10.6092/issn.2038-3460/17345
In the last decades, health and illness have been redefined by the technological artefacts. This research explores users’ opinions of the potentials and limits of apps related to the self-management of type 1 diabetes. Our research takes the “app” to be a socio-cultural artefact whose meanings and practices are mediated by situated practices and knowledges. The analysis has been conducted on two different kinds of texts: the description provided by the app itself (commercial description) and the reviews provided by app users (customer reviews). Our aim is thus to contribute to the study of how technological tools contribute to the processes of patients empowerment.
application/pdf
2038-3460
17345
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Barbara Morsello
https://creativecommons.org/licenses/by-nc-sa/2.5/
Tecnoscienza – Italian Journal of Science & Technology Studies
customer reviews
Self–management and Type 1 Diabetes. How Technology Redefines Illness
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Essays
2017-07-20
2023-06-22
2017-07-20
2023-08-30
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TS
Barbara Morsello
2017/07/20
10.6092/issn.2038-3460/17345
51
University of Roma Tre
2038-3460
1
customer reviews
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71
Self–management and Type 1 Diabetes. How Technology Redefines Illness
https://tecnoscienza.unibo.it/article/download/17345/16194
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                                                                                      Essay
                                                                                              51




Self–management and Type 1 Diabetes
How Technology Redefines Illness

           Veronica Moretti                                 Barbara Morsello
               University of Bologna                         University of Roma Tre



     Abstract: In the last decades, health and illness have been redefined by the
     technological artefacts. This research explores users’ opinions of the poten-
     tials and limits of apps related to the self-management of type 1 diabetes.
     Our research takes the “app” to be a socio-cultural artefact whose meanings
     and practices are mediated by situated practices and knowledges. The anal-
     ysis has been conducted on two different kinds of texts: the description pro-
     vided by the app itself (commercial description) and the reviews provided by
     app users (customer reviews). Our aim is thus to contribute to the study of
     how technological tools contribute to the processes of patients empower-
     ment.

     Keywords: Type 1 diabetes; apps; patient empowerment; commercial de-
     scription; customer reviews.

     Corresponding author: Veronica Moretti, Department of Sociology and
     Business Law, University of Bologna – Strada Maggiore 45, 40125 Bologna,
     Italy. E-mail: veronica.moretti4@unibo.it.




1. Introduction

     As the digital revolution has emerged in the last decade, opportunities
for patients to access and share healthcare information have expanded.
Consequently, a new form of ‘patient 2.0’ (Danholt et al. 2013) emerged
and should be analysed.
    Technological tools are fundamental in guiding laypeople as they be-
come more aware of, and informed about, their illnesses. Technological
tools that redefine our culture of therapy and self-care have proliferated in
the health market. These tools can be used in several manners. As sug-
gested by the Green Paper on mobile Health – mHealth – (2014, 1)
“mHealth solutions cover various technological solutions that among oth-
ers, measure vital signs such as heart rate, blood glucose level, blood pres-
sure, body temperature and brain activities. Prominent examples of apps
                                                                                         51
 TECNOSCIENZA
 Italian Journal of Science and Technology Studies
 8 (1) pp. 51–71 – ISSN 2038–3460
                                                     2017
 www.tecnoscienza.net
52                                                           Tecnoscienza – 8 (1)

are communications, information and motivation tools, such as medication
reminders or tools offering fitness and dietary recommendations”. Some
claim that in the 2.0 era the patient becomes a sort of self-entrepreneur
(Maturo 2015), who can control both the process and the result of the ther-
apy or healthcare. Consequently, as Bruni and Rizzi (2013) point out, in
the case of patient 2.0, the production of reliable data is dependent on the
patient because s/he wields the technological tool necessary for collecting
that data. In addition, as Maturo and Setiffi (2016, 478) observed: “as the
sources of medical information shift from those controlled by doctors such
as medical records and specialist journals to interactive websites and online
communities, it is easier for individuals and patients to find information,
get support and share their illness experiences with others with the same
condition”.
    The number of people chronically ill is steadily increasing, which indi-
cates the need for services that ensure continuity of patient care and assis-
tance. About 117 million people suffer from chronic illnesses in the United
States, while one out of four adults has two or more chronic health condi-
tions (Center for disease control and prevention 2012). In Europe, those
figures are even higher: around 150 million Europeans were chronically ill
in 2005 (European Observatory on Health Systems and Policies 2005). Pa-
tient self–management is increasingly perceived as a viable alternative to
the currently strained health care system (Busse et al. 2005). In this alter-
native scenario, new technological tools dealing with health would become
part of patients daily lives.


2. Self-management of Type 1 Diabetes through Mobile
Apps

    Type 1 diabetes is a chronic disease that occurs when the pancreas does
not produce enough insulin or when the body is not able to effectively use
insulin. Insulin is the hormone that regulates blood sugar; hyperglycaemia
is a common effect of uncontrolled diabetes that causes serious systemic
damage, especially to nerves and blood vessels. Diabetes is an important
public health problem; it is one of four non-communicable diseases
(NCDs) that world leaders have deemed “priority,” i.e. prioritized for pre-
ventative action (WHO 2016). Globally, an estimated 422 million adults
were living with diabetes in 2014, compared to 108 million in 1980.
    Type 1 diabetes is known as juvenile, childhood-onset, or insulin-de-
pendent diabetes, as it requires daily administration of insulin in various
doses and with varying frequency. The cause of type 1 diabetes is unknown,
and the disease is not preventable at our current level of scientific
knowledge. According to a 1999 report prepared by the World Health Or-
ganization, a healthy way of life, i.e. the maintenance of normal body
weight accompanied by regular physical activity, can delay or prevent the
Moretti & Morsello                                                         53

onset of type 2 diabetes and, at the same time, help to control type 1 dia-
betes.
    The adoption of self-management practices is a foundational resource
in the process of controlling and managing type 1 diabetes and its effects.
Routine self-monitoring allows diabetes to exist in the background of the
patient's social life by contributing positively to its normalization (Spencer
et al. 2013). According to the WHO’s latest global report on diabetes
(2016), mobile technology can improve the management of diabetes in that
it encourages users to adhere to treatment plans meant to manage their
disease.
    The advent of new technologies such as smart phones, Internet, tablets,
as well as of increasingly sophisticated health monitoring devices (glucose
meters, blood pressure monitors, oximeter), is accompanied by the minia-
turization of those monitoring devices, as nanotechnology continues to de-
velop.
This could result in increased efficiency of health services by adding value
and efficiency to a continuum of self-care strategies (Lehocki et al. 2012).
The use of mobile devices, which today more than ever affects every sphere
of one’s social and personal life, may change the face of health care by of-
fering a new avenue for the management of one’s disease. Health-related
technologies take the place of a personal care assistant who supports a pa-
tient in the management and organization of the daily flow measurement
and who assists in administration of care and personal data. Recent ad-
vances in ICT have enabled the design and development of new patient-
centric models for these health-related technologies (Mougiakakou et al.
2009). Self-management of diabetes offers a representative example of in-
tense patient engagement with health management practices and with the
organization of health services.
The personal management of type-1 diabetes requires patients to have spe-
cific skills, which concern the measurement of their values in relation to
the available technological tools. In order to better manage their disease,
patients with type-1 diabetes have to develop medical skills. They must take
steps to adapt to new habits and even a new lifestyle. Ideally, patients
should also learn how to interact with the health technologies they use,
thereby achieving a greater sense of responsibility and control in their ex-
perience of illness.
    At the same time, the patient faces the burden of dealing with the emer-
gence of new pressures and complexities in health management. The emer-
gence of health technologies has completely restructured the form of clin-
ical encounter between doctor and patient. Information about one’s health
is distributed in a fragmented way and shared over a wide healthcare net-
work. In the centre of this network we find the patient, who is increasingly
held responsible both for his or her self-care and for the accuracy of data
that is useful for professional supervision of the disease, which he or she
measures (Bruni and Rizzi 2013). Clinical encounters that address patients’
54                                                            Tecnoscienza – 8 (1)

mismanagement of measurement technologies offer a clear example of the
heavy responsibility assigned to patients.
    Such appointments are characterized by two main activities: inspecting
the patient’s clinical documentation and verifying the relationship between
patients and technological tools. The self-management services generally
have the following characteristics:
  - acquiring patient data communication;
  - supporting compliance to treatment;
  - visualizing of the state of health;
  - educating the user.
    Several studies show that the use of mobile technology has a direct im-
pact on the management of chronic diseases (Free et al. 2013). With regard
to diabetes in particular, these studies evidence that mobile phone inter-
vention has led to statistically significant improvement in glycaemic control
and self–management in diabetes care (Liang et al. 2011).
    According to Research2Guidance's annual survey, 76% of mobile
health app publishers see diabetes as the self-care area with the highest
business potential for mobile health. Currently only 1.2% of people with
diabetes who own a smartphone or tablet use apps to manage their condi-
tion. Research2Guidance predicts that this percentage will rise to 7.8%, or
24 million people, in 2018.
    As mentioned above, digital technologies have expanded opportunities
for people to access and share information related to their personal health.
In addition, “mHealth solutions support the changing role of patients from
a passive to a more participative role, while enhancing their responsibility
over their own health through sensors that detect and report vital signs,
and mobile apps that encourage them to adhere to diet and medication”
(EU 2014, 5). Indeed, many apps have been designed for the health market.
The functions and contents of these medical apps provide useful insight
into discourses related to illness and chronic conditions. As shown by
Lupton (2014), apps are new digital technology tools, but they are also so-
ciocultural products located within pre-established circuits of discourse
and meaning. Moreover, these tools are now playing a crucial symbolic role
in our social lives; from this perspective, the integration of technological
devices with longstanding cultural relationships reflects the dominant
place held today by science and technology in our society (Magaudda
2015). Using these technological tools, it is possible to increase doctor-pa-
tient interaction (using an app as a medium) and to improve the relation-
ship between the patient and his/her illness (using the app as a memo).


3. Methodology

    Type 1 diabetes and the apps designed for its sufferers are particularly
ripe for analysis for two reasons: first, adolescents’ notorious propensity for
Moretti & Morsello                                                           55

new technological tools; and second, the fact that self-management at a
young age is even more difficult and challenging than it is for adults. In-
deed, measuring blood sugar levels is not always easy, especially on occa-
sions in which having a chronic illness may be stigmatized, as some patients
mention in their reviews of health apps. In addition, several studies (Mol
and Law 2004; Ho and O’Connor 2014) examine a wide range of psycho-
logical issues related to adolescent self-management of disease, including
stress, burn-out, depression, peer relationships and diabetes-related family
conflict.
    This study in based on content analysis of the 5 most downloaded dia-
betes apps: mySugar Logbook, Diabetic Connect, Diabetes Pilot, Bant, and
MyNetDiary. Commercial descriptions and customer reviews have been
used to evaluate the strengths and weaknesses of these new technological
tools in the managing of type 1 diabetes. Several studies have been con-
ducted through content analysis (Lupton 2014; Lupton and Jutel 2015;
Maturo and Setiffi 2016; Maturo, Mori and Moretti 2016). The ways in
which apps verbally and visually represent the human body provide insight
into contemporary notions of embodiment, health and disease. Examining
the words used in the app titles, images and descriptions on the store, in-
cluding the logo and screenshots employed to illustrate what the app offers
potential users, is a way of identifying the tacit assumptions that underpin
the apps and their truth and authority claims (Lupton 2014, 612).
    These diabetes apps belong to different categories and they were
searched in the App Store using the formula “most downloaded diabetes
apps” during February 2016.
    Specifically, we focused our analysis on the self-tracking possibilities
offered by those apps. Four out of five apps offer a standardized method
to calculate the level of glucose in blood and offer the possibility of creating
a food database in which to check the calories of foods. Although we have
considered apps from 3 different categories – Medical, Health & Fitness
and Social Networking – all of the apps can be considered helpful in man-
aging self-monitoring as this chronic illness requires. Further, all five apps
make use of gamification in order “to increase influence and encourage
engagement and activity” (Luminea 2013, 13). We can define gamification
as the use of game features in non-game situations (Groh 2012; Maturo
2015). Often, such recreational elements are considered important as
means to motivate employees to be more productive or to motivate patients
to be more constant and precise with self-monitoring. However, gamifica-
tion is also becoming widely used to foster consumption among individu-
als. As far as diabetes apps are concerned, the use of quantification helps
people to be more diligent in their self-monitoring.
    Commercial descriptions and customer reviews of these apps touch on
themes that can be broken down into four main areas, each of which we
have analysed: the language used by the app, the app’s visual features (de-
sign), the services provided by the app, and the app’s targeted users.
56                                                           Tecnoscienza – 8 (1)

4. Findings

4.1 Commercial Descriptions

    The first linguistic component of our research investigates the commer-
cial descriptions of diabetes apps, and in particular, which of their charac-
teristics their sellers choose to highlight. Commercial descriptions play a
fundamental role in our content analysis because they help us to under-
stand how “digital technologies have been developed within a wider ideo-
logical environment, one which has shaped their social evolution both ma-
terially and symbolically” (Magaudda 2015, 2). As aforementioned, our
content analysis focuses on four main aspects of the apps: the language
used by app developers, the app’s visual features, the services of the app
itself, and the app’s target group of users.
    Regarding the first aspect – the language used by the App Store – we
found that diabetes apps are described in technical terms specifically asso-
ciated with diabetes; at the same time, these descriptions are simple and
clear because they are intended to make sense to customers. According to
the commercial description of, e.g., the app MyNetDiary’s Diabetes
Tracker, it is possible to make a lifestyle change and acquire good habits
through:
  - checking remaining food calories;
  - viewing BG average and next check reminder;
  - reviewing daily foods;
  - getting tips and recommendations about today’s food;
  - logging water and weight;
  - logging foods-selecting from favourites or dictating searches.
    These instructions, presented as a list, are straightforward. Focusing on
guidelines for basic components of everyday life (weight, exercise, food
and water), this list offers the customer small-scale steps to follow in order
to better manage his or her diabetes: apparently, it is enough to follow these
clear instructions and the advice listed in the app’s description.
    The connection between food and illness management ought not go
unmentioned: as Mol (2008, 3) points out, “(nutritious) food and (curative)
drugs may have similar effects on the body.”
    The visual features of an app – the second aspect of apps we analysed
– prove to be particularly important, because they concern the app’s visual
impact, and may thereby influence a user’s overall perception and use of
the app. Indeed, pleasant visual features can encourage monitoring activity,
transforming a boring task into a fun and recreational activity (gamifica-
tion). For instance, the junior version of MySugar LOGBOOK (a version
of the app intended particularly for young people) can – according to its
commercial description – help one get motivated and involved in his/her
diabetes therapy.
Moretti & Morsello                                                         57

    It is also worth noting that game design involving personal activity mon-
itors may contribute to youth engagement with self-tracking, health, and
identity. The Junior version, for example, makes easier the collection of
data through a “monster” (Slimer, see fig. 1), a diabetes avatar.




                         Fig. 1 – App mySugar Logbook.

    This app is particularly intended for children who suffer from type 1
diabetes, because the activity of self-management is turned into something
interactive and amusing. Moreover, the app makes it is possible to share
data with one (or both) of the child’s parents. This app can be used through
the registration of the child – name and phone number – and the parent,
who must insert several details. The child/user has to manage his/her self-
monitoring by selecting different icons that represent physical status –
great, good, bad – at different moments throughout the day (before a meal,
after a meal, before sports, after sports). In addition, the young user has
the task of collecting data (blood glucose level) and of taking pictures of
meals. Other important functions concern estimating amounts of carbohy-
drates and, in the case of injecting insulin, the units of basal and bolus in-
jected; the child can write notes about his/her care management and send
them to the parents. Every time the child monitors the relevant metrics of
his/her body and sends his/her data successfully, he/she receives a reward
(points) that forms a part of the process of his/her self–management.
Through this app, it is possible to create graphs and histograms related to
the level of blood glucose, using a timetable that involves days, weeks and
months. It becomes possible to track and analyse personally relevant data
with less effort.
58                                                                 Tecnoscienza – 8 (1)




                                  Fig. 2 – App Bant.

     The third area we analysed, the services provided by diabetes apps, can
– according to their commercial descriptions – improve and facilitate the
illness management. Using the app Diabetes Pilot, it is possible to find
track trends in 14 categories, among which are blood sugar levels, medica-
tions and diet. First and foremost, the patient is tasked with selecting time,
the day/hour in which he/she starts with the monitoring, category1 and
value in order to start with this tracking. Consequently, the app, on the
basis of the precise records entered by the user, draws glucose and weight
graphics. The app can also function as a memo/notebook because it allows
patients to search past data, to scan barcodes on food packages in order to
track food and carbohydrate intake, and to learn about the calories, fat
proteins, sodium nutrients and cholesterol in foods. It is also possible to
set reminder alerts on any record. Another important feature of the app is
the possibility of its calculating the user’s insulin-level. Through the app’s
Data Sharing function, it is possible for a user to save, print and email re-
ports directly from the app. The transfer can be made using an email data
file or WiFi Sync. The possibility of data transfer should be seen as a way
to simplify medical appointments. These services undoubtedly foster quan-
tification; let us now consider the Bant app (see fig. 2), in order to get a
better idea of how these apps can simplify self-management among young
patients.
     Nowadays, getting medical information through the web seems to be a
simple and predictable activity: “consumers are starting to do this individ-
ually, in collaboration with health peers, who also have greater prominence
now, and in co-care with physicians and other medical professionals”
(Swan 2009, 494). However, most of the services require a subscription

   1
     Unfiled, imported, breakfast, after breakfast, lunch, after lunch, dinner, after
dinner, snack, feeling hypo, sick.
Moretti & Morsello                                                          59

that allows the patient to get all food database updates, unlimited records
and unlimited access to all services.
    Finally, the reference group consists of all sufferers of type 1 diabetes.
Many patients receive their diabetes diagnoses at a young age; interper-
sonal connection and the exchange of experiences by users are among the
main services of these apps in their effort to promote a healthy lifestyle. For
someone with the disease, sharing how diabetes affects his or her life can
help alleviate the stress and anxiety it provokes. This psychological aspect
of having diabetes, as we will see from user reviews of the apps, is particu-
larly delicate. Apps like Diabetic Connect are designed primarily to pro-
mote healthy eating habits by way of connecting people so that they can
share their feelings and personal experience of the disease. Especially
among youth, peer support is considered fundamental to achieve happi-
ness. Through this app, it is possible to get connected with the largest com-
munity of diabetes patients on the web (see fig. 3). The app principally
offers users the possibility of following discussions while on the go, asking
questions, and adding comments to a forum.
    Discussions on the app/forum are ranked according their popularity:
how many likes and comments they receive. A user can also choose differ-
ent topics (insulin, stress, type 1 diabetes, oral medications, finances etc.)
to read about. To join the community and post a comment or subscribe to
a discussion, users create patient profiles.




                        Fig. 3 – App Diabetic Connect.
60                                                                  Tecnoscienza – 8 (1)

4.2 Customer Reviews

    The second linguistic component of our analysis concerns users’ cus-
tomer reviews, i.e. the comments and suggestions they make informed by
their use of the diabetes apps. These comments2 were collected from some
of the online forums we identified as the most popular. Here are some ex-
amples of the numerous blogs and forums we analysed in the course of our
research. First, we considered www.diabetes.co.uk, a digital community
that supports people with diabetes in the U.K. and other countries. This is
undoubtedly one of the most interesting such forums in terms of its users’
access and ability to comment: whereas some blogs and forums require a
user to have a special subscription, no such subscription is necessary on
this site. Using this forum consists in a user interacting with other members
of the forum by answering questions they have posed, or by a user submit-
ting new questions of his/her own. A similarly important webpage is
www.childrenwithdiabetes.com, an online space designed for use exclu-
sively by parents of diabetic children. In Italy, the most popular forum is
www.diabetando.it, a community which requires some registration but
which offers a highly accessible, user-friendly comment section.
    Customer reviews of apps give voice to the needs of individual users
and bring to light their problems with and suggestions for the latest tech-
nological tools intended for diabetics. In addition to the commercial de-
scriptions of the apps, four main components of users’ feedback have also
been analysed in our research. These four components are: 1) apps lan-
guage; 2) apps visual features; 3) apps services; 4) apps users.
    Regarding the first, the syntax of an app proves important to users. As
noted by Berger and Luckmann (1966), language allows us to objectify hu-
man expression; understanding language means understanding the reality
of everyday life.

         I had a lot of trouble controlling my blood sugar, and my last A1C was
     8.5, up a bit from before. The issue was estimating proper insulin based on
     what I was eating. With the software here, in the last month my estimated
     A1C is hovering between 6.2 and 6.3.
                  [Crossfire, diabetes–pilot.iapps4you.com, Diabetes Pilot app)]

    Users describe the way diabetes demanded a complete reconstruction
of their habits, and further, how apps have played a helpful role in that
reconstruction:

     I just joined this forum and it helped answer a lot of questions I had. Espe-
     cially how to cope emotionally with the diagnosis of a chronic disease. And


     2
      Every comment reported is quoted exactly and is publicly available at the
websites listed. No registration to the cited forums or private pages was required
to access these comments.
Moretti & Morsello                                                                      61
    some of the more practical ways to live with changing your lifestyle. I travel
    a lot for business and will admit it’s been a challenge in some ways. I really
    miss Sonic cherry limeades (LOL).
                           [Dderm, tudiabetes.org, MySugar LOGBOOK app]

    Regarding the second object of our analysis – app design – individuals
prefer visually pleasant layouts and features, which can make less rote the
process of collecting and recording one’s medical or physical data. This
gamification of a tedious burden is particularly interesting in that it casts
electronic gaming in a new light. Gaming is often considered harmful3 and
is the leading causes of some common diseases among children.

        The chart of my weight helps me see if I’m staying on track.
                         [Hopester4, iphone.informer.com, MyNetDiary app]

    I’m truly enjoying the design and layout of your website. It’s very easy on
    the eyes which makes it much more enjoyable for me to come here and visit
    more often. Did you hire out a designer to create your theme? Outstanding
    work!
     [Anonymous, everydayupsanddowns.com.uk, MySugar LOGBOOK app]

    The third object of our analysis, namely the services these apps offer
their users, is important because the more distinct services an app offers,
the more its users interact with one another. Further, the use of these health
tracking tools in the management of disease is very important because “the
logic of care for diabetes involves the broader process of diagnosing, in-
forming, injecting, encouraging and so forth, a process in which the patient
is not only acted upon by medical professionals, but is also a principal actor
his or herself. In this sense, caring is “a collective effort of uncertain prac-
tices shared by doctors, nurses, patients, relatives and friends, and even
technologies” (Turrini 2010, 75).

    I lost over the past 10 months was with the other app, but if I had known
    about this I would have used it exclusively. It’s accuracy with nutrition in
    relation to diet, exercise, weight, & calories is the best I have seen so far. As
    a result of this app I better able to manage my tendencies toward diabetes,
    completely eliminated any cholesterol issue, and better track BP, which as
    returned to normal […] This app does it all and allows to track your pro-
    gress in many levels.
                             [hawk_fam003, mynetdiary.com, MyNetDiary app]

   An individual patient’s use of an app services can prove indispensable
not only for his or her disease management, but also for his or her entire



    3
      We refer to the abuse of video games by children that can lead to obesity. For
further information, please refer to the study of Vandewater et al. (2004).
62                                                                  Tecnoscienza – 8 (1)

medical team. Self-monitoring can, in fact, be essential for successful dia-
betes management, in that “the relegation of data-collection to patients or
caregivers is a part of a therapeutic alliance in which data is used by patients
for self–management purposes but is also shared with healthcare provid-
ers” (Piras and Miele 2016, 3).

     I highly recommend this application for diabetics and their care givers, not
     only for the quality of the software but the diligent and quick response I
     had from the Company when I commented about a concern. The applica-
     tion is extremely useful, inputting of data is quick, far better than flipping
     through log and carb counting books. I have had a chance to utilize the
     desktop version and must say that it is a far beyond what I had hoped for
     when choosing this application. The data syncing is easy to set up and trans-
     fers seamlessly to and from each device. Reports are clear and easy to ex-
     port, print and email to Doctors.
             [E. Scarborough, diabetes-pilot.iapps4you.com, Diabetes Pilot app]

    Finally, by way of studying user reviews, we analysed which people or
populations make use of these apps. As aforementioned, having Type 1
diabetes is a very complicated experience, “particularly for young people
for whom diabetes self-management evolves alongside adaptation to devel-
opmental changes in association with individual contextual factors and dis-
ease course” (Cooper et al. 2007, 474). The effective treatment of diabetes
requires more from a patient than the mere acceptance of the problems the
disease causes: it also requires the acquisition of particular skills (Bruni and
Rizzi 2013). Essentially, a person diagnosed with diabetes must play a
highly active role in the reshaping of his or her daily life, a reality inter-
preted by men and subjectively meaningful to them as a coherent world
(Berger and Luckmann 1966). The changes to daily life which diabetes de-
mands can cause patients’ psychological stress or denial or cognitive disso-
nance about what managing their illness requires:

     Ok, so I was diagnosed about 2yrs ago and I hate: the daily testing (actually
     have not been testing), the 3 times a year A1C, and everything about diabe-
     tes. I am really struggling with what I know I should be doing and what I
     am not doing.
                [Practice grandma, diabeticconnect.com Diabetic Connect app]

Another essential aspect of our analysis concerns the use of these forums
by the relatives of people with diabetes. In many cases, parents are
interested in using technological tools (e.g. apps and forums) in order to
help their children in the management of their disease and, more than
anything, in having satisfying social lives. In particular, the issue of peer
acceptance – notoriously delicate and important during adolescence – is
on many relatives’ minds.
Moretti & Morsello                                                                      63
    So, my little sis, age 17, is a super cool person. But she wants to be so normal
    that she doesn’t take care of her diabetes when she is around friends. I have
    tried so hard to get her to explain to them how important it is or to try to
    find friends that will understand that she has to take care of it – but unfor-
    tunately she refuses. Any suggestions?
                           [Eggo sis, diabeticconnect.com Diabetic Connect app]

    My son use to be like that with his friends, but I sat him down and told him
    that if he wanted to go place and hang out with his friends then he would
    have to tell them about his diabetes. At first I think he was scared, scared
    that they would think that he was weird, but after he told them, they under-
    stood and even wanted to know more about it. It is so hard on teenager,
    because they do not want to be different.
                 [Frustrated mom, diabeticconnect.com Diabetic Connect app]

    Finally, in the same vein, we highlight use of forums by romantic part-
ners of diabetics, and in particular, their curiosity about the disease and
starting a relationship with a diabetic:

    My boyfriend has type 1 diabetes. He doesn’t like taking care of himself
    when it comes to giving himself insulin. I’m not for sure but most of the I
    know when he gives himself to much insulin. He gives himself too much a
    lot and his sugar gets low like 25–30 low and I have to feed him and he never
    remembers.
                       [amy12852, diabeticconnect.com Diabetic Connect app]

    Hello, I am not sure if this is the right place to ask this type of question, but
    I really do not have anyone else that I can ask. Me and this girl have shown
    interest in each other, we haven’t really gotten serious […]. Anyway, my
    concern is that she has type 1 diabetes, I do not really know too much about
    diabetes, but just what I’ve been reading over the past days and I am won-
    dering how this will affect our relationship. Will she have tons and tons of
    health issues, and is it wrong or insensitive of me to think, maybe I do not
    want to even get started on it, and end it before things start?
                      [Anonymous diabeticconnect.com Diabetic Connect app]

    It has become evident that patients can influence the outcome of their
treatment4 and health care service. Following a phenomenological ap-
proach, medicine, illness and health become real symbolic systems with
specific functions, and consist of a set of meanings, values and behavioural
norms. Patients’ autonomy and self-determination in adhering to medical
care and treatment plans have been issues much discussed in recent years
– not only in pharmacological terms, but also in terms of instructions for


    4
      The concept of compliance becomes a key parameter in the clinical manage-
ment and evaluation of experimental protocols of medical treatments. The critical
factors that influence the level of compliance are the type of disease, the cultural
structure of the patient, the physician's role, environmental interference.
64                                                                   Tecnoscienza – 8 (1)

the adoption of a lifestyle conducive to making more effective recom-
mended treatment.


5. Interpretation

    Through content analysis – of both commercial descriptions and cus-
tomer reviews – it was possible to identify the potential of these applica-
tions, as well as the limits to what they can offer. Although further research
is necessary, we outline below the strengths and weaknesses of diabetes
apps according to our analyses.

5.1 Strengths

     Self-care can surely benefit from the use of health apps. For instance,
the continuous monitoring function of interstitial glucose (CGM5), which
such technology encourages, can be highly beneficial: according to the Re-
gional Observatory for Innovation in Emilia Romagna (2014, 3), those ben-
efits include “improved glycaemic control, a reduction in hypoglycaemia,
and improved measures of physical condition (e.g. weight loss) and quality
of life. The improvement in intermediate outcomes should help reduce
short and long-term complications”. These apps offer a reminder service
(alarms), which patients can use to keep track of the tasks they must carry
out. Such services are being adopted around the world, especially in the
most disadvantaged areas. The Senegalese government, for example, uses
mobile technology during Ramadan to improve diabetes management by
sending citizens text messages with health tips (e.g. that one should drink
1 litre of water each morning before beginning the day’s fast, a list of foods
to avoid when breaking a fast in the evening, and information for health-
care providers about medication management during fasts) (WHO 2016).
     A second benefit of health apps – following the analysis of Rich and
Miah (2014) – is their potential as public pedagogical tools. Indeed, patient
education is a crucial component of diabetes management, especially in the
case of type 1 diabetes, many of whose patients must learn to manage their
disease at a very young age. We can define public pedagogy, in basic terms,
as assistance in improving one’s self-monitoring offered outside of a formal
educational structure (Rich, Miah 2014). The use of health-focused apps
may not only may serve a preventive function but may also allow the
smoother management of diabetes in the earliest phases of the disease,


     Device that allows to obtain frequent measurements of glycemic level and to
     5

rebuild the profile of a diabetic patient's blood sugar level with a time resolution of
a few minutes. For further information please refer to the Regional Observatory for
Innovation in Emilia Romagna (2014) Innovative medical devices for the manage-
ment of diabetes. Updating the short report number 6.
Moretti & Morsello                                                          65

providing new patients with information and therapeutic services. These
technological offerings aid patients in adapting to the new lifestyle that di-
abetes management requires.
    A third benefit of these mobile apps is the reduction of the cost of treat-
ment. According to the National Diabetes Statistics Report (2014, United
States), the total costs related to diabetes in 2012 were around 245 billion
USD, of which 176 billion USD related to direct medical costs (outpatient
and emergency care; inpatient hospital care; medications and medical sup-
plies such as injection devices and self–monitoring consumables; and long–
term care), while indirect costs (disability, job loss, premature death) ac-
counted for around 69 billion USD. According to the 2016 report of the
Italian Society of Diabetology, the International Diabetes Federation (IDF)
has estimated global spending on the prevention and treatment of diabetes
and its complications for the year 2015 to be 673 billion USD. Projections
for the year 2040 estimate an expenditure of over 802 billion USD, an in-
crease of 20%, in contrast to the substantial stability of the expected pop-
ulation in 2040. In Italy, the total expenditure estimated by the IDF for
2015 amounted to 12 million USD, with an expected growth for 2040 of
14.4% which is slightly smaller than that expected at the European level
(18%). The use of these applications could alleviate some of these costs by
decreasing visits to the doctor through patients’ ability to send metrics
about their health via email.
    Another positive contribution of these apps is their gamification in
gathering data, and the related levels of rewards they offer users.
     In several contexts, such as health management, game design involving
personal activity monitors is highly promising. Accumulating a large num-
ber of points, especially in the first app we analysed, shows a high level of
adherence to a treatment plan on the part of the patient. However, incen-
tivizing rewards cannot be considered the sole motivation for boosting in-
tense control. Children’s autonomy in managing their diabetes is wrapped
up with (factors involved in) their acquisition of wider independence from
the parents. This practice, in fact, requires much effort. A patient decides
to make diligent use of technological tools in managing his or her disease
only once he or she recognizes the centrality of his or her role in effective
health management (Lehocki et al. 2012).
    Finally, we highlight the power of patient-to-patient influence, consid-
ering foremost blood sugar-tracking habits. Interpersonal connections
made through social networks or forums that involve the exchange of in-
formation may promote healthy practices. Our analysis of forums and cus-
tomer reviews highlighted that most teenagers affected by diabetes can im-
prove the tracking and management of their health metrics by sharing tips
and comments with other patients online.
66                                                               Tecnoscienza – 8 (1)

5.2 Weaknesses

     Let us turn to apps’ weaknesses. Although most of them include a warn-
ing that the information they offer should not be taken as medical advice,
it is worth our considering more specifically the potential risks use of these
apps may involve. Recorded glucose, food, medication and other data
should be verified with healthcare professionals. This is because resultant
insulin dose recommendations will be decided based on both contextual
and behavioural factors: “the potential for new risks arising from the use
of medication apps is suggested by the withdrawals of a small number of
products, including an insulin dose calculator developed by a pharmaceu-
tical company, because of clinically relevant errors” (Huckvale 2015, 2).
The health market is growing rapidly and several medical apps are designed
to make diagnoses; one of the most discussed debates is to what extent
these diagnoses can or should be taken seriously by patients. If apps are
becoming widely prescribed by doctors, could they replace traditional
physical exams meant to diagnose patients? This seems unlikely: the pro-
cess of diagnosis requires a more nuanced process of cooperation on many
actors’ parts in the name of achieving precise information about a patient’s
condition.
     At the same time, technological objects and artefacts become constitu-
ent elements of the clinical encounter between doctor and patient 2.0
(Bruni and Rizzi 2013). The patient’s load is simultaneously lightened (in
that he or she can use technological tools to make self-management easier)
and burdened (in that considerable pressure accompanies the responsibil-
ity of care being transferred from the doctor to the patient).
      In fact, it is not easy to establish if these tools can effectively improve
the quality of life of patients with chronic illness, or if they are only a short-
cut to reducing the operating costs of care services. Innovation potential,
however, is high. It is important to establish and keep in mind that these
technological tools and telemedicine services can be useful only if patients
are highly motivated to manage their disease in an autonomous and con-
scious way.
     Indeed, “by shifting the load of responsibility from the way in which
society organizes public life to the way in which individuals organize their
own lives, the neoliberal ethos is carrying out a highly depoliticizing oper-
ation” (Maturo, Mori and Moretti 2016, 264).
     The last drawback of these technologies that we must consider is their
social implication. Self-management and quantification through health
apps presupposes a social construction of the body as something that is an
enterprise, or rather as an ‘embodied enterprise’, given that the symptoms
of a chronic illness are evaluated and categorized digitally. In this sense
“medical technologies provided health care providers with effective tools
to coerce others into approved, healthy lifestyles” (Timmermans and Berg
2003, 97). Moreover, surveillance practices are often associated with both
care and control (Brighenti 2011). This form of self-monitoring can be
Moretti & Morsello                                                         67

shared on social networks, thus overturning the foucauldian panopticon
idea: the subject does not want to watch over everyone; rather, he demands
to be monitored and evaluated by everyone. Moreover, he wants not only
his external behaviour to be monitored and evaluated, but also his mental
states and physiological data. New technological tools increase the visibility
of relationships between the individual body and the body of the popula-
tion, and shed light on the way these two bodies form the two poles of the
control itself (Brighenti 2011). Intimacy becomes extimacy; surveillance
becomes inter-veillance; the panopticon becomes the endopticon (Maturo,
Mori and Moretti 2016).


6. Conclusion: An App a Day Keeps the Doctor Away?

    It has hard to deny that the growth of technological devices such as
apps has created new opportunities for health care and disease manage-
ment. Moreover, these medical applications increase the amount of low–
cost or free information and publicly accessible data about diabetes, facili-
tating patients’ self-management. Alongside these valuable functions, sev-
eral issues with these tech tools must be noted.
    First, in its focus on self-care and self-diagnosis, technology around di-
abetes plays a large role in the redefinition of the illness; apps and forums
like those we have discussed locate the individual patient and his or her
identity at the centre of treatment. By way of these apps, self-management
of one’s disease becomes a playing field of opportunities to reinvent the
self: technological devices and services become an integral part of the dia-
betic lifestyle. In this way, these technology-borne tools seem to aid in sat-
isfying the adoption and management of a new lifestyle required by disease;
apps are designed not to force patients to alter their lifestyles (so to adapt
to the disease), but rather to make disease-management more adaptable to
the lifestyles patients already have.
     These turnabout technologies play a crucial role in that they give the
patient an additional resource with which to empower him or herself. Nev-
ertheless, focusing on apps as empowering forces in patients’ lives diverts
attention from the real risks associated with a lack of professional medical
care. The doctor, as a mediator between the individual and the disease,
should have a central and irreplaceable role in a clinical counter, a role
founded on the knowledge he or she possesses and the experience-based
expertise that he or she can offer a patient. Still, it may be the case that
these apps allow doctors to achieve greater familiarity with their patients;
and perhaps the patient’s increasing adeptness in self-tracking and new
skills in self-management partially erode the boundaries imposed by the
professional status of physicians.
    Further, the self-management that apps and other technology engender
appears to give laypeople more opportunity to monitor their bodies and
68                                                                  Tecnoscienza – 8 (1)

health in line with the discourses of healthism and control that pervade
contemporary medicine (Lupton and Jutel, 2015). The potential of this in-
novation to improve self-care is profound. Still, it is important to establish
that these technological tools and telemedicine services are useful only if
patients are highly motivated to manage their disease in an autonomous
and conscious way. The risks associated with simple self-care that is not
integrated with other sources of healthcare must be taken into considera-
tion, so to avoid assigning patients disproportionate responsibility for their
health and wellness.
    In conclusion, our analysis shows that these tools not only promote
communication between users in the dimension of patienthood, but also
open up a new dialogue between patient and doctor. For the most effective
diabetes management, it is important to create a communicative triad of
patients, physicians, and caregivers, in which technology facilitates com-
munication, especially about management of the disease. The management
of life with the disease affects more than the patient alone. In fact, there are
many different actors who should not be overlooked in the creation of new
technological tools. This is crucial in the process of ensuring that patient
empowerment is more than a mere rhetorical tool for health policies.
Health-management technologies must not become an isolated channel
through which healthcare enters people’s lives: rather, they ought to offer
support to patients, so that diabetes (and the challenges it presents) can
exist in the background of patients’ daily lives.


Acknowledgements

   While this article is the result of several discussions between the au-
thors, Veronica Moretti has written sections 3, 4, and 5.; Barbara Morsello
has written sections 1, 2. and 6.


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