Understanding user interactions with the artificial pancreas

The ‘artificial pancreas’ is a new treatment for diabetes which allows for the automatic control of blood glucose levels by replicating some of the functions of a healthy pancreas. The system wirelessly links together a set of devices – a continuous glucose monitor (CGM) and insulin pump, both body-mounted, and a tablet-mounted algorithm – in order to calculate and administer the optimal amount of insulin required at any given time. Following successful lab-based studies with adolescents and pregnant women with Type 1 diabetes, in which the system improved blood glucose control by 22% and 35% respectively, researchers at Cambridge are now carrying out research on the safety, efficacy, and feasibility of the system for pregnant women with Type 1 diabetes in the home setting. This research is important because of potential gaps between lab-based efficacy and real-world effectiveness – gaps which may emerge because of pressures and commitments unrelated to diabetes (e.g. childcare responsibilities).

Blood glucose control is particularly important for pregnant women with Type 1 diabetes owing to the heightened risk of obstetric complications, neonatal mortality, and occurrences such as preterm delivery, stillbirth, and foetal macrosomia, which is 3.5 times more likely to occur in the babies of Type 1 mothers than in the rest of the population. The artificial pancreas, which in this study is being used overnight in conjunction with standard (i.e. user-directed) CGM and pump treatment during the day, offers participants the capacity to control their blood glucose levels overnight – around 50% of hypoglycaemia occurs overnight, when diabetics are typically less able to respond in a timely fashion.

As a co-investigator on the current study, my research focuses on the micro-level interactions between study participants and the artificial pancreas system, and how that interaction might be shaped, and potentially shape in turn, participants’ views about, and interactions with, wider domains such as science, technology, and medicine. The artificial pancreas is a prominent example of how new medical technologies are increasingly extending themselves into the body in personal, ubiquitous, continuous, and digitally mediated ways, often against the backdrop of an illness or disorder (such as diabetes) which dramatically raises the stakes for technology usage patterns. In common with other personal medical devices, the artificial pancreas raises a number of significant issues, ranging from the ontological – are we now talking about a triality of mind, body and machine, rather than a duality of mind and body – to the practical: is it reasonable to expect diabetics to trust machines to control their body? I approach these issues from a ‘sensemaking’ perspective, drawing on the work of organisational sociologist Karl Weick and others.

I was recently invited to give a talk on digital sociology at the University of Warwick, and took the opportunity to present some initial findings from my research. I presented three case studies of study participants, who each represented very distinctive and individual approaches to the artificial pancreas. The first participant dropped out of the study altogether owing to difficulties she experienced with the insulin pump used in the study, which was different in a number of ways from her own insulin pump. However, she also expressed concerns about being ‘controlled’ by a machine overnight, and it is possible that this concern – a common, and understandable, fear – contributed in some way to her decision to drop out.  The second participant, who described herself as an ‘early adopter’ of new technologies in general, engaged much more enthusiastically with the system, and described it as dong a ‘really fantastic job of keeping me in line.’ Nevertheless, she did have some concerns about glitches and what she saw as a cautious approach to blood glucose control; as such, participation in the study led her to adopt a slightly more sceptical approach to new technologies. The third participant, finally, began the study as something of a technophobe, with a complex and difficult relationship with new diabetic (and non-medical) technologies. Through the process of participating in and reflecting upon the study, however, this user transformed her approach to diabetic technology and technology more widely, illustrating the potential for specific instances of technology usage to alter wider attitudes – in this case by effecting a transition from technophobe to technophile.

Overall, these case studies demonstrate the need to replace techno-determinism – the notion that usage can unproblematically be ‘read off’ from technology design – with more nuanced approaches to medical technology as it is used and experienced in everyday contexts. Technologies, insists Karl Weick and others, are essentially ‘equivocal’ – i.e. they give rise to multiple possible interpretations and meanings, each of which are equally valid for the user concerned. Since different individuals tend to interpret technology differently, a range of outcomes is likely to result – in the cases discussed above, a non-user, a user who became slightly more cautious, and a user who became dramatically more enthusiastic about new technology. Users’ interpretations of technology, and the outcomes they give rise to in conjunction with the ‘affordances’ of technology (i.e. what it allows), can be influenced, but not determined, by others. Accordingly, the question for medicine is how to design interventions so that optimal outcomes result from participants’ own interpretations.

 

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