Old age, with its greater prevalence of chronic disease, offers an interesting vantage for the anthropology of everyday competence.  Because the aged--in particular, those over age 85--represent the fastest growing segment of the US population and because minority elders are the fastest growing segment within the aged population, there is an acute need to understand the ways daily competence is defined and executed in varying social contexts.

    To assess a person’s ability to perform the broad array of activities required for independent living, we must not only be able to measure ability, but to know something about the social and environmental contexts in which the individual uses these abilities. Some people, for example, are able to perform a task; others do so only by altering the task, reducing its frequency or receiving help.  Still others are able to perform the task but do not, perhaps because they lack the opportunity.  Finally, there are those who are simply unable to perform daily tasks due to a cognitive deficit or another health condition.  These considerations form the basis of two research projects in which I am involved that examine issues of everyday competence experienced by middle-and lower-class families facing chronic health decline.

Ethnography of Function

    Daily competence in older people involves both self-care (eating, bathing, dressing, using the toilet) and household management (using the telephone, handling money, preparing a meal, going outside, shopping).  Loss of these competencies makes an elder dependent on family and paraprofessionals for quality of life and, indeed, survival.

    In a study conducted in Washington Heights, New York City, we used an ethnographic protocol to examine the ways elders interpret questions about their competence. To date, we have conducted over 50 interviews in a multicultural sample drawn from Medicare beneficiaries, with a mean age of 78 and a range of chronic disease conditions. Using a series of structured probes to elicit descriptions of the ways elders actually perform basic tasks, we have found that reports of “difficulty” are colored by a variety of considerations.  Some responses relate to the complexity of tasks; for example, elders may be competent with “indoor” or “lobby” clothing (bathrobes, slippers, sweaters), but not with clothing used outside apartments. Those who are competent only with indoor clothing may overestimate their abilities and report no difficulty.  The same tendency to overestimate applies to “getting outside”; many of these elders take elevators to lobbies but rarely leave their buildings.

    Another factor involved in people’s judgements of their own competence is perceived skill. Elders may report difficulty with a task when they are unsatisfied with how well they do it or how long it takes, as in the case of light housework. By underestimating their competence, they risk limiting their activities unnecessarily.

    A further consideration is perceived control.  An elder who admits she is no longer competent to write a check (perhaps because of tremor or low vision) may not report difficulty if she has another way to complete the task, such as delegating this responsibility to another family member with whom she sits when it is time to pay bills.

Getting at Validity

    Ethnography of function teaches a great deal about the way competencies match up against the tasks of daily life, and also how people evaluate and report on their own functional ability in health surveys. This is an especially important effort for anthropology, since survey researchers are increasingly concerned that survey items have appropriate content validity.  Functional assessment items drawn from this ethnographic effort may allow us to better predict those more likely to decline over follow-up, and thus help us identify appropriate targets for intervention.   For example, elders prone to overestimate functional ability are likely to be at greater risk for falls, injuries or other acute medical events and should be targeted for health promotion efforts.
    To help identify targets for intervention, we have added an additional component to the study to examine factors involved in proxy reports: factors at work when family members under- or overestimate the competence of those in their care. We have found, for example, that the more protective family caregivers tend to describe their elders as less capable overall. Moreover, the fact that Spanish speakers report greater protectiveness than English speakers suggests that we consider cultural differences and context when evaluating elder competency.

“Fair or “Poor” Health

    To understand the effect of environmental and social contexts on perceived health, we are looking at the ways middle- and low-income minority men report their health. Interviews with a sample of 200 African-American men in Harlem, NYC (aged 50-74, ascertained through a random digit-dial telephone survey, using survey items from the Behavioral Risk Factors Survey, Centers for Disease Control), found that nearly a quarter reported their current health to be “fair” or “poor,” despite the fact that they experienced no days with symptoms (“bad health days”) during the past month.  In national samples of men of similar age, only 10.6% fall into this category; and in national samples of African-American men, only 13% do so.  These differences are striking and suggest that there is either greater prevalence of ill health in Harlem or that features of daily life in Harlem lead these men to report poor or fair health more frequently than men in other samples.
    Our working hypothesis to explain this discrepancy, is that the Harlem men fall into a group that Patricia Draper, in a very different context, called “the obligatorily active” (“Work and aging in two African societies: !Kung and Herero,” in B Bonder, Occupational Performance in the Elderly, 1994).  If these men have medical conditions that affect perceived health without affecting the number of days they recognize as “bad,” it may be because they are forced to be active.  In a different social context—where healthcare is more accessible, for example--such health problems might lead them to limit activity and report bad health days.  We suspect that this may be a particular feature of the middle- and low-income experience of health.

Future Directions

    Anthropology has much to teach about the assessment of everyday competency and the effect of disease on such competency.  As our experience shows, policy-makers and funders welcome this perspective, especially when it can be used to refine current approaches to measurement.  This effort will be important for elder citizens and the families responsible for their care.

    Steven M Albert is Assistant Professor of Neuropsychology (Gertrude H Sergievsky Center and Neurology) and Public Health (Sociomedical Sciences) at Columbia U. This research is supported by the National Institute of Aging and Centers for Disease Control.. Albert’s recent publications address measurement of quality of life in people with dementia, medication competencies in people with HIV, and time use as an indicator of disability.  He can be reached at sma10@columbia.edu.