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How does health feel? Towards research on the affective atmospheres of digital health

How does health feel? Towards research on the affective atmospheres of digital health The concept of affective atmospheres has recently emerged in cultural geography to refer to the feelings that are generated by the interactions and movements of human and nonhuman actors in specific spaces and places. Affective atmospheres can have profound effects on the ways in which people think and feel about and sense the spaces they inhabit and through which they move and the other actors in those spaces. Thus far, very little research has adopted this concept to explore the ways in which digital health technologies are used. As part of seeking to redress this lacuna, in this essay I draw on previously published literature on affective atmospheres to demonstrate and explain the implications of this scholarship for future theoretical and empirical scholarship about digital health practices that pays attention to their affective and sensory elements. The article is structured into six parts. The first part outlines the concepts and research practices underpinning affective atmospheres scholarship. In the second part, I review some of the research that looks at place, space and mobilities in relation to affective atmospheres. In the third part I focus more specifically on the affective atmospheres of medical encounters, and then move on to digital technology use in the fourth part. I then address in the fifth part, some relevant scholarship on digital health technologies. I end the essay with some reflections of directions in which future research taking up the concept of affective atmospheres in the context of digital health technologies can go. The key research question that these topics all work towards is that asking ‘How does digital health feel?’ Keywords Affective atmospheres, digital health, digital sociology, feeling, the senses Submission date: 6 October 2016; Acceptance date: 20 February 2017 Introduction Affective atmospheres are shaped by their multisen- The concept of affective atmospheres has recently sory properties: how spaces and places are physically emerged in cultural geography to refer to the feelings encountered via their visual, haptic, aural, olfactory that are generated by the interactions and movements and taste properties is central to the feelings they gen- of human and nonhuman actors in specific spaces and erate. Affective atmospheres can have profound effects places. In this literature, affects are conceptualised as on the ways in which people think and feel about and relations between humans and nonhumans, perceived sense the spaces they inhabit and through which they and felt through the body. Affective atmosphere is move and the other actors in those spaces. People both understood as an assemblage of affect, humans and contribute to the affective atmospheres they encounter nonhumans that is constantly changing as new actors and are affected by them. A key feature of this concept 14 enter and leave spaces and places. An affective is the recognition that affect is not an individual atmosphere is often felt or sensed by humans entering a place rather than directly observed or represented in News & Media Research Centre, Faculty of Arts & Design, University of words or images, although these can also contribute to Canberra, Australia affective atmospheres. Affective atmospheres are dif- Corresponding author: fuse, contingent and emergent, as humans respond to Deborah Lupton, News & Media Research Centre, Faculty of Arts & Design, the presence and withdrawals of other humans and to University of Canberra, Australia. nonhumans. Email: deborah.lupton@canberra.edu.au Twitter: @DALupton Creative Commons NonCommercial-NoDerivs CC-BY NC-ND: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License (http://www.creativecommons.org/licenses/by-nc-nd/3.0/) which permits non-com- mercial use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 DIGITAL HEALTH response but is shared and collective, an intensity of targeted by digital health technologies tend to be feeling that moves between people. Affective atmos- glossed over or ignored in these accounts. pheres can be experienced similarly, but the same As part of seeking to redress this lacuna, in this essay I people in the same spaces may also be experiencing draw on previously published literature on affective different affective atmospheres as they may be respond- atmospheres to demonstrate and explain the implications 5,6 ing to different elements in the space. of this scholarship for future theoretical and empirical In this review essay, I discuss the ways in which the scholarship about digital health practices that pays atten- concept of affective atmospheres can be applied to tion to their affective and sensory elements. The article is understand the sociocultural dimensions of digital structured into six parts. The first part outlines the con- health technologies, including their sensory properties. cepts and research practices underpinning affective Digital technologies are widely advocated in medical atmospheres scholarship. In the second part, I review and preventive health settings in the interests of deliver- some of the scholarship that has explored the entangle- ing more effective and less expensive healthcare and ments of place, space and mobilities in relation to affective encouraging people to take responsibility for promot- atmospheres. These are the principal topics that have ing their health or to engage in self-care for chronic been addressed thus far using the notion of affective illnesses. Digital health technologies used for these pur- atmospheres. In the third part, I focus more specifically poses include telemedicine technologies, blogs, wikis, on the affective atmospheres of medical encounters, and videos, websites, search engines, online discussion then move on to digital technology use in the fourth part. forums and social media for the provision of informa- I then address, in the fifth part, some relevant scholarship tion about medical matters and for patient support, on digital health technologies. I end the essay with some health and medical apps for mobile devices and other reflections of directions in which future research taking software, digital patient self-care and self-monitoring up the concept of affective atmospheres in the context of devices, implantable, wearable and ingestible sensors digital health technologies can go. for biometric monitoring, health and fitness gaming devices, smart devices for monitoring and providing Affective atmospheres: concepts and care to the elderly, emergency response systems, digital research practices imaging software for medical diagnosis, virtuality real- ity and augmented reality for medical education and It is important to emphasise the mutual co-constitutive training, electronic patient records and other health nature of the generation of affective atmospheres informatic systems, digital disease surveillance soft- between people and nonhuman actors. Scholars who ware, robotic surgery and 3D printing of prosthetics have adopted the affective atmospheres approach often and human anatomical replicas. Many of these technol- draw on phenomenological philosophical perspectives, ogies are also used in a wide variety of settings beyond particularly as espoused in the work of Merleau-Ponty. the medical clinic and hospital, including the home, In his phenomenology, Merleau-Ponty emphasised the workplaces and schools. interembodiment and intersubjectivity of humans with Very little scholarship has attempted to apply the other humans and with the environment around 7,8 concept of affective atmospheres to the context of them. Recent sociomaterialist scholarship has also health, illness and healthcare. Even less research has been influential. Like other sociomaterial perspec- 911 directly focused on digital health technologies. Using tives, scholarship on affective atmospheres highlights digital health technologies can be a profoundly emo- the role of nonhuman actors in human experience: other tional and sensory experience, with significant implica- living things, objects, space and place are accorded tions for the understanding of human bodies, health detailed attention in what is described as a ‘more-than- and illness states and medical care. Discussions about human world’. the uses of digital health technologies in popular media, Some scholars working on affective atmospheres such as technology blogs and research published in the now often refer to a post-phenomenological position, medical literature, tend to emphasise the rationalised in which embodied experience and practices, including purposes and outcomes of these technologies. While the sensory and sensual, are the main foci. This position these accounts are overtly about the diagnosis and med- departs from the interest in language and discourse that 1214 ical care or monitoring of human bodies, they are stran- has recently dominated much social theory. The gely decorporealised. There is little focus on the sensory terms ‘non-representational’ or ‘more-than-representa- and affective dimensions of digital health technologies, tional’ are sometimes employed in this literature to and how these may encourage or inhibit people (both emphasise the decentring of language and the turn patients and practitioners) from wanting to use them or towards affect and practice. This has entailed a focus finding them effective. The visceralities, vitalities, fleshi- on the phenomena of human experience that are felt or 2,4 ness, messiness, intensities and perversities of the bodies performed rather than directly articulated. Lupton 3 The practices of sensing through human embodiment, affective atmospheres and technologies has tended to 5,14,19 and the emergence of feelings and emotions from these centre on practices such as cycling or on other 3,20 practices, are integral to the production and experience forms of transport, such as travelling on trains and 6,15 21 of affective atmospheres. Affective atmospheres are driving and parking cars or on specific places and 2224 sometimes open to conscious identification, but also spaces, particularly those that are public. This operate at the pre-conscious or non-conscious level or research has identified how space and place can feel somewhere between. Some of the feelings and practices safe, secure, pleasurable and pleasant or uncomfort- that are part of affective atmospheres can be difficult to able, risky, threatening or dangerous through a com- 2,15 express in words. Research methods in scholarship on plex combination of elements. affective atmospheres, therefore, tend to employ qualita- As Merriman points out in his account of car park- tive and interpretive methods that focus on embodied ing spaces, aspects such as the cost of parking, ease of practices, habits, routines, actions, performances and access, the lighting of the space, its availability, the behav- forms of exchange and communication which often iour of other drivers using the space and many other elem- 1,2,4 operate subconsciously, in addition to the words ents can influence the affective atmospheres of these people use to explain their practices and ideas. spaces, and consequently shape whether drivers are will- Researchers adopting these approaches argue that mean- ing or able to use them. There are often complex ‘affective ing can emerge from routine sensory practices and habits economies’ and aesthetic judgements interbound with 1,12,17,18 rather than the other way around. affective atmospheres, shaping the ways in which space The affective resonances of these embodied practices and places are built, managed and controlled. and the ways in which the senses are engaged are cen- Some of this research has centred on the entangle- tral aspects that are targeted for exploration in this type ments between bodily sensations and emotional of research. This research may involve the use of responses. Bissell’s analysis of the stress of commut- images, autoethnography, detailed fieldwork and ing by train, for example, develops a non-representa- ethnographic work with close observations of other tional perspective on bodies. He draws on his own people’s behaviours and responses in a specific space, experience of commuting as well as an interview with audio-recording of soundscapes and notes about sen- another commuter (chosen as a case study from several sory perceptions of the environment: how the world he had conducted) to examine the gradual processes by looks, smells, feels, sounds and tastes. Researchers which stress develops as a result of regular commuting. exploring affective atmospheres may ask people to re- Simpson’s study involving cyclists in the city of enact their mundane practices and take photographs, Plymouth, UK, identifies the ways in which other audio-recordings and videos of these re-enactments, road and footpath users contribute to the cyclists’ feel- move along with them as they move through space ings of comfort and relative safety in moving through and place (‘go-alongs’), ask them to use a voice recor- these places. The behaviour of pedestrians or car dri- der to recount their experiences in the moment, write vers, for example, who express anger, hostility or frus- field notes as part of autoethnographic work on per- tration about having to share paths and roads with sonal experiences, use cultural probes in the attempt to cyclists can shape cyclists’ felt experiences as they investigate non-obvious and creative responses to encounter these other users, leading to the creation of research questions, ask people to wear digital sensors ‘uncongenial atmospheres’. to elicit digital data about their bodies, and participate The spaces and places in and through which people in people’s everyday activities (play a game with them, move and encounter each other and the broader sets of engage in their work with them, spend time in their shared practices, rules or laws that may govern these homes and so on). Part of this focus is exploring aspects locations are central to the generation of these feelings. concerning how people feel comfortable or ‘at home’ People can behave in hostile ways to cyclists, for exam- using digital technologies, while others may feel less ple, because they feel as if cyclists are encroaching on secure or at ease, and what the implications are for their space in crowded traffic conditions or breaking the any differences between people. Some of these methods law. Cyclists respond to expressions of this hostility, will be explained in further detail below in relation to perhaps leading them to engage in more aggressive specific research projects. styles of cycling or to avoid certain routes. The entanglements of humans, nonhumans, sensory sensa- tions and affect are complex and interactive. Affective atmospheres of place, space and mobilities Affective atmospheres of medical encounters Perhaps because the concept of affective atmospheres was first developed in cultural geography  and par- While few scholars have explicitly directed attention to ticularly in mobilities research  previous work on the affective atmospheres of medical spaces, work in 4 DIGITAL HEALTH medical geography, science and technology studies and elements such as the embodied care they received from the sociology of health and illness has explored the the healthcare professionals working at the centre, importance of the emotional dimensions and material- avoidance of the social expectations of family members, ities of care and the nature of space and place in making new friends with other patients and opportu- patients’ and practitioners’ experiences of illness and nities to move around in the rural setting and observe healthcare. Some of this research has drawn attention the wildlife as providing a sense of freedom, relief, to the production of feeling states as part of socioma- expansiveness and calm that promoted patients’ feel- terial encounters of humans and nonhumans. ings of safety, self-confidence and relaxation. Bell and Medical care can be a profoundly emotional experi- colleagues emphasise the importance of ‘green’ envir- ence for the people involved, including healthcare prac- onments (outdoor areas with vegetation) and ‘blue’ titioners and other carers as well as patients or other lay environments (outdoor areas with bodies of water) in people. When people’s bodies and health and illness helping people cope emotionally with periods and life states are the foci of digital technology use, they can transitions involving stress or turmoil, such as the often be very vulnerable or otherwise find themselves intensive parenting of young children, high work 2527 dealing with strong feelings. Sociologists and demands or the onset of illness or impairment. anthropologists have highlighted the importance of The materialities of care literature has also identified sensory engagements between healthcare professionals the heterogeneous elements that contribute to affective 3537 and patients as part of diagnosis, assessment of patient atmospheres in medical and therapeutic settings. wellbeing and recovery, the development of medical Van Hout and colleagues have demonstrated how sen- 2831 knowledge and developing the patient’s trust. sory perception is important to palliative care nurses’ While interpersonal engagements are vital elements, assessments of their patients when making home visits. incorporating space, place and other nonhuman actors The nurses use various sensory appraisals to discern how extends this understanding of the affective dimensions well their patients are faring, including, not only talking of the medical encounter. The hospital or medical clinic to and looking at their patients to assess their physical could be understood as a specific type of affective characteristics, but also viewing the relative state of tidi- atmosphere, in which the various human actors ness and cleanliness of the home and its garden, its smell involved (e.g. practitioners, patients and their families), and other sensory factors that can hint at the health and together with a range of nonhuman actors (e.g. rooms, wellbeing of its occupant. Although the researchers do views of the outside world through the windows, indoor not use the term affective atmospheres, their account of plants, furnishings, pharmaceuticals, medical technolo- the palliative care nurses identifies many elements of gies and devices, air temperature, odours, sounds and how atmospheres are generated in this setting and how so on) co-produce and experience the feelings that are the nurses themselves are sensing and contributing to part of this space and place. These spaces can generate these atmospheres as part of their working routines a range of feeling and often ambivalent emotions: anx- and habits. iety, fear, frustration, shame, distress, pain, boredom Working from an affective atmospheres perspective, and a sense of being at risk may coincide with relief, Anderson and Ash recount their (separate) personal trust, comfort and feelings of safety. The physical sen- experiences in vignettes detailing waiting in UK sations people encounter when they are part of these National Health Service hospitals for medical care to spaces, including noises, smells, tastes and haptic be delivered to a sick child (in the case of one author) experiences, are central to their affective responses. and an optometry appointment (in the case of the These spaces can be healing and calming in their affect- other). They begin with recounting the importance of ive atmospheres, but they can also be uncongenial attempting to give a name to an affective atmosphere as spaces. an initial step in understanding it. Anderson and Ash In medical geography research, there are references describe the affective atmospheres they experienced and to the contributions that place, space, living creatures contributed to as ‘anxious waiting’, a feeling generated and other nonhuman elements make to what has been by the emotional demeanours and voices of the people entitled ‘therapeutic landscapes’. Therapeutic land- waiting around them in the hospital waiting rooms, the scapes are those natural or built environments, includ- practices of the hospital staff and the sounds, odours, ing the people and other living things that inhabit them, tactility and appearance of the waiting room and the in which people feel better and achieve a sense of well- hospital environment generally in which they are 27,3234 being. The concept recognises that the affective located. They refer to incidents they observed when and sensory dimensions of these spaces and places are the affective atmosphere suddenly changed because of vital to human wellbeing. Conradson gives the exam- the cry of a child, or the appearance of a visibly upset ple of an English rural respite care centre. His inter- patient with a catheter in her nostril, altering the rela- views with the patients spending time there identified tive calm into a more intense, negative mood. Lupton 5 Ash’s inquiry into the different types of atmos- Affective atmospheres of digital technology use phere generated by the iPhone 4 is one of the few Bringing this kind of research together with a focus on accounts of the affective atmospheres of digital devices digital health technology use offers a perspective that and software use published thus far. He places the tech- can consider the digital dimensions of therapeutic land- nology at the centre of his analysis, seeking to identify scapes, including not only how humannonhuman how this device is part of a set of relations that gener- assemblages generate positive affects that contribute ates affect. Ash focuses on moments of breakdown, to wellbeing and good health but also how negative when the iPhone fails to work as expected. One exam- affective atmospheres may detract from or hinder ple he gives is the design of antenna in the iPhone 4, good health and recovery from illness. Some research- which did not work well in picking up signals when the ers adopting these approaches to investigate the affect- phone was held by users in a certain way. The sensory ive aspects of media employ a ‘not-media-centric’ capacities of the phone and the user were both limited approach to media studies in their work. This refers by this problem, causing emotional responses on the to the attempt to consider media use (including digital part of users (mostly annoyance and frustration). media technologies) in their full environmental con- Understanding these kinds of specificities of affor- texts, including the ways in which these media are mar- dances of technologies (in other words, how they struc- keted (which serve to suggest how people should ture and allow use by human and other nonhuman emotionally respond to them), the other objects with actors) and the ways in which nonhuman actors inter- which people engage as they are using media and the act with others (in this case, the mobile phone antenna 38,39 spaces and places in which they do so. with the wireless signals in the air around it) is import- This focus on broader contexts has become even ant to realising the affective atmospheres of which they more important as digital technologies have become are a part. Ash draws attention in his analysis to the 40,41 mobile, wearable, implantable and ingestible. ways in which digital devices like smartphones and their Human encounters with their digital devices can be surrounding technological infrastructures (such as wire- highly personal and intimate. As digital devices are con- less signals) generate atmospheres which shape how stantly moving on and with human bodies, they are objects and humans encounter each other. thereby continually entering new relations with The personal information generated, recorded and humans and other nonhumans and generating new assessed by digital technologies can also contribute to atmospheres. Digital devices have become human com- affective atmospheres. Digital devices are often imbri- panions, cohabiting with them. They touch or even cated within networks and systems of surveillance: par- enter human flesh; they live on and with human bodies; ticularly those that generate detailed information about they monitor human movements in private and public people. Routine encounters with digital technologies spaces; they can inhabit the intimate domains of mood, online searches or browsing, smartphone and app use, slumber and sexual activity with the use of apps and online purchases, social media interactions, moving wearables to track these elements of human life. around in public spaces fitted with digital sensors The visual, aural and haptic aspects of digital continually work as part of digital surveillance, produ- 4851 device use are becomingly increasingly important to cing flows of data. Awareness of these processes the affective atmospheres of their use. The design of and technologies and encounters with personal data the appearance of the device and its user interface is can contribute to affective states. important in generating feeling. Touchscreens offer Focusing on how people generate and respond to new ways of interacting visually and haptically with their personal data, myself and colleagues conducted 44,45 digital devices. Many smartphones, tablets and what we describe as a ‘digital sensory ethnography’ to wearable devices now vibrate, buzz, play music or examine both cycling and digital self-tracking practices, melodic sounds and make other sounds to notify examining the affective capacities of the personal data the user that they have new messages, an appoint- generated by cycling self-tracking. They video-taped ment coming up or have reached a self-tracking cyclists (located in the Australian cities of Canberra goal. The Apple Watch, for example, described by and Melbourne) re-enacting preparing for a routine Apple CEO Tim Cook as ‘the most personal device’ commuting ride, including getting the self-tracking ever created by the company, not only monitors the devices ready, positioning them on their bodies or on haptic functions and movements of the wearer’s their bicycles and turning them on, and then re-enact- body, but also communicates with the wearer using ing what they did when they finished the commute. The ‘taptics’, or tapping her or him on the wrist. This participants also wore a GoPro (GoPro, Inc, USA) mode of communication is described on the Apple mini camera on their cycling helmets during a typical website as a way of providing alerts intimately and commute, so that we researchers had footage of the ‘with a more human touch’. cyclists’ perspective of their rides, including whether 6 DIGITAL HEALTH they looked at their self-tracking devices during their Australian interviewees talked about ‘creepy’ digital cycle. The video footage of the trip was viewed together surveillance practices and their concerns that other by researchers and participants, discussing how they actors knew too much about them, without really felt on the trip, what the weather was like, the road knowing who these actors were. conditions, other users of the road or path and how As these studies suggest, the ways in which personal the data they were collecting about their ride may data are collected and engaged with can ‘feel right’ or have contributed to their affective and sensory experi- ‘feel wrong’, depending on the context. The concept of ences of their cycling. affective atmospheres recognises these ambivalences 6,16 These methods generated research material that and ambiguities, acknowledging their co-existence. allowed us researchers to discuss the digitised dimen- Just as digital devices and practices related to these sions of affective atmospheres. These included the inter- devices can contribute to affective atmospheres; so 54,55 actions of weather conditions with how cyclists felt too can the digital data these devices generate. during their trips or how they reviewed their data and We can then begin to talk about affective atmospheres their memories of previous cycling trips and their ‘data- of data: how assemblages of flesh, code, data, device, fied’ performances, which contributed to their assess- place, space and time generate feeling. ments of how good their bodies were feeling and how well they were performing. By incorporating the par- Affective atmospheres of digital ticipants’ engagements with their cycling data into the health technologies notion of affective atmospheres, this study represents one of the first to acknowledge that these types of digi- Little research thus far has investigated the affective tal data can be part of these atmospheres: in the case of intensities of digital health technologies in the context these cyclists, as they rode their bicycles and felt the of the generation of affective atmospheres. However, a sensation of the cycling trip through and with their body of literature exists in the sociology of health and bodies and interpreted the digital data generated from illness and science and technology studies that identifies their self-tracking devices. the sensory and affective dimensions of patients’ and Another relevant study is that conducted by Ellis practitioners’ engagements with digital health technol- and colleagues, who conducted interviews with UK ogies. Contributors to this literature do not engage with respondents about being the subjects of externally the affective atmospheres concept and tend to focus on imposed surveillance by technologies in public spaces individuals’ experiences and how they are socially pro- such as CCTV cameras and biometric trackers as well duced rather than take the collective and heterogeneous as in private spaces of internet and smartphone use. sociomaterial perspective promoted in the affective Ellis and colleagues found that their participants were atmospheres approach. Nonetheless, some of their find- often unable to fully articulate their concerns about ings are relevant to understanding elements of the being subjects of such digital surveillance, but rather atmospheres that are generated with these technologies. expressed them in terms of affective responses. These This research has revealed that people can come to researchers refer to the affective atmospheres of surveil- rely emotionally on their digital health devices. Some lance that they identified in their interviews, noting that patients monitored by telemedical and other remote these atmospheres tended to be registered in extra-dis- monitoring devices think about them as caring cursive embodied activities. Their participants often felt machines, in whom they invest their trust and faith. ambivalent about digital surveillance technologies. People can be reliant on life-giving devices like insulin They described sensing that someone was watching pumps and pacemakers and they can gain reassurance 57,58 them, and only sometimes realising this fact: when sud- and a sense of security from using them. These at- denly noticing a CCTV camera in a public place, for home or in-body technologies, along with the human example. Alternatively, these participants talked about caregivers attending patients, can contribute to thera- feeling wary of revealing too much information about peutic affective atmospheres. The opposite is also true, themselves, without being able to fully express why this however. If digital health technologies such as these fail wariness was warranted. to work as expected, users often respond with negative Ellis and colleagues suggest that because continual strong emotions. This can be even more the case of they digital surveillance has become a feature of everyday are relying on the technologies to support their health life, its affective consequences are often difficult for or provide relief from illness or pain. As Oudshoorn people to articulate, reflect on or acknowledge. But has noted, the vulnerabilities that these dependencies even when practices are taken for granted, they are may generate are rarely acknowledged. Some people not necessarily fully accepted: it is here that some- do not like how their homes are transformed into med- times-inchoate affective responses can be generated. ical clinics when they are encouraged to engage in self- Lupton and Michael similarly found that our care and self-monitoring, finding the technologies and Lupton 7 their notifications intrusive and constant reminders of A lot of self-tracking software enables people to their illness, or resent the invisible labour that is share their data with others. The athletic platform required of them to learn about and tinker with the and app Strava, for example, has an overt focus on technologies to make them useful and domesticate the promoting ‘social fitness’, involving members exchan- 5963 technologies into their mundane routines. ging their data and providing support and motivation The often very personal and sensitive information to each other by commenting on each other’s data. generated by digital health monitoring technologies It also provides a function for members involving devices can also stimulate strongly-felt responses. uploading images of their cycling trips or runs, so Research on people who are engaging in self-tracking that they can show other members where they have 65,82 or self-care practices has demonstrated that when the travelled. Several other self-tracking apps encour- numbers ‘look good’, they feel confident, happy and age users to upload their data to social media platforms 52,64,65 gain comfort. However, when their data are like Facebook or Twitter. As this example demon- ‘bad’, suggesting that people’s health is suffering or strates, the developers and marketers of technological they are failing to achieve the goals they have set them- products sometimes make deliberate attempts to create selves, this can be unsettling and anxiety- and fear- certain kinds of affective atmospheres in their users. 52,58,66,67 provoking. They recognise the importance of sociality, support The intimate interpersonal nature of digital technol- from others and feeling part of a community of users ogies used for communication with other people also with similar objectives. Social media platforms are an requires consideration. Digital media forums and social obvious example, with their invitations to users to share media provide a multitude of opportunities for people their thoughts, feelings and experiences in verbal or to engage in communication with each other that may image form with other users and to comment on be intensely personal. As researchers in cultural studies those uploaded by others. Indeed, the move towards and internet studies focusing on the intersections of the visual in social media platforms (greater use of place, space, emotion and digital technologies have photographs and videos) as well as the use of hashtags, recently argued, digital media can provide a space in emojis, images and memes, are all techniques that are which people can exchange personal details, thoughts used to express and share feeling states more potently. and feelings, become friends and develop feelings of One of the few studies to focus on affective atmos- intimacy: in some cases, without ever meeting face-to- pheres in a healthcare setting is that undertaken by 6872 face. As part of the sharing affordances of digital Hollett and Ehret of a hospitalised child’s use of the 73 83 media, many discussion forums, blogs, content cur- online game Minecraft. The authors show how these ation platforms and social media sites as well as messa- types of games generate feeling between human players ging services explicitly encourage users to share their and the nonhuman entities in the game, facilitating the feelings with other users and to engage in practices construction of active, sensing bodies. Human and non- such as liking, sharing or commenting on their content human bodies together configure atmospheres that can and using visual media such as selfies, images, memes affect other bodies interacting in the game (including 7476 and emoji symbols to convey and share affect. the researchers themselves, who were participating as Sometimes these social networks can be important players). The hospital setting in which the young boy sources of emotional support related to health, illness was playing Minecraft also contributed to the affective and other embodied experiences. Research on women’s atmosphere of the game as he experienced it, while the use of digital media in pregnancy and during the early affects generated by the game spilled into the hospital years of motherhood, for example, has demonstrated environment. that women find blogs, online discussion forums and In this space, medical actors interacted with gaming websites that offer information and allow users to share actors to generate the affective atmosphere experienced their experiences with each other to be helpful and reas- by the young oncology patient who was playing the suring, alleviating some of the isolation, uncertainty game. As Hollett and Ehret put it, in this context, and heightened sense of responsibility that many feel ‘material things (e.g. beanbags, zombie moans, nurses, during their transition to motherhood. The use of intravenous (IV) poles) are agentive, affective bodies’. online forums for discussing experiences of illness has They use the notion of ‘the interruption’ to examine the been very popular since the early days of the internet, ways in which the flow of experience is disrupted, caus- now augmented by social media, content curation plat- ing bodies to move or behave unexpectedly. These forms, apps and dedicated patient support platforms interruptions contribute to the affective atmospheres 7880 such as PatientsLikeMe. These and other digital of digital game-playing. Thus, for example, in the hos- media for the representation and discussion of personal pital setting in which the boy in their study was playing experiences could readily be conceptualised as spaces Minecraft, a nurse sometimes entered while he was that generate affective atmospheres. playing to administer his medication and check on his 8 DIGITAL HEALTH wellbeing, or a biometric monitoring technology started . the mobilities of digital health affective atmospheres beeping insistently, signalling his sensory reactions to  what changes when people move through space the game he was playing. These were interruptions to and place and interact with other people and other his game-playing (and those participating with him). technologies during this movement?; However, the game-playing also interrupted the . the specific affordances of digital health technologies bodily care the boy was scheduled to receive from the in place, space and time for lay people, their family medical or therapy staff. The interruptions were part of carers and healthcare practitioners; the affective atmospheres in which the boy was both . the intimacies, vulnerabilities and ambivalences of playing the game and receiving medical care. the affective atmospheres of digital health; . the affective and sensory dimensions of people’s Future research directions for digital health encounters with and interpretations of the personal affective atmospheres health and medical data generated by digital health technologies; and In this review, I have drawn attention to the ways in which scholarship on affective atmospheres may have . the implications of all of these aspects for how lay relevance for critical digital health studies research, people and practitioners respond to and engage with including analysis of the sensory dimensions of digital digital health technologies. health technologies. To summarise, the following elem- ents are central in previous research in affective The key research question that these topics all work atmospheres: towards is ‘How does digital health feel?’. There are sev- eral deliberate ambiguities in this question, as it inquires . acknowledgement of the role of the human senses in not only what people feel (which can refer to both to sen- responding and contributing to affective sory responses and affects) when they use these technolo- atmospheres; gies but also how the technologies participate in feeling (or . the shared and relational nature of affective atmos- how they act as sensors working on the human body and pheres across and between human and nonhuman generate affects in human bodies). Research that can actors; engage with these topics and questions will go some way . the ephemeral, emergent and often subconscious in providing greater insights into the experience of using nature of affective atmospheres; and digital health technologies and what capacities these tech- . the importance of using research methods which nologies have for fulfilling the kinds of promises they focus on embodied practice, feeling and action as make in improving health and medical care. well as on language and discourse. How does it feel to use health and medical apps to track your bodily functions (or those of the people you The concept of affective atmospheres offers many care for)? How does it feel to be a doctor in the tele- possibilities for future research in critical digital medicine encounter, bereft of the sensory knowledges health studies. Rather than positioning patients or lay of your patients’ bodies that hands-on examination people as disaffected, rational and autonomous con- provides you and attempting to compensate and impro- sumers of digital health technologies (who may need vise in this situation? How does it feel to be an elderly to be persuaded or nudged to recognise the potential person or person with a chronic illness monitored by a and benefits these technologies may offer them), this range of smart objects at home? How does it feel to be a focus on affect acknowledges the often barely conscious medical trainee learning about human bodies using a feelings that underpin motivations to engage in the use virtual patient’s body? How does it feel to be an oper- of these technologies  or alternatively, how people ating theatre nurse assisting in robotic surgery? How improvise or resist using them  and the collective does it feel to engage in self-tracking of your biometrics and relational nature of these feelings. Some of the and attempt to make sense of what the data ‘tell you’? topics and research questions that might be addressed In all these cases, and in many more concerning the use include the following: and meaning of digital health, an understanding of feel- ings in both meanings of the word  sensory and affect- . the sensory and affective dimensions of the ways in ive  and the atmospheres they create is integral to fully which people touch, carry, wear and implant digital comprehending how digital health technologies inhabit health technologies on and into their bodies; and generate lifeworlds. . the ways in which these technologies interact with each other as well as with humans and other nonhu- mans, generating affecting atmospheres via these Contributorship: This article was authored solely by DL and there encounters; were no contributions from any other person. Lupton 9 19. Jones P. 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How does health feel? Towards research on the affective atmospheres of digital health

Digital health , Volume 3 – Apr 10, 2017

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© The Author(s) 2017
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2055-2076
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10.1177/2055207617701276
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Abstract

The concept of affective atmospheres has recently emerged in cultural geography to refer to the feelings that are generated by the interactions and movements of human and nonhuman actors in specific spaces and places. Affective atmospheres can have profound effects on the ways in which people think and feel about and sense the spaces they inhabit and through which they move and the other actors in those spaces. Thus far, very little research has adopted this concept to explore the ways in which digital health technologies are used. As part of seeking to redress this lacuna, in this essay I draw on previously published literature on affective atmospheres to demonstrate and explain the implications of this scholarship for future theoretical and empirical scholarship about digital health practices that pays attention to their affective and sensory elements. The article is structured into six parts. The first part outlines the concepts and research practices underpinning affective atmospheres scholarship. In the second part, I review some of the research that looks at place, space and mobilities in relation to affective atmospheres. In the third part I focus more specifically on the affective atmospheres of medical encounters, and then move on to digital technology use in the fourth part. I then address in the fifth part, some relevant scholarship on digital health technologies. I end the essay with some reflections of directions in which future research taking up the concept of affective atmospheres in the context of digital health technologies can go. The key research question that these topics all work towards is that asking ‘How does digital health feel?’ Keywords Affective atmospheres, digital health, digital sociology, feeling, the senses Submission date: 6 October 2016; Acceptance date: 20 February 2017 Introduction Affective atmospheres are shaped by their multisen- The concept of affective atmospheres has recently sory properties: how spaces and places are physically emerged in cultural geography to refer to the feelings encountered via their visual, haptic, aural, olfactory that are generated by the interactions and movements and taste properties is central to the feelings they gen- of human and nonhuman actors in specific spaces and erate. Affective atmospheres can have profound effects places. In this literature, affects are conceptualised as on the ways in which people think and feel about and relations between humans and nonhumans, perceived sense the spaces they inhabit and through which they and felt through the body. Affective atmosphere is move and the other actors in those spaces. People both understood as an assemblage of affect, humans and contribute to the affective atmospheres they encounter nonhumans that is constantly changing as new actors and are affected by them. A key feature of this concept 14 enter and leave spaces and places. An affective is the recognition that affect is not an individual atmosphere is often felt or sensed by humans entering a place rather than directly observed or represented in News & Media Research Centre, Faculty of Arts & Design, University of words or images, although these can also contribute to Canberra, Australia affective atmospheres. Affective atmospheres are dif- Corresponding author: fuse, contingent and emergent, as humans respond to Deborah Lupton, News & Media Research Centre, Faculty of Arts & Design, the presence and withdrawals of other humans and to University of Canberra, Australia. nonhumans. Email: deborah.lupton@canberra.edu.au Twitter: @DALupton Creative Commons NonCommercial-NoDerivs CC-BY NC-ND: This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 3.0 License (http://www.creativecommons.org/licenses/by-nc-nd/3.0/) which permits non-com- mercial use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 DIGITAL HEALTH response but is shared and collective, an intensity of targeted by digital health technologies tend to be feeling that moves between people. Affective atmos- glossed over or ignored in these accounts. pheres can be experienced similarly, but the same As part of seeking to redress this lacuna, in this essay I people in the same spaces may also be experiencing draw on previously published literature on affective different affective atmospheres as they may be respond- atmospheres to demonstrate and explain the implications 5,6 ing to different elements in the space. of this scholarship for future theoretical and empirical In this review essay, I discuss the ways in which the scholarship about digital health practices that pays atten- concept of affective atmospheres can be applied to tion to their affective and sensory elements. The article is understand the sociocultural dimensions of digital structured into six parts. The first part outlines the con- health technologies, including their sensory properties. cepts and research practices underpinning affective Digital technologies are widely advocated in medical atmospheres scholarship. In the second part, I review and preventive health settings in the interests of deliver- some of the scholarship that has explored the entangle- ing more effective and less expensive healthcare and ments of place, space and mobilities in relation to affective encouraging people to take responsibility for promot- atmospheres. These are the principal topics that have ing their health or to engage in self-care for chronic been addressed thus far using the notion of affective illnesses. Digital health technologies used for these pur- atmospheres. In the third part, I focus more specifically poses include telemedicine technologies, blogs, wikis, on the affective atmospheres of medical encounters, and videos, websites, search engines, online discussion then move on to digital technology use in the fourth part. forums and social media for the provision of informa- I then address, in the fifth part, some relevant scholarship tion about medical matters and for patient support, on digital health technologies. I end the essay with some health and medical apps for mobile devices and other reflections of directions in which future research taking software, digital patient self-care and self-monitoring up the concept of affective atmospheres in the context of devices, implantable, wearable and ingestible sensors digital health technologies can go. for biometric monitoring, health and fitness gaming devices, smart devices for monitoring and providing Affective atmospheres: concepts and care to the elderly, emergency response systems, digital research practices imaging software for medical diagnosis, virtuality real- ity and augmented reality for medical education and It is important to emphasise the mutual co-constitutive training, electronic patient records and other health nature of the generation of affective atmospheres informatic systems, digital disease surveillance soft- between people and nonhuman actors. Scholars who ware, robotic surgery and 3D printing of prosthetics have adopted the affective atmospheres approach often and human anatomical replicas. Many of these technol- draw on phenomenological philosophical perspectives, ogies are also used in a wide variety of settings beyond particularly as espoused in the work of Merleau-Ponty. the medical clinic and hospital, including the home, In his phenomenology, Merleau-Ponty emphasised the workplaces and schools. interembodiment and intersubjectivity of humans with Very little scholarship has attempted to apply the other humans and with the environment around 7,8 concept of affective atmospheres to the context of them. Recent sociomaterialist scholarship has also health, illness and healthcare. Even less research has been influential. Like other sociomaterial perspec- 911 directly focused on digital health technologies. Using tives, scholarship on affective atmospheres highlights digital health technologies can be a profoundly emo- the role of nonhuman actors in human experience: other tional and sensory experience, with significant implica- living things, objects, space and place are accorded tions for the understanding of human bodies, health detailed attention in what is described as a ‘more-than- and illness states and medical care. Discussions about human world’. the uses of digital health technologies in popular media, Some scholars working on affective atmospheres such as technology blogs and research published in the now often refer to a post-phenomenological position, medical literature, tend to emphasise the rationalised in which embodied experience and practices, including purposes and outcomes of these technologies. While the sensory and sensual, are the main foci. This position these accounts are overtly about the diagnosis and med- departs from the interest in language and discourse that 1214 ical care or monitoring of human bodies, they are stran- has recently dominated much social theory. The gely decorporealised. There is little focus on the sensory terms ‘non-representational’ or ‘more-than-representa- and affective dimensions of digital health technologies, tional’ are sometimes employed in this literature to and how these may encourage or inhibit people (both emphasise the decentring of language and the turn patients and practitioners) from wanting to use them or towards affect and practice. This has entailed a focus finding them effective. The visceralities, vitalities, fleshi- on the phenomena of human experience that are felt or 2,4 ness, messiness, intensities and perversities of the bodies performed rather than directly articulated. Lupton 3 The practices of sensing through human embodiment, affective atmospheres and technologies has tended to 5,14,19 and the emergence of feelings and emotions from these centre on practices such as cycling or on other 3,20 practices, are integral to the production and experience forms of transport, such as travelling on trains and 6,15 21 of affective atmospheres. Affective atmospheres are driving and parking cars or on specific places and 2224 sometimes open to conscious identification, but also spaces, particularly those that are public. This operate at the pre-conscious or non-conscious level or research has identified how space and place can feel somewhere between. Some of the feelings and practices safe, secure, pleasurable and pleasant or uncomfort- that are part of affective atmospheres can be difficult to able, risky, threatening or dangerous through a com- 2,15 express in words. Research methods in scholarship on plex combination of elements. affective atmospheres, therefore, tend to employ qualita- As Merriman points out in his account of car park- tive and interpretive methods that focus on embodied ing spaces, aspects such as the cost of parking, ease of practices, habits, routines, actions, performances and access, the lighting of the space, its availability, the behav- forms of exchange and communication which often iour of other drivers using the space and many other elem- 1,2,4 operate subconsciously, in addition to the words ents can influence the affective atmospheres of these people use to explain their practices and ideas. spaces, and consequently shape whether drivers are will- Researchers adopting these approaches argue that mean- ing or able to use them. There are often complex ‘affective ing can emerge from routine sensory practices and habits economies’ and aesthetic judgements interbound with 1,12,17,18 rather than the other way around. affective atmospheres, shaping the ways in which space The affective resonances of these embodied practices and places are built, managed and controlled. and the ways in which the senses are engaged are cen- Some of this research has centred on the entangle- tral aspects that are targeted for exploration in this type ments between bodily sensations and emotional of research. This research may involve the use of responses. Bissell’s analysis of the stress of commut- images, autoethnography, detailed fieldwork and ing by train, for example, develops a non-representa- ethnographic work with close observations of other tional perspective on bodies. He draws on his own people’s behaviours and responses in a specific space, experience of commuting as well as an interview with audio-recording of soundscapes and notes about sen- another commuter (chosen as a case study from several sory perceptions of the environment: how the world he had conducted) to examine the gradual processes by looks, smells, feels, sounds and tastes. Researchers which stress develops as a result of regular commuting. exploring affective atmospheres may ask people to re- Simpson’s study involving cyclists in the city of enact their mundane practices and take photographs, Plymouth, UK, identifies the ways in which other audio-recordings and videos of these re-enactments, road and footpath users contribute to the cyclists’ feel- move along with them as they move through space ings of comfort and relative safety in moving through and place (‘go-alongs’), ask them to use a voice recor- these places. The behaviour of pedestrians or car dri- der to recount their experiences in the moment, write vers, for example, who express anger, hostility or frus- field notes as part of autoethnographic work on per- tration about having to share paths and roads with sonal experiences, use cultural probes in the attempt to cyclists can shape cyclists’ felt experiences as they investigate non-obvious and creative responses to encounter these other users, leading to the creation of research questions, ask people to wear digital sensors ‘uncongenial atmospheres’. to elicit digital data about their bodies, and participate The spaces and places in and through which people in people’s everyday activities (play a game with them, move and encounter each other and the broader sets of engage in their work with them, spend time in their shared practices, rules or laws that may govern these homes and so on). Part of this focus is exploring aspects locations are central to the generation of these feelings. concerning how people feel comfortable or ‘at home’ People can behave in hostile ways to cyclists, for exam- using digital technologies, while others may feel less ple, because they feel as if cyclists are encroaching on secure or at ease, and what the implications are for their space in crowded traffic conditions or breaking the any differences between people. Some of these methods law. Cyclists respond to expressions of this hostility, will be explained in further detail below in relation to perhaps leading them to engage in more aggressive specific research projects. styles of cycling or to avoid certain routes. The entanglements of humans, nonhumans, sensory sensa- tions and affect are complex and interactive. Affective atmospheres of place, space and mobilities Affective atmospheres of medical encounters Perhaps because the concept of affective atmospheres was first developed in cultural geography  and par- While few scholars have explicitly directed attention to ticularly in mobilities research  previous work on the affective atmospheres of medical spaces, work in 4 DIGITAL HEALTH medical geography, science and technology studies and elements such as the embodied care they received from the sociology of health and illness has explored the the healthcare professionals working at the centre, importance of the emotional dimensions and material- avoidance of the social expectations of family members, ities of care and the nature of space and place in making new friends with other patients and opportu- patients’ and practitioners’ experiences of illness and nities to move around in the rural setting and observe healthcare. Some of this research has drawn attention the wildlife as providing a sense of freedom, relief, to the production of feeling states as part of socioma- expansiveness and calm that promoted patients’ feel- terial encounters of humans and nonhumans. ings of safety, self-confidence and relaxation. Bell and Medical care can be a profoundly emotional experi- colleagues emphasise the importance of ‘green’ envir- ence for the people involved, including healthcare prac- onments (outdoor areas with vegetation) and ‘blue’ titioners and other carers as well as patients or other lay environments (outdoor areas with bodies of water) in people. When people’s bodies and health and illness helping people cope emotionally with periods and life states are the foci of digital technology use, they can transitions involving stress or turmoil, such as the often be very vulnerable or otherwise find themselves intensive parenting of young children, high work 2527 dealing with strong feelings. Sociologists and demands or the onset of illness or impairment. anthropologists have highlighted the importance of The materialities of care literature has also identified sensory engagements between healthcare professionals the heterogeneous elements that contribute to affective 3537 and patients as part of diagnosis, assessment of patient atmospheres in medical and therapeutic settings. wellbeing and recovery, the development of medical Van Hout and colleagues have demonstrated how sen- 2831 knowledge and developing the patient’s trust. sory perception is important to palliative care nurses’ While interpersonal engagements are vital elements, assessments of their patients when making home visits. incorporating space, place and other nonhuman actors The nurses use various sensory appraisals to discern how extends this understanding of the affective dimensions well their patients are faring, including, not only talking of the medical encounter. The hospital or medical clinic to and looking at their patients to assess their physical could be understood as a specific type of affective characteristics, but also viewing the relative state of tidi- atmosphere, in which the various human actors ness and cleanliness of the home and its garden, its smell involved (e.g. practitioners, patients and their families), and other sensory factors that can hint at the health and together with a range of nonhuman actors (e.g. rooms, wellbeing of its occupant. Although the researchers do views of the outside world through the windows, indoor not use the term affective atmospheres, their account of plants, furnishings, pharmaceuticals, medical technolo- the palliative care nurses identifies many elements of gies and devices, air temperature, odours, sounds and how atmospheres are generated in this setting and how so on) co-produce and experience the feelings that are the nurses themselves are sensing and contributing to part of this space and place. These spaces can generate these atmospheres as part of their working routines a range of feeling and often ambivalent emotions: anx- and habits. iety, fear, frustration, shame, distress, pain, boredom Working from an affective atmospheres perspective, and a sense of being at risk may coincide with relief, Anderson and Ash recount their (separate) personal trust, comfort and feelings of safety. The physical sen- experiences in vignettes detailing waiting in UK sations people encounter when they are part of these National Health Service hospitals for medical care to spaces, including noises, smells, tastes and haptic be delivered to a sick child (in the case of one author) experiences, are central to their affective responses. and an optometry appointment (in the case of the These spaces can be healing and calming in their affect- other). They begin with recounting the importance of ive atmospheres, but they can also be uncongenial attempting to give a name to an affective atmosphere as spaces. an initial step in understanding it. Anderson and Ash In medical geography research, there are references describe the affective atmospheres they experienced and to the contributions that place, space, living creatures contributed to as ‘anxious waiting’, a feeling generated and other nonhuman elements make to what has been by the emotional demeanours and voices of the people entitled ‘therapeutic landscapes’. Therapeutic land- waiting around them in the hospital waiting rooms, the scapes are those natural or built environments, includ- practices of the hospital staff and the sounds, odours, ing the people and other living things that inhabit them, tactility and appearance of the waiting room and the in which people feel better and achieve a sense of well- hospital environment generally in which they are 27,3234 being. The concept recognises that the affective located. They refer to incidents they observed when and sensory dimensions of these spaces and places are the affective atmosphere suddenly changed because of vital to human wellbeing. Conradson gives the exam- the cry of a child, or the appearance of a visibly upset ple of an English rural respite care centre. His inter- patient with a catheter in her nostril, altering the rela- views with the patients spending time there identified tive calm into a more intense, negative mood. Lupton 5 Ash’s inquiry into the different types of atmos- Affective atmospheres of digital technology use phere generated by the iPhone 4 is one of the few Bringing this kind of research together with a focus on accounts of the affective atmospheres of digital devices digital health technology use offers a perspective that and software use published thus far. He places the tech- can consider the digital dimensions of therapeutic land- nology at the centre of his analysis, seeking to identify scapes, including not only how humannonhuman how this device is part of a set of relations that gener- assemblages generate positive affects that contribute ates affect. Ash focuses on moments of breakdown, to wellbeing and good health but also how negative when the iPhone fails to work as expected. One exam- affective atmospheres may detract from or hinder ple he gives is the design of antenna in the iPhone 4, good health and recovery from illness. Some research- which did not work well in picking up signals when the ers adopting these approaches to investigate the affect- phone was held by users in a certain way. The sensory ive aspects of media employ a ‘not-media-centric’ capacities of the phone and the user were both limited approach to media studies in their work. This refers by this problem, causing emotional responses on the to the attempt to consider media use (including digital part of users (mostly annoyance and frustration). media technologies) in their full environmental con- Understanding these kinds of specificities of affor- texts, including the ways in which these media are mar- dances of technologies (in other words, how they struc- keted (which serve to suggest how people should ture and allow use by human and other nonhuman emotionally respond to them), the other objects with actors) and the ways in which nonhuman actors inter- which people engage as they are using media and the act with others (in this case, the mobile phone antenna 38,39 spaces and places in which they do so. with the wireless signals in the air around it) is import- This focus on broader contexts has become even ant to realising the affective atmospheres of which they more important as digital technologies have become are a part. Ash draws attention in his analysis to the 40,41 mobile, wearable, implantable and ingestible. ways in which digital devices like smartphones and their Human encounters with their digital devices can be surrounding technological infrastructures (such as wire- highly personal and intimate. As digital devices are con- less signals) generate atmospheres which shape how stantly moving on and with human bodies, they are objects and humans encounter each other. thereby continually entering new relations with The personal information generated, recorded and humans and other nonhumans and generating new assessed by digital technologies can also contribute to atmospheres. Digital devices have become human com- affective atmospheres. Digital devices are often imbri- panions, cohabiting with them. They touch or even cated within networks and systems of surveillance: par- enter human flesh; they live on and with human bodies; ticularly those that generate detailed information about they monitor human movements in private and public people. Routine encounters with digital technologies spaces; they can inhabit the intimate domains of mood, online searches or browsing, smartphone and app use, slumber and sexual activity with the use of apps and online purchases, social media interactions, moving wearables to track these elements of human life. around in public spaces fitted with digital sensors The visual, aural and haptic aspects of digital continually work as part of digital surveillance, produ- 4851 device use are becomingly increasingly important to cing flows of data. Awareness of these processes the affective atmospheres of their use. The design of and technologies and encounters with personal data the appearance of the device and its user interface is can contribute to affective states. important in generating feeling. Touchscreens offer Focusing on how people generate and respond to new ways of interacting visually and haptically with their personal data, myself and colleagues conducted 44,45 digital devices. Many smartphones, tablets and what we describe as a ‘digital sensory ethnography’ to wearable devices now vibrate, buzz, play music or examine both cycling and digital self-tracking practices, melodic sounds and make other sounds to notify examining the affective capacities of the personal data the user that they have new messages, an appoint- generated by cycling self-tracking. They video-taped ment coming up or have reached a self-tracking cyclists (located in the Australian cities of Canberra goal. The Apple Watch, for example, described by and Melbourne) re-enacting preparing for a routine Apple CEO Tim Cook as ‘the most personal device’ commuting ride, including getting the self-tracking ever created by the company, not only monitors the devices ready, positioning them on their bodies or on haptic functions and movements of the wearer’s their bicycles and turning them on, and then re-enact- body, but also communicates with the wearer using ing what they did when they finished the commute. The ‘taptics’, or tapping her or him on the wrist. This participants also wore a GoPro (GoPro, Inc, USA) mode of communication is described on the Apple mini camera on their cycling helmets during a typical website as a way of providing alerts intimately and commute, so that we researchers had footage of the ‘with a more human touch’. cyclists’ perspective of their rides, including whether 6 DIGITAL HEALTH they looked at their self-tracking devices during their Australian interviewees talked about ‘creepy’ digital cycle. The video footage of the trip was viewed together surveillance practices and their concerns that other by researchers and participants, discussing how they actors knew too much about them, without really felt on the trip, what the weather was like, the road knowing who these actors were. conditions, other users of the road or path and how As these studies suggest, the ways in which personal the data they were collecting about their ride may data are collected and engaged with can ‘feel right’ or have contributed to their affective and sensory experi- ‘feel wrong’, depending on the context. The concept of ences of their cycling. affective atmospheres recognises these ambivalences 6,16 These methods generated research material that and ambiguities, acknowledging their co-existence. allowed us researchers to discuss the digitised dimen- Just as digital devices and practices related to these sions of affective atmospheres. These included the inter- devices can contribute to affective atmospheres; so 54,55 actions of weather conditions with how cyclists felt too can the digital data these devices generate. during their trips or how they reviewed their data and We can then begin to talk about affective atmospheres their memories of previous cycling trips and their ‘data- of data: how assemblages of flesh, code, data, device, fied’ performances, which contributed to their assess- place, space and time generate feeling. ments of how good their bodies were feeling and how well they were performing. By incorporating the par- Affective atmospheres of digital ticipants’ engagements with their cycling data into the health technologies notion of affective atmospheres, this study represents one of the first to acknowledge that these types of digi- Little research thus far has investigated the affective tal data can be part of these atmospheres: in the case of intensities of digital health technologies in the context these cyclists, as they rode their bicycles and felt the of the generation of affective atmospheres. However, a sensation of the cycling trip through and with their body of literature exists in the sociology of health and bodies and interpreted the digital data generated from illness and science and technology studies that identifies their self-tracking devices. the sensory and affective dimensions of patients’ and Another relevant study is that conducted by Ellis practitioners’ engagements with digital health technol- and colleagues, who conducted interviews with UK ogies. Contributors to this literature do not engage with respondents about being the subjects of externally the affective atmospheres concept and tend to focus on imposed surveillance by technologies in public spaces individuals’ experiences and how they are socially pro- such as CCTV cameras and biometric trackers as well duced rather than take the collective and heterogeneous as in private spaces of internet and smartphone use. sociomaterial perspective promoted in the affective Ellis and colleagues found that their participants were atmospheres approach. Nonetheless, some of their find- often unable to fully articulate their concerns about ings are relevant to understanding elements of the being subjects of such digital surveillance, but rather atmospheres that are generated with these technologies. expressed them in terms of affective responses. These This research has revealed that people can come to researchers refer to the affective atmospheres of surveil- rely emotionally on their digital health devices. Some lance that they identified in their interviews, noting that patients monitored by telemedical and other remote these atmospheres tended to be registered in extra-dis- monitoring devices think about them as caring cursive embodied activities. Their participants often felt machines, in whom they invest their trust and faith. ambivalent about digital surveillance technologies. People can be reliant on life-giving devices like insulin They described sensing that someone was watching pumps and pacemakers and they can gain reassurance 57,58 them, and only sometimes realising this fact: when sud- and a sense of security from using them. These at- denly noticing a CCTV camera in a public place, for home or in-body technologies, along with the human example. Alternatively, these participants talked about caregivers attending patients, can contribute to thera- feeling wary of revealing too much information about peutic affective atmospheres. The opposite is also true, themselves, without being able to fully express why this however. If digital health technologies such as these fail wariness was warranted. to work as expected, users often respond with negative Ellis and colleagues suggest that because continual strong emotions. This can be even more the case of they digital surveillance has become a feature of everyday are relying on the technologies to support their health life, its affective consequences are often difficult for or provide relief from illness or pain. As Oudshoorn people to articulate, reflect on or acknowledge. But has noted, the vulnerabilities that these dependencies even when practices are taken for granted, they are may generate are rarely acknowledged. Some people not necessarily fully accepted: it is here that some- do not like how their homes are transformed into med- times-inchoate affective responses can be generated. ical clinics when they are encouraged to engage in self- Lupton and Michael similarly found that our care and self-monitoring, finding the technologies and Lupton 7 their notifications intrusive and constant reminders of A lot of self-tracking software enables people to their illness, or resent the invisible labour that is share their data with others. The athletic platform required of them to learn about and tinker with the and app Strava, for example, has an overt focus on technologies to make them useful and domesticate the promoting ‘social fitness’, involving members exchan- 5963 technologies into their mundane routines. ging their data and providing support and motivation The often very personal and sensitive information to each other by commenting on each other’s data. generated by digital health monitoring technologies It also provides a function for members involving devices can also stimulate strongly-felt responses. uploading images of their cycling trips or runs, so Research on people who are engaging in self-tracking that they can show other members where they have 65,82 or self-care practices has demonstrated that when the travelled. Several other self-tracking apps encour- numbers ‘look good’, they feel confident, happy and age users to upload their data to social media platforms 52,64,65 gain comfort. However, when their data are like Facebook or Twitter. As this example demon- ‘bad’, suggesting that people’s health is suffering or strates, the developers and marketers of technological they are failing to achieve the goals they have set them- products sometimes make deliberate attempts to create selves, this can be unsettling and anxiety- and fear- certain kinds of affective atmospheres in their users. 52,58,66,67 provoking. They recognise the importance of sociality, support The intimate interpersonal nature of digital technol- from others and feeling part of a community of users ogies used for communication with other people also with similar objectives. Social media platforms are an requires consideration. Digital media forums and social obvious example, with their invitations to users to share media provide a multitude of opportunities for people their thoughts, feelings and experiences in verbal or to engage in communication with each other that may image form with other users and to comment on be intensely personal. As researchers in cultural studies those uploaded by others. Indeed, the move towards and internet studies focusing on the intersections of the visual in social media platforms (greater use of place, space, emotion and digital technologies have photographs and videos) as well as the use of hashtags, recently argued, digital media can provide a space in emojis, images and memes, are all techniques that are which people can exchange personal details, thoughts used to express and share feeling states more potently. and feelings, become friends and develop feelings of One of the few studies to focus on affective atmos- intimacy: in some cases, without ever meeting face-to- pheres in a healthcare setting is that undertaken by 6872 face. As part of the sharing affordances of digital Hollett and Ehret of a hospitalised child’s use of the 73 83 media, many discussion forums, blogs, content cur- online game Minecraft. The authors show how these ation platforms and social media sites as well as messa- types of games generate feeling between human players ging services explicitly encourage users to share their and the nonhuman entities in the game, facilitating the feelings with other users and to engage in practices construction of active, sensing bodies. Human and non- such as liking, sharing or commenting on their content human bodies together configure atmospheres that can and using visual media such as selfies, images, memes affect other bodies interacting in the game (including 7476 and emoji symbols to convey and share affect. the researchers themselves, who were participating as Sometimes these social networks can be important players). The hospital setting in which the young boy sources of emotional support related to health, illness was playing Minecraft also contributed to the affective and other embodied experiences. Research on women’s atmosphere of the game as he experienced it, while the use of digital media in pregnancy and during the early affects generated by the game spilled into the hospital years of motherhood, for example, has demonstrated environment. that women find blogs, online discussion forums and In this space, medical actors interacted with gaming websites that offer information and allow users to share actors to generate the affective atmosphere experienced their experiences with each other to be helpful and reas- by the young oncology patient who was playing the suring, alleviating some of the isolation, uncertainty game. As Hollett and Ehret put it, in this context, and heightened sense of responsibility that many feel ‘material things (e.g. beanbags, zombie moans, nurses, during their transition to motherhood. The use of intravenous (IV) poles) are agentive, affective bodies’. online forums for discussing experiences of illness has They use the notion of ‘the interruption’ to examine the been very popular since the early days of the internet, ways in which the flow of experience is disrupted, caus- now augmented by social media, content curation plat- ing bodies to move or behave unexpectedly. These forms, apps and dedicated patient support platforms interruptions contribute to the affective atmospheres 7880 such as PatientsLikeMe. These and other digital of digital game-playing. Thus, for example, in the hos- media for the representation and discussion of personal pital setting in which the boy in their study was playing experiences could readily be conceptualised as spaces Minecraft, a nurse sometimes entered while he was that generate affective atmospheres. playing to administer his medication and check on his 8 DIGITAL HEALTH wellbeing, or a biometric monitoring technology started . the mobilities of digital health affective atmospheres beeping insistently, signalling his sensory reactions to  what changes when people move through space the game he was playing. These were interruptions to and place and interact with other people and other his game-playing (and those participating with him). technologies during this movement?; However, the game-playing also interrupted the . the specific affordances of digital health technologies bodily care the boy was scheduled to receive from the in place, space and time for lay people, their family medical or therapy staff. The interruptions were part of carers and healthcare practitioners; the affective atmospheres in which the boy was both . the intimacies, vulnerabilities and ambivalences of playing the game and receiving medical care. the affective atmospheres of digital health; . the affective and sensory dimensions of people’s Future research directions for digital health encounters with and interpretations of the personal affective atmospheres health and medical data generated by digital health technologies; and In this review, I have drawn attention to the ways in which scholarship on affective atmospheres may have . the implications of all of these aspects for how lay relevance for critical digital health studies research, people and practitioners respond to and engage with including analysis of the sensory dimensions of digital digital health technologies. health technologies. To summarise, the following elem- ents are central in previous research in affective The key research question that these topics all work atmospheres: towards is ‘How does digital health feel?’. There are sev- eral deliberate ambiguities in this question, as it inquires . acknowledgement of the role of the human senses in not only what people feel (which can refer to both to sen- responding and contributing to affective sory responses and affects) when they use these technolo- atmospheres; gies but also how the technologies participate in feeling (or . the shared and relational nature of affective atmos- how they act as sensors working on the human body and pheres across and between human and nonhuman generate affects in human bodies). Research that can actors; engage with these topics and questions will go some way . the ephemeral, emergent and often subconscious in providing greater insights into the experience of using nature of affective atmospheres; and digital health technologies and what capacities these tech- . the importance of using research methods which nologies have for fulfilling the kinds of promises they focus on embodied practice, feeling and action as make in improving health and medical care. well as on language and discourse. How does it feel to use health and medical apps to track your bodily functions (or those of the people you The concept of affective atmospheres offers many care for)? How does it feel to be a doctor in the tele- possibilities for future research in critical digital medicine encounter, bereft of the sensory knowledges health studies. Rather than positioning patients or lay of your patients’ bodies that hands-on examination people as disaffected, rational and autonomous con- provides you and attempting to compensate and impro- sumers of digital health technologies (who may need vise in this situation? How does it feel to be an elderly to be persuaded or nudged to recognise the potential person or person with a chronic illness monitored by a and benefits these technologies may offer them), this range of smart objects at home? How does it feel to be a focus on affect acknowledges the often barely conscious medical trainee learning about human bodies using a feelings that underpin motivations to engage in the use virtual patient’s body? How does it feel to be an oper- of these technologies  or alternatively, how people ating theatre nurse assisting in robotic surgery? How improvise or resist using them  and the collective does it feel to engage in self-tracking of your biometrics and relational nature of these feelings. Some of the and attempt to make sense of what the data ‘tell you’? topics and research questions that might be addressed In all these cases, and in many more concerning the use include the following: and meaning of digital health, an understanding of feel- ings in both meanings of the word  sensory and affect- . the sensory and affective dimensions of the ways in ive  and the atmospheres they create is integral to fully which people touch, carry, wear and implant digital comprehending how digital health technologies inhabit health technologies on and into their bodies; and generate lifeworlds. . the ways in which these technologies interact with each other as well as with humans and other nonhu- mans, generating affecting atmospheres via these Contributorship: This article was authored solely by DL and there encounters; were no contributions from any other person. Lupton 9 19. Jones P. 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Digital healthPubmed Central

Published: Apr 10, 2017

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