Ican Study
Ican Study
Ican Study
Abstract
Background: The explosion of consumer electronics and social media are facilitating the rise of the Quantified Self
(QS) movement where millions of users are tracking various aspects of their daily life using social media, mobile
technology, and wearable devices. Data from mobile phones, wearables and social media can facilitate a better
understanding of the health behaviors of individuals. At the same time, there is an unprecedented increase in
childhood obesity rates worldwide. This is a cause for grave concern due to its potential long-term health consequences
(e.g., diabetes or cardiovascular diseases). Childhood obesity is highly prevalent in Qatar and the Gulf Region. In this
study we examine the feasibility of capturing quantified-self data from social media, wearables and mobiles within a
weight lost camp for overweight children in Qatar.
Methods: Over 50 children (9–12 years old) and parents used a wide range of technologies, including wearable sensors
(actigraphy), mobile and social media (WhatsApp and Instagram) to collect data related to physical activity and food,
that was then integrated with physiological data to gain insights about their health habits.
In this paper, we report about the acquired data and visualization techniques following the 360° Quantified Self (360QS)
methodology (Haddadi et al., ICHI 587–92, 2015).
Results: 360QS allows for capturing insights on the behavioral patterns of children and serves as a mechanism to
reinforce education of their mothers via social media. We also identified human factors, such as gender and cultural
acceptability aspects that can affect the implementation of this technology beyond a feasibility study. Furthermore,
technical challenges regarding the visualization and integration of heterogeneous and sparse data sets are described in
the paper.
Conclusions: We proved the feasibility of using 360QS in childhood obesity through this pilot study. However, in order
to fully implement the 360QS technology careful planning and integration in the health professionals’ workflow is needed.
Trial Registration: The trial where this study took place is registered at ClinicalTrials.gov on 14 November 2016
(NCT02972164).
Keywords: Quantified Self, eHealth, Wearable
* Correspondence: [email protected]
†
Equal contributors
1
Qatar Computing Research Institute, Hamad bin Khalifa University, HBKU
Research Complex, Qatar Foundation, Education City, Doha, Qatar
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Fernandez-Luque et al. BMC Medical Informatics and Decision Making (2017) 17:37 Page 2 of 13
track of at least one health parameter (e.g., weight, diet, project was led by Qatar University and consequently re-
or physical activity) [14]. Related to the behavior of ceived ethics approval from the Qatar University Institu-
tracking our own health is the concept of Quantified tional Review Board. In addition, all participants and their
Self. In a 2009 paper, M. Swan defined Quantified Self parents/guardians, provided informed consent prior to
(QS) as: Quantified self-tracking is the regular collection participation.
of any data that can be measured about the self such as Table 1 lists the timeline and processes involved in the
biological, physical, behavioral or environmental infor- ICAN study. The 360QS technologies were deployed in
mation” [15]. The rationale behind QS is that quantify- the intervention group from January to August 2016 but
ing aspects of a daily life through maintaining journals not all of the participants consented to using the pro-
or logs that can help the individual (or the caregiver) to vided 360QS technologies. Therefore, in this paper, we
better understand hidden patterns. For example, patients focus on the subset of participants from the study that
suffering from migraines have been advised to keep diar- interacted with the 360QS technologies and the feasibil-
ies of daily activities to identify triggers. Other common ity of using such technology.
examples are food logs, menstruation diaries, growth
and vaccination charts for children, and so on. Quanti-
Demographics
fied Self is also present in social media, where people
Overweight and obese children from several male and
share their weight diaries [16], sleep logs [17], blood glu-
female Qatari schools, in the age range of 9 to 12, partici-
cose levels [18], photos about eating preferences [19], etc.
pated in the interventions. The schools were randomized
The Quantified self-movement in the health domain is
between intervention groups and control groups. There
also often part of a social context [20].
were 53 boys and 55 girls in the intervention group while
Sensors and wearable technologies are sources of data
the control group consisted of 60 boys and 59 girls.
for Health Quantified Self [21]. In recent years the pro-
duction costs of wearable devices have reduced drastic-
ally as they became major consumer products, especially Health intervention
in the fitness and health sector [22]. In parallel, smart- The health intervention consisted of a set of health
phones with multiple sensors (e.g., accelerometers or coaching and education actions as follows:
light sensors) have become mainstream. Moreover, im-
plantable devices are often integrated with wearable de- Health camp: two-week weight management camp
vices, such as implantable glucose meters. Also mobile from January 24 to February 4, 2016, which included
devices are integrating data from smart homes and physical and social activities, lifestyle coaching and
Internet of Things devices such as smoke detectors. nutrition counseling.
These developments have all led to the Quantified Self Weekend clubs: ten-week program from February
movement becoming more mainstream and at a point 20, 2016, where every weekend for four hours, par-
where incorporating these technologies within the health ticipants received further reinforcement to acquire
domain. The popularity of QS technologies for fitness healthy behaviors.
and wellness is paving the way for the development of Summer break: during the summer break (June -
health applications to support health behavioral change. August 2016) a group of mothers participated in a
This also highlights the need to study the use of QS to
support behavioral change in populations such as over- Table 1 Timeline of the ICAN Study
weight children. Date Module Process Description
The efforts towards the creation of data-driven holistic 09/2015 Recruitment Students list with physiological data
obtained
views of the individual are reaching unprecedented levels
as part of the precision medicine and Big Data for 10/2015 Recruitment Overweight/obese kids selected for study
Health initiatives [23]. For example the Kavli HUMAN 10/2015 Recruitment Parents contacted for information session
Project is an effort to aggregate health-related data from 11/2015 Recruitment Study information session; consent forms
10,000 individuals in New York City containing health, given out to parents
education, genetics, environmental and lifestyle informa- 01/2016 Intensive Camp Health camp begins (Food photos collected)
tion that will be collected over a period of 20 years [24]. 02/2016 Intensive Camp Health camp ends (Phones with Instagram,
Activity trackers given)
Methods 02/2016 Weekend Clubs Weekend clubs begin
The 360QS technology was tested within a research 05/2016 Weekend Clubs Weekend clubs end
project for childhood obesity in Qatar called ”Adaptive 06/2016 Summer Break WhatsApp intervention for mothers begins
Cognitive Behavioral Approach to Addressing Overweight
08/2016 Summer Break WhatsApp intervention for mothers ends
and Obesity among Qatari Youth” (ICAN Study) [4]. The
Fernandez-Luque et al. BMC Medical Informatics and Decision Making (2017) 17:37 Page 4 of 13
mobile intervention using WhatsApp to reinforce two-week health camp to gain insights on dietary
healthy eating and behaviors. preferences.
Physiological Data: Physical health of the participants
was measured periodically via height, weight, etc. to
The 360QS implementation obtain an overall picture of the impact of the
The 360QS implementation in the ICAN Study involved intervention on participants’ health.
different technologies:
The wearable devices and mobile social media are clear
Wearable devices: Wearable devices (actigraphy examples of QS technologies that can be used to capture
sensors) were used to monitor sleep and physical data about individuals’ behaviors. The health camp food
activity of the participants. photos and physiological data was not captured by the in-
Mobile Social Media (Photos and Messaging): We dividuals, but the research team. The food photos can be
incorporated the use of social media for tracking combined with the other data sources to gain more in-
dietary habits of participants (Instagram) and health sights on the health behaviors of the individuals.
education of mothers (WhatsApp). Figure 1 shows the data collected over time for the
Health camp food Photos: We also captured photos 2016 trial using each 360QS technology. It also indicates
of the food consumed by participants during the the time periods with data overlaps. For example,
Fig. 1 Datasets overview for the 360QS implementation - Volume of collected data from different sources per day. The volume is given in terms
of number of participants from which data have been collected for a given day. Each row shows the volume from unique data sources (top five
rows) and from combinations of two or three data sources (bottom rows). The combinations of sources are useful to show those data sources for
which data is available for the same participants so the complementarity between various data sources can be analyzed in these cases
Fernandez-Luque et al. BMC Medical Informatics and Decision Making (2017) 17:37 Page 5 of 13
between January 31, 2016 and February 4, 2016, for to learn food preferences of participants, which could in
about 10 participants, we have food photos collected turn assist the nutrition professionals in designing diet
during the camp, physiological data, as well as actigra- plans for weight loss, and also give calories estimates of
phy sensor data. As explained below, we need to be the food consumed during the camp.
aware that these technologies were not applied homoge-
neously in all the subjects. Not all the mothers accepted Weekend clubs: actigraphy sensor
to participate in the WhatsApp intervention, and only a In order to study the physical activity and sleep patterns,
subsets of subjects received mobile phones for taking we used actigraphy. Actigraphy sensors were given at
food photos using Instagram. the end of the health camp to be used during the week-
All the data collected during the trial was integrated end clubs. An actigraphy device is a wearable medical
using anonymized participant identifiers and stored in a device, which captures motion using accelerometers and
secure database. This integration facilitated the study other sensors to identify patterns in physical activity and
and analysis of the data. sleep. We used the device Axivity AX3 (see product
website: http://axivity.com/product/ax3) that has been
Physiological data used before in clinical studies [25]. The Axivity device is
As part of the clinical research protocol, all the partici- waterproof and was given to participants to be worn at
pants’ physiological parameters were measured over time. all times as a wristband. The device was given to 67 par-
That includes weight, height, body mass index (BMI), ticipants; 16 in the control group (8 boys and 8 girls)
body fat percentage, waist circumference and blood pres- and 51 in the intervention group (26 boys and 25 girls).
sure. These parameters were taken during recruitment, Since the battery life of the device as well as its data
start and end of the health camp, during the weekend storage memory is about four weeks, we recharged the
clubs and also at the end of the program. devices and downloaded the data for participants in the
intervention group multiple times during the weekend
Health camp: food photos clubs.
During the two-week health camp, before and after pho-
tos of food trays (breakfast and lunch) were manually Weekend clubs: social media - instagram
taken for all participants for ten days, i.e. twenty meals, A total of 50 mobile phones with a pre-configured Insta-
as shown in Fig. 2. The goal of this data collection was gram account were given to parents of participants (30
boys and 20 girls) at the end of the health camp, to take A total of 21 mothers were enrolled in this study, with
photos of the food eaten by their children in the 3 dropouts at the beginning of the study, resulting in 18
remaining duration of the program, and upload to the participants (mothers of 7 boys and 11 girls) who com-
Instagram account. This was done in order to monitor im- pleted the study. The data collected included the par-
pact of the health camp on the participants’ dietary habits ticipation in the WhatsApp group, responses to the
and also capture dietary preferences of the families. health tips and also whether the participants had seen
Figure 3 shows one of the participants’ Instagram photo. the messages or not in order to evaluate the attrition of
this intervention.
Summer break: social media - WhatsApp
In the ICAN study, face-to-face sessions with parents Results
were organized for health education. Furthermore, we Health camp: food photos
contacted parents asking for their interest in using mo- The dataset collected was cleaned and labeled using par-
bile technology or social media to reinforce the educa- ticipant identifier, meal type (lunch or breakfast) and
tional support. Only the mothers showed interest in food tray state (before-meal or after-meal), resulting in
such additional support, with the majority mentioning 2,753 photos. An extensive menu list was prepared by
WhatsApp as their preferred communication channel. identifying all food items served during the camp. The
We designed an educational intervention for mothers food photos were grouped into before-meal and after-
using WhatsApp for a 12-week period of the summer meal photos per user per day per meal. The labeling
break. Educational content was adapted to the WhatsApp tasks were then assigned to local volunteers via a web
channel (e.g., short educational messages, see Fig. 4). application where they labeled each task to indicate food
These messages also incorporated the use of behavioral items present on the participants’ trays, along with the
nudges, in particular commitment to support the health amount left on the tray at the end of the meal for each
changes of their children. The group was moderated by a food item.
dietitian and a pharmacist who shared messages that in- Figure 5 shows the percentage of food left on partici-
cluded: daily reminders, weekly healthy tips, weekly com- pants trays grouped into six major food types - fruits;
mitment for a health change and answers to questions vegetables; dairy (milk, cheese, yogurt); fish, poultry,
raised by mothers. meat; grains and beans/legumes; desserts and sugary
this is most likely related with a higher level of engage- That BMI change is comparing the values at beginning
ment in their health. of health camp with the values at the end of Weekend
clubs. The children of participating mothers got an aver-
age BMI change of −0.058 compared to 0.0455 for those
Summer break: social media - WhatsApp not participating (the different was not significant with
A total of 18 mothers participated in the WhatsApp sup- p = 0.7879 and permuted p = 0.5709). This indicates a
port group after the Weekend clubs. This was done to bias where more engaged mothers in terms of health are
provide educational support during the summer break. also more likely to opt-in for the enrollment in this so-
We analyzed the already acquired weight loss at the time cial media intervention. The interaction declined over-
of enrollment in WhatsApp. time with regards of messages sent in the WhatsApp
Table 2 Correlation of the proportion of food eaten, grouped send questions or confirmations with regards to health
by a food type, to the child’s change in BMI tips and comments. Furthermore, 17 out of 18 partici-
Group Correlation p-value Permuted p-value pants received and read all the messages during the
vegetable −0.055 0.611 0.413 intervention. Only one dropout happened during this
fruit 0.061 0.573 0.943 period, which was a month after the Whatsapp group
started.
egg −0.065 0.559 0.556
porridge −0.145 0.185 0.021
dairy −0.122 0.269 0.224 Discussion
meat 0.027 0.803 0.166 Principal Results
fish −0.093 0.526 0.767 Human factors and acceptability
soup 0.120 0.282 0.983 In order to minimize the participant burden, we did not
perform questionnaire-based usability evaluation and ra-
pasta −0.084 0.526 0.133
ther focused on actual system usage. Instead we looked
rice 0.225 0.050 0.949
into the attrition towards the use of the different types
bread −0.014 0.897 0.296 of technology. Then our findings were discussed with
dessert −0.141 −0.141 0.227 the healthcare professionals that interacted directly with
the children and their families to gain insights about the
group (146 in June,108 in July and 23 in August). An potential reasons.
important topic during June was the Holy Month of We found significant differences with regards to the
Ramadan and also its impact on nutrition (e.g., big family participation and acceptability across the genders. Over-
meals during evenings, fasting). It is common in Qatar all, the engagement of the females was higher. Girls used
that families travel abroad during the summer holidays, the wearable devices much more as instructed. Mothers
especially August, which might have also influenced did enroll in the social media intervention where as not
mobile usage and resulted in reduced interactions. a single father showed interest in participating. More-
June was also the month with more questions from over, mothers of girls were the majority in the Whatsapp
the participating mothers. Only four participants did not group. This highlights the importance to take into
Fig. 7 User interface of the visual analytic tool for actigraphy sensor data The interface allows comparing two participants’ activity level (left side)
for the full time period and on daily-based average during week and weekend days (right side). Specific clinical measurements like BMI or body
fat can also be compared during the same time period (line charts)
Fernandez-Luque et al. BMC Medical Informatics and Decision Making (2017) 17:37 Page 10 of 13
The collected data can be useful to healthcare providers visualization of Electronic Health Records (EHR) for
to analyze children profiles and guide them to improve helping decision making [34], also including Quantified
their health (for instance determining which food is pre- Self data [35–37] but in those studies the QS data is lim-
ferred, or at which time a child is willing to be active and ited to wearable sensors data. Folter et al. studied the in-
using this knowledge to orient the child’s behavior); but tegration of health habit data (e.g., motion data for
also for researchers to improve on the measurement pro- physical activity) to help decision making of healthcare
tocols and techniques (for instance how to make children professionals [36]. Ledesma et al. studied techniques for
more diligent in wearing or using the devices? how to de- visualizing personal health data, but not including social
velop analysis techniques to extract more relevant infor- media data. In our case we are looking into helping
mation from the data?); and finally for the children to understand health behaviors (and not clinical aspects) in
keep track of their progress in a specific attractive user a more heterogeneous and sparse data set. Implementa-
interface (shall the children be put in competition with tion Research methodologies [38–40] can provide a good
each other? or only aware of their own results? or be put framework for future work about the integration of
in situation to help each other? what kind of information 360QS in this type of health interventions.
to show to children? and in which way to make it attract-
ive for them?). Each of these needs require specific visual Limitations
interfaces carefully designed in close collaboration with The implementation of the 360QS was not integrated in
the targeted end-users and professional experts in children the workflow of the health intervention; therefore we
health, nutrition, pedagogy and psychology. have not studied how such an ecosystem can be imple-
mented in a way that can enhance the intervention. Fur-
Comparison with prior work ther research should look into the best strategies to use
To our knowledge this is the first reported exploration the most promising 360QS technologies as part of the
of the use of Quantified Self for personal health in an regular intervention.
Arab country. Our study is highlighting many of the so- The clinical trial was registered after the recruitment.
cietal challenges that can be faced in introducing digital However, in this study we do not look into the health out-
health interventions in the younger Arab population. comes derived from the use of the 360QS ecosystem. Our
There are previous studies in the region, but they have study design was not implemented to infer health outcomes
focused on a much narrower implementation of eHealth that would have required a very different experimental
technologies [29] and specially focusing on diabetes and setup. We looked at statistical significance of health out-
obesity in the adult population [30, 31]. Another novelty comes for descriptive purposes, overall the p-values were
of our study is the combination of social media as an low and the mere fact that some correlation values are
additional source of health quantified-self data. This is small is quite positive if we consider the very small sample
increasingly important since consumers are using social size and the presence of multiple confounding factors.
media for health purposes. There are other projects Our study focuses on 9 to 12 years old children, and
looking into the integration and visualization of Quan- consequently our findings might not be generalizable to
tified Self health data [32, 33], but do not include the the entire age spectrum of childhood obesity. Further,
heterogeneous datasets as we have. our study has taken place with Qatari public schools
Apart from heterogeneity, our datasets have an added where the medium of education is Arabic. Consequently,
complexity of being sparse. Sparsity of the data poses our findings might not be applicable to the non-arabic
significant challenges for visualization. This data sparsity speaking segments of the population in Qatar.
can be attributed to human factors since we do not ad- In order to be able to understand the reasons for low
dress visualization of data for people adherent to the usage of some of the 360QS technologies, we will need
‘Quantified Self ’ movement but rather individuals who to perform qualitative studies (e.g. questionnaires, semi/
are in need of a more active role in their health. This is structured interview) addressing different aspects of the
a substantial difference if we consider that many Quanti- Technology Acceptance Model [5] and Human Factor
fied Self users are highly motivated individuals [20] and Engineering methods. Further, ways to visualize the 360QS
that they do not represent the vast majority of people in data to help decision-making were not addressed in this
need of support for behavioral change. study and it is part of future work.
An additional challenge that we describe is how to in-
tegrate that information into meaningful visualizations Conclusions
that can help understand the health patterns of the indi- In this study we explored the feasibility of using the 360°
viduals. This is not answered in our paper, but we pro- Quantified Self technology to capture health-related data
vide some innovative examples of visualization of this within a childhood obesity intervention. The integration
type of data. There are other studies looking in the of mobile, social media, wearable and health data is
Fernandez-Luque et al. BMC Medical Informatics and Decision Making (2017) 17:37 Page 12 of 13
feasible but there are many potential challenges related Received: 26 October 2016 Accepted: 25 March 2017
to human factors and technical issues (e.g. gender differ-
ences in technology usage). It is not yet clear if the in-
creased adherence to technology was more prevalent References
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