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Abstract

The purpose of this research is to explore designs and functions people like to have in wearable trackers and how these differ between novice and experienced users. Interviews were conducted with 20 people, consisted of novice and experienced users living in the US, by asking preferred designs and functions of wearable trackers for oneself and others, preferences on sharing the tracked data, and suggestions in designs and functions of wearables. The data were analyzed qualitatively. It is recommended to make wearable trackers as accessory types that are small, lightweight, and neutral colored. Wearable trackers can offer self-tracking of moods and feelings for novice users and self-track physical activities for experienced users. Novice users are more likely to track others' physical health and experienced users preferred to track social media posts of others. Experienced users more reluctant to share their data with others than novice users. The results of this research will be helpful for designers, engineers, and marketers in the process of designing wearable technology.

Introduction

The market for wearable technologies, wearable products and related technologies that incorporate fashion, computer sciences, advanced electronic technologies and other interdisciplinary areas, have significantly developed and a number of companies have released different types of wearables since 2014 (Büyüközkan et al. 2016; Page 2015). Among various wearable technologies, wearable trackers are one of the most common types. These are body-worn or hand-held devices or technologies that automatically collect data for better understanding of self, others, or the environment (Charara 2017; Lamkin 2015; Lupton 2014; Michaelis et al. 2016; Sawh 2017a; Schüll 2016). Examples of leading products with these functions include the Apple Watch, Samsung Gear, Fitbit, and Jawbone (Michaelis et al. 2016; Schüll 2016). Wearable trackers can enhance understanding of self, others, and the environment and enable users to select more appropriate reactions to new situations (Lupton 2014). Although there are many benefits, approximately 30% of individuals return their wearables after 6 months of use (Ledger and McCaffrey 2014; Michaelis et al. 2016).

To develop successful wearable trackers, it is essential to understand users of such trackers and their opinions on designs and functions by conducting interviews or analyzing comments as part of a user-centered design methodology (Holtzblatt et al. 2004; McCann 2009; Motti and Caine 2016). In previous research, significant differences were found between novice users (NC) and experienced users (EX) in their technology acceptance (Fishbein and Ajzen 1977), decision criteria (Bettman and Sujan 1987), perceived usefulness and periods of use (O'Cass and Fenech 2003; Smith and Brynjolfson 2001), purchase intentions (Sherrell et al. 2015), and use motivators (Stragier et al. 2016). Although, there is research on understanding user needs and wants for wearables (Gao et al. 2015; Koo and Fallon 2017; Koo et al. 2016; Stead et al. 2004), little attention has been paid to understanding the differences between NC and EX of wearable trackers. In addition, interviews are considered key techniques of user-centered design methodology, but there is a lack of research seeking to hear consumers' actual voices (Holtzblatt et al. 2004). Thus, the purpose of this research is to investigate what designs and functions NC and EX each like to have in wearable trackers and interviews were performed. The results of this research will be helpful for designers, engineers, and marketers in the process of designing wearable technology to target different level of EX.

Literature review

Literature reviews were conducted on (a) theoretical foundations to explore how different experience levels of users could influence user attitudes and behaviors; (b) the meanings of tracking oneself and others using wearables to understand how people would perceive tracking culture and what they would want from wearable trackers; and (c) the development and characteristics of wearable trackers to investigate what kinds of designs and functions of wearable trackers consumers have available in the market and which are missing. These literature reviews were used to prepare interview questions and to analyze the data for this study.

Theoretical foundations

The Unified Theory of Acceptance and Use of Technology (UTAUT) and Technology Acceptance Model (TAM) provide insights into experience level influences and facilitators and barriers to the use of wearables in this study. Two important factors for user acceptance of technology are perceived ease of use (PEOU) and perceived usefulness (PU) (Davis et al. 1989; Preusse et al. 2016; Ma et al. 2017; Venkatesh et al. 2012). Perusse et al.'s ( 2016) research found that lower PEOU and PU decreased the acceptance rate of wearables. Other problems and barriers to the use of wearable technology include weakness/lack of durability (Paul et al. 2014; Wang et al. 2016a, b), discomfort (Bowman et al. 2016), invasive monitoring (Coorevits and Coenen 2016), inaccuracy (Kim et al. 2007; Preusse et al. 2016); limited designs (Colgan et al. 2016; Tomberg et al. 2015; Wang et al. 2016a, b), cost (Donkin 2016), uselessness (Donkin 2016; Motti and Caine 2016) and difficulty of use (Coorevits and Coenen 2016). Researchers have endeavored to develop durable products that can withstand frequent washing or long-term use through methods such as coating the surface of the conductive materials or applying nanotechnologies (Paul et al. 2014; Wang et al. 2016a, b). According to the literature, consumers want wearable trackers to be useful, durable, comfortable, non-invasive, accurate, aesthetically pleasing, reasonably priced, useful, and easy to use and care for. The satisfaction with these aspects may affect consumer attitudes about wearable trackers.

Tracking self and others

Wearable technologies track blind spots and help users visualize everyday living in real-time (Schüll 2016; Swan 2013). Wearables can let individuals see and understand the reality of themselves and others, including choices they make such as taking the stairs or the elevator (Schüll 2016). Seeing these everyday choices allows individuals to see how their choices impact them and to enable or encourage them to make better choices (Schüll 2016). Wearable trackers can extend and improve self-awareness and self-management (Schüll 2016; Starner 2013). Schüll ( 2016) stated that wearables like personal sensors can be a sixth sense, capturing information which the ordinary senses cannot. Swan ( 2013) described these technologies as a sort of fourth-person perspective on the self. The self is considered the data in this era (Schüll 2016), however, other researchers, including anthropologists, have expressed concern about the growing use of these technologies. They argue that if the definition of the self is confined to a body that generates data, the ability to process experiencing and achieve self-understanding will atrophy. Since there are many aspects of the self and subjectivity that wearables still cannot track, the focus on data that can be tracked will increase the gap between the real self and the amassed, datafied self (Schüll 2016; Viseu and Suchman 2010).

Another use of self-tracking technology could be the self-adoption of government surveillance (Berson 2015). Miltgen et al. ( 2013) applied UTAUT and TAM to their research and found that concern for privacy influences the acceptance of tracking. Although wearables have tremendous potential to benefit people through functions such as managing individuals' health and providing insights to doctors (Bravo et al. 2016; Michaelis et al. 2016), many researchers have pointed out the privacy issues raised by tracking health data and users' activities through wearables (Brubaker 2017; Lamb et al. 2016; Li et al. 2016). With the development of big data analysis algorithms, information about health issues, activities, and location can be used by companies in fields, such as marketing, health insurance, medicine, social media, and more (Brubaker 2017). However, people may want to conceal their tracked data from others, and these tracked data can be hacked or sold by others without the users' knowledge. To solve privacy issues, wearables can limit the accessibility of users; develop security for networks to block hackers; and use biometrics such as fingerprints, pupils, walking patterns, and blood vessels; but more developments are required to solve the privacy issues created by the continuous evolution of wearable technologies (Blasco et al. 2016; Casale et al. 2012; Mitra and Wen 2016). Previous research has shown a relationship between personality and perceptions of the privacy of wearable technology. For example, people with a high tendency towards neuroticism knew more about third-party data sharing (Lamb et al. 2016). If individuals perceive more benefits than privacy risks, they may be more likely to adopt the device (Li et al. 2016). Thus, users may have different tendencies to share collected data with others according to data type and perceived privacy threat.

Types of wearable trackers

Physical activities

The most common type of wearables tracks physical activities. There are various types including smart watches, smart bands, patches, and garments. Wearable trackers for physical activities can quantify an individual's daily activity and have the benefit of being a cost-effective solution to motivate the individual to exercise (Michaelis et al. 2016). These wearables can track the user's location through a Global Positioning System (GPS); track vital signals such as heart rate (HR), burned calories, steps, speed, and time; monitor sport activities, sleep patterns, or even diet behaviors using accelerometers, gyroscopes, heart-rate sensors, galvanic skin response sensors; and can notify users when they achieve activity goals (Michaelis et al. 2016; Shelgikar et al. 2016). Smart watches are a representative type of fitness tracking wearables (Chittenden 2017). Smart watches can track multiple aspects of activities and have various other functions such as allowing users to manage calls and texts and set alarms to manage their schedule (Lamkin 2015; Sawh 2017a, b). Similar to smart watches, smart bands track multiple aspects of activity. However, smart bands are smaller and more simply designed than smart watches and have more limited screen interfaces (Charara 2017; Winchester 2015).

Physical and psychological health

Environment and daily lifestyle

In sum, based on the literature review, the following two research questions were derived: (1) what kind of designs and functions do NC and EX each want for wearable trackers? (2) what kind of designs and functions do NC and EX each like and dislike on existing wearable trackers?

Methods

Population and study sample

Interviews were conducted in this study to understand designs and functions people like to have in wearable trackers and their differences among people with different wearable trackers use experiences. After receiving approval from an Institutional Review Board (IRB), the researchers conducted personal interviews with participants. A total of 20 participants in the ages of 20-40 living in the US were recruited through purposeful sampling and were divided into two groups of ten participants each (Creswell 2013). This represent the major consumers of wearable technologies who are in the age range of 20s through 40s for both genders (Harris Poll 2015; Salah et al. 2014). The first participant group was consumers over the age of 18 who knew what wearable technology is but had no experience using wearables. The other group was EX over the age of 18 who knew what wearable technology is and had used wearables.

Data collection procedure

Emails were sent out through the university system and the local wearable technology community to recruit volunteers to participate in the interviews. Each participant was individually interviewed in person for about an hour in a university lab. Two interviewers explained the research purpose and procedures and received consent forms if participants agreed. The interviewers took notes and audiotaped the interviews.

Interview questions

The interview included nine questions: two about demographics such as age and gender, five about preferred tracking functions, and two about suggestions for wearable technology product designs. Five questions about tracking functions were used to answer research questions 1 and 2 on the designs and functions consumer wanted: (1) self-defining qualities: what qualities do you feel define who you are? (Schüll 2016); (2) tracking dimensions for self: 'what dimensions of yourself would you like to track?' (Koo and Fallon 2017; Preusse et al. 2016; Viseu and Suchman 2010); (3) knowing about others: what would you be interested to know about others? (Koo and Fallon 2017; Michaelis et al. 2016); (4) sharing about self: what qualities do you wish the world knew about you? (Koo and Fallon 2017; Lamb et al. 2016); (5) conceal about self: what qualities of yourself do you attempt to conceal? (Koo and Fallon 2017; Lamb et al. 2016; Li et al. 2016). The two questions about product design suggestions were asked: (1) what aspects do you like and dislike about current products? (Preusse et al. 2016) and (2) do you have any suggestions for improving the design and function of current wearable products in the market? (Michaelis et al. 2016; Preusse et al. 2016). Based on UTAUT and TAM, modifications and reinforcements could be made to wearable trackers that would enhance users' positive attitudes toward the devices based on the results. Such positive attitudes influence users' acceptance of new technologies (Wu et al. 2016).

Pilot interviews were conducted with four participants, two NC and two EX of wearables. Based on the pilot interview, the questions were modified to clarify the meanings by using easier words or adding more definitions of wearable technology related products, especially for NC. The definition of wearable technology for tracking was "devices that can collect data, track activities, and customize experiences to users' needs and desires" (Thierer 2015, p. 1). The examples of wearables were chosen to communicate with participants and to ask about their opinions of these wearables. The seven tracking wearables chosen were the Apple watch, Fitbit, Jawbone, Sensoria, Athos, Misfit, and Ringly. These products were selected based on three main criteria following Michaelis et al.'s ( 2016) research method: (1) successful products which have recently become key players in the market (Michaelis et al. 2016); (2) products with a wide range of functionality such as accessories versus garments, and monitoring vital signs versus managing tasks and schedule; and (3) products which expert participants have used.

Data analysis procedure

The recorded files were transcribed for each question and open coded to extract important themes for qualitative data analysis (Creswell 2013; Tracy 2012). The numbers of common themes and participants were calculated for quantitative descriptive analysis such as frequency and percentage (Creswell 2013). The number of participants who mentioned each major theme was counted and divided by the total number of participants. There were participants who commented more than one major theme for each question. Tracking dimensions included fitness and physical health. Fitness can be analyzed by tracking physical activity and locations (Michaelis et al. 2016; Shelgikar et al. 2016). However, tracking health relies more on monitoring vital signs or symptoms of diseases (Chen et al. 2016; Davies 2017). Thus, in the data analysis, tracking disease symptoms was counted as tracking physical health and tracking general activities was counted as tracking fitness. Two researchers cross-checked the transcriptions and coded data and major themes. The total number of dividing agreements of the coded data was assessed using IBM's Statistical Package for the Social Sciences (SPSS) in version 23.0. The Cronbach's reliability coefficient was 0.908, indicating good internal consistency (Shrout and Fleiss 1979).

Results and discussions

Sample characteristics

The participants included ten NC of wearable technology [NC: mean (M)age = 22, standard deviation (SD)age = 2.91, range of 20-25, all females] and ten EX who had used wearables for at least a year (EX: Mage = 33.6, SDage = 6.99, range of 26-40, five females and five males). Among the EX, the most frequently used device was the Fitbit (60%), followed by the Apple watch (30%), Misfit (10%), Athos (10%), Sensoria (10%), Jawbone (10%), and Ringly (10%).

Research question 1 findings

Self-defining qualities

When asked to define themselves, participants referred to their personality (35%), physical activities (30%), interpersonal relationship (20%), physical attributes (10%), and diet regulations (10%) (Table 1). Among the NC, participants most commonly defined themselves by personality attributes (70%) such as self-driven (50%), extrovert (40%), or creativeness (40%) or introvert (20%). The next most commonly mentioned attribute was physical activities (40%) such as playing sports, active person, or being healthy, all of which are dimensions which many wearables track. Among the EX, participants most commonly defined themselves by qualities such as interpersonal relationships (40%) such as "maintenance of healthy and happy family and friend connections" (#EX3). The next most common was physical activities (20%). EX4 said, "I have always worked out," and EX9 commented, "I work out a lot...certainly staying fit and thin is something that I am very concerned about." Another common attribute was diet regulations (20%). EX3 said, 'I think I am really aware about what I eat... I am really interested in eating healthy." Both NC and EX talked about physical activities, which are the most typical tracking dimensions of wearables (Mukhopadhyay 2015; Swan 2012). Physical activities were defined as the self-defining quality for both groups; however, NC cared more about personality and EX about interpersonal relationships. According to Lupton ( 2014), the tracking self-culture consists of self-awareness (understanding of self), self-improvement (adjusting the self), and self-interest (studying the self as an interesting subject). Tracking these attributes, that represent the self could help people visualize the self and allow people to be self-aware, self-improving, and self-interested (Schüll 2016; Swan 2013).

Table 1 Results for the research question 1

Tracking dimensions for the self

Among all participants, the dimension they most wanted to track in themselves was physical activities (60%), followed by moods and feelings (40%), diet regulations (30%), sleep patterns (30%), and consumption habits (10%) (Table 1). NC and EX preferred somewhat different tracking dimensions for the self. NC wanted to track moods and feelings (80%), such as anxiety or stress level, to enhance their self-awareness and self-regulation. For example, "Anxiety level...track when I'm most nervous and relaxed and can figure out why that is...stress levels" (#NC1). "It would be cool to see my different stress levels at multiple points throughout the day and I could see if there are any peak points where my stress level is higher at a certain time" (#NC3). "Distractions, nervousness, anxiety, tiredness, I think it's easier to deal with feeling nervous or anxious when I know it...if a watch or something were telling me I was nervous, I think I'd be less nervous..." (#NC7). The other most preferred tracking dimension was physical activities (80%), such as daily activities, exercises, and changes in the body like muscle gain, abdominal muscles, forearms, burning calories, bulking, heart rate, blood pressure, and dehydration levels. Participants wanted to track these activities to enhance their knowledge and growth. NC referred to eating habits as one of their self-defining qualities and also wanted to track diet regulations (60%) through burned calories, weight loss, and diet. They also wanted to track sleep patterns (60%) through their sleeping schedule and sleep quality. NC10 said, "...Tracking depth of sleep, how much sleep is best for health, what time I should wake up, and environmental factors affecting sleep."

EX also liked to track physical activities (40%) such as running speed and duration and monitoring muscle changes while working out. The other dimension EX wanted to track was consumption habits (20%) such as how much they spend in a year. These kinds of functions can be incorporated into apps for existing wearables instead of developing devices solely for tracking consumption habits. For example, the Billings Pro app for the Apple watch can track time, mileage, and expenses (Fearn 2016). Both NC and EX also considered physical activities to be important self-defining qualities, and many existing wearables track physical activities. Designers could develop wearable trackers that can track moods and feelings for NC and physical activities for both NC and EX. However, none discussed tracking their immediate surroundings and the environment in which they were located through practices such as recording photos or videos as reviewed in the literature.

Knowing about others

The most preferred aspects that NC were interested in knowing about others' physical health (70%), which was also the most preferred when considering all participants. Tracking physical health included tracking heart rate or blood pressure. The other aspects the NC wanted to track in others were moods and feelings (60%), including changes of moods and feelings or stress levels; and locations (30%), such as using GPS and tracking children's locations for safety reasons. EX wanted to know about others' social media posts (20%), including photos and writings people share on social media. Physical health, related to physical activities, and moods and feelings were also preferred tracking dimensions for the self. However, participants did not mention wanting to use location as an aspect of tracking the self. Developers would need to consider how to track these different data to satisfy different target groups of NC and EX.

Sharing about self

Participants in both groups wanted to share their moods and feelings (20%), physical health (15%), physical activities (20%), and interests (15%) (Table 1). However, 25% of participants were reluctant to share tracked data or only wanted to share it with small groups (15%). When asked what qualities they wanted other people to know about them, NC mentioned their psychological status such as moods and feelings (40%), which others could use as a hint for better interpersonal relationships. Other information they wanted to share was their interests (30%), to show "who I am and what I am good at," and physical health (30%), such as burned calories and heart rate. Among EX, many preferred not sharing about themselves (50%) due to discomfort and concerns about privacy. The aspects they wanted to share with others were physical activities (40%) like number of steps they walked. Several wanted to share only with small groups (30%) of their families or friends. Interestingly, none of the NC were concerned about the privacy issues that EX mentioned. Use experience could have raised these issues for EX (Drugge et al. 2006). Interestingly, 50% of EX, who have used wearables, did not want to share their tracked data with others, and only 30% wanted to share with small groups due to privacy issues, which was not commented by NC. The experience of using wearables may arouse attention to privacy issues and developers could consider how to protect the privacy of users, and make them feel comfortable when using wearables (Drugge et al. 2006). Thus, designers would need to consider how to develop wearable trackers without violating privacy issues especially for EX.

Conceal about self

Participants in the NC wanted to conceal their moods and feelings (50%) because they sometimes wanted to hide feelings such as anger, sadness, or nervousness (Table 1). They did not want to affect others or provide negative impressions. Another aspect they wanted to conceal was personality (30%), such as lack of organization or lack of confidence, because they felt that these traits are private. Also, they wanted to hide physical attributes (30%) like weight or skin imperfections. Similarly, EX also wanted to conceal personalities (50%) such as negative personalities.

Participants wanted to conceal their moods and feelings, personalities, and physical attributes. However, personality was the most frequently mentioned self-defining quality and moods and feelings were one of the top desired functions for tracking the self, knowing about others, and sharing with others. People liked to know about others' moods and feelings but wanted to conceal their own. Information about individuals' personalities and moods and feelings could be used for tracking the self but not always shared with others. Thus, designers could consider how to better protect users' privacy while still providing the benefits of tracking. For example, data shared with others could use fewer specific words such as "stressed" when tracking moods and feelings (Raij et al. 2011). Designers of wearable technology might further consider the use of filters or permission dashboards to give users greater control over how their data is revealed to others and who gets to see it.

Research question 2 findings

The aspects that could affect consumer attitudes toward wearable trackers defined in the literature reviews and two main factors influencing acceptance of technologies in UTAUT and TAM were also found in the participants' responses (Table 2). Between the NC and EX groups, NC mentioned more design related aspects such as size and colors, and EX mentioned more functional aspects, and only EX mentioned privacy as a disliked aspect.

Table 2 Results for the research question 2

Like and dislike aspects

NC were those who had no experience in using wearable technology. Thus, they saw images and heard information about wearables such as Apple watch, Fitbit, Jawbone, Sensoria, Athos, Misfit, and Ringly, which were products that the EX group had used. When asked what aspects they liked about these products, NC mentioned small size (40%) of wearables that made them more portable; unobtrusiveness (40%) so that the wearables were invisible and could be used in various contexts; gender- neutral colors (30%) such as black, beige, grey, or white; accessory type (20%) so that the wearables could be used as fashionable items; the function of tracking mood and feelings (20%) through methods such as measuring heart rate; simple designs (20%) which made the products easy to use; and soft materials (20%) so that the devices were comfortable to wear. EX liked functions of syncing to apps (40%) such as automatically syncing the monitored data to apps and having an increased battery life (20%) over previous versions or other wearables.

When asked what NC did not like, the aspect that participants mentioned most frequently was that wearables were unnecessary functions (40%) because many of their functions overlapped with smartphone functions or the products required connecting with smartphones. The unnecessary functions, which relate to usefulness, could affect the acceptance of wearable trackers (Davis et al. 1989; Preusse et al. 2016; Venkatesh et al. 2012). Other disliked aspects were discomfort (30%); color (20%), such as bright or neon colors that are hard to match with various clothes and attract others' attention; and heavy weight (20%). Also, cost (20%) was mentioned as a barrier to using wearables. Regarding the cost, consumers' perceived value of technology will enhance the acceptance of technologies (Donkin 2016; Preusse et al. 2016). The aspect EX disliked was durability (20%) because using devices for daily activities can be limited when a device cannot be used in high temperatures, is not waterproof, or requires a great deal of maintenance. Participants also talked about the difficulty of use (20%) such as setting up the device. Similarly, Preusse et al. ( 2016) also found that the disliked aspects of wearables included issues with difficulty of use. For example, "I realized that it would take me more than 5 min to set the thing up and sync it with my phone" (#EX9). Some participants also worried about privacy (20%), as EX3 mentioned:

I have looked at their policy and they have your data and they can do whatever they like with it. There are so many options like they are using your data for individual commercials and everything... I don't feel comfortable about sharing my data about anything.

Suggestions on designs and functions

When participants were asked to suggest ways to improve the designs and functions of wearable products, NC wanted to improve the designs so that devices could be more fashionable (80%) and not sporty, futuristic, high-tech, structured, or concrete looking; unnoticeable (30%) so that they could be hidden or not stand out; changeable (30%) so that the device could be personalized or matched with a variety of clothes in daily life; lightweight (20%); small (20%) so that the device could be more portable and worn for a long time; and suitable for versatility in users (20%) such as elderly people to use. When asked about functions, they wanted to have accessories for tracking moods and feelings (20%), such as nail polish, rings, or necklaces that can show when moods and feelings are changing dramatically or show the user's current mood. NC3 said, "Like with mood rings or mood necklaces in which the design/color could constantly change depending on the information it was receiving...it'd be cool to be able to tell from a glance that something is changing/updating." Participants also commended about wanting cost (20%) to be more reasonable. Low cost can lower the risk level of accepting new technologies or products (Rogers 2003). EX suggested more focus on functions. Specifically, they wanted to enhance schedule and task management skills (40%), managing physical health (40%), and tracking moods and feelings (30%). For example, "I think that it would be really cool if somehow, there was something that was like reading your mind or that like could be like, "Oh, you had this like emotional pattern, you know, and you tensed up here" (#EX6). The other suggested functions are monitoring physical attributes (20%) such as body size and weight, and being customizable (20%), with features such as modifying codes or pressing buttons to change functions or interfaces.

Conclusion and implication

This research explored designs and functions people like to have for wearable trackers and how these are different between NC and EX. The results of this research will be beneficial for wearable technology developers and fashion designers in the development process. People in the fashion industry can market wearable trackers by considering possible designs and functions considering target groups of different experience levels.

Regarding to practical implications, it is recommended to make wearables as small, lightweight, neutral colored. Devices could be fashionable accessory types made of soft materials that automatically sync data to apps with increases battery lives. Designers can develop wearable trackers according to target users depend on their experience level of wearable technology. The functions could include: (1) self-tracking moods and feelings, physical activities, diet regulations, or sleep patterns for NC and physical activities or consumption habits for EX; and (2) tracking others on their physical health or moods and feelings for NC and social medial posts for EX. These functions were recommended to be independent from smartphones, thus, the wearables are necessary in themselves. Since EX more concerned about the privacy issue, designers would need to consider how to protect tracked data when targeting EX.

The privacy protection could also be important on wearables especially when tracking moods and feelings, personalities, physical attributes, and physical health (Brubaker 2017; Lamb et al. 2016; Li et al. 2016). Thus, developers would need to consider how to protect users' privacy such as providing options on the wearables of sharing the tracked data with others or even with the companies; to limit the accessibility of users; to develop security against hackers; or to use biometrics as reviewed in the literature (Blasco et al. 2016; Casale et al. 2012; Mitra and Wen 2016).

This study only interviewed with 20 people in the US with uneven portion of male and female participants in a wide range of ages focusing on wearables for tracking functions. It will be worthwhile to conduct quantitative surveys or user tests with existing wearables with participants with different demographic backgrounds including age, gender, resident location, and occupations such as developers on wearables for tracking or with different functions as future research. In addition, the future study of the modeling testing with UTAUT and TAM using the quantitative study design would be meaningful.

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Authors' contributions

SK conducted interviews, analyze data, and wrote the manuscript. KF conducted interviews and contributed to the manuscript writing. All authors read and approved the final manuscript.

Acknowledgements

This paper was supported by Konkuk University in 2017.

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Written informed consent was obtained from all participants for the research.

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1. Department of Apparel Design, Konkuk University, Seoul, 05029, South Korea

Sumin Helen Koo

2. University of California, Davis, Davis, CA, 95616, USA

Kristopher Fallon

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Correspondence to Sumin Helen Koo.

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Koo, S.H., Fallon, K. Explorations of wearable technology for tracking self and others. Fash Text 5, 8 (2018). https://doi.org/10.1186/s40691-017-0123-z
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DOI: https://doi.org/10.1186/s40691-017-0123-z

Keywords

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Explorations of wearable technology for tracking self and others - Fashion and Textiles

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The purpose of this research is to explore designs and functions people like to have in wearable trackers and how these differ between novice and experienced users. Interviews were conducted with 20 people, consisted of novice and experienced users living in the US, by asking preferred designs and functions of wearable trackers for oneself and others, preferences on sharing the tracked data, and suggestions in designs and functions of wearables.

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According to the Guardian, Sound Therapy "believe that our bodies contain 'energy frequencies' and that sonic frequencies can be used to reattune these energies when they go off key. All you have to do is lie down and bask in the tuneful beauty of 'pure' sound".

Sound has been a tool for promoting the physical and emotional health of the body for as long as history can account for, deeply rooted in ancient cultures and civilizations. The ancient Egyptians used vowel sound chants in healing because they believed vowels were sacred. Tibetan monks take advantage of singing bowls, which they believe to be "a symbol of the unknowable" whose "vibrations have been described as the sound of the universe manifesting.". Also When some American Indian medicine men and women were called upon to heal an ailing tribesmember, they would fast in order to receive a song in dream or vision instructing them in how to carry out the treatment of their patient.

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According to Dr. Suzanne Evans Morris, Ph.D., a speech-language pathologist:

Research shows that different frequencies presented to each ear through stereo headphones... create a difference tone (or binaural beat) as the brain puts together the two tones it actually hears. Through EEG monitoring the difference tone is identified by a change in the electrical pattern produced by the brain. For example, frequencies of 200 Hz and 210 Hz produce a binaural beat frequency of 10 Hz (The difference in 210 Hz and 200 Hz is 10 Hz). Monitoring of the brain's electricity (EEG) shows that the brain produces increased 10 Hz activity with equal frequency and amplitude of the wave form in both hemispheres of the brain (left and right hemisphere).

A series of experiments conducted by neuro-electric therapy engineer Dr. Margaret Patterson and Dr. Ifor Capel, revealed how alpha brainwaves boosted the production of serotonin. Dr. Capel explained:

As far as we can tell, each brain center generates impulses at a specific frequency based on the predominant neurotransmitter it secretes. In other words, the brain's internal communication system-its language, is based on frequency... Presumably, when we send in waves of electrical energy at, say, 10 Hz, certain cells in the lower brain stem will respond because they normally fire within that frequency range.

It's very intriguing to think that something as simple as sound, as music, which we have come to treat as utterly pleasurable entertainment, has not only been used to promote healing and well-being, but has proven to work through research as well.

If your mental health is of concern, try listening to a binaural beat to generate alpha waves between 8 and 14 Hz to produce more serotonin. Another option is to take advantage of music that promotes a relaxed alpha state in the brain such as classical music.

Another interesting study utilised a different method of sound therapy (Himalayan singing bowls, transitioning to Gongs, transitioning to crystal singing bowls, transitioning to therapeutic percussion). It was delivered in two ways - by a live soundbath, where subjects lay on the floor and received around 35 minutes of sound, and by a recording of the same which was available online. The focus of this research was to answer the following questions:

1. Is live sound more or less effective than digitally recorded and delivered sound and across what domains?

2. What are the consciousness altering effects of this method and to what degree are the domains effected?

3. What are the therapeutic benefits of sound induced ASC?

Data was analysed by a test known as a Chi Square analysis to gauge significance. Statistically significant, highly significant and extremely significant data was produced in the domains of Physical Relaxation, Imagery, Ineffability, Transcendence of Time and Space, Positive Mood, Insightfulness, Disembodiment and Unity across both live and recorded studies. These findings have far-reaching implications for the use of sound therapy, specifically sound induced altered states of consciousness (ASC) going forward. The findings provide further understanding of the depth at which live therapeutic sound compared to a recording is experienced. On the whole the experience in a live study seemed to be more emotionally moving, with participants being able to put their experience into words and experiencing joy. This may be due to the presence of the instruments and that vibrations can be felt travelling through the body, whereas the recorded sound seemed to create deeper introspection and a deeper ASC. This is rather like comparing being at a live concert to listening to an MP3 recording - the former is more rousing, and the latter more immersive. Both groups seemed to benefit from the relaxing effect of the sound and lost their usual sense of time and space.

Fonti:
Collective Evolution British Academy of Sound Therapy

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Sound Therapy and well-being: some scientific studies

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According to the Guardian, Sound Therapy "believe that our bodies contain 'energy frequencies' and that sonic frequencies can be used to reattune these energies when they go off key. All you have to do is lie down and bask in the tuneful beauty of 'pure' sound".

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1-Page Summary 1-Page Book Summary of The Practice of Adaptive Leadership

When your organization is facing changing conditions or never-before-seen challenges, the only way to survive is to adapt. In The Practice of Adaptive Leadership, you'll learn how to lead your organization through the difficult, uncomfortable, and sometimes dangerous process of adaptation. First, you'll learn what adaptive leadership is and the kinds of challenges it can help address. Then, you'll learn how to diagnose and treat challenges. Finally, you'll learn how to build an adaptive company culture.

What Are Adaptive Leadership and Adaptive Challenges?
"Adaptive leadership" is marshaling people to tackle problems with unknown solutions and thrive while doing so.

(Shortform example: When a sales company expanded into a new region, adaptive leaders marshaled people to figure out what sales processes-or what completely new procedures-would work best in the new region's market.)

These problems with unknown solutions are called "adaptive challenges." The only way to solve them is for the people in organizations to learn and change. (Challenges with known solutions are called "technical problems" and can be solved using existing workflows and expertise.) Adaptive challenges have the following qualities:

Loss. To move forward, old ways have to be left behind.

Resistance. People resist change because they fear the loss that comes with it.

Discomfort. Since the solution is unknown, addressing adaptive challenges involves experimentation, iteration, failure, disorientation, and conflict, all of which must often be uncomfortably endured for a long time.

Adaptive Leadership Is Dangerous

Since adaptive problems don't have known solutions, you won't be able to fix them by following pre-existing directions and protocols. Therefore, adaptive leadership is dangerous-it involves challenging the expectations of the very people who gave you power.

For example, if a company hired you to run a department, they'll want you to follow their directions and run the department in the way they expect. They'll expect you to stay within your scope of authority and defer to them, even if this isn't effective. Thus, changing your leadership style to face an adaptive challenge may upset your superiors.

Practice Adaptive Leadership to Achieve a Purpose

Since adaptive leadership will make people resist you and potentially jeopardize your job, it's only worth practicing when it will help you or your organization achieve a purpose- a cause that brings you or your organization meaning and that you value. To determine what your or your organization's purpose is:

1. Assess actions rather than words. What you do is a better indicator of what you value than what you say.

2. Consider what you or your organization is willing to take risks to do. If you're willing to take a risk for something, this suggests you value it.

3. Ask yourself or your organization what you're ultimately trying to do. Then, descend a level of abstraction until you reach a concrete purpose. (Shortform example: If your ultimate goal is to "save the planet," ask yourself what action you could take to do that-perhaps you might start a company that builds electric cars, and your purpose becomes to sell a lot of electric cars.)

Diagnosis

You can diagnose adaptive challenges within your organization by:

Assessing the adaptive capacity of your organization and the people within it

Assessing your own adaptive leadership abilities

Assessing the specific adaptive challenges you and your organization are facing

These assessments will help you understand the scope of the problem and the resources you have available (or can acquire) to address it.

Assess Your Organization

There are five characteristics to consider when assessing an organization's adaptive capacity:

Characteristic #1: Sector membership. Consider what sector (not-for-profit, private, public) your organization belongs to and how this affects its adaptability. For example, private sector organizations are usually driven by profit and competition, and like to stick with what worked in the past. Sticking to the past doesn't help them adapt.

Characteristic #2: Formal structure. Consider how your organization's formal structures, such as the organizational chart, encourage or discourage adaptability, both implicitly and explicitly.

Characteristic #3: Culture. Consider how myths, practices, norms, and conventions (especially in meetings) govern people's behavior and encourage or discourage adaptability.

Characteristic #4: Habits. Consider the default perspectives and behaviors the people in your organization take and how these affect its ability to change.

Characteristic #5: Politics. Consider how everyone in your organization relates to each other, both formally and informally, and how this affects their openness to adaptive change. When faced with an adaptive challenge, what's at stake for everyone, what's their preferred outcome, what are they loyal to, what are their values, and how much power do they have? Do these factors help or hinder people's adaptability?

Assess Yourself

There are four characteristics to consider when assessing your leadership abilities and capacity for adaptation:

Characteristic #1: Psychology. Consider your background, culture, experiences, loyalties, values, pet peeves, and triggers. Consider how these factors impact how adaptable you are.

Characteristic #2: Repertoire. Consider the strategies you use to effect change in yourself and others. The more varied your approaches, the better your chances of success because you can be effective in more contexts.

Characteristic #3: Roles. Consider your multiple selves and the roles you play, and how these help or hinder your ability to lead others or yourself through adaptation. (Shortform example: In some groups, you may represent level-headedness; in others,...

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The Practice of Adaptive Leadership Book Summary by Ronald A. Heifetz

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When your organization is facing changing conditions or never-before-seen challenges, the only way to survive is to adapt. In The Practice of Adaptive Leadership, you'll learn how to lead your organization through the difficult, uncomfortable, and sometimes dangerous process of adaptation. First, you'll learn what adaptive leadership is and the kinds of challenges it can help address.

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1-Sentence-Summary: Lost Connections explains why depression affects so many people and that improving our relationships, not taking medication, is the way to beat our mental health problems. Favorite quote from the author:
Read in: 4 minutes

You don't have to look very far to find someone who suffers from depression. If you don't have it, you probably know someone who does. The World Health Organization estimates a whopping 300 million people suffer from depression worldwide. And those numbers only seem to be going up.

It's a huge problem, so we must have some sense of what causes it, right? There are many theories, but we don't know exactly why depression happens, or why it's becoming more prevalent. Most of us accept the explanation that it's something wrong with brain chemistry. But what if I told you this might not be the whole picture?

In Johann Hari explores the lesser-known side of depression and Lost Connections: Why You're Depressed and How to Find Hope, anxiety. He explores the cutting-edge science of curing people without medication. He uncovers the truth that depression isn't just a biological ailment, but an environmental and psychological one too. His thoroughly researched and fascinating argument is that the key to treating depression is in re-establishing lost connections in our lives.

I learned these 3 powerful lessons from this book:

1. Depression is not the result of a chemical imbalance.

2. There are nine main causes of depression, and they all have to do with difficult life circumstances.

3. Social prescriptions help people feel valued and connected while medication does not.

Let's take a closer look at what Hari has to say!
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Lesson 1: A chemical imbalance doesn't cause depression.

I know this one is a lot to swallow. And honestly, I would take it with a grain of salt. While the studies Hari presents are scientifically accurate, the conclusions he comes to may be only one side of this story. But I believe hearing this side is important.

Hari was diagnosed with depression in his 20's and began taking antidepressants. After ten years of his doctor upping his dosage to give him relief, he came to the max dosage. Still depressed, he realized he needed to try something else. Hari began his own extensive research on depression and was shocked by what he found.

Modern society has told us for years that depression is the cause of a chemical imbalance. But have we ever questioned where this idea began? After talking to researchers, Hari learned that there is little evidence that a chemical imbalance causes depression, or that standard antidepressants work.

In the '90s, a Harvard professor named Irving Kirsch looked into antidepressant research . He discovered many antidepressants on the market were no more effective than placebos. He was the first of many to look into the questionable efficacy behind antidepressants.

Most of these drugs are classified as serotonin reuptake inhibitors (SSRI's). The belief is that they increase serotonin levels in depressed people to normal levels. Hari found that the idea that serotonin helps people with depression actually has little evidence to support it. This claim was likely just pushed by pharmaceutical companies.

Lesson 2: There are nine common reasons for depression, mostly from hard life situations.

So what is the cause of depression then? Hari's theory is that there are nine causes or disconnections, and most of them have to do with difficult life circumstances. Here they are:

1. Disconnection from meaningful work. Those with the least control and authority in the workplace are the most likely to have depression. We need to feel like what we do has meaning.

2. Disconnect from others. Loneliness and no sense of belonging are big indicators of depression.

3. Disconnect from meaningful values. Our consumer-driven society has left us detached from worthwhile values, which in turn contributes to depression.

4. Childhood trauma. This found the more traumatic a person's childhood is, the more likely they are to have depression and anxiety.

5. Disconnect from status. In areas with larger gaps in wealth, such as the US, there are higher rates in depression.

6. Disconnect from nature. People who live in greener neighborhoods feel less stress and despair than those who don't.

7. Disconnect from a secure and hopeful future. . They had control over their Native Americans on government-controlled reservations had staggeringly high suicide rates. In reservations where they had control of their own laws, elections, police, and schools this was not a problem destiny and were less likely to commit suicide.

8. Genes. We do know that there is a genetic influence in depression, though it only accounts for 37 percent of cases.

9. Changes in the brain. Neuroplasticity is how the brain changes from experience. Because of this, when people spend more time with thoughts of despair rather than joy, it can strengthen the negative feeling areas.

Lesson 3: Social prescriptions are a great way to help people with depression by making them feel valued and connected.

The solution for depression that Hari comes up with is a social prescription. Rather than turning to medication, doctors are starting to realize the value of social prescriptions. They help people reconnect with others around them, have meaningful work, meaningful values, and give a chance for people to overcome trauma from their past.
In effect, social prescriptions reconnect the lost connections.
Hari gives an example of a social prescription given to a nurse who was bullied at work and depressed. The social prescription her doctor gave was to work on a project with a small group of similarly disconnected people. Their task involved turning an abandoned area in London into a garden.

The people united and were able to share past traumas and things they had in common. They could reconnect with nature and identify meaningful work that meant something to the neighborhood. All of this improved her mental health. She was able to stop her medication and started her own gardening center.

Lost Connections Review

While some might see the notion that depression isn't a chemical imbalance pretty radical, Hari makes it very convincing. We know that antidepressants don't work for a lot of people, so looking for other ways to help people with depression is essential. Lost Connections has some great suggestions for how people can reconnect and discover meaning to deal with depression.

Read full summary on Blinkist >>

Learn more about the author >>

Who would I recommend the Lost Connections summary to?

The 20-year-old college student studying psychology, a 46-year-old mother of teenagers who are showing signs of depression and anxiety, and anyone who is struggling with their mental health.

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1-Sentence-Summary: Lost Connections explains why depression affects so many people and that improving our relationships, not taking medication, is the way to beat our mental health problems. Favorite quote from the author: Read in: 4 minutes You don't have to look very far to find someone who suffers from depression.

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Faculty of Education, University of Cambridge, Cambridge, United Kingdom

Social Research Institute, Institute of Education, University College London, London, United Kingdom

The role of digital technology in shaping attention and cognitive development has been at the centre of public discourse for decades. The current review presents findings from three main bodies of literature on the implications of technology use for attention and cognitive control: television, video games, and digital multitasking. The aim is to identify key lessons from prior research that are relevant for the current generation of digital users. In particular, the lack of scientific consensus on whether digital technologies are good or bad for children reflects that effects depend on users' characteristics, the form digital technologies take, the circumstances in which use occurs and the interaction between the three factors. Some features of digital media may be particularly problematic, but only for certain users and only in certain contexts. Similarly, individual differences mediate how, when and why individuals use technology, as well as how much benefit or harm can be derived from its use. The finding emerging from the review on the large degree of heterogeneity in associations is especially relevant due to the rapid development and diffusion of a large number of different digital technologies and contents, and the increasing variety of user experiences. We discuss the importance of leveraging existing knowledge and integrating past research findings into a broader organizing framework in order to guide emerging technology-based research and practice. We end with a discussion of some of the challenges and unaddressed issues in the literature and propose directions for future research.
Socrates: 'O most expert Theuth, one man can give birth to the elements of an art, but only another can judge how they can benefit or harm those who will use them. And now, since you are the father of writing, your affection for it has made you describe its effects as the opposite of what they really are. In fact, it will introduce forgetfulness into the soul of those who learn it: they will not practice using their memory because they will put their trust in writing [...] and they will imagine that they have come to know much while for the most part they will know nothing [...] since they will merely appear to be wise instead of really being so'. (Plato, Phaedrus)
Introduction

In Phaedrus, Socrates warns about how writing might reduce people's capacity to memorize information. Paradoxically, we know how Socrates felt only because one of his students, Plato, did not feel the same. As the brief passage indicates, the merits and pitfalls of new innovations have been debated at least ever since the invention of writing ( Puchner, 2017).

The current review introduces and summarizes the available evidence from three main bodies of literature on the impact of technology on attention and executive functions, from both a functional and developmental perspective: television, video games, and digital multitasking with the aim of identifying key lessons for the current generation of digital users. We integrate research across developmental and educational psychology, and neuroscience to uncover the diverse theoretical camps, nuances, and contradictions within the existing scientific literature. We use existing research to propose an organizing framework which accounts for the role of content, context, purpose, individual and social factors in shaping observed outcomes in a way that is relevant to present-day digital users. A central theme emerges from the literature: the interaction between technology and human cognition is complex and multidimensional. We end with a discussion of some of the challenges and unaddressed issues in the literature and propose directions for future research to improve how technology-cognition interactions are studied, interpreted, and translated from research to practice.

The Importance of the Early Years

During the first years of life and up until early adulthood, the brain undergoes a period of significant plasticity, creating billions of new connections that are essential for the development of hearing, language, and executive skills ( DiPietro, 2000; Fuhrmann et al., 2015). The childhood and the teenage years are therefore characterized as periods of important functional and structural reorganization, during which there is a high level of susceptibility of the brain to external stimuli.

The importance of the early years for cognitive development has led to concerns both in academic research as well as the popular media about the extent to which the use of different technologies during childhood and adolescence may have a lasting impact on brain development, as well as social, emotional, and cognitive functioning ( Greenfield, 2003, 2015; Carr, 2011; Turkle, 2011; Alter, 2017; Orben and Przybylski, 2019). As more children access digital technologies sooner ( Chaudron et al., 2018; Hooft Graafland, 2018), engage in a greater variety of activities using such technologies and in different contexts ( Ofcom, 2020) the perceived importance of understanding the effects of technology use grows and guidelines designed to reduce harm and promote benefits proliferate ( Straker et al., 2018).

A Brief Overview of Attention and Cognitive Control

Attention

Cognitive Control

Cognitive control, otherwise known as executive functions (EF) or executive control, is broadly defined as the cognitive processes that underlie motivation and goal-directed behaviors. EF are generally defined by three broad categories: inhibition (impulse and inhibitory control of automatic responses, self-regulation, and delay of gratification); shifting (task switching, mental-set shifting, and cognitive flexibility); and updating (working memory operations) ( Dreher and Berman, 2002; Aron, 2008). Cognitive control is closely related to individuals' voluntary and sustained-attention. It determines which information in the immediate environment will be attended and processed ( Koechlin and Summerfield, 2007).

Technology and Cognitive Outcomes: Exploring the Literature

Television and video games have historically been at the centre of public discourse and research on the effects of digital technology on developmental and cognitive outcomes. In today's society, however, the growing use of 'connected devices' has led to a more generalized worry about the effects of screen-based devices on children ( Bell et al., 2015).

This recent shift to a broader focus on 'screen time' in the research literature can be partially explained by the inability to differentiate between different forms of digital content ( Orben and Przybylski, 2019). Connected and portable devices support an increasingly wide range of activities and contents. Mobile phones, for example, can be used to browse the internet, watch television, play games, and access social media. Traditional television, on the other hand, is being replaced by platforms like Netflix, Amazon Prime, and YouTube, which can be accessed using any device of choice ( Ofcom, 2020). There is thus an inherent difficulty with isolating specific types of digital content to study despite an increasingly wide variety of digital content accessed by children, whereas grouping everything into broad categories like 'screen time', 'mobile devices', or 'social media' is of little use when attempting to draw precise conclusions about the cognitive implications of modern digital technologies.

The existing literature therefore largely reflects outdated devices and patterns of use, while also failing to take into account the nuances of how users engage with more modern 'connected devices'. This is also reflected in policy guidelines which tend to focus on limiting the quantity of screen exposure, with little reference being made to the quality of engagement with digital content ( American Academy of Pediatrics, 2016; Rütten and Preifer, 2016; Ponti et al., 2017). However, there is still much value to be gained from the existing literature if adequately put in context. In particular, the building blocks that have been identified in past literature can provide useful insight for evaluating how newer and more complex forms of digital media might interact with human cognition.

Furthermore, given the growing variety of digital technologies, it becomes increasingly important to identify whether effects on cognition differ in systematic ways depending on the context in which digital media are used, their content and user characteristics. Doing so requires identifying and testing moderators of underlying relationships between digital technology and cognition. This review examines the existing literature to identify which factors appear to consistently moderate differences in the strength of the association between technology use and cognition. This information can help formulate hypotheses to guide future research and increase the likelihood that such studies will inform evidence-based policy to benefit the current generation of digital users.

Television and video games have been favorite leisure time activities among children worldwide for decades. The current review covers the television and video game literature as these two forms of technology they have been extensively studied in the past and because many of the features characterizing television and video games constitute the building blocks of more modern digital content on the internet and social media. We then review the newer digital multitasking literature, which addresses some of the contextual considerations which are most relevant today: technology is often used in combination with other activities, including work, school, and social interaction. Indeed, there is an additional challenge associated with studying the cognitive implications of modern digital devices in that they can be accessed anywhere and anytime.

Television

As the form of media that has been around longest, television has historically been the focus of much research on the influence of technology on cognition and development. The experience of viewing television has remained fairly constant throughout the years, although different, more modern, forms of digital media afford users greater opportunity to control what, when and how they view video content. Nonetheless, many of the changes that newer forms of digital media afford could also be achieved in the past by augmenting the limited possibilities for active viewer control through ad-on technologies, such as video recorders, DVD players and antennae. As a result, there is a relatively large literature base exploring television and cognitive outcomes in children, and many of the features that characterize modern-day viewing of video content have already been explored in the television literature. However, the quality of much of the literature is low, offering mainly correlational and cross-sectional evidence with small effect sizes, thus leading to identification problems. Moreover, the existing literature is ripe with inconsistencies and conflicting results, a possible indication of heterogeneous treatment effects: results could differ, for example, depending on the type of television programming considered, population group studied, and cognitive outcomes measured, factors that are not always possible to examine and account for when considering estimated associations.

Attention Engagement During Television Viewing

Television programming is characterized by features such as fast-paced images, highly salient stimuli, and, in many cases, content breaks (e.g., commercials). Some scholars have argued that such features may not be conducive to the development of cognitive and attentional control in children. There remains, however, some disagreement as to the exact mechanisms through which these formal features might interact with cognition in both the short- and long-term.

Anderson et al. (1987) first coined the term attentional inertia to describe the phenomenon that children become progressively less likely to look away from television after they had been watching for some time. Based on their observations, the probability of a child looking away peaks at around 1 second of viewing and then progressively decreases with time, leveling off at the 15-second mark ( Anderson et al., 1987; Burns and Anderson, 1993). Subsequent studies also found that viewers are less likely to react to distractors or changes in content if they had been watching television for at least 15 seconds ( Anderson and Lorch, 1983; Anderson et al., 1987; Richards and Turner, 2001). These findings led scholars to theorize that viewers initially attend programming based on whether the content is comprehensible, however, after some time, attention becomes generalized to the medium (television screen), rather than the content, so that breaks and changes in content do not necessarily distract away from the screen, and may actually have the opposing effect ( Anderson et al., 1987). This view led scholars to consider that television programming encourages passive viewer engagement, prioritizes bottom-up processing, and therefore does little to train children's sustained attention ( Lillard and Peterson, 2011).

Other studies have shown that content that is difficult to understand or filled with breaks and distractions results in the continuous disruption of sustained attention ( Lorch and Castle, 1997; Pempek et al., 2010; Richards, 2010). This has led some scholars to argue that certain features of programming, like shorter scene lengths, and content cuts, may overstimulate developing brains and can be especially detrimental to the development of cognitive control in children ( Wright and Huston, 1983; Valkenburg and Vroone, 2004; Goodrich et al., 2009). Indeed, several cross-sectional studies found that preschool viewing of quality programming without commercials was positively associated with measures of attention and executive control, whereas viewing similar content with commercials correlated with poor performance ( Hudon et al., 2013; Nathanson et al., 2014). These findings suggest that the presence of commercial breaks require children to constantly disengage and re-engage their attention to the screen, promoting a reactive style of attention and making it particularly difficult for young viewers to link concepts together and extract meaning from programming ( Valkenburg and Vroone, 2004). This is especially problematic given that modern web-based video content is often free of charge when advertisements are introduced, requiring user subscriptions to avoid commercial content ( Radesky et al., 2020), which in the long term could lead to increased socio-economic (SES) disparities in attention as a result.

Television Viewing During Infancy and Later Attention Difficulties

However, while these studies appear to suggest that early television viewing may increase the risk of developing attention difficulties, the weight of the evidence does not conclusively support a clear association between television viewing and adverse cognitive outcomes. Indeed, several studies have failed to replicate the association between television viewing in moderate amounts and the development of later attention difficulties. For example, subsequent reanalysis of the National Longitudinal Youth Survey dataset using a non-linear model found that the risk of developing attention difficulties was significant only for 10% of children who watched over 7 h of daily television ( Foster and Watkins, 2010), indicating that television exposure during infancy may be detrimental to attention only at very high levels of viewing.

In support of this interpretation, Obel et al. (2004) used a similar design with a Danish sample, found no significant association between early childhood television exposure and the development of attention difficulties later on. The authors attributed these conflicting results to the fact that Danish children watch less television on average than their American counterparts (only 6% of Danish children watched over 2 h of daily television at 3 years, compared to 50% in the American sample). Therefore, it is likely that Danish children, on average, do not surpass the critical daily viewing threshold where the association between television viewing and attention may become significant ( Obel et al., 2004).

The What, When, and How: The Importance of Television Quality

Many studies suggest that the type of programming may be more important than the total viewing time and that any association between television and cognition is dependent on both the content and context of viewing (for review see: Zimmerman and Christakis, 2007; Kostyrka-Allchorne et al., 2017). For example, Zimmerman and Christakis (2007) reported that viewing entertainment television before age 3 was associated with adverse attention outcomes later on. However, the same study found that viewing educational programming was not associated with any adverse cognitive outcomes. Indeed, childhood viewing of educational television may be beneficial to the development of executive functions, basic academic skills, and social behavior in children over two ( Wright et al., 2001; Zill, 2001; Fisch et al., 2005; Schmidt and Anderson, 2009; Anderson and Subrahmanyam, 2017; Kostyrka-Allchorne et al., 2017).

What qualifies as 'high-quality' or 'educational' content, however, has been another topic of contention among researchers. Some studies have linked educational cartoons like Blues Clues and Dora the Explorer to positive learning outcomes and executive function in children ( Linebarger and Walker, 2005; Barr et al., 2010; Fisch, 2014). Others, however, find that exposure to any type of content that provides non normative stimulation, characterized by rapid pace and atypical sequencing, can have negative consequences for the development of attention and cognitive control, even if the storyline itself is educational ( Goodrich et al., 2009; Christakis et al., 2012; Nathanson et al., 2014). Moreover, recent research by Kostyrka-Allchorne et al. (2019) suggests that the degree of realism of video content may affect young children's executive function to a greater degree than the pace of programming, and that attention is sensitive to the interactive effects between realism and pace. The authors suggest that the degree of realism of television programming may provide a buffer against the negative effects of rapid pace.

The Who, Where, and Why: Individual Characteristics, Social, and Family Factors

Television Summary

Taken together, the existing evidence exploring the cognitive implications of childhood television viewing remains inconclusive. Certain features of television programming, like fast-pace and non-normative stimulation, may be harmful to very young children by taxing cognitive resources and encouraging bottom-up processing ( Valkenburg and Vroone, 2004; Goodrich et al., 2009; Lillard and Peterson, 2011). However, strong evidence supporting any long-term association between television viewing in moderate amounts and cognitive development is currently lacking. Moreover, the literature suggests that the quality of content and social context of viewing are important moderators of the association between television and cognition in children. As children develop the ability to comprehend, and therefore, learn from television content ( Anderson and Hanson, 2010), the long-term cognitive implications may differ depending on whether the alternative uses of children's time would be devoted to more enriching activities, such as learning or high-quality interaction with parents ( Linebarger et al., 2014). Educational television programming may, therefore, be particularly beneficial for improving long-term academic outcomes for children from non-native speaking households and lower socio-economic backgrounds.

Video Games

Video games are electronic games that require behavioral interaction with a user interface in order to generate audio-visual feedback on a display device. Games are broadly classified based on the system they are played on: arcade games, consoles, handheld devices, computers, and more recently, mobile phone devices. They also encompass various genres based on game-play type and purpose: action, shooter, adventure, role-playing, simulation, strategy, puzzles, cards, racing, and educational ( Adams, 2014). Contrary to viewing video content, which affords users only limited possibilities for active engagement, video games are interactive activities that encourage players' cognitive and motor engagement with simulated worlds ( Shaffer et al., 2005).

In contrast to television studies, however, video game research conducted on younger children is only beginning to emerge. Most of the existing literature thus tends to focus on adult or adolescent populations. This is in part a reflection of the fact that, in the past, playing videogames required physically entering arcades, and in part of the fact that young children are unable to properly engage with complex video games (e.g., action video games) that are often the focus of academic research.

Attention and the Brain During Video-Game Play: Evidence From Training Studies

The potential use of video games as tools for cognitive enhancement has been a topic of much investigation in the gaming literature. Some scholars suggest that video games provide ideal learning opportunities for children by promoting informal exploratory learning and enhancing problem-solving skills ( Greenfield et al., 1994). Players must continuously integrate a range of sensory inputs, respond (or ignore) perceptually salient stimuli and implement adaptive strategies to meet the ever-changing demands of complex virtual environments ( Bavelier et al., 2012a). Proponents of the Learning to Learn Hypothesis argue that gaming can be used to enhance broad aspects of cognition, and can lead to general improvements in attentional capacity, cognitive control, pattern recognition, problem-solving abilities, and more efficient learning strategies ( Bavelier et al., 2012a; Green and Bavelier, 2012; Prensky, 2012).

Numerous training studies have demonstrated improvements on specific measures of visuospatial cognition after short periods of playing video games, including visuospatial selective attention ( Feng et al., 2007; Spence et al., 2009), visual search ( Green and Bavelier, 2003, 2007; Wu and Spence, 2013), visuospatial working memory ( Thorell et al., 2009), response selection ( Dye et al., 2009a, b; Hutchinson et al., 2016), multiple object tracking ( Oei and Patterson, 2013, 2015), dual-task switching ( Li et al., 2009; Strobach et al., 2012) and spatial reasoning skills ( De Lisi and Wolford, 2002; Sims and Mayer, 2002; Haier et al., 2009; Boot et al., 2011; Uttal et al., 2013). These findings are further supported by evidence that playing action video games, even over a relatively short period of time, can modify the neural responses associated with top-down cognitive control and improve the modulation of visuospatial selective attention ( Bavelier et al., 2012b; Krishnan et al., 2013).

The weight of the evidence from gaming literature, however, suggests that that the degree of cognitive transfer is largely dependent on the content of the game and on the specific cognitive skills that are recruited during game-play ( Green and Bavelier, 2006; Boot et al., 2008; Strobach et al., 2012; Oei and Patterson, 2014, 2015; for review see: Subrahmanyam and Renukarya, 2015). In other words, it seems unlikely that video-game play can lead to broad improvements in cognitive function on tasks which are markedly different from that in which the original training occurred ( Pillay, 2003; Subrahmanyam and Renukarya, 2015). Neural evidence also suggests that skill transfer is more likely to occur between overlapping brain regions ( Dahlin et al., 2008), supporting that transfer is limited where a game and task do not recruit similar perceptual templates, and that any post-training benefits of gaming are likely task-specific ( Przybylski and Wang, 2016; Azizi et al., 2017; Sala and Gobet, 2018).

Moreover, although cognitive improvements have been reported across numerous video game training studies ( Feng et al., 2007; Dye et al., 2009a; Li et al., 2009; Spence et al., 2009), many other studies either do not support, or directly contradict, the visuospatial and perceptual benefits of gaming ( Boot et al., 2008, 2011; Kennedy et al., 2011). Indeed, the evidence on the skill benefits of gaming topic is inconsistent and is characterized by an overreliance on self-report, small sample sizes, and cross-sectional study design. Additionally, much of the experimental evidence in the domain has been collected using convenience samples of adults, or intervention studies on university students, and therefore suffers from a plethora of methodological shortcomings which limits the generalizability of findings ( Boot et al., 2011; Przybylski and Wang, 2016).

Cognitive Profiles of Video-Gamers

However, not all research supports that playing video games during childhood is detrimental to attention, especially in moderate amounts. One longitudinal study, for example, found that in contrast to early television viewing, playing electronic games at age 5 was not significantly associated with any adverse behavioral or cognitive outcomes at age 7 ( Parkes et al., 2013). Another study of 7 to 11-year-old children found that only children who played over 9 h of video games per week were more at risk of conduct problems and reduced prosocial abilities. Moreover, moderate gaming frequency (1 h per week) was associated with superior visuomotor skills in the same sample ( Pujol et al., 2016).

There is also evidence indicating superior cognitive control among action video-game players as young as 7 years old ( Dye and Bavelier, 2004; Wu and Spence, 2013; Cain et al., 2014). For example, experienced action video-game players seem to be better than non-gamers at ignoring irrelevant distractions ( Green and Bavelier, 2003; West et al., 2008; Dye and Bavelier, 2010; Mishra et al., 2011; Chisholm and Kingstone, 2012, 2015), attending information over long periods of time ( Boot et al., 2008), localizing targets ( Chisholm et al., 2010; Hubert-Wallander et al., 2011; Wu and Spence, 2013), tracking multiple objects simultaneously ( Green and Bavelier, 2006; Bavelier et al., 2010), and switching between tasks ( Strobach et al., 2012; Pohl et al., 2014; Bavelier and Green, 2019). One study by Colzato et al. (2013) found that experienced gamers were faster and more accurate on working memory updating and monitoring (N-back and stop-signal tasks), but showed comparable response inhibition to non-gamers. These results suggest that video games might enhance cognitive control without necessarily affecting impulsivity, which is in direct contrast to the much-cited reports linking video games to attention difficulties and violent tendencies in children ( Barlett et al., 2009; Gentile et al., 2012).

There is also evidence to suggest that playing video games (particularly action video games) can enhance specific cognitive skills in the long-term (for reviews see: Spence and Feng, 2010; Bavelier et al., 2012a; Green et al., 2016). Cross-sectional studies report that frequent gamers, compared to non-gamers, exhibit superior attentional capacity in central and peripheral vision processing ( Green and Bavelier, 2003; Dye and Bavelier, 2004), performance on a variety of visuospatial tasks ( Green and Bavelier, 2006, 2007; Hubert-Wallander et al., 2011; Wu and Spence, 2013; Green et al., 2016). Consistent with behavioral findings, brain imaging studies suggest that experienced gamers exhibit less activation in the visual cortical area for motion processing and in the frontoparietal network during attention-demanding tasks, suggesting better top-down control of visuospatial selective attention ( Bavelier et al., 2012b; Feng and Spence, 2018). Therefore, although mostly based on cross-sectional data, the literature reveals that there may be long-term cognitive benefits to playing certain video games that require a high degree of user engagement, particularly in older age groups.

While boys have historically dominated the gaming sector, the growing popularity of online games among young people has led to a shift in the gender gap: the proportion of girls in the United Kingdom playing video games online has increased from 39% in 2019 to 48% in 2019 ( Ofcom, 2020). Indeed, mobile gaming is currently the fastest growing video game segment, becoming increasingly popular with young people, among whom mobile games are the second most downloaded type of app in 2019 ( Mordor Intelligence, 2020). Despite this growing popularity of video games across different demographics, there still remains much debate regarding whether the reported benefits of game-play are due to pre-existing group differences between gamers and non-gamers, and whether extensive video game practice by non-gamers can lead to cognitive benefits and performance improvements on unrelated tasks.

The Who and Why: Individual Differences and Other Considerations

The perceptual benefits of game-play may also vary as a function of age ( Dye et al., 2009b; Hartanto et al., 2016). This is because different components of attention develop at different rates. Attentional orienting and executive control, for example, are stable by age 7, whereas attentional alerting continues to develop well into adolescence ( Rueda et al., 2005). In support of this, performance enhancements as a result of video-game training seem to decline with age, with adolescents benefiting more than adults, and young children benefiting most ( Lövdén et al., 2010; Hartanto et al., 2016). Similarly, cross-sectional studies have shown that individuals who begin playing video games before the age of 10 perform better on various measures of attention, compared to those who began playing at later ages, a possible indication of critical-age effects ( Dye et al., 2009b; Latham et al., 2013).

The What, When, and How: Video-Gaming Beyond the Lab

Conversely, some scholars argue that frequent gaming may increase dependency on external rewards ( Swing et al., 2010). For example, one study found that frequent teenage gamers showed stronger functional activation in the ventral striatum during loss processing, a region associated with dopaminergic responses to feedback anticipation and reward processing ( Kühn et al., 2011). However, as neuroimaging studies rely on small samples and do not account for prior group differences, the causal direction of the association between gaming and neurocognitive outcomes remains unclear.

As with television, the form and purpose of a game may be an important factor to consider when assessing the cognitive implications of video-gaming. For example, preliminary research suggests that educational games presented through age-appropriate interactive mediums (e.g., a touch screen device) may support literacy and mathematics skill acquisition for young children, particularly for those from underprivileged households ( Neumann and Neumann, 2017; Neumann, 2018). These results suggest that as digital technologies become more sophisticated and allow for more immersive and interactive experiences, the cognitive benefits of gaming may become more pronounced.

Video Games Summary

Taken together, the evidence summarized suggests that gaming may be associated with both positive and negative outcomes which depend on the intensity of gaming, type of game, the outcomes being measured and individual characteristics of players. Action video games, in particular, seem to be associated with benefits in visual and spatial selective attention in older populations, particularly on tasks requiring top-down cognitive control. However, strong evidence supporting broad skill enhancement beyond specifically trained tasks is currently lacking, and only few studies have been conducted on children. Moreover, the literature suggests that individual differences in cognitive function and prior gaming experience may, at least in part, account for the reported differences between gamers and non-gamers, further supporting a bidirectional link between gaming and cognition ( Powers et al., 2013). In other words, individuals may be more drawn to video games (and other digital content) that suit their own abilities. Due to differences in cognitive plasticity across different stages in development, the age of onset at which individuals first begin playing video games is also an important factor to consider: the longer the lifelong gaming practice, the greater the cognitive implications ( Hartanto et al., 2016). Finally, while there are preliminary studies supporting the motivational benefits of interactive technologies, there is a paucity of research on whether the purpose of a game (e.g., academic), context (e.g., school) and family factors (e.g., SES) may moderate long-term cognitive outcomes of video-game play.

Media Multitasking

In contrast to traditional digital technologies like television and video-game consoles not connected to the internet, which allowed users to perform only one or a limited set of activities, newer digital devices can be accessed anytime, anywhere, and while performing multiple concurrent tasks. In other words, the line between being 'online' or 'offline' is becoming increasingly blurred. Moreover, the same device can be used to play video games; search for information; talk with friends; upload pictures on social media and watch videos. These trends highlight the growing difficulty with isolating when, how, and why the current generation is using their digital devices. The media multitasking literature accounts for some of these contextual considerations which are most relevant to the current generation of digital users by emphasizing that using technology while performing other tasks, or engaging in different activities with the same medium can moderate the cognitive outcomes associated with its use.

Mechanisms of Multitasking

Cognitive Profiles of Heavy Media Multitaskers

In recent years, there has been mounting research interest in determining whether digital multitasking is associated with deficits or benefits to various aspects of cognitive control and information processing ( Lui and Wong, 2012; Alzahabi and Becker, 2013; Minear et al., 2013; Ralph et al., 2015; Cain et al., 2016; Uncapher et al., 2016). It has been proposed that multitasking disrupts sustained attention, thereby impeding self-regulatory abilities, motivation, memory and learning ( Lee et al., 2012; Wei et al., 2012; Wood et al., 2012; Rosen et al., 2013; Stothart et al., 2015; Grieco-Calub et al., 2017; May and Elder, 2018).

While these results suggest that frequent media multitasking may negatively interact with top-down cognitive control, taken together, the subsequent literature only partially supports this claim. In a recent replication study, Wiradhany and Nieuwenstein (2017) failed to reproduce the findings by Ophir et al. (2009) which linked chronic media multitasking to cognitive deficits. Several other cross-sectional studies found that heavy media multitasking was not related to behavioral measures of cognitive control ( Baumgartner et al., 2014; Cardoso-Leite et al., 2015). Moreover, some studies suggest that there may even be cognitive benefits to frequent media multitasking ( Lui and Wong, 2012; Alzahabi and Becker, 2013; Yap and Lim, 2013).

Overall, the evidence suggests that while individuals who multitask heavily with technology tend to self-report more attention difficulties, distractibility, and impulsivity ( Levine et al., 2007; Bowman et al., 2010; Junco and Cotten, 2012), these subjective assessments do not necessarily align with objective performance-based measures ( Junco, 2012; Levine et al., 2013; Baumgartner et al., 2014). For example, higher levels of multitasking seem to be related to self-assessed everyday attention lapses, but unrelated to performance-based measures in the domains of sustained-attention, working memory, interference management, task-goal management, and inhibitory control (for reviews see: Van Der Schuur et al., 2015; Uncapher et al., 2017; Wiradhany and Nieuwenstein, 2017).

The reason for this inconsistency might be that performance-based and self-report assessments measure different aspects of cognition (for a discussion see: Toplak et al., 2013). Moreover, these results suggest that heavy media multitaskers are not necessarily less able to control and sustain their attention, but rather, that heavy multitaskers may choose to engage differently with their environment ( Ralph et al., 2015). This may reflect individual differences in thresholds for motivation and engagement, rather than attention per se. Indeed, high levels of media multitasking has also been linked to greater impulsivity ( Sanbonmatsu et al., 2013), greater delay discounting ( Wilmer and Chein, 2016), and a preference for speed at the expense of accuracy on cognitive assessments ( Minear et al., 2013).

Media Multitasking and Learning

It should also be noted that the majority of studies investigating the effects of multitasking on academic performance have been conducted using cross-sectional designs, with small convenience samples of limited populations and rely considerably on self-report. The wide variability in measurement and task design (e.g., type of multitasking activity and context) may account for some of the conflicting findings within the literature. Moreover, course grades are often used as proxies to infer the effects of media multitasking on attention or cognitive control, but such studies generally do not measure these constructs directly. It, therefore, remains difficult to interpret the mechanisms through which the observed effects may be occurring in the short-term, and what specific cognitive functions may be implicated in the long term.

The Who: Individual Differences in Multitasking Outcomes

There is some evidence that individual differences in cognitive capacity and neural profiles ( Lehle and Hübner, 2009; Miller et al., 2009; Reissland and Manzey, 2016; van der Schuur et al., 2020), and functional maturity ( Cepeda et al., 2001; Maquestiaux et al., 2004) may moderate the relationship between of multitasking and cognition. For example, age-related improvements in task-switching ability ( Reimers and Maylor, 2005) indicate that young children may suffer from more information loss and executive control deficits while engaging in more than one task simultaneously. To date, however, the study of individual differences such as age, gender, socioeconomic background and dispositional moderators in the area of digital multitasking has largely been ignored.

It should also be noted that many of the findings on the detrimental effects of multitasking are achieved in controlled experimental settings and focus on very narrow measures of cognitive performance ( May and Elder, 2018). From this perspective, the long-term implications and higher-order benefits derived from multitasking with digital technology may be quite different from the immediate effects reported in short-term studies. Similarly, individual differences in thresholds for motivation and engagement, or preference for highly stimulating environments may account for some of the observed variance in multitasking outcomes ( Ralph et al., 2015).

The What, When, and How: The Importance of Multitasking Quality and Context

While few studies have directly assessed the facilitating role of media multitasking, one meta-analysis found that user control, task relevance and contiguity (i.e., the physical distance between tasks) moderated the effects of multitasking on cognitive performance ( Jeong and Hwang, 2016). When user control is high, individuals are more easily able to adjust the task-switching speed and pace of content to decrease their cognitive load. Additionally, the cognitive load of multitasking is lesser when two tasks are related and physically near, particularly for visual tasks (i.e., which are displayed on a single medium). Therefore, drawing conclusions about the effects of digital multitasking as a whole may be over-simplistic. Outcomes likely differ based on the degree of cognitive and motor resources required for each individual task (i.e., active vs passive engagement); how closely they relate to one another (conceptually and physically); and how easily they are combined.

Digital Multitasking Summary

Taken together, the weight of the evidence does not conclusively demonstrate that digital multitasking impairs attention and cognitive control in a global or persistent manner. Heavy media multitasking seems to be negatively related to subjective measures of attention in everyday life, but unrelated to objective measures of sustained-attention and cognitive control ( Van Der Schuur et al., 2015; Uncapher et al., 2017). These results may reflect individual differences in motivation and engagement, rather than attention per se ( Baumgartner et al., 2014), suggesting a potential bidirectional link between multitasking frequency and cognition. However, there remains a paucity of longitudinal research to establish causality. Multitasking with digital devices while learning has also been shown to impede comprehension, recall, and academic performance ( Van Der Schuur et al., 2015). However, this may be due to the reduction of time dedicated to academic activities ( Fox et al., 2009), rather than the disruption of sustained attention. Moreover, there is some indication that individual differences in neurocognitive profile ( Miller et al., 2009), disposition ( Ralph et al., 2015), and age ( Reimers and Maylor, 2005) may moderate the relationship between task-switching and cognition. However, the study of individual differences has largely been ignored in the digital multitasking literature. Finally, there is growing evidence that some tasks are more easily combined than others, thereby facilitating greater information processing ( Wang et al., 2015). Future research should focus on examining contextual moderators to discern when and how digital multitasking may be beneficial.

Discussion

Timing and Age Considerations

The literature suggests that both the frequency and cumulative time spent engaging with digital media may matter. Overall, there is little support for a negative long-term association between digital technology use in childhood in moderate amounts and long-term cognitive deficits ( Foster and Watkins, 2010; Pujol et al., 2016). However, the evidence also indicates that the greater the cumulative time spent engaging with digital media (i.e., age of initial exposure), the greater the cognitive implications, both good and bad ( Hartanto et al., 2016). For example, cross-sectional studies suggest that individuals who begin playing video games at earlier ages perform better on various measures of attention, compared to those who began playing at later ages ( Dye et al., 2009b; Latham et al., 2013). As such, the common operationalisation of technology use based on the frequency of weekly screen-time ( Bavelier et al., 2012b), without accounting for lifelong cumulative exposure and age of initial exposure, may not adequately capture these crucial timing considerations ( Hartanto et al., 2016).

The fact that portable devices allow individuals to engage with digital applications anytime anywhere increases the frequency of use and overall amounts of time spent using digital technologies, leading to an increase in the number of children engaging in excessive use from younger ages ( Siibak and Nevski, 2019; Ofcom, 2020). New portable devices support applications that limit the amount of time individuals engage with them, that can be set up either by children themselves or by their parents and carers. Installing such applications or implementing other strategies aimed at moderating access to digital media can help mitigate excessive digital media use during development.

The literature also indicates that there are critical age effects in the way children engage with digital technologies. This is because different components of cognition develop at different rates and are more or less plastic across different stages of development ( Rueda et al., 2005). For example, certain features of television programming, like fast-pace and non-normative stimulation, may overtax infants' cognitive resources and encourage bottom-up processing in the short-term ( Valkenburg and Vroone, 2004; Goodrich et al., 2009; Lillard and Peterson, 2011). However, these same features may not be problematic for older children, and can even be beneficial to training specific aspects of cognition if presented through interactive mediums, like video games ( Pempek et al., 2010; Strobach et al., 2012). Similarly, age-related improvements in cognitive control ( Reimers and Maylor, 2005) indicate that young children may suffer from more information loss and executive control deficits while engaging in more than one task simultaneously. This is supported by evidence that even exposure to background television can disrupt sustained-play and reduce the quality and quantity of parent-child interactions, which is critical for language acquisition and the development of cognitive and social skills ( Schmidt et al., 2008; Christakis et al., 2009; Barr et al., 2010; Pempek et al., 2014). Therefore, while the literature does not conclusively demonstrate that childhood exposure to technology impacts attention and cognitive control, there is some indication that exposure may not be beneficial for infants whose cognitive faculties may not be sufficiently developed to properly engage with digital media.

Mirroring increases in the amount of time children spend accessing digital media, in recent years there has been an increase in the number of children who access digital technologies at a very early age and who do so for extended amounts of time ( Ofcom, 2020). Efforts should be made to ensure that very young children are not exposed to digital media or spend only limited periods of time engaging in digital applications, rather than preventing all children, including older children from engaging with such media.

The Degree of User Engagement and User Control

The degree of user engagement during digital technology use is also an important factor to consider in moderating cognitive outcomes. We define active user engagement as the ability to exert top-down voluntary attentional (and motor) control over digital media, rather than passive (bottom-up) information processing. For example, although mostly based on cross-sectional data, the literature suggests that there may be certain cognitive training benefits to playing video games that are goal-oriented and highly interactive, particularly in older age groups whose cognitive and motor faculties are sufficiently developed to actively engage with such games ( Subrahmanyam and Renukarya, 2015). Therefore, the degree of interactive engagement during digital media use may moderate long-term cognitive outcomes, such as skill acquisition. However, as young children are unable to properly engage with complex digital media (e.g., action video games) which are often the focus of academic research, most existing studies so far have focused on adolescents and adults.

The Alternative Use of Time

The literature suggests that the long-term implications of digital technology use depend on the type of activities it displaces. This is relevant for understanding why results across the existing literature can be highly heterogeneous. For example, the fact that media multitasking seems to be unrelated to objective measures of cognitive control ( Van Der Schuur et al., 2015) suggests that related performance deficits may be due to the fact that media multitasking displaces the amount of time dedicated to secondary tasks (e.g., learning) ( Fox et al., 2009). In other words, media multitasking may decrease the degree of efficiency required for a task, while not necessarily affecting cognitive faculties directly. This suggests that the amount of time displaced from secondary tasks is a more robust indicator of the media multitasking effects than objective measures of cognition.

Parenting style and family environment also seem to moderate the relationship between digital technology and cognitive outcomes by determining the value of alternative uses of children's time and the type of content being accessed. For example, as children develop the ability to comprehend, and therefore, learn from television content ( Anderson and Hanson, 2010), the long-term implications of educational programming differ depending on whether the alternative uses of children's time would be devoted to more enriching activities, such as learning or high-quality interaction with parents ( Linebarger et al., 2014). Educational technologies, such as game-based learning may, therefore, be particularly beneficial for children from underprivileged households and can help bridge early academic gaps between different socio-economic backgrounds.

Parents, carers, and education professionals should consider working with children to ensure that their digital media use does not displace activities that are associated with their immediate but also long-term health, well-being and cognitive control. Having dedicated time for high-quality parent-child interactions, for engaging in physical exercise and home study can ensure that digital media use does not displace but, rather, complements other enriching ways in which children spend their free time.

Research Gaps and Future Directions

Although the current review has identified several key findings regarding the cognitive implications of digital technology use among youth, there remain important research gaps. To further advance the field, we propose four directions for future research: examining causality; establishing a theoretical foundation; identifying individual and contextual differences; and improving methods and measurement.

Examining Causality

Establishing a Theoretical Foundation

The review of the existing literature reveals a field of enquiry that lacks a comprehensive theoretical framework that could account for a rapidly evolving technological and social landscape and how this interacts with biological and neurological processes involved in cognitive development. Because of this, the possible cognitive mechanisms underlying the relationship between digital technology use and cognition remain unclear. Without a mechanistic account it remains difficult to say whether multitasking with digital devices is markedly different from multitasking with non-digital tasks, or whether viewing video content through portable media significantly differs from viewing the same content through television sets when considering the effects such viewing has on attention and cognitive control. Therefore, future research should focus on identifying the exact mechanisms through which digital technologies may be interacting with cognition across development.

A clear theoretical foundation would also allow the field to advance by merging the current fragmented literature and lessen researchers' need to re-evaluate mode-of-delivery effects every time a new digital technology becomes available. Such a framework should focus on incorporating how factors like formal features, content, context, individual and social factors moderate how much benefit or harm can be derived from using digital technology. This would allow emerging technologies to be evaluated against an existing evidence base, rather than disregarding past research altogether and attempting to answer the same basic questions that have already been answered in the past ( Orben, 2020). It would also allow the field to move past the prevailing causational viewpoint, which assumes that all individuals are equally affected by the new technology ( Grimes et al., 2008).

Identifying Individual and Contextual Differences

Improving Methods and Measurement

Although concerns regarding screen-based media primarily focus on children, few experimental studies have actually been conducted on children. Moreover, the literature is characterized by small convenience samples, small effect sizes, and questionable tools for measuring digital technology use patterns. In the short term, the field would be aided by more high-powered experimental research, with larger samples of diverse populations and more robust statistical methodology which takes into account individual factors, social demographics, and technology use histories. Moreover, when possible, studies should aim to include multiple measures of the same cognitive process and emphasize which precise outcome variables are being assessed (i.e., which subdomains of cognition), why they have been chosen, and how they are measured.

Author Contributions

MV conceived the study, reviewed the literature, and drafted the manuscript. FB conceived the study and drafted the manuscript. Both authors contributed to the article and approved the submitted version.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

References

Kirschner, P. A., and Karpinski, A. C. (2010). Facebook ® and academic performance. Comp. Hum. Behav. 26, 1237-1245. doi: 10.1016/j.chb.2010.03.024

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A Review of Evidence on the Role of Digital Technology in Shaping Attention and Cognitive Control in Children

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The role of digital technology in shaping attention and cognitive development has been at the centre of public discourse for decades. The current review presents findings from three main bodies of literature on the implications of technology use for attention and cognitive control: television, video games, and digital multitasking.

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Introduction

There is robust evidence that humor has positive effects in various life contexts, such as improving private life (e.g., romantic relationships; Hall, 2017), working life (e.g., job satisfaction, motivation; Mesmer-Magnus et al., 2012), or education (e.g., student learning; Savage et al., 2017). Moreover, studies have shown that self-directed activities targeting humor (e.g., McGhee, 2010; Wellenzohn et al., 2016) increase happiness and resilience and, in positive psychology, humor is even considered as a morally positively valued trait (i.e., a character strength; Müller & Ruch, 2011; Peterson & Seligman, 2004). While humor research is an ever growing field that generates more and more interest, some areas are understudied. For example, there is only limited knowledge on the impact of humor in specific occupations. We aim at narrowing this gap in the literature by studying a particular group of healthcare professionals (HCPs): Medical Assistants (MAs) in Germany. Thus far, research suggested that HCPs may benefit from using humor by better coping with problematic situations and to foster positive social relationships (Dean & Major, 2008; McCreaddie & Wiggins, 2008; Wanzer et al., 2005). However, it has mainly focused on nurses and physicians, while paying little attention to other HCPs, such as physiotherapists (Thomson, 2010) or dentists (Nevo & Shapira, 1989). In this initial study we aim at learning more about how MAs use humor in their everyday work life and whether they see any benefits from using it.

In Germany, becoming a certified MA requires passing a three-year vocational education and training (VET); this means that MA apprentices learn through both, in-company training and a vocational school. Having passed VET successfully results in a recognized vocational qualification that qualifies for the work as an MA (Bundesinstitut für Berufsbildung, 2009). MAs work primarily in doctors' practices or in hospitals, supporting physicians in their everyday work by performing clinical (e.g., drawing blood) and administrative tasks (e.g., appointment scheduling). MAs are the first contact person for patients in need of help; this makes them the "glue" for the healthcare system in several countries (Taché & Hill-Sakurai, 2010; Chapman et al., 2015; Erstling et al., 2019). In Germany, given that the COVID-19 pandemic strongly increased the number of worried patients turning to their primary care physician, MAs have become even more vital (Schnitzler et al., 2021). With MAs having such a core role in the healthcare system, the absence of research on the use of humor in their work is surprising. Using a qualitative approach, this study extends the literature on the usage and perceived functions (i.e., implicit beliefs about functions) of humor in HCPs by investigating its potential, the conditions for a successful use of humor as well as the role of humor styles.1

State of Research on Humor in Healthcare and Purpose of the Current Study

MAs' Need for Resources and the Potential of Humor for HCPs

As previously discussed, MAs play a crucial role in the healthcare system in several countries (Chapman et al., 2015; Erstling et al., 2019; Schnitzler et al., 2021). Therefore, keeping MAs' well-being and work performance high-to help them avoid mental illnesses or quitting (e.g., due to burn-out or poor work relationships)-is essential (Dreher et al., 2021; Vu-Eickmann et al., 2018).

The Job Demands-Resources (JDR) model posits that achieving this goal calls for job demands to be low and job resources to be high (Demerouti & Bakker, 2011). However, recent studies indicate that, for German MAs, job demands are very high; especially, the workload (e.g., time pressure, too many patients) and job control is typically low (e.g., due to interruptions and multitasking; Viehmann et al., 2017; Vu-Eickmann et al., 2018; Zaroti, 2015). Moreover, Dreher et al. ( 2021) surveyed more than 2,000 German MAs and show that COVID-19 led to the addition of newer demands (e.g., high risk of infection, uncertainty about the temporal scope of the crisis). Although Vu-Eickmann et al. ( 2018) found that MAs report having some resources (e.g., diversity of activities, patient interaction), they stress the importance of exploring and promoting more resources (Chapman et al., 2015; Dreher et al., 2021; Vu-Eickmann & Loerbroks, 2017). Furthermore, as the few studies on German MA apprentices indicate high job demands and high turnover for MA apprentices-who are in vocational education and training (i.e., VET) - exploring potential resources not only for experienced MAs but also for MA apprentices is critical (Schnitzler et al., 2021; Wiethölter, 2012).

One potential resource could be humor. Summarizing the literature on humor in healthcare there may be three ways humor can function as a resource in HCP work. First, humor serves as a tool for coping with stress, negative emotions and problems at work (e.g., death, illness, problematic patients), thereby also potentially improving the HCPs' mental health (Linge-Dahl et al., 2018; McCreaddie & Wiggins, 2008; Wanzer et al., 2005). Second, humor is a tool for building and maintaining trustful and coequal relationships either with patients or within a working team, thereby increasing patient cooperation and positive teamwork (Dean & Major, 2008; Linge-Dahl et al., 2018; Proyer & Rodden, 2020). Third, humor serves as an educational tool improving, for example students' attention, critical thinking, and emotional intelligence (Baid & Lambert, 2010; Bennett, 2003; Chabeli, 2008). However, as everyday working requirements of HCPs differ, the perceived functions of humor differ, too. Regarding interactions with patients for example, physicians use humor to reduce hierarchies and for counseling (Berger et al., 2004; Zayts & Schnurr, 2011) while nurses use humor to help patients cope (e.g., with illness and pain) or to comfort them (Dean & Gregory, 2005; Ji-Min & Hyunjoo, 2015). Moreover, most of the literature on humor functions in healthcare focuses on hospital and palliative care settings, lacking studies in primary care and practice settings (e.g., MAs' context).

Thus, given that both MAs and MA apprentices have a high need for resources, and given that humor serves as a broad resource for other HCPs, researchers need to investigate functions of humor for MAs and their education. Research findings on humor as a resource for other HCPs likely serve as a starting point. But with humor being context specific and with working and educational contexts of HCPs differing, findings for nurses and physicians are not necessarily applicable to other HCPs in general and to MAs in particular (McCreaddie & Wiggins, 2008).

Conditions of Successful Humor and the Role of Humor Styles in the HCP-Context

As humor might also have negative outcomes (e.g., feeling laughed at and therefore humiliated or excluded), it is crucial to investigate not only functions of humor but also conditions under which humor can be valuable for healthcare (Grainger, 2004; Platt et al., 2016; Schweikart, 2020). By summarizing the literature on humor in healthcare, we identify three main conditions that facilitate a successful use of humor (i.e., eliciting only positive reactions in everyone present as well as reaching the goal of the humor). First, there must be a positive social basis between the interlocutors (e.g., trustful relationship and a safe environment; Almeida & Nunes, 2020; Dean & Gregory, 2005; Siegel, 2005). Second, strong negative emotions must not be involved (e.g., highly anxious and stressed-out patients or recent loss; Bennett, 2003; Jones & Tanay, 2016; Pinna et al., 2018). Third, HCPs must possess social sensitivity to assess if humor is appropriate (e.g., empathy, identifying emotions; Dean & Major, 2008; Ji-Min & Hyunjoo, 2015; Olsson et al., 2001). However, most studies dealing with conditions under which humor can be valuable in healthcare either are non-empirical or mention but do not focus on these conditions. Moreover, these studies do not consider the role of different humor styles (e.g., benevolent humor vs. sarcasm/cynicism) that might require different conditions to be successful.

Yet, distinguishing between different humor styles - primarily between light (e.g., benevolent humor and fun) and dark styles (e.g., sarcasm and cynicism) is essential. Meta-analyses show that light styles correlate positively with mental health (e.g., optimism, well-being), whereas dark styles mostly correlate negatively (Jiang et al., 2020; Schneider et al., 2018). Also, they might contain exceptions to the rule: For example, some probably must not be based on a positive social interaction between the interlocutors (e.g., sarcasm). In healthcare, the appropriateness of HCPs' use of dark humor, in particular, has long been an ambivalent topic as it helps HCPs to cope (e.g., with problematic patients) and foster team bonds and identification, but on the long term might dehumanize healthcare and demoralize HCPs (e.g., by creating prejudices and barriers; Aultman, 2009; Berk, 2009; Wear et al., 2009). Thus, some authors conclude that dark humor is "functional shorthand" (Piemonte, 2015, p. 384) but overall maladaptive.

Further, studies also show that the appropriateness of the usage of dark humor depends on how dark humor is defined. For example, whereas sarcasm and cynicism aim at humiliating people, gallows humor aims at humiliating tragic events and their symptoms (e.g., death, pain), making gallows humor an accepted coping resource (Aultman & Meyers, 2020; Watson, 2011). Further, a recent study with 104 nurses shows that aggressive humor (i.e., humor at others' expense) correlates negatively to mental health, whereas self-deprecating humor (i.e., humor at one's own expense) correlates positively (Navarro-Carrillo et al., 2020). Therefore, researchers who explore humor styles in healthcare need to define dark humor carefully and distinguish between specific dark styles. However, literature on humor styles in healthcare is still scarce, let alone studies that use an established humor style framework that distinguishes between different light and dark styles like the Comic Style Markers (CSM) by Ruch et al. ( 2018). The CSM comprise fun (good-natured jesting), wit (clever and spontaneous word plays), benevolent humor (tolerant, gentle and forgiving view on weaknesses and mistakes), nonsense (going beyond logical boundaries), irony (saying the opposite of what is meant that is only understood by insiders), satire (criticizing inadequacies with the aim to improve them), sarcasm (critical, biting remarks and Schadenfreude) and cynicism (comments that question morality and hypocrisy; CSM definitions by Hofmann et al., 2020).

The Current Study

As the previous sections not only stressed the potential value of humor as a resource for MAs, but also highlighted the relevance of conditions for successful humor as well as the role of humor styles, this study explores MAs' use of humor in everyday work and education with the following three main objectives. By applying a qualitative approach this study investigates (a) the perceived functions of MAs' use of humor as a resource for MAs to master everyday work successfully; (b) the perceived conditions under which humor can be valuable for MAs; and (c) the role of different humor styles described in the CSM model (Ruch et al., 2018).

Method

As to our knowledge, there is no study on the role of humor for MAs' work and education to date, we applied a primarily explorative approach, gathering qualitative interview data close to MAs' everyday use of humor (i.e., real-life examples of humorous situations) thus confirming ecological validity of the construct of humor in the MA-context.

Recruitment and Sample

The study was conducted in Germany with German MAs. We included persons currently working as an MA - full time or at least 75% of a full time equivalent - having at least one year working experience. As investigating the functions of humor in MAs' VET (i.e., Vocational Education and Training) was part of the research aim, we also sought for MA apprentices and favored MAs, who formerly or currently worked with MA apprentices. Recruitment ran from May until September 2020 via several channels (e.g., inquiries in doctors' offices, personal contacts, social media).

We finally interviewed 14 German MAs aged 20-42 working in doctors' single or group offices within teams of two to ten MAs, except for one MA being the only MA in a psychiatric practice and another MA working as head of 40 MAs in an ambulatory healthcare center. Interviewees were all female. However, as women are strongly over-represented in this occupation (Kathmann & Dingeldey, 2013), the findings of this study should be representative for this occupation regarding gender. MAs worked in different medical fields (e.g., general medicine, orthopedics and pediatrics; Online Resource 1). In order to - at least partly - control for possible COVID-19-induced changes of MA-working conditions that could have influenced humor instances we ensured that none of the MAs worked with severe COVID-19 patients. While twelve participants had at least three years MA-job-experience, two participants were still MA apprentices, both in their second year of VET. Further, nine of the experienced MAs currently or at least formerly worked with apprentices. At the beginning of the interview, we made sure that apprentices did the same daily work-related activities as the experienced MAs to ensure comparability across statements on humor.

Data Collection

We conducted an individual interview with each of the recruited 14 MAs (July to October 2020). Due to pandemic-induced restrictions on gatherings, interviews were conducted via telephone. Further, as two MAs had highly restricted time capacity, they provided us their answers to interview questions in written form. All participants were provided with information on data privacy and gave written consent to data gathering and processing. Interviews were conducted in German (selected quotes are translated into English by the author) and took on average 90 min - including warm-up questions (regarding e.g., job-tasks and working climate).

All interviews were half-standardized and followed an interview guideline with the main topic The Role of humor in everyday work and in-company training of MAs. While some questions were standard in every interview (see below), we asked individual questions depending on the process and content of each interview (e.g., follow-up questions if the MA talked very emotionally about a specific humorous situation). Mandatory questions included (translated into English; for the full interview guide see Online Resource 2):

Can you tell me about humorous situations in your everyday work? Give some examples!

Imagine a new MA apprentice is beginning his/her VET in your practice tomorrow - What advice would you give her/him to take along regarding the use of humor?

What role does humor play for your work as an MA?

Conducting the interviews in a half-standardized way allowed (a) comparability between the interviews and at the same time (b) individual requests that motivated MAs to share even more humorous situations. We audiotaped and transcribed the telephone interviews with the help of a research assistant who followed transcription rules (e.g., verbatim transcription and noting if the MA laughed or chuckled during the interview). Moreover, four of the interviewees additionally journaled situations in which humor occurred at work for two weeks. These journal entries served as additional data that we analyzed the same way as the interviews.

Data Analysis

As intentions of the study were both, exploratory (i.e., exploring concrete functions and conditions) and theory-driven (i.e., applying the CSM by Ruch et al., 2018), we used qualitative content analysis with a combination of inductive (i.e., data-driven) and deductive (i.e., theory-driven) coding to analyze the data. In particular, we followed the variable-oriented approach by Schreier ( 2012) that enables analyses of frequencies and overlaps of codes allowing not only to gather (a) qualitative insights into functions and conditions of MAs' use of humor, but also (b) evidence on their respective relevance as well as on the relation between functions of humor and humor styles. For the analysis, we used the software MAXQDA (Kuckartz & Rädiker, 2019).

The process of data analysis had six steps. Firstly, we read all interviews to get an overall impression on the role of humor in MAs' everyday work. Secondly, we deductively created the two separate main codes Functions of humor and Conditions of successful humor and inductively created a subcode every time we found a new distinct humor function/condition in the data. The functions/conditions either were named by the MA (e.g., MA states "humor reduces anxiety", MA#5) or emerged indirectly (e.g., MA talks about using humor in front of a patient whose anxiety thus decreased; or MA spontaneously uses humor in the interview to cope with aspects of her work). When suitable, we subsumed emerging functions/conditions under already existing codes to attain similar abstraction levels. Further, an other/unclear code was created to prevent forcing a coding decision in the following steps. Moreover, we analyzed both shared humor (i.e., humorous remarks in a conversation) as well as imagined humor (i.e., humor that only occurred in the MA's head). The process of creating codes resulted in two coding systems (i.e., Functions/Table 1 and Conditions/Table 2). Thirdly, we conducted two coding trials with psychology students to validate the coding systems. Both systems - including a revision of Functions taking into account the disagreements of the first rating - yielded high inter-rater-reliabilities (IRR; Functions: Fleiss' Kappa = 0.77, z = 35.57, p < 0.001; Conditions: Fleiss' Kappa = 0.88, z = 18.13, p < 0.001; 4 raters; Landis & Koch, 1977; Sim & Wright, 2005). Fourthly, we coded the data using the two final coding systems. Every segment containing a humor function/condition was dedicated to only one subcode of the respective system.

Table 1 Perceived functions of MAs' use of humor as well as occurrence of humor styles

Table 2 Perceived conditions of MAs' successful use of humor

Fifthly, we deductively created a coding system for humor (comic) styles (i.e., Styles), using the descriptions of the CSM (Ruch et al., 2018) - which are on a relatively low abstraction level and close to everyday behavior - and further analyzed and coded each Function-segment regarding its prevailing comic style. When style was unclear, we coded Unclear. Applying such a validated framework that also contains a quantitative assessment instrument facilitates potential future research aiming at validating qualitative findings on the use of comic styles and their relation to functions of humor in the MA-context, or healthcare in general. In the result tables we will summarize the styles into light (i.e., benevolent humor, fun); dark (i.e., sarcasm, cynicism); and ambivalent MA-specific humor styles (i.e., nonsense, wit, irony, satire); this is based on the factorial structure of the CSM as well as suggestions on HCP-specific applications of the CSM (Hofmann et al., 2020; Proyer & Rodden, 2020; Ruch et al., 2018). Having an ambivalent category in this particular context reflects that these styles can have positive and negative effects and can be used for positive (e.g., coping, strengthening in-group cohesion) and negative (e.g., belittling) purposes in the daily work of MAs. Sixthly, using the Code-Relations-Browser of MAXQDA, we analyzed the frequencies of code overlaps between Functions and Styles to investigate relationships and patterns.

Results

The main coding phase of all 14 interviews resulted in 674 coded segments (427 =  Functions 207 =  Conditions; 40 =  other/unclear). Overall, every interviewee talked about humor as a positive and essential aspect of everyday work (e.g., "Without humor, you couldn't do this job for long", MA#11; "Humor is essential for survival", MA#3) that might increase well-being of patients as well as MAs' work satisfaction, motivation, and performance. Two MAs who stated that humor in their team was rather scarce - and who provided significant less humor examples, respectively - also stated that working climate in their practice is bad. However, depending on the situation and the interlocutor, humor might also have negative consequences and thus requires certain conditions to be successful.

Perceived Functions of MAs' Use of Humor in their Everyday Work and Education

In sum, 15 perceived functions of MAs' use of humor emerged (Table 1). MAs spontaneously differentiated between humor (a) within the MA team (incl. when MA is alone); (b) with patients; and (c) with apprentices (i.e., VET).

Humor in Situations within the Team

Regarding team-situations, seven distinct functions of MAs' use of humor emerged ( N = 236), from which five were coping functions and two were social functions. Regarding coping, MAs used humor to cope either with everyday work in general ( n = 30; e.g., "With humor I can handle and frame this better" - MA#2) or with specific work strains. Mostly, MAs used humor to - without patients' knowing - cope with demands or shortcomings of patients ( n = 61; e.g., calling overly demanding patients "little bloodsuckers" - MA#4; or commenting on wrong assumptions about medical topics with "Lord, send brain from heaven" - MA#11). Further, MAs reported using humor to cope with own or colleagues' shortcomings ( n = 40; e.g., commenting on having forgotten something with "Well, apparently styling my hair was more important" - MA#2) and conflicts ( n = 29; e.g., placing a dancing Santa-Clause figure on the counter to signal truce - MA#7). Finally, MAs used humor to cope with high workload ( n  = 16); for example, by comparing the practice to a "call-center " (MA#12) or by doing fictional yoga poses to relax (MA#10).

Regarding social functions, MAs, on the one hand, used humor to foster team cohesion ( n = 45). By using in-jokes or running jokes (e.g., talking in funny languages) or by pranking a colleague (e.g., hiding a stinky cheese under the counter) they created "a feeling of cohesion" and "mutual memories" (MA#5). On the other hand, MAs stated using humor to reduce hierarchies ( n  = 15) to their supervisors (e.g., physicians). Humor - provided that it is bilateral - brings MAs "on eye level" with their supervisors (MA#5). However, this function emerged relatively rarely in the MAs' narratives, probably because MAs have a rather "professional" (MA#9) relationship with their supervisors.

Humor in Situations with Patients

In situations with patients ( N = 123), MAs' use of humor showed four different functions. First, MAs used humor to help patients cope with illness or medical procedures ( n = 40). MAs commented, for example, on a broken leg (e.g., "Anyway, you still have another one, right?" - MA#14), or an unpleasant mammography screening (e.g., "Imagine that the apparatus (....) just wants to hug you very tight" - MA#9) to soothe patients and to reduce their physical tension, in turn facilitating working with the patient. Second, MAs reported using humor to build a connection to patients ( n  = 35). MAs, for example, commented on patients' (a) characteristics (e.g., comparing a patient's blood sample with the red color of his shirt - MA#2) or (b) mishaps (e.g., commenting a patient offering her credit card rather than her insurance card with "Well, for this one I need the PIN, too!" - MA#13) to approach patients individually, thus keeping humanity in a medical world and increasing patients' compliance.

Third, MAs used humor to keep face in terms of own or work-related shortcomings ( n = 26). MAs commented, for example, own mishaps (e.g., after dropping something "Thank God, it didn't fall upwards - otherwise I would need a ladder" - MA#10) or malfunctioning devices (e.g., "The computer needs some cuddles" - MA#7) to keep face and thus calm the waves, preventing patients from getting disgruntled. Fourth, MAs used humor to educate and convince patients (e.g., starting a specific type of intervention recommended by a medical doctor; n  = 22). MAs humorously clarified wrong assumptions about medical issues (e.g., convincing an old patient to go to the hospital, otherwise his "legs will abandon" him - MA#2) or pointing out patients' misbehavior (e.g., making a male patient aware of standing too close to another male patient by saying "If this is not your husband, please keep some distance" - MA#8).

Humor in Situations with Apprentices (i.e., in VET)

VET-specific situations with apprentices emerged less often than patient- or team-situations ( N  = 68), probably because (a) five interviewees never worked with apprentices and (b) talking about humor in one's own apprenticeship needs retrospection. Still, four functions of MAs' use of humor emerged.

First, MAs used humor to take away apprentices' fears and to encourage them ( n = 19). In particular, MAs used humor to reduce apprentices' fears of making mistakes (e.g., commenting on a too firm bandage with "At least, the bandage would have lasted the whole day" - MA#13) to reduce apprentices' insecurity and to encourage them to keep learning. Still, half of the interviewees stated that during their own apprenticeship the experienced MAs "made fun of the apprentice's mistakes" (MA#3) instead of helping the apprentice to cope. Second, MAs stated using humor to integrate apprentices into the practice team ( n  = 19). MAs for example used little pranks or teasing (e.g., teasing an apprentice for losing his drivers' license - MA#7) or integrate apprentices into team-insiders (e.g., insider of ironically commenting on one's own mistakes - MA#2), to give them a feeling of being an appreciated team member and to establish a trustful relationship to the apprentice.

Third, MAs used humor to educate and convince apprentices ( n = 17). MAs for example used creative humorous terms to help apprentices to memorize medical facts or taboos (e.g., "Don't be a registration shrew" - MA#4) or they humorously comment on apprentices' shortcomings to prevent (further) mistakes (e.g., "If you want to KILL the patient, you may try drawing blood from his wrist" - MA#11). The fourth function Set apprentices an example of using humor ( n  = 13) does not describe humor as a method facilitating VET - as the other three functions - but as training content (e.g., teaching how to use humor to reduce patients' fears or how to tell if humor is appropriate). However, MAs who talked about humor as VET-content emphasized that simply telling the apprentices is not enough and you should rather show them in terms of a role model.

Conditions of MAs' successful Use of Humor

Every interviewee emphasized that a successful use of humor requires specific conditions to prevent negative reactions of interlocutors and to increase the probability of the intended outcome of the humor (e.g., reactions like laughing, smirking, disclosing personal information instead of making a long face and ignoring or criticizing the MA's humor). In sum, six conditions for a successful use of humor emerged (Table 2). First, the MA and her interlocutor (e.g., patient, colleague) should have a (positive) social basis ( n = 62). Knowing one's counterpart's "experiences and mentality" (MA#11) and especially her/his "type of humor" (MA#4) increases the probability of humor success. Moreover, having "the right chemistry" (MA#8) is even better than just knowing one's counterpart. Second, the interviewees emphasized that everyone involved in the humorous situation should be in a humorous mood (i.e., mood to interact humorously; n  = 48). Regarding situations with patients, MAs emphasized not to use humor in high emotional situations (e.g., fear of losing a child due to a febrile seizure - MA#14; or anger as one is not getting ones preferred medicine - MA#4). Regarding team-humor, on the other hand, "to spread humor in (a) practice the employees must be happy" (MA#12); for example, through the fulfilment of basic needs like appreciation and autonomy (MA#2).

Third, MAs highlighted the importance of social sensitivity ( n = 35; i.e., "gut feeling" - named by four MAs; or "tact" - MA#9) to assess if humor is appropriate. This includes detecting verbal and nonverbal "signals" (MA#9) like facial expressions (e.g., smiling and eye-contact) and posture (e.g., open and approachable) as well as empathizing with interlocutors (e.g., their needs and emotional cognition) to assess if someone is in a humorous mood. Fourth, MAs need enough time and interactions ( n  = 25). As in "acute and stressful situations" (MA#14) humor is scarce, MAs need breaks like "five minutes at the end of a team meeting" (MA#5) or "breathers" to "keep (their) humor" (MA#4). Moreover, phases when MAs work alone (e.g., sort patient files) or talk to patients on the phone instead of face-to-face, do not provide enough possibilities to use humor; at least those types that require social interactions, while humorous ideas or thoughts would probably be observable.

Fifth, MAs should go step by step when applying humor ( n = 19). MAs advised to first "check the situation, before getting out (the) joke collection" (MA#13) by "waiting and watching" how the other one acts (MA#5). MAs often started with a small talk (e.g., "Did you had a good way here?" - MA#5) and if the counterpart is talkative they "take it up" (MA#9) and "slide in with a funny commentary" (MA#10). Sixth, MAs should use matching nonverbal communication when using humor ( n  = 18), like facial expressions (e.g., smiling, winking or wide opened eyes) and pitch of the voice (e.g., sounding "extra naïve" or exaggeratory - MA#2). MA#13, for example, named two situations in which she did not get the irony, as her counterparts conveyed the humor "in such a serious way (...) being totally straight-faced".

The Occurrence of Humor Styles

Overall, MAs used all eight CSM; we decided to additionally code for gallows humor (e.g., Watson, 2011; Table 1 & Online Resource 3) as it seemed rather typical for MAs in the present study. Light (i.e., benevolent humor, fun) and dark (i.e., sarcasm, cynicism) humor - both containing two CSM - emerged relatively balanced ( n light = 133 vs. n dark = 103), while ambivalent styles emerged relatively scarcely ( n  = 109), considering that this category contains five specific styles (i.e., wit, nonsense, irony, satire, and gallows). However, the frequency of humor styles differed regarding the type of interlocutor. For example, while MAs used dark humor in 46% of situations within the team, with patients and apprentices, dark humor was scarce (9%/14%).

Further, the number of examples given for each style differed between humor functions. In team situations, for example, when coping with patients' demands and shortcomings and with team conflicts or disagreements MAs used dark humor in more than 50% of the segments, while when coping with shortcomings, light and dark humor were used equally. Two MAs described the dark humor in team-situations - mostly sarcasm - as "positive" (MA#10) or "benign" (MA#4) sarcasm, as - at least from their perspective - the interlocutor "understands it" and knows that "it is not meant like that" (MA#4). Regarding situations with patients, when helping patients cope and when educating or convincing patients, MAs mostly used ambivalent styles (coping = 58%, especially wit and gallows humor; educating = 59%, especially satire). When keeping face in terms of own or work-related shortcomings, on the other hand, light humor prevailed (77%, especially benevolent humor). Further, when taking away apprentices' fears and when integrating apprentices into the practice team, light humor was dominant (taking away fears = 69%, especially benevolent humor; integrating = 71%, especially fun), while when educating and convincing apprentices, ambivalent styles prevailed (81%; especially wit and satire).

However, although in most perceived functions certain humor styles prevailed, other styles also occurred to relatively high amounts (e.g., when helping patients cope, ambivalent styles prevail (58%), but closely followed by light humor; 42%). Moreover, as absolute coding frequencies (a) differed between functions and (b) were relatively low for some functions (especially, in situations with apprentices), the findings should not be over-interpreted.

Discussion

The interviews offered valuable initial insights into MAs' use of humor in work and education, specifically providing insights into (a) distinct perceived functions of MAs' use of humor in different situations (i.e., within team, with patients, with apprentices), (b) conditions for humor to be successful and (c) the occurrence of different humor styles and their relation to humor functions. The key findings are that MAs actually perceive a broad range of functions of humor in their working life and that they employ a variety of humor styles, with those being more positive and encouraging more frequently mentioned. However, interactions concerning the situation were noticeable; namely, that with patients and apprentices MAs state to use mostly light (especially benevolent humor) and ambivalent (especially wit) styles, whereas within the team they use mostly dark humor (especially sarcasm). Further, MAs perceive several essential conditions for humor to be successful and to reach its aim in the interaction with patients and colleagues.

Coping-Social-Educational: Functions of MAs' Use of Humor are multifaceted

Data analysis revealed various perceived functions of MAs' use of humor. For example, MAs used humor to (a) cope with different work strains (e.g., shortcomings of patients, conflicts); (b) foster social cohesion and relationships; and (c) educate and convince others. This relates well to the three main functions of humor in healthcare, which we identified during literature analysis (i.e., coping - McCreaddie & Wiggins, 2008; social - Dean & Major, 2008; educational - Chabeli, 2008). However, these three main functions have different aims and outcomes depending on the type of interlocutor. For example, while in team-situations, MAs reported using humor rather as a valve for their own negative emotions (e.g., letting out anger due to problematic patients), in situations with patients, they used humor to help patients relax (e.g., due to painful treatment). Further - regarding the social function - in team-situations, MAs suggested that humor strengthens cohesion, while with patients they argued that humor has the potential to improve patients' compliance and helps to keep humanity. In situations with apprentices, on the other hand, they indicated that humor helps making apprentices feel an appreciated team member. When coding the examples provided, it was evident that some functions cannot be as easily assigned to one of the three main functions. For example, when keeping face in terms of own or work-related shortcomings, MAs use humor to mitigate the shortcoming (i.e., coping) and simultaneously keep a good impression (i.e., social). A study of humor in palliative care identified a similar function called express dignity (Dean & Gregory, 2005).

Further, the topic coping with peoples' shortcomings (e.g., mistakes and misfortunes) stands out in particular. MAs reported using humor to cope with own, patients' and colleagues' shortcomings and they help apprentices to cope with their shortcomings. However, half of the interviewed MAs reported negative experiences regarding dealing with mistakes during their own apprenticeship (i.e., experienced MAs made fun of them). Some of them even wish that their current team would cope more humorously with colleagues' mistakes. In the literature on HCPs' use of humor, coping with peoples' mistakes and misfortunes rarely is a distinct function (e.g., the function mitigating own errors by Archer et al., 2019). Therefore, MAs should try to increase their use of benevolent humor when coping with colleagues' and, especially, with apprentices' mistakes to create a positive error culture in the long-term.

Moreover, despite potential recall biases (e.g., memorizing and reporting specific situations), coding frequencies provide some suggestions on the relevance of the perceived functions of MAs' use of humor. For example, humor was mostly used for coping functions ( N = 235), second most used for social functions ( N = 114) and least used for educational functions ( N = 39). Even in VET-situations only 25% of segments were dedicated to the function educate and convince apprentices, while in 75% of segments humor served other functions (e.g., encouraging or socializing). These findings support former studies on humor in medical education, which found similar functions and relevance distributions of functions (e.g., humor fosters learning but also, and more often, relaxes students; Chabeli, 2008; Liu et al., 2017), but on the other hand, also add insights into the relevance of certain educational functions. Overall, the identified functions of MAs' use of humor support the literature on functions of HCPs' use of humor (i.e., coping, social and educational), but also provide new insights regarding further functions (e.g., coping with shortcomings) as well as concerning the potential relevance of functions (i.e., coding frequencies). For practice, in particular, the findings (a) suggest for which working requirements humor might be a valuable resource (e.g., adding a hint of humor when soothing patients, or when teaching apprentices) and (b) provide concrete examples for MAs' use of humor (e.g., humorous phrases, words and behavior) for different occasions (e.g., within team, with patients).

Conditions of MAs' successful Use of Humor - Social Competencies as Key?

Data analysis revealed six distinct conditions MAs highlighted for preventing negative outcomes of humor (e.g., humiliating) and increasing the success of humor (e.g., relieving). Taking a look at the literature on conditions of successful humor in healthcare, it appears that the three most frequently coded conditions support the three main conditions that we found during literature analysis; namely, positive social basis (e.g., Dean & Gregory, 2005), avoiding high emotional situations (e.g., Jones & Tanay, 2016), and Social Sensitivity of HCPs (e.g., Ji-Min & Hyunjoo, 2015). However, regarding the second condition, MAs stated not only to avoid humor in highly emotional situations with patients, but to - in situations within the team - use humor only with colleagues who have a certain job-satisfaction and are thus in the mood to act humorously. As the remaining three conditions, emerge only scarcely in the - mostly non-empirical - studies on HCPs' use of humor so far (e.g., Osincup, 2020; Siegel, 2005), they give additional insights into conditions of successful humor in healthcare. While Enough time and interactions suggests, that the occurrence of humor depends on working conditions (e.g., low workload and frequent face-to-face interactions), Going step by step, and Matching nonverbal communication give concrete behavioral advices for the application of humor (e.g., small talk before using humor and adapting pitch of the voice).

Further, comparing the six conditions, it appears that four of them might interrelate. Having a high social sensitivity and knowing how to communicate adequately might facilitate a careful step by step approach as well as building up a positive social basis to people. This suggests a common meta-condition like social competencies (Dietzen & Tschöpe, 2019). Indeed, several psychological studies find robust correlations between social competencies and humor styles (e.g., Amjad & Dasti, 2020; Yip & Martin, 2006). However, study designs rarely allow causal inference and humor is never operationalized as humor success (i.e., humor that leads to positive reactions and outcomes independent of humor style). Therefore, further studies need to investigate the causal relationship between social competencies and humor success, especially in HCPs.

Lastly, as literature on humor styles in healthcare shows that dark humor can humiliate and discourage people, one could expect light humor to be a condition for successful humor. However, in the data, conditions emerged during situations with light as well as dark humor. This suggests that both - light and dark humor - could be unsuccessful and that MAs face the difficulty to ensure specific conditions in both cases. Hence, person × situation-factors need to be considered. Taking into account that (a) humor has high potential for MAs and (b) social competencies might play a key role for successful humor, a combination of humor- as well as social competencies-trainings might be useful to help MAs to confidently use humor in an appropriate and helpful way. Findings provide suggestions for learning contents (e.g., application possibilities of humor like soothing patients; essential social competencies like emotion detection) as well as for successful transfer into everyday work (e.g., work-related humor examples; recommendations for supervisors how to enable the occurrence of humor at work). As MAs suggested that a certain level of MA-happiness is essential to engage with humor, especially McGhee's ( 2010) training might be a suitable approach, as it aims at fostering a positive sense of humor gradually (i.e., preventing potential reactance) with the final step "finding humor in the midst of stress" (i.e., enabling MAs to find humor even if their level of happiness is rather low). For example, Linge-Dahl et al. ( 2022) recently ameliorated nurses' self-reported distress levels and elevated mood by means of humor workshops based on McGhee's approach. However, as there might always be gelotophobes (= people who fear being laughed at) among the participants, implementing such programs in practice must be done carefully (cf. Platt et al., 2016).

MAs' Use of Humor Styles is situation-specific: Is Dark Humor justified?

Frequency and overlap analyses show that the number of reported humor styles differed regarding type of interlocutor (e.g., more dark styles in the team than with patients or apprentices) and function (e.g., with patients: mostly light styles to keep face while mostly ambivalent styles to educate/convince patients). This suggests that MAs - maybe purposefully - choose using a certain humor style dependent on its suitableness and potential success in a situation (e.g., mocking styles might be riskier with (new) patients; benign humor might be most successful to reduce fears of insecure apprentices). It will be interesting to test in the future what implicit theories and learning experiences from past behaviors MAs use for selecting the styles and what cognitive processes inform such decisions-or whether other explanations (e.g., following one's own preferred humor style) will explain usage of a specific humor style best.

Further, the relatively high amount of dark humor in situations within the team stood out - especially, the high frequency of reported sarcasm to cope with different strains (Table 1) needs to be highlighted. As sarcasm can have negative outcomes (e.g., humiliation, prejudices; see Aultman, 2009; Berk, 2009), one might recommend MAs to decrease their use of dark humor. For example, instead of mocking colleagues because of their shortcomings, MAs could apply more virtuous humor styles like satire to correct those shortcomings (Proyer & Rodden, 2020). However, interviewees emphasized positive attributes of sarcasm in everyday work (e.g., a valve to let off "steam", part of the team culture), even naming it "positive/benign sarcasm" (MA#4 & MA#10). One explanation for these findings might be that interviewees are only aware of the short-term outcomes (e.g., relieving) of dark humor, and not its negative long-term outcomes (e.g., dehumanization and demoralization; see e.g., Piemonte, 2015).

However, as empirical studies on humor styles in healthcare are still scarce and as the findings of this study suggest that MAs see potential benefits of the usage of dark humor in the team-context, further studies investigating the benefits of dark humor for the team-context seem warranted. Moreover, this, as well as the finding that the occurrence of humor styles varies with functions, suggest the existence of certain humor style-combinations that might be optimal for the MA-context (e.g., preferring light humor, but using also dark humor now and then). The few existing empirical studies on the combination of humor styles suggest, for example, that dark humor styles are not - or at least less - damaging when used alongside positive humor styles (Evans & Steptoe-Warren, 2018; Leist & Müller, 2013).

Limitations and Future Directions

While this study provides new insights into the potential of MAs' use of humor, it also has some methodological limitations. First, as the sample consists of only (a) 14 and (b) German MAs, validity and generalizability of findings is restricted - especially for the humor functions in VET-situations, as only two apprentices participated and only few VET-functions could be coded. Having the COVID-19 pandemic challenging the German healthcare system heavily since March 2020 (i.e., increased workload of MAs), recruitment of MAs was difficult and was a hindrance for collecting a larger sample. Therefore, future studies should test the newly derived hypotheses (e.g., social competencies as crucial factor for humor success, the existence and benefits of different humor style-combinations) with larger and more diverse samples. Further, the a) uneven shares of experienced MAs versus apprentices and b) different ways of data collection (i.e., only written vs. only oral vs. oral and journal) might also have influenced the results (e.g., keeping a journal might have induced positive mood and thus awareness for especially positive humor instances; Wellenzohn et al., 2016).

Moreover, as the COVID-19-pandemic had a severe influence on HCPs' well-being (Dreher et al., 2021) and might have influenced the occurrence of humor at the workplace (e.g., increased dark humor to cope with the uncontrollability), findings might be biased. Although, we tried to control this bias by excluding COVID-19-specific humor-statements and -examples (e.g., "One cough is not enough for quarantine" - MA#4), findings are probably still influenced (e.g., more dark humor like sarcasm). Further, all interviewees primarily talked about positive - and not negative - functions of humor. This may have different reasons like sampling bias (i.e., only MAs who have a positive view on humor), social desirability (i.e., not admitting using humor for antisocial purposes) or perception bias of the MA (e.g., patient perceives an illness and thus a joke on that illness as more severe than the MA does but - being dependent on the MA - laughs anyway). Therefore, future studies should explore potential negative functions of MAs' use of humor (e.g., increasing one's own status by belittling someone else) for example by interviewing patients and/or the MA's colleagues on how they perceive the MA's humor. Related to that, of course, there are other ways of operationalizing successful humor than those used in the present study. Therefore, follow-up studies could take additional variables into account (e.g., an analysis of language use or direct observations of facial expressions either when recounting humorous incidents or when being in a humorous interaction with a patient).

Further, despite the high IRR of the two coding systems, functions and conditions of humor might interrelate, respectively. For example, a humor-induced team cohesion might in turn increase the mutual - even humorous - coping with work strains (Smith et al., 2013). Still, these causal interrelations are probably not absolute and differentiating between the single functions allows the depiction of the manifold application possibilities of humor.

Conclusion

This qualitative study with MAs from different medical fields gives crucial insights into the role of humor in MAs' everyday work and education. MAs use humor with different interlocutors (e.g., colleagues, patients, or apprentices) for various coping-, social and educational purposes (e.g., coping with strain, connect with patient, and educate apprentices). This suggests that humor is a multifaceted resource for MAs. Further, findings emphasize the relevance of specific conditions for a successful use of humor (e.g., social sensitivity of MA, humorous mood of interlocutor) and indicate a situation-specific usefulness of different humor styles (e.g., using light humor to help patients cope but dark humor to cope with own strains). Although further studies need to examine the generalizability of these findings, this study provides a first framework of a positive and successful use of humor for MAs as well as various approaches for further research on humor in healthcare and MAs in particular.

Acknowledgements

The authors thank the Medical Assistants who participated in the study; especially, given their highly increased workload due to COVID-19.

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Authors and Affiliations

1. Federal Institute for Vocational Education and Training, Division 1.4 - Competence Development, Bonn, Germany

Julia Raecke

2. Department of Psychology, Martin-Luther University Halle-Wittenberg, Halle, Germany

Julia Raecke & René T. Proyer

Contributions

Conception and design of the work: JR and RP. Data collection: JR. Data analysis: JR. Drafting the manuscript and critical revision: JR and RP.

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Correspondence to Julia Raecke.

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All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

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Before participating in the study, all participants provided their informed consent regarding interview recording as well as the analysis and the publishing of anonymized data.

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Raecke, J., Proyer, R.T. Humor as a Multifaceted Resource in Healthcare: An Initial Qualitative Analysis of Perceived Functions and Conditions of Medical Assistants' Use of Humor in their Everyday Work and Education. Int J Appl Posit Psychol 7, 397-418 (2022). https://doi.org/10.1007/s41042-022-00074-2
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DOI: https://doi.org/10.1007/s41042-022-00074-2

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Keywords

Humor

Healthcare

Medical Assistants

Resources

Comic Style Markers

Positive Education

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Humor as a Multifaceted Resource in Healthcare: An Initial Qualitative Analysis of Perceived Functions and Conditions of Medical Assistants' Use of Humor in their Everyday Work and Education - International Journal of Applied Positive Psychology

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It has been argued that humor serves as a crucial resource for healthcare professionals (HCPs). For example, they can use it to cope with work stress, to build relationships with patients, and/or to educate medical students and residents-to name but a few functions. However, empirical studies on the importance of humor among HCPs are still scarce.