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from just above your head"; "Bend down and pick up clothing from the floor";. "Open jars which have been previously opened"; "Stand up from an armless.
The Great

Efficacy

of Personal and

Equipm-ent Assistance

in

Reducing

Disabilit

Lois M. Verbrugge, PhD, MPH, Catherine Rennert, MD, MPH, and Jennifer H. Madans, PhD

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Difficulties in doing everyday tasks become common as people age and develop chronic health problems. Great effort goes toward reducing these difficulties through a variety of interventions and accommodations. Two common strategies are personal assistance (having someone help do the task) and equipment assistance (using special aids and devices). How much does such assistance actually relieve difficulties? For US adults who report having much difficulty doing or being unable to do 12 common tasks, we describe their use of personal and equipment assistance and the efficacy of such assistance-that is, how often disability is reduced or resolved by the assistance.

Personal and equipment assistance reduce task demand. They operate at the immediate periphery of the individualfor example, another person cutting one's toenails, or a cane in one's hand. Both kinds of assistance aim to solve problems in physical, mental, or social functioning, but their subjective impact is distinct. Disability advocates note that autonomy and self-sufficiency are maintained when equipment is used but are lost with personal assistance. Still, equipment is not easy to accept because it is often visible, becomes an "extra part" of the body, and requires attentiveness and sometimes skill.' The topic of assistance is germane to two arenas of medical sociology-selfcare and coping. Self-care refers to all behaviors a person uses to prevent disease, limit illness, and restore health and function.4' Research has focused on self-care behaviors in a person's regular life, including the use of assistance,5'6 and on responses to daily physical and mental symptoms.7-'2 Active and passive forms of coping with health problems have been studied by health psychologists.'13-'6 Coping concepts and instruments have penetrated widely into research on stress, chronic pain, specific diseases, and health

requirements.3

Background The Nature of Assistance in Disablement The process of disablement involves a causal route

.38

linking pathology, impair-

ments, functional limitations, and disability.'-3 Functional limitations are restrictions in basic physical and mental actions such as grasping, walkng, and speaking intelligibly. Disability is health-related difficulty doing social roles and activities such as housecleaning, driving a car,

bathing, or gardening. People rarely allow disablement

to

take its course without efforts to retard or stop the process. Many strategies can be tried, such as therapeutic drugs, prayer, use of a cane, cognitive adaptation, home modifications, and quitting one's job. Strategies operate in two basic ways: some increase

capability by boosting

an

individual's physical or mental abilities, whereas others reduce demand by dimin-

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physical and mental

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Introduction

Lois M. Verbrugge is with the Institute of Gerontology, University of Michigan, in Ann

Arbor and, since June 1996, Westat Inc, Rockyulle, Md. Catherine Rennert and Jennifer H. Madans are with the National Center for Health Statistics, Hyattsville, Md. Requests for reprints should be sent to Lois M. Verbrugge, PhD, MPH, Institute of Gerontology, 300 N Ingalls, University of Michigan, Ann Arbor, MI 48109-2007. This paper was accepted May 30, 1996. Editor's Note. See related editorial by Satariano (p 331) and comment by Kasl (p 333) in this issue.

March 1997, Vol. 87, No. 3

Personal and Equipment Assistance

gerontology.17-20 Qualitative studies of coping with chronic disease provide longer-term perspectives of accommoda-

tions.21'22 Empirical Research on Use and Impact ofAssistance Population health surveys provide abundant data on rates of personal and equipment assistance use for problems with activities of daily living (i.e., personal care) and with instrumental activities of daily living (i.e., basic household management).23-29 The surveys often obtain detailed data about types of personal helpers and equipment. Differentials in use of assistance by age, gender, and other sociodemographic variables are routinely reported in such surveys, especially the gerontological ones. This has prompted research on social network, psychological, social resource, and health factors that explain the use of personal assistance, especially formal vs informal types.3034 With the exception of Zimmer and Chappell,35 however, there has been scant scientific interest in factors explaining the use of equipment. Thus, factors that direct people toward personal vs equipment assistance are scarcely known.36 What difference does assistance make? Little research exists on how assistance affects happiness and life satisfaction, improves functioning, and reduces chances of institutionalization. High disability plus personal assistance is associated with lower well-being for older men; for women, the association is with high disability plus equipment assistance.36 On efficacy, "we do not know the types of products that are necessary to fulfill the needs of seniors or the types of individuals who are best helped by devices."35(p'86) This article's purpose is to study the efficacy of personal and equipment assistance for relieving difficulties in doing everyday tasks among US adults.

Hypotheses 1. We expect a higher overall use of assistance by women, elderly persons (ages 75+), and persons unable to do a task on their own. This expectation is based on women's predisposition to take health actions for problems, on the assumption that older persons make a more conscious and willing adjustment to health problems than younger persons, and on the greater severity implied by

inability (unable). 2. We expect higher percentages of personal assistance for women, elderly March 1997, Vol. 87, No. 3

persons, and unable persons. Women's stronger social inclinations and men's high value set on self-reliance are the rationale for differences by gender. (Countering this is older men's higher chance to be married and thus to have greater access to personal help.) Less physiological potential for improvement for older persons and severely disabled ones, and the fact that using equipment requires more competence and energy than having human assistance, are the rationales for the other two differentials. 3. No hypotheses are stated for efficacy. There is no obvious basis for thinking that men or women have better chances of improvement. And although nonelderly persons and those who have much difficulty may have more physiological potential for functional improvement, those with worse health and disability circumstances (elderly and unable persons) may be more motivated and successful in finding effective help. Lastly, the qualities of human vs equipment help that would make one type systematically more beneficial than the other are hard to

envision.

Data and Methods Data Set Data are from the First National Health and Nutrition Examination Survey (NHANES I) Epidemiologic Follow-up Study (NHEFS) conducted from 1982 to 1987 by the National Center for Health Statistics. The baseline survey was NHANES I, a national multistage probability sample of the noninstitutional US population aged 1 to 74 surveyed from 1971 to 1975.37,38 In the 1980s, three follow-ups were conducted of the 14 407 NHANES I participants aged 25 to 74 at baseline.3941 The first wave of NHEFS (1982 to 1984) included a personal interview for all nondeceased persons (n = 10 523). The second wave (1986) had a telephone interview for nondeceased persons who were aged 55+ at baseline (n = 3027). The third wave (1987) had a telephone interview for all nondeceased persons (n = 9526). Proxy interviews were accepted if necessary. At the times of the NHEFS, people were generally 10 to 15 years older than they were at baseline; almost all were aged 35 to 90.

Variables In each follow-up interview, respondents were asked about difficulty doing 28

everyday tasks without assistance: "Please tell me if you have no difficulty, some difficulty, much difficulty, or are unable to do [Task X] at all when you are by yourself and without the use of aids." The items were adapted from Fries et al.,42 Rosow and Breslau,43 and Katz et al.44 For 12 tasks, respondents who stated that they had much difficulty or were unable on their own were asked, "Do you have help from another person?" and "Do you have help from a mechanical aid or device?" Those using assistance were then asked about degree of difficulty (none, some, much, or unable) they encountered using assistance: "With help, how difficult is it for you to do [Task X]?" The 12 tasks are as follows: "Dress yourself, including tying shoes, working zippers, and doing buttons"; "Reach and get down a 5-pound object (bag of sugar) from just above your head"; "Bend down and pick up clothing from the floor"; "Open jars which have been previously opened"; "Stand up from an armless straight chair"; "Walk a quarter mile (two or three blocks)"; "Walk from one room to another on the same level"; "Walk up and down at least two steps"; "Get into and out of bed"; "Get in and out of the bathtub"; "Get on and off the toilet"; "Get in and out of a car." Conceptually, most tasks relate to functional limitations; a few (dress, bathe, toilet) relate to disability. The tasks are organized into three groups according to their predominant reliance on upper extremities (hand, arm, shoulder, trunk), lower extremities (foot, leg, hip), or both extremities. Upperextremity tasks are the dress, reach-andlift, bend, and open items (n = 4). Lowerextremity tasks are the stand and walk items (n = 4). Both-extremity tasks, which involve whole body transfer, are the in-and-out and on-and-off items (n = 4). In analyses, consistent results were sometimes found for all tasks involving lower extremities (n = 8), and this is denoted "lower extremities (alone or combined)." Types of assistance are personal only, equipment only, both, or neither Consistent results were sometimes found for personal assistance, whether by itself or with equipment, and this is denoted "personal (only or both)." The similar situation for equipment is "equipment (only or both)." In this article, degree of difficulty on one's own is called intrinsic disability, and degree of difficulty with assistance is called actual disability.3'45 The difference between unassisted and assisted degrees American Journal of Public Health 385

Verbrugge et al.

TABLE 1-Use of Assistance by Persons with Much Difficulty or Inability (Percentage Distributionsa)

Upper extremities Dress Reach and lift 5 pounds Bend down to floor Open jars Lower extremities Stand up Walk 1/4 mile Walk across room Walk up steps Both extremities Get in and out of bed Get in and out of bathtub Get on and off toilet Get in and out of car

Personal Only

Equipment Only

Both

Neither

No.b

72.7 72.5 58.3 72.7

3.8 3.7 9.9 7.5

4.5 5.7 6.7 9.6

19.0 18.1 25.1 10.2

468 774 586 334

31.1 18.5 17.2 21.5

24.1 21.8 45.9 32.4

20.7 16.3 25.0 26.6

24.1 43.4 11.9 19.5

547 1164 344 693

46.8 34.9 31.7 52.4

19.3 20.3 35.1 8.6

15.2 16.4 20.2 26.8

18.7 28.4 13.0 12.2

348 918 347 590

Source. NHANES-1 Epidemiologic Followup Study. aEach row sums across to 100%. bPersons with NA (not ascertained) on one or both assistance questions are deleted; number of NA ranges from 11 (get in and out of bed) to 90 (walk 1/4 mile).

of difficulty is

a

straightforward

measure

of efficacy.

Analysis Samples For each of the 12 tasks, an analysis sample was created consisting of persons who reported having much difficulty or being unable in an NHEFS follow-up. This is a small percentage at any particular wave; for example, in 1982 to 1984, those with much difficulty range from 0.7% (walk across room) to 2.9% (walk a quarter mile); those who were unable range from 0.6% (get in and out of bed) to 4.9% (walk a quarter mile); and the sum of the two ranges from 1.5% (get on and off toilet) to 7.8% (walk a quarter mile) (table available on request). Scanning 1982 to 1984, then 1986, and then 1987, we chose the first instance of a respondent reporting having much difficulty or being unable. A person was represented just once in an analysis sample but could be in several such samples if he or she had multiple disabilities. Numbers of respondents range from 334 (open jars) to 1164 (walk a quarter mile) (Table 1). In all samples, the majority of persons were female (64% to 77%) and aged 75 + (56% to 77%); of those under age 75, 68% to 87% were aged 55 to 74 in the analysis samples. For brevity, respondents are called "much difficulty persons" and "unable persons." The samples and results refer to US community-dwelling adults with moderate to severe functional difficulties in the mid-i 980s. 386 American Journal of Public Health

Statistical Procedures Cross-tabulations were estimated to study differentials in type of assistance used by gender, age (