Assessing the Public Health Impact of the mHealth App Business

Do mobile health applications (mHealth apps) promise solutions to such pressing public health problems as increasing access to care, reducing inequalities in health, lowering health care costs, and providing people with new tools to reduce risky behavior and manage chronic diseases? To answer this question, public health professionals and researchers need to examine how the more than 259 000 mHealth apps now available in the US market¹ contribute to improved population health now and will in the future.

In this issue of AJPH, Grundy et al. (p. 1783) provide evidence that may temper the often uncritically enthusiastic response to mHealth apps from the media, business, and some health professionals and policymakers. In a social network analysis of the financial relationships among app developers, investors, funding sources, and content advisers of a purposive sample of 491 mHealth apps in the United States, Canada, and Australia, the authors found several causes for concern.

CAUSES FOR CONCERN

First, they report that most best-selling mHealth apps are developed by private companies with multiple connections to larger corporations in the technology, fashion, entertainment, and pharmaceutical sectors and with venture capital firms. Leading developers of health apps include such major transnational corporations as Medtronic plc (Ireland), Koninklijke Philips N.V. (Netherlands), Google (US), Omron Corporation (US), Apple, Inc. (US), LifeWatch AG (Switzerland), Withings (France), and Nokia Corporation (Finland). Grundy et al. also note that the mHealth financial and production ecosystem remains “hidden from public view,” making it difficult to assess bias and conflicts of interest. Few major apps have clearly identified scientific or clinical advisers, and these advisers may hold multiple scientific, clinical, and financial roles. In the pharmaceutical industry, these blurred lines have contributed to the inappropriate use of medications, withholding data from regulators, and misleading marketing claims.²

Several broader trends provide additional causes for concern. First, the evidence base for safety and effectiveness of mHealth apps is thin. In a review of 137 patient-facing mHealth apps, Singh et al. found that few had been evaluated, especially for use by vulnerable populations.³ Only 23% of the tested apps responded appropriately when a user entered information that indicated a danger such as suicidal mood or ideation. More than a third (36%) lacked any privacy policy. In addition, sellers, users, clinicians, and researchers did not agree in their ratings of apps, suggesting lack of consensus on what makes an app helpful and effective.

Second, mHealth apps have the potential to widen rather than reduce inequalities in health. New technologies often first benefit the better off. Grundy et al. note that because health apps are often monetized and linked to the promotion of other products and services, they are targeted at the “White, worried, and well” rather than the poor and underserved (p. 1783). For the large corporations that are expected to dominate the mHealth market in coming years,¹ the focus on profitability shapes which apps get developed and which populations will be targeted in marketing these products.

JEOPARDIZED PUBLIC HEALTH

These market trends may have other adverse consequences. As more businesses enter the field, the number of new apps is growing rapidly, with 100 000 new products added in 2016.¹ At the same time, demand, measured in sales, is slowing, falling from a 35% growth rate in 2015 to 7% in 2016.³ In other business sectors, the combination of market consolidation, increased competition, and overproduction has jeopardized public health. In the firearm industry, for example, new technologies led to overproduction of mass-manufactured guns, and industry consolidation left fewer, bigger companies with more resources for product development and marketing. The subsequent drop in demand for firearms from hunters and sports shooters led the industry to restore profitability by developing more lethal weapons and marketing them aggressively with fear-based campaigns.⁴ Similar trends have been documented in tobacco, alcohol, and ultraprocessed food.⁵

In this case, maintaining profitability as the number of mHealth apps for sale grows may lead app developers to make more misleading claims, cover up defects, or market unscrupulously. The large companies that are consolidating control of this market have the deep pockets needed to invest in marketing, lobbying, and challenging public oversight. Already weak and overlapping regulations, inadequate funding, and lax enforcement limit public monitoring of mHealth apps. James L. Madara, chief executive officer of the American Medical Association, has called mHealth apps “digital snake oil,” observing that “though these products may be well-intentioned, far too many provide incomplete or inaccurate snapshots of a patient’s health and ultimately fail to deliver on their promises.”⁶

LACK OF REGULATION

At present, most mHealth apps available to consumers are not regulated by the Food and Drug Administration (unless they connect to a medical device) or by the privacy rules of the Health Insurance Portability and Accountability Act of 1996.³ Although the Federal Trade Commission has suggested best practices on privacy, security, and truthful claims, it has neither the expertise nor the staffing to monitor the marketing practices of the mHealth apps available in the United States. In the past few years, the tech, pharmaceutical, and fashion companies that are moving into mHealth apps have pioneered a wide array of new marketing strategies. These include cloaked Web sites that extoll the virtue of products without disclosing their corporate sponsorship, “native advertising,” in which users tout a product without revealing they are being rewarded by the company, and “content marketing,” in which digital and traditional media carry stories sponsored by producers of products, sometimes without disclosure of their role.⁷ As the federal government moves to rescind or defund key public health regulatory functions, health app developers seeking to grow their market share could promote wider use of untested or unsafe products.

For universities, mHealth apps raise other questions. Are university-based mHealth app developers required to disclose their corporate affiliations or report their income? Are they liable when companies irresponsibly market products researchers have developed? Will the lure of patenting health apps lead researchers to abandon open source apps, favoring the development of apps for customers who can afford them, rather than those who could benefit most?

NEED FOR EMPIRICAL EVIDENCE

In the final analysis, new technologies are neither good nor bad for health. Neither uncritical promotion of mHealth apps nor reflexive Luddite opposition will help to assess their long-term impact on health. What determines whether mHealth apps or other emerging technologies provide net benefit or harm to health is both the specific characteristics of the products and who has the power to decide how they are deployed. Public health researchers can contribute useful evidence in both domains.

Certainly, empirical evidence is needed to determine the safety, benefits, and risks of particular mHealth apps for specific populations. In addition, however, as Grundy et al. observe, more evidence is needed on how the structure, governance, and practices of the mHealth industry influence what products are developed, how and to whom they are marketed, and to what extent they contribute to improving population health and reducing health inequalities.