking? Research has revealed the prevalence of limited health literacy across the globe. Health literacy involves a complex set of inter-connected skills, including acting upon health information. This commentary puts attention on health literacy as an essential human tool to better equip people to overcome barriers and use devices to leverage their full potential.

Keywords

self-tracking health literacy behavior change personal informatics barriers

Self-tracking: a technological tool for health

Everybody is doing it. It is not just the gym junkies or professional athletes anymore. There is a growing movement related to self-tracking (also known as quantified self, life-logging, self-optimization, living by numbers, and body-hacking, among other terms). Why do so many people like to use these ‘intelligent tools’ like shiny sensors, always-on gadgets, or mobile apps to keep an eye on their every move and function? Do they really help us drive healthy behavioral changes and take better control of our life? According to Fox (1), 46% of trackers say that this activity has changed their overall approach to maintaining their health. This means less than half report ‘actionable benefits’.

Every day people are recording much more than their number of steps, food intake, or insulin levels. Tracking one’s moods, breathing, caffeine intake, alcohol consumption, shopping habits, sexual activity, emailing, teeth brushing, and baby’s diaper changing are becoming common practice. Today, the combination of metrics, self-improvement, and technology make it easier than ever to gather, analyze, and use data for prevention and maintenance of wellness (2). Or is it? Can measuring our everyday activities really help us to improve our quality of life? How ‘health literate’ do we have to be to reap actionable health benefits from self-tracking?

Health literacy as a human tool for health

Health literacy involves more than handling words and numbers, or installing the latest health app on your iPhone. While literacy, numeracy, and technology skills, among others are important for health literacy in today’s information-rich society, it is what people do with the information that has a major impact on their well-being (3). Health literacy involves a complex set of inter-connected skills and abilities, including being able to act upon health information. Health literacy is critical to empowerment (4). The European Health Literacy Survey (HLS-EU) Consortium defines health literacy as: ‘Health literacy is linked to literacy and entails peoples’ knowledge, motivation and competencies to access, understand, appraise, and apply health information in order to make judgments and take decisions in everyday life concerning healthcare, disease prevention and health promotion to maintain or improve quality of life during the life course’ (5). This implies that health literacy refers not only to an individual’s skills and abilities, but the demands and complexities within which people live, work, learn, and play. Research has revealed the prevalence of low health literacy in many countries (6). For example, there are major gaps in health literacy in Europe as revealed by the HLS-EU with 47% of the population on average in eight European countries (Austria, Bulgaria, Germany, Greece, Ireland, Netherlands, Poland, and Spain) estimated to have insufficient or problematic levels of health literacy (7). The collection of global evidence presented in WHO’s 2013 Solid Facts: Health Literacy highlight a ‘health literacy crisis in Europe and beyond’, as ‘weak health literacy competencies have been shown to result in less healthy choices, riskier behavior, poorer health, less self-management and more hospitalization’ (8). So, what does this mean for the self-trackers?

New trendy wearable consumer devices (e.g. Fitbit), smart gadgets (e.g. shoes, clothing), and countless smart phone apps have encouraged individuals to monitor their body functions and actions with the potential to analyze, present, and share data. With many tracking systems emerging, a website was created to track the trackers. To date, the Quantified Self (QS) Guide to Self-Tracking Tools website features 505 tools (9). Whether collecting bodily functions such as urine color, or environmental conditions such as UV, there is growing literature in this human–computer interaction (HCI). For example, many HCI researchers have focused on motivations for behavior change and individuals’ responses to self-tracking, including factors such as personal benefits and gratification (10); adopting or quitting tracking practices (11); and types of self-tracking technologies as a means of motivation (12). One question to consider is whether people want to change their behavior because of a technology, or if they are using technology because they want to change. According to Rooksby et al. (12), ‘What people decide to track using consumer products, what trackers they decide to use, and how they use them over days, weeks, months and potentially lifetimes remains understudied.’ Patel et al. argue that wearable devices are facilitators (13), not drivers of health behavior change and ‘using wearable devices to effectively promote health behavior change is a complex, multistep process.’ Wearable devices have limitations (11), producing a gap between devices recording information and the sustainability of individual behavior change (13). An underlying key question to consider is whether people have the knowledge, competencies, and motivation to accurately gather, interpret, communicate, and use (i.e. health literacy) multiple devices producing multiple data sets that they are using for personal health and well-being.

Stages of self-tracking and health literacy

Personal informatics is an emerging area of study within HCI. Li et al. noted that ‘there is no comprehensive list of problems that users experience using these systems, and no guidance for making these systems more effective’ (11). Consequently, their work studying how people use personal informatics systems has resulted in a stage-based model, which outlines five psychological stages in the process of engaging in self-tracking, including preparation, collection, integration, reflection, and action (11). The model reveals barriers occurring at each stage, with an earlier stage affecting the later stages. People often focus only on one stage (i.e. collecting data on number of steps or hours slept), which ignores the overall purpose, iterative process, and intended outcome of self-tracking. It is necessary to look at the self-tracking system as a whole encompassing both a system-driven (technology) and user-driven system (health literacy) to reap the potential rewards. Table 1 offers an application of health literacy to the stage-based model to overcome identified barriers during the self-tracking process.

Table 1.

Application of health literacy to the stage-based model to overcome barriers during the self-tracking process.

Stage	Description	Barriers or problems	Application of health literacy skills – examples
Preparation	People’s motivation to collection information; how they determine what information to collect; how to record it	Determining what information to collect; what tool(s) to use	Access	• Ability to readily find best-fit tool(s) for personal health needs, which avoids the abandonment and gaps of data during switching of tools • Ability to afford devices with demonstrated effectiveness
Collection	People collect information about themselves	Tool related (operational); user-related (lack of time, forget to collect information leading to sparse datasets, lack of motivation); data-related (input of data relies on subjective ratings with no standard for entering)	Comprehend Use	• Ability to understand device instructions, steps, and alerts • Ability to remember to wear device regularly; charge regularly for working order; actively update accurate data sets
Integration	People prepare collected data for reflection stage	Effort required by individual to organize data from multiple inputs and in varying formats, and transcribe data	Use	• Ability to use additional equipment and technology (i.e. wearable device, smart phone, computer) to actively input or transfer accurate data sets
Reflection	People look at and reflect at outputs of collected information	Difficulties retrieving, exploring, understanding information; lack of time	Comprehend Evaluate	• Ability to understand health information and derive meaning from data • Ability to interpret health data for positive, informed decision-making and lifestyle planning and adjustments
Action	People choose what they want to do with their new understanding of the information	Most systems do not have specific suggestions on what actions to take next	Use Communicate	• Ability to apply comprehension for concrete action • Ability to share accurate personal data and health strategies with others via devices and social media

According to the Ottawa Charter for Health Promotion (14), ‘People cannot achieve their fullest health potential unless they are able to take control of those things which determine their health.’ With so much automated technology promoting the self-tracking craze, how much user control is required during the process (i.e. active tracking) and how much user control is being lost to the system performing the tasks (i.e. passive tracking)? We must remember that the technology alone does not facilitate change to optimize health benefits. How far can a number go without human competencies and context? While apps may be more reliable than our memory by taking the guess-work out of counting multiple units associated with our daily activities, do we know how to accurately interpret and use this data? To gain insights, people often need to track multiple metrics at once and must understand and analyze the correlations between them. For example, how does what you eat, weather conditions, and activity levels affect your migraine frequency and intensity? Although new apps are emerging to import multiple data sets to output charts, visualizations, and spreadsheets to examine correlations, human skills, competencies, and motivation, efforts are required to make meaning out of these data.

No ‘know thyself’ without health literacy

It is important to look beyond the product promises and uses, whereby the act of purchasing a tool or downloading an app is believed to help us know ourselves better leading to self-knowledge, reflecting an intention to change, and declaring personal control or empowerment. Asking under what assumptions are these promises made is fundamental. For example, is the health literacy proficiency of users assumed for self-tracking? The self-tracking discourse of ‘know thy numbers’ to ‘know thyself’ to lead a healthier life is made clear, but acknowledging the underlying, essential user skills during the change process and what users are to actually do with ‘thy numbers’ for sustained positive change is much less clear.

Health literacy is a promising human tool to better equip people to overcome barriers to progress through the self-tracking stages and use devices to leverage their full potential. According to the Calgary Charter on Health Literacy (15), an individual can be health literate by using the skills needed to find, understand, evaluate, communicate, and use information. To be a health literate self-tracker, ideally a person is able to: (i) locate and access the appropriate device(s) for their personal health needs and to track the targeted behaviors; (ii) comprehend and carry out instructions to use devices accurately and regularly; (iii) make informed positive health decisions using the data; (iv) plan and follow the daily life adjustments required for better health informed by the data; (v) know how and when to access health care and services to support personal health plans when appropriate; and (vi) communicate accurate health data and clear health promoting messages with others in self tracking communities.

To help achieve this ideal, the first step is to raise awareness of health literacy, publicly and among those who champion self-tracking tools. The Calgary Charter on Health Literacy outlines key principles that are intended to support the development of curricula, initiatives, and tools to improve the health literacy of the public and of those who work in any capacity in healthcare or related systems (15). Providing a range of opportunities for education for health literacy can take place through learning activities, case studies, workshops, and online modules. Learning opportunities can address a number of audiences (e.g. K-12, adult education, health professionals), goals (e.g. introduce health literacy, build skills, application to daily life), and barriers to learning (e.g. individual, systemic). It is important to address individual barriers (e.g. provide outreach to seniors, ensure culturally-appropriate trainings,) and system barriers (e.g. increase number of health literacy specialists, offer affordable educational opportunities). Improving health literacy is an important determinant of health that can guide and support self-tracking efforts towards better health.

Footnotes

Declaration of conflicting interests

The authors declare that there are no conflicts of interest.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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