This paper examined user experiences with wearable health trackers in Cambodia, contributing new insights into the reception of this technology and the wider study of mHealth in LMICs. As described, most participants had little or no experience with wearable health trackers or smartphone applications for health monitoring prior to the study, with the exception of postgraduate students in Phnom Penh. Nonetheless, the large majority of participants reported a positive experience with the device, increased health awareness and a willingness to use and recommend the device to other people after the study period. In general, participants found the health wearable useful, suggesting a similar device would be well received and could be used as a tool to monitor and control risk factors for NCDs in Cambodia, including in rural areas where access to preventive care for NCDs is limited [15].
The findings also indicate that product design and features should be tweaked to maximise technology uptake and utilisation. As we have seen, the need to charge the device was off-putting for many participants, suggesting that a self-charging battery would likely increase utilisation, particularly amongst households with limited access to electric power. Furthermore, as documented in our study and previous surveys [18], ownership of a smartphone in rural Cambodia is still low. Thus, a standalone device that can be fully operated without smartphone support would be more suitable for wide use. Lastly, a solid, waterproof design would appeal to those participants, particularly farmers, that were concerned about water damage.
Further consideration of the study findings and the study context highlights other potential challenges to technology uptake. In particular, the use of consumer health wearables is premised on an individualistic concept of care in which “digitally engaged patients” are expected to manage their own preventive health efforts [19]. Even if wearables can be designed to deliver messages and reminders based on the analysis of user data, continued use still requires a commitment to actively incorporate self-care into daily routines. In Cambodia, this may conflict with traditional culture and social norms, which emphasise the collective, social dimension of caring and disease management, particularly for the elderly. In this respect, it is worth noting that most hypertensive participants in our sample reported having regular check-ups with health providers but only a few were used to monitoring their own blood pressure.
Cost may be another important barrier to product uptake amongst poorer populations. While the average willingness to pay was high (US$ 11.4) relative to a gross national income per capita of US$ 1,530 (World Bank 2019), many participants in the lowest tertile were willing to pay only a fraction of the estimated market value (which is about US$ 30) and less than two thirds were willing to buy the watch. Thus, wide technology uptake would require some form of subsidisation or the development of a lower-cost technology, bearing in mind that participants in our study were sensitive to product design and quality. Alternatively, a public-private partnership could be devised to reduce costs and increase participation, as seen recently in Singapore [20]. In 2019, Fitbit, a leading manufacturer of consumer wearables, partnered with the government of Singapore to develop a large public health program seeking to better understand the health behaviours and lifestyles of Singapore residents using wearable technologies. Under this program, participants are given a Fitbit smartband for free, provided they consent to sharing their data with Singapore’s Health Promotion Board, a government agency under the Ministry of Health which uses collected information to carry out large studies of population health and health risks [20]. In Cambodia, a similar arrangement could be made, although adequate regulations and technical safeguards should be in place to ensure the protection of data privacy.
Lastly, any new technology is just one component of sustainable development along with other important domains such as human resources and wider infrastructure. In recent years, for example, the One Laptop per Child initiative distributed low-cost “children machines” designed to empower youth in LMICs to learn without their schools and teachers [21]. The rationale was that efforts to reform curricula in some low-income countries were too slow or expensive and teacher training was seen as of limited value due to teacher absenteeism. Nonetheless, this program was successful only in contexts where other key gaps were addressed, including sustaining school attendance by teachers and students and dissemination of course materials [22]. Similarly, health wearables alone are unlikely to have any significant impact on health outcomes in Cambodia and elsewhere. Sustainable program implementation would also require health system integration, public funding, and improvements in the quality of care, which remains a significant challenge in Cambodia [23]. In recent years, other mHealth interventions have been piloted in Cambodia including smartphones applications to deliver messages for hypertensive and diabetic patients [24], to improve newborn care awareness in rural areas [25], to remind users about available family planning methods [26], and to support community-based malaria surveillance [27]. While these programmes have generally had a positive impact on health outcomes, sustainability of donor-driven initiatives without domestic funding and full ownership has been a recurrent challenge.
Study limitations
The small sample size is a clear limitation of this study. In addition, the survey questionnaires were largely structured, with only a few open-ended questions. Therefore, we could not gain in-depth qualitative insights into individual perceptions and experiences with the given technology. This exploratory study was also carried out over a relatively short period due to time and resource constraints. As a result, we could not examine phenomena that would require a longer timeframe such as behaviour change. Finally, the study methodology relied on self-assessed measures of health status and determinants, which are prone to recall and other subjective biases [28].