m.c. schraefel, Aaron Tabor, Josh Andres
We don't know how to measure sleep; the best we can do is ask, "How do you feel?" This was the summary given by Mary Morrell during a seminar on sleep at the Inbodied Interaction Summer School this past August at the University of Southampton, U.K. Her perspective was surprising, given that the speaker is both a professor of sleep and respiratory physiology at the National Heart and Lung Institute, Imperial College London, as well as a lead researcher in developing an in-ear EEG sleep monitor —specifically designed to measure brain activity during sleep. She is not alone, though. Leading sleep scientist Matthew Walker  likewise says that while there are many practices associated with improving sleep quality and quantity, the best that state-of-the-art sleep science can do to assess the effect of sleep is to ask, you guessed it, "How do you feel?"
At the University of Konstanz, health psychologist Britta Renner and her team specialize in personal and social engagement with food, toward building strategies to support healthier eating. One recent study explored how food qualities affect our sense of well-being over time. Participants took photos of what they ate and were asked how they felt throughout the day. The data showed that participants reported feeling better, for longer periods, after eating colorful (i.e., more nutrient-rich) foods versus processed foods .
In professional sports, injury is a huge cost. When not refining training approaches for elite/professional athletes to reduce injury and improve their performance, Z-Health founder Dr. Eric Cobb trains coaches in functional neurology techniques to support athletic practice and reduce injury. En route back from a recent stint working with a professional English football team, Cobb said that some of the world's best professional teams are moving away from high-tech physiological and performance measures to guide training, in favor of asking athletes, "How do you feel?" Rather than data dashboards of HRV, blood pressure, hours slept, and so on, he offers athletes a simple checklist to help them track how they feel over time. He then connects these questions with a neurologically driven approach to help them feel and perform better. "It seems to be working," he said. "They're winning more games and winning medals, and injuries are down."
In inbodied interaction, we use this very question, how do you feel?, as our polestar for helping people tune their well-being via the in5 (inbodied five) in particular (see article on tuning in this section). We frame this inbodied approach as insourcing. In the following sections, we unpack this framing and explore how it opens up new geography for health-tech design.
In a conversation about eating practices, Natasha Milic-Frayling, professor and chair of data science at the School of Computer Science, University of Nottingham, suggested that when we go out to dinner or buy a premade meal, we are outsourcing our nutrition to a third party. Drawing on this metaphor, we propose that current mainstream health approaches and interactive health tools also frequently promote the outsourcing of aspects of our health.
Hiring a physical trainer, for example, outsources the design, management, and motivation of exercise to a third party. Those with sufficient affluence can simply buy the skills needed to design and deliver such a practice. Recent HCI work shows it's possible to crowdsource traditional types of in-gym strength workout plans , automating this part of the outsourcing, reducing cost, and potentially increasing accessibility.
Rather than rely on external prescriptions and data tracking in perpetuity, we design tools to help one build self-knowledge.
Outsourcing has become a part of much of our lives. But when it comes to our well-being, and how we build our cultures to support that well-being, that outsourcing comes at a cost. Reliance on an app or plan for our fitness means we may not build the knowledge, skills, or practice to connect that fundamental how do you feel? with what we need to know to achieve and maintain that well-being and performance across contexts. We rely on the external data, not our internal knowledge and experience, to tell us if we are on track.
Inbodied interaction proposes insourcing as a complementary approach to outsourcing for interactive health design. By insourcing, we mean that, rather than rely on external prescriptions and data tracking in perpetuity, we design tools to help one build self-knowledge around the various health practices that affect us (within, for example, the in5) across contexts. We learn how to ask how do you feel? and how to both assess and tune that state for ourselves.
Across these articles, we have proposed concepts like building self-awareness and self-knowledge to support tuning. From an inbodied interaction framing, where the body is the site of adaptation, we can similarly draw on and incorporate the physiological foundations of such explorations into our design work via, for example, processes like interoceptive awareness . Interoceptive awareness is a longstanding concept in physiology that speaks to the very real internal processes that support our capacity to be aware of not only our own internal processes—in particular its signals about the state of those processes—but also how these signals affect our sense of self in the world. Examples of these signals include our awareness of our pulse, our blood pressure, our digestion, and even our capacity to perceive and recover from stress or pain. These allostatic processes all also relate to the inbodied lens of the body as homeostatic (see this section's introductory article).
Over the past 15 years in particular, neurophysiology has developed a deeper understanding of interoceptive processes and the range and diversity of experiences affected by our interoceptive acuity. For HCI, these explorations open up new physiological pathways from the midbrain and cerebellum to the vagus nerve, connecting to the circumbodied, and in particular the microbiome, as it informs the gut-brain axis.
In inbodied interaction, we suggest that designing tools to support interoceptive awareness is an essential component of insourcing: It leverages an inbodied foundation around which we can refine and expand our health assessment of how do you feel? The in5's MEECS (move, eat, engage, cogitate, sleep; see tuning article) can each be used to affect and enhance our interoceptive sensitivity. Likewise, mindfulness work, already popular in HCI , is also increasingly connected with developing, monitoring, and measuring interoceptive sensitivity and affect. While this work is in its early stages, we see potential in designing tools that can bring mindfulness (attention) to inbodied actions, from movement to sleep, specifically toward sensitizing, refining, and expanding the space of how we feel, and therefore opening the design options to support practices to tune in feeling better.
The above is an exceedingly brief introduction to interoception as a functional component of insourcing for awareness toward positive adaptation via tuning. It's mentioned here mainly to demonstrate that intellectual, abstract concepts of self-awareness are fundamentally grounded in physical, inbodied pathways; that interoception, like balance or vision, represents an orchestration of our 11 internal, physical systems to support and process interoceptive experiences. As such, they are, like any inbodied process, adaptive: They can become weak from disuse, but they can also be strengthened by deliberate practice and assessment. The in5 are one set of volitional pathways that can be presented and tuned deliberately to strengthen these complex processes of awareness, for health adaptation across contexts.
We can use insourcing and outsourcing as vectors to design and evaluate health tools. We can use these vectors to explore research and design problems such as:
- When is outsourcing appropriate?
- How do we deliberately use outsourcing to support insourcing? For example, what measures, feedback, and tracking are used to support more quantitative assessment?
- How do we assess improvements in self-awareness over time? For instance, how well can someone debug their current state using their instantiations of any of the in5?
- If we are reluctant to move in a design from outsourcing to insourcing, how do we validate that reluctance or challenge it? For example, the DIYpancrease.org project is exemplary in challenging beliefs around outsourcing and insourcing technology, data, and how one feels, where agency is a key part of health.
Insourcing and outsourcing as design vectors let us situate our health technologies within a new continuum of aspiration for our tools' effects. Thus, the design space for health opens further, with more options and more opportunities to make a positive difference.
This framing does not rule out outsourcing; rather, it informs the choices we make about health design, making this aspect explicit and visible for interrogation as a design choice. This approach means that we can interrogate directly whether or not we are choosing an insourcing or outsourcing approach in our designs, or something else.
The insource/outsource dichotomy or continuum lets us interrogate what we are attempting to support—outsourcing, automation, insourcing—and why, and for how long. For example, much HCI work in health has focused on managing aspects of care for critically ill persons, so outsourcing care is not only appropriate but also vital. But for how long and in what contexts does outsourcing remain the only or best option? Within these continua, our evaluation of health tools and services can be vetted in terms of a clearer range of possibilities. For example, how might we design for the cycle that helps a person move from outsourcing care to insourcing? Within that cycle, what do we need to know about the in5 skills or support for that person to help them build the skills and knowledge to sense the signals to enable them to tune in truly feeling better.
By making insourcing/outsourcing an explicit continua, we can more deliberately situate HCI work oriented both to broaden self-awareness of health states and to help manage a health practice more deliberately toward tuning. Work in n-of-1 studies from Health Mashups and Tummy Trials are very much oriented around personal, internal assessment of responses and practices. We suggest there are opportunities from this work to build up more general health practice designs that leverage such exploration, guided testing, and reflection.
Much of HCI health work has also focused on habit formation via persuasive technology. Habits are automated practices that are triggered by context. In other words, we do them by rote and reflex. By focusing on insourcing, we may find that we can do less persuading more building of interoceptive feeling/benefit to make these practices more attractive, resilient, and enduring.
There are some implicit assumptions underlying our design focus on inbodied interaction in general, and insourcing in particular: that there is value for individuals both to have and to own the knowledge, skills, and practice needed to be able to self-tune health; that self-awareness of the internal signals for tuning, and the associated skills to manage tuning, are fundamental to the self-care necessary for healthful independence; and that designing services to support such independence is a social good, if not a social right.
Indeed, there are ethical implications in such a social contract, where we know that opportunities for effective self-care are overly limited because many people are too time and cash poor, as Casey Chosewood of the CDC's Total Worker Health program frames it, to be able to practice tuning. When one lives in a food desert and works multiple jobs, where does experiencing the inbodied benefits of increasing dark vegetables and more sleep fit in? Can we, for example, coordinate food resources that would otherwise go to waste with, say, retired persons who love to cook, working on food trucks to take healthy meals to hotel workers who would otherwise use government food coupons to buy fast food? Can we thus co-design with these communities smart services that will build a community's and an individual's access to and experience of in5 fundamentals—for example, helping them to test out food choices and build their awareness of the signals to tune how they feel, while supporting optimal sleep time, rich social engagement, and cognitive skills stimulation?
Insourcing/outsourcing can be a very simple frame to situate our designs in health. If our designs are to outsource an action—to create a follow-along prescription—is that because we are attempting to do something for someone so they don't have to do it? And if so, why? For how long? In what contexts? If we wish to insource—to help someone own that process—what signals can we leverage? How might we use the in5 to connect and build that awareness? What knowledge, skills, and practices might be built, over what time period, to help create that independence and awareness?
We may also consider transitions between in- and outsourcing. For example, we can design services to help plan meals and deliver foods against personal requirements, where selection, prep, and delivery is outsourced to that service. Concurently, interactive tools may help one build awareness of the interoceptive signals, from energy level to satiety, associated with those foods, insourcing skill building to tune well-being.
In sum, from an inbodied interaction perspective, we suggest that the insourcing/outsourcing continua gives us several additional and novel ways to consider our design work for health, well-being, and performance, for both individual and infrastructure/social interaction support, across demographics.
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m.c. schraefel directs the International Wellthlab (wellthlab.soton.ac.uk). Its mission is to explore where and how interactive technology can help make normal better, for all, at scale. firstname.lastname@example.org
Aaron Tabor is a Ph.D. student in the HCI Lab, University of New Brunswick. His work applies inbodied interaction to explore connections between breathing practices and health, wellness, and performance. He is leading the upcoming 3rd Body as Starting Point workshop on inbodied interaction this April at CHI 2020. Aaron.Tabor@unb.ca
Josh Andres leads user experience and HCI at IBM Research Australia. His work focuses on investigating intelligent-like systems as human partners to inform the design of systems that support human potential. Josh.email@example.com
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