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Applying ethnography to digital health aims; challenges and opportunities – by Charlotte Hawkins

By Laura Haapio-Kirk, on 10 August 2019

Author: Charlotte Hawkins

Photo (CC BY) Charlotte Hawkins

How can a holistic ethnographic understanding of ageing experiences, particularly related to health mobile phone engagement, contribute to an mHealth initiative and improve the accessibility of health services and information through mobile phones? This applied challenge in the ASSA project has initiated partnerships with digital health practitioners in most of our fieldsites – in particular, with collaborators working within existing phone practices. This aligned with our early finding across the fieldsites, that mobile phones are commonly used for health purposes, but through communication on apps evidently most popularly used, such as calls, Facebook and WhatsApp. In Kampala, I worked with The Medical Concierge Group (TMCG), a medical call centre founded by Ugandan medics to improve the accessibility, affordability and quality of healthcare. They offer a 24-hour toll-free phone line, SMS, WhatsApp and Facebook access to a team of doctors and pharmacists and have 50,000 interactions each month. At the time of fieldwork, they were in the process of researching the development a psychiatric call line, or ‘telepsychiatry’. This early stage of service development meant that TMCG were interested in and able to accommodate holistic ethnographic insight in their considerations.

Ethnographic insights included systematic information on 50 low income research participants’ existing mobile phone and mobile health practices as relevant to accessing TMCG services. For example, access to airtime and data is intermittent, with a tendency towards regular low-cost subscriptions. This suggests that calling or using the internet could be inaccessible to users at least once a day. Furthermore, 54% of participants had made health-related calls in the last month, and 27% of their previous three remittances were for health purposes, which confirmed an existing propensity to use mobile phones to support family health – but only across their own network of friends and relatives. Interviews with 50 respondents encountered during the wider ethnography also offered TMCG feedback on mental health perceptions, experiences and help-seeking preferences. These interviews were predominantly with older people, mostly older women, who would not typically opt to engage with research on mental health, and yet who represent an advisory position within their family or community. This also included interviews with health workers, including psychiatric clinicians at the local government hospital, and private health clinicians within the fieldsite. Research showed that treatment for mental illness was perceived to be unavailable, costly, or stigmatised. Often respondents said they prefer to handle mental health problems through prayer or counselling within their community, with hospital treatment sought only once problems become severe. This suggested that optional, confidential, accessible or community-based mental health services could be useful for low-income people in Kampala, if advertised accordingly.

Initially, the wide-reaching interview responses were considered thematically, from causality to treatment seeking, and condensed into representative quotes for presentation back to the team. More recently, alongside the team, these themes have been expanded to inform a draft publication in psychiatric journals, which TMCG hope to use seek further funding. We also hope to further disseminate findings in accessible formats amongst other digital and mental health service providers in Kampala. As familiar to many applied medical anthropologists, translating interpretive, subjective and relativist ethnographic information within positivist, objective and universalist medical paradigms brings challenges, such as risking that complex human experiences and perceptions are reduced into ‘practical’ or digestible concepts (Kleinman, 1982; Scheper-Hughes, 1990). However, this assumes that the health practitioners and their discipline are not open to understanding their patient’s everyday realities, which has not been the case in this instance, perhaps reflecting a particular affinity between anthropology of digital health – appropriation of phone based health services is entirely dependent on their relevance and usefulness for their target populations.

The on-going collaborative process has also highlighted what anthropology might learn from the research and writing processes of health disciplines, for example: ensuring findings are widely disseminated and thus accessibly written; avoiding anecdotal, emotive or biased claims; and ensuring that quantitative statements, “many people said xxx”, are qualified and backed-up. The collaboration has  also confirmed that the flexibility of anthropological research and richness of qualitative insight potentially has much to offer health programmes, to ensure their contextual relevance. In ethnographic research, we have the privilege of time, which comes with in-depth insight, and familiarity with the community – time and understanding which we can offer usefully to other audiences. The data provided can perhaps confirm a hunch of a practitioner from the area but can also surprise them. When documented and publicised, the data encourages practitioners to both tailor their approach, but also allows them to share the specific requirements of their target population, encouraging others to do the same – or hopefully even to offer funding to support them.

 

REFERENCES

Scheper-Hughes, N. Three Propositions for a Critically Applied Medical Anthropology. (1990) Social Science & Medicine 30 (2): 189-97.

Kleinman A. The teaching of clinically applied medical anthropology on a psychiatric consultation-laison service. In Clinically Applied Anthropo1ogy: Anthropologists in Health Science Settings (Edited by Crisman N. and Maretzki T.) Reidel. Dordrecht, 1982.

 

Health and Ethics – by Pauline Garvey

By Laura Haapio-Kirk, on 1 August 2019

Author: Pauline Garvey

The current advertising slogan for Gaelic Sports Clubs is ‘Where We All Belong’. The girl is shown holding a hurl for the sport called camogie. Gaelic sports including camogie for women and hurling for men have a huge national following, all-Ireland finals easily fill the national stadium with 80,000 spectators.

 

Why is it important to be active, or is it important to be active in specific ways? In recent years there has been mounting focus on health and wellbeing, as evident in the launch of the ‘Healthy Ireland Framework’ (2013-2025) a Government-led initiative that aims to enhance the population’s health. In this initiative health is presented as a public good, of individual and social concern. In the face of troubling temptations that arise with modern lifestyles the launch of this framework explicitly carries an ethical imperative: individual health, it asserts, affects the quality of everybody’s life experience. It is for the collective good to maintain one’s health. The approach recommends that the way to enhance wellbeing is less by focussing on the negative and more by highlighting what one can do to stay well. It recommends, in other words, a focus on the positive instead of the retribution of a poor quality of life that comes with bad behaviour.[i]

Often such initiatives focus on activities. From my fieldwork with middle-class Dubliners I have learned that staying well and being healthy is often talked about as routinised and collective in nature. People gather to walk, run or do yoga and the group aspect is an essential ingredient in the diverse efforts to stay healthy. When people talk of ‘activities’ they are often referring to group activities rather than solitary ones. Lots of keep-fit activities like walking or running can be done alone, yet they seem to be more successful when done with others. Respondents who attend tai chi classes might attend with a friend, and even if they don’t join these groups to extend their social networks they seem to prefer them to following a YouTube course online. This is interesting because it implies there is an added feel-good factor to the demonstration of healthy living beyond the benefits that come with social interaction. It is not just about being healthy, I suggest, but pursuing health in the company of others carries an added benefit in a cultural context where consensus is highly valued.

Younger respondents who have children report emphasis on mindfulness in schools where the health and wellbeing of children and young adults is couched as a social and spiritual category as much as a physical one. The National Council for Curriculum for example states that in ‘health promotion, health is about more than physical health and wellbeing. It is also concerned with social, emotional and spiritual health and wellbeing.’[ii] What we are seeing therefore is an interesting blurring of health, ethics and even spirituality to the degree that it is difficult to discern their distinctions.

 

References:

[i] A Framework For Improved Health and Wellbeing 2013 – 2025, available online https://assets.gov.ie/7555/62842eef4b13413494b13340fff9077d.pdf)

[ii] The National Council for Curriculum and Assessment. https://curriculumonline.ie/getmedia/007175e5-7bb7-44c0-86cb-ba7cd54be53a/SCSEC_SPHE_Framework_English.pdf

‘Ikigai’ – what is your purpose in life? By Laura Haapio-Kirk

By Laura Haapio-Kirk, on 25 July 2019

Photo (CC BY) Laura Haapio-Kirk.

I went to meet Wada san* on his land in the heart of the mountains of Tosa-cho, where he grows the plant sasaki, common in Shinto ceremonies and used to decorate altars. He keeps ducks who help him to take care of his rice by eating weeds and harmful insects, and by fertilising the rice crop. He knows the paths and trees in his forest as well as a city person would know the streets and buildings of their neighbourhood. School children often come here to learn about nature and see how we can work with it, such as by making beautiful things out of wood, or healing ourselves with plant remedies. He told us that the plants that are able to grow and thrive here in the mountains, growing up through other vegetation, have the strength to survive and therefore when you eat them you too gain some of that vitality. Along with my research assistant Lise Sasaki and two friends, we spent several hours walking and talking together about happiness and the things in life that give a sense of purpose, in Japanese termed ikigai. While this is quite an abstract term, Wada san was able to explain his ideas through vivid analogies to the landscape that surrounds him.

“What is happiness? Human being’s happiness… I’ve heard that it is health. But after that, its whether or not you find the job you want to devote your life to. I have lived through many jobs and have picked up skills throughout. Now I use those skills to do what I do, my passion. My life story, my life history is written in the mountains, and is remembered by the mountains. Working in an office, once you retire someone else will take on your job. But in this rural area the trees I have planted will grow and remain here, and the trees will be cut down and I will plant them again. It will be a cycle. Not only that cycle, but here – (shows us the rings of a cut tree) you can see how much it has grown, how much it has lived. The trees, even if they are chopped, they will live on as someone else’s house or in another form. It reincarnates as several things. Trees live once in the mountains, giving us oxygen and giving to us our life. And it lives that way. But in its second life, it is transformed into our homes, giving us comfort. We can’t see the oxygen, but it produces it – let’s say it was living in the mountains for 50 years and then it was chopped down and lived as a house for 50 years. Then it has lived for 100 years.”

Wada san explained that trees, like humans, are naturally wild, but that with the right kind of nurture they can find their way in the world. He said that when we are becoming an adult we have to choose our path in life and our role in society – trees are the same. For many people I have spoken to the idea of ikigai is linked to the satisfaction you gain by fulfilling your role in society, especially when you see your positive impact on others. Whether through making delicious bean paste sweets and sharing them with people, or in taking workshops to become a better teacher for your students, people agree that one element of ikigai is about trying your best in serving others.

Everyone has a different definition of ikigai. For some people it refers to dreams and ambitions, such as pursuing a career as an artist, for others it is about doing daily activities which align with one’s interests such as learning English, or for others it is more about the thing in life that you could not live without, such as your children. For some people it is about enjoyment of life, for others it is about the fulfilment of obligations, and some people are in between – a sense of ikigai can come in both difficult and joyous moments and it is more about an underlying feeling of immersion in life.

The English translation of “purpose in life”, it seems, is completely inadequate for understanding the broad range of meanings that ikigai can have in Japan. In England we often talk about life dreams, or working towards goals that we want to achieve. But it seems that people here think about life purpose in a more subtle way, through trying your best day-to-day and being fully present in whatever you are doing. Wada san explained that we must live in the now, rather than waiting for happiness in the future. I think this is an important lesson for us all, especially for people living hectic city lives far removed from the cycles and rhythms of nature. We can often get caught up in our to-do lists and anxieties rather than being fully aligned with our passions and the flow of life.

Human beings are always worried, human being all have anxiety. If your passion wins over, you’re okay. If anxiety takes you over, you can’t take a step. You think life and death are far apart? They’re next to each other. You can die anytime you know? It’s up to you whether you stay anxious or live to the fullest, with passion.” 

Thank you to Wada san for sharing your time, wisdom, and inspiring passion for nature with us.

 

*Wada san is a pseudonym because this man preferred to remain anonymous.

Pandora turned 70 and she just opened the box again. By Marília Duque

By Laura Haapio-Kirk, on 3 July 2019

Photo (CC BY) Marilia Duque.

Author: Marilia Duque

I am packing up to leave my field site after a 15-month ethnography with older people in Sao Paulo. One thing I learned is that a smartphone is not smart by default. Most of the times, specially for older people, a smartphone could be a stupid little thing that releases a new set of problems they now have to deal with, just like a Pandora’s box.

The character of Pandora can be perfectly represented by a 70-year-old lady I met who just received her box in the form of a gift from her son. This pandora’s box contained many gifts: a telephone, camera, calendar and computer and they were all hidden inside a Samsung Galaxy phone. Pandora’s husband warned her: “You should never turn this on. We are not supposed to steal technology from the youngsters”. Pandora then left the smartphone inside its box for weeks until she found out she was not invited to her old school annual reunion. The explanation they gave to her? “It was all set up through our WhatsApp group, dear”. In a mix of rage, sorrow and curiosity, Pandora immediately opened her smartphone’s box and turned it on.

As in the Greek myth, our Pandora also released some plagues and devils she now has to deal with. In her case, she faced fear, low self-steam, and anxiety. She first experienced fear of breaking the device, fear of being charged for something she was not using, and fear of erasing something important, like the pictures of her youngest grandson’s swimming competition. She then experienced a lost of self-esteem because her smartphone’s display was set to sleep after just 30 seconds of inactivity and she just didn’t have the proper time to think about what to do before the screen turned off. And when she asked her son for some help, he simply had no patience to explain to her what was happening. Instead, he took her smartphone from her hands, reset the sleep mode to 5 minutes and gave it back to her saying “it is intuitive, even children are supposed to learn how it works”.  Pandora still doesn’t use her smartphone to its full potential, but a friend from her church has downloaded WhatsApp for her. She has finally joined her old school friends’ group and also her charity group, her meditation group and her family group. Now Pandora experiences anxiety because she has to manage so many messages that just keep coming without interruption. Pandora doesn’t understand that the connection is on 24 hours a day, 7 days per week, but she can choose not to be.

Curiosity was what made Pandora open her smartphone’s box and turn it on for the first time. But it is also curiosity which is the only thing that can save her. With curiosity (and with a little help from her friends), Pandora can dig deeper into her smartphone until she finds a solution – ‘hope’. It is hope that was left remaining in Pandora’s box. She will make ten mistakes for each thing she does right. She will be annoyed because she can enlarge the font size and the display size of her smartphone, but this will disrupt her WhatsApp screen lay-out and she will feel lost again. Even so, with time, she will become more confident to try new things and make new mistakes and learn with them. In doing that, Pandora will discover that one more gift was left inside her smartphone. Pandora will finally experience the smartness of her smartphone. A smartness that is only achieved in practice, when the smartphone provides a solution for someone’s need or desire.

Fear, low self-steam and anxiety will still exist. But Pandora won’t have time to pay much attention to them. She is now checking Google Maps for the easiest way to go to a museum with her friends. She is deciding to take an Uber so she can improve her English with Duolingo during the trip. She is experiencing that fraction of smartness that makes her think that her smartphone was actually a gift from the gods to mankind. A gift she had the curiosity to open and the courage to keep it on.

Downsizing, Rightsizing, Upsizing — by Daniel Miller

By Xinyuan Wang, on 24 June 2019

A while back, Pauline Garvey and myself decided to write a chapter for our book about downsizing. This means that we rather assumed that downsizing would be an evident phenomenon for the age group we are studying, mainly people in their sixties and seventies. Certainly, in Ireland there is pressure on older people; hints from the media and the state that moving to a smaller home would help free up large family homes for families with children and perhaps release equity for their own children who are finding it hard to buy their own homes.

I found that most of my informants resent such pressure, feeling that they have worked hard for and deserve their homes. Their children may be living abroad and when visiting, my informants want to host them in their own homes.  Anyway, there are no hotels in Cuan. These people often want to move from the older estates they currently live in, where houses are typically expensive to maintain. But the evidence, confirmed from interviews with estate agents, is that they are not downsizing. Rather they aspire to move to new build houses, but with at least three bedrooms. When visiting such houses I found that they use this opportunity to express their desire to be modern and youthful. Far from squeezing possessions accumulated over decades into small retirement flats, they give these away and embrace modern furnishings and styles for their bright new houses.

Similarly, while they may be getting rid of their many accumulated possessions in the process. They may use this realign themselves with modern sensibility, viewing these actions as evidence that they have embraced the modern ‘green’ environmentalist perspective. So both in moving home and in divesting themselves of possessions, it seems that, far from preparing for ageing, they are seeking ways to become more youthful and more attached to contemporary mores.

Other evidence suggests that there is only limited transfers of equity down the generations to enable younger people to buy their own homes.  It seems more common for them to suggest that their children’s families can come back and stay in these reasonably spacious homes, while they are saving money to purchase their own. Most commonly, these children really want to be able to buy a home within Cuan itself, and this is expensive.

Actual downsizing is important in relation to frailty at whatever age this arrives. Alongside the need for specialist aids, downstairs bedrooms and toilets and, when required, a move to specialist sheltered accommodation or a nursing home. But, consistent with our earlier findings, this is about physical need. Otherwise, it seems to matter little whether people are in their eighties or fifties, they no longer consider themselves as old people who have to shrink their worlds, rather they remain concerned to find strategies for updating their world and remaining contemporary.

I thought this was quite an original, even radical finding; but perhaps we have not gone far enough. A 2016 report by the UK’s NHBC Foundation called Moving insights from the over-55s based on a survey of 1,500 households who have moved home, suggests that nearly a third have actually upsized, that the most popular homes are four bedrooms and that 46% have put more money into their new homes, rather than released equity. Unfortunately, the survey is not broken down by age. It is not then surprising that terms such as rightsizing are coming to displace downsizing. What that report doesn’t do, which we hope our project will do, is delve into the deeper context that may explain why this is happening.

 

New and Old Friends — by Charlotte Hawkins

By Xinyuan Wang, on 9 June 2019

Many people in the Kampala field site who use Facebook like to use it to search, add and chat with new friends. They sometimes attribute it to ‘friendliness’, enjoying making contact with new people and chatting to them. A few also see it as an opportunity to network and learn from others.

Nakito is 48 and owns a salon with her son. They also share a smartphone as they don’t have money to buy their own, with each taking ownership on alternate weeks; they even change the password so the other can’t access it without their permission on their week. She uses Facebook to look up friends, add them and send messages. Mostly they are other women who live in Uganda. She would never meet with them but just chats to pass the time.

Nakito with her grandson, her son working in the background

Opoka is 48 years old and has had a smartphone for 5 years. He uses Facebook to talk to old friends and look for new ones. “When a new face appears we’re eager to talk to them”.  He especially likes finding international people, learning from them, sending photos and sometimes exchanging phone numbers.

Amigo also accepts or sends requests on Facebook, “creating friends worldwide…you see their photos, you like some and want to make friends…maybe they can take you to a higher level.” Like Nakito, he wouldn’t meet them in person, and generally loses contact eventually, “like one in Spain, we used to chat a lot, but my phone got stolen so we lost contact”.

Frank is only 33 and also sometimes likes to find new friends on Facebook by sending requests or receiving them. They are ‘outside Uganda and all over the world’. He said, “I like chatting to new people and meeting friends. I like people and being friends”.

Namubiru is a 45 year old market vendor. She has old friends she connects to on Facebook, but also is sometimes looking for new friends. Her kids even look for new friends for her. Usually they are ‘from here’, women or families. She’s never seen them in person, it’s ‘just to make friends’, like families sometimes can’t come ‘live’ in person so they connect on the phone. Her kids can call them and they chat, just asking them how they are; they always want to find out how her elderly mother is.

‘Checking on people’ is probably the most common use of mobile phones more generally. In a survey on phone use conducted with 50 respondents last year, we asked people who their previous 3 phone calls were with, the purpose and duration; 34 of 150 (23%) phone calls were for the purpose of ‘checking on friends and relatives’, or them ‘checking on me’; “they wanted to know how I am”, “he wanted to know how home is”. They were generally brief phone calls, less than 2 minutes. Exchanging greetings through the phone acknowledges connections and reiterates the importance of such relational ‘presence’, even if at a distance.

Smartphone and the ‘sense of ritual’ in daily life — by Xinyuan Wang

By Xinyuan Wang, on 31 May 2019

Mr. Shou taking photos for elderly residents (photo by Xinyuan Wang)

I have not been photographed by a proper camera for ages! It feels so special…nowadays most people only take photos by mobile phone.

79-year-old Mengyun claimed with a big smile after posing for the portrait photographing. Mengyun is one of my neighbors who joined an oral historical project which I co-operate with the local residential compound in Shanghai. As part of the project, I invited Mr. Shou, a professional photographer, to take portrait photos for a few families.

Mr. Shou taking photos for elderly residents (photo by Xinyuan Wang)

Mr. Shou is an experienced photographer who has done a lot of work especially among the elderly. He sees this none-profit photography project as something he has to do with great respect:

Many people passed away without a proper photograph. Every person deserves a proper portrait photo in his or her life. What I want to do is not just take photos, but keep the great memory of the person. I take it with great respect and people can also feel the sense of ritual. Life needs sense of ritual, don’t you think so?”

Mr. Shou always mentioned the phrase ‘sense of ritual’ (yi shi gan) to highlight the significance of the photography session. After seeing how the three-generational family finally arranged a photo slot which can suit every member’s schedule after four-day back-and-forth coordination on the family WeChat group; how the bedridden lady struggled to get up and put on lipstick for the photo-taking, which she had not applied since she was ill; how people moved the heavy furniture around several times to find a best backdrop for the family group photo, I have to admit Mr. Shou is right in many ways – probably the mere fact that this photo is not taken by a smartphone but a ‘proper camera’, as Mengyun put it, has given people the sense of the ritual, so that they are more willing to make an effort to make it better.

Mr. Shou taking photos for elderly residents (photo by Xinyuan Wang)

The cost of photography was definitely one of the main reasons that photo-taking was such as special thing in the past old days. As Guancheng, 70s, recalls: “About forty years ago when I grew interested in photography, it was such a luxury hobby. I remember clearly at the farm camp[1] (nong chang) my monthly salary was about 22 rmb, and at that time a roll of film cost almost 10 rmb, plus the cost of developing the film etc. the cost of taking 30 ish photos was about half of my monthly salary!

On top of it, 50 years ago a camera was so expensive to the degree that almost no individual or household could afford one. People had to borrow cameras from the work unit (dan wei) or rent cameras from camera shops. Given the opportunity of having a photo taken was so rare, the process of arranging photo-taking was also an important part of the ritual.

In many cases, people can remember in great detail about things which were not captured by the photo – such as who took the photo, and in what situations they had the chance to get a photo taken. However sometimes people couldn’t even remember other persons on the photo. The mere fact that the invisible things could get memorized while the visible things could get lost of a photograph seems to lead to an understanding that the very event of photo-taking can be as important as the photograph itself, if not more important.

It seems that the rise the smartphone has killed the ‘sense of ritual’ of daily life as taking photos by smartphones nowadays has become such a mundane activity. However, along with the decline of one kind of ritual, the proliferation of smartphone has created new ‘rituals’ in daily life.

‘New rituals’ being taking photos of the food before a meal – you have to take photos first otherwise you are not fully appreciating the food and the hospitality.

“I don’t think she likes the meal tonight as she didn’t even take any photo of the dishes.” Ms. Huang (58) said showing evident disappointment, after an important dinner to which she treated her son and his fiancée.

‘New rituals’ – i.e.  the taking of many photos and selecting a small portion of them to post on WeChat – the social life of photographs online has become a significance aspect of photo-taking as well as the way people perceive their daily life.

Alice, 35, described her mother’s ‘ritual’ of taking and posting photos: “When she visits somewhere, she really doesn’t have a lot to do, excepting taking loads of photos, and after the visit, she spends a lot of time polishing these photos, adding filters, and after that she carefully selects nine of them[2] to post on her WeChat, editing the text meticulously and then she checks her smartphone almost every two second to see who has liked her photos and what kind of comments she received. And then, the next day you can overhear her WeChat video call with her close friends, complaining who has not liked her posts for a long time.”

Actually, what Alice observed about her mother’s photo-taking ritual is not rare among people of all ages I know in Shanghai. Given the ‘cost’ of taking a photo as well as taking a short video is nothing in the age of smartphone, the ‘willing’ of taking a photo or video speaks directly to people’s attitude and evaluation of things – ‘Is it worthwhile being recorded?’ or ‘Is it worthwhile being posted on my WeChat?’

In the field work, I have observed various situations where people created new rituals out of the daily use of smartphone. The discussion of the relationship between smartphone use and ‘sense of ritual’ will continue in my further study.

[1] Where he was sent to receive re-education from peasants in 1960s.

[2] on WeChat, one post only allows nine images

The shades of menopause In Yaoundé —by Patrick Awondo

By Xinyuan Wang, on 24 May 2019

Photo by Swathi Sridharan

Among the remaining taboos of Cameroonian society are some gender and sexuality issues. Menopause is one of them. You hardly find anything in public discourse on this issue. There is no forum dedicated to menopause nor research groups or reports.

Social science researchers, especially anthropologists, have tried to understand menopause in Cameroon. Their view on the issue is binary and culturalist. Apart from Mbarga’s work comparing menopause in Cameroon and Switzerland[1], most of the studies are anachronistic and globally fail on giving a clear understanding of this issue in the contemporary context.

Research by the French anthropologist Jeanne-Francoise Vincent[2] on Beti women in the central region of Cameroon in the 1970s suggests that menopause signifies the end of sexual submission for women in this patriarchal society. The beti culture constructs menopause as the beginning of a period of “initiative and development”. Thus, menopause marks “the beginning of a new period in which women can also exercise their power and their ability to become equal to men” (2003 131). This transformation of the status of the person must be accepted by the husband. ” The arrival of menopause is for women therefore a way to lead their own life.

This change is evident in language which names “the menopausal woman in a rewarding way and designates her as” an important woman, an accomplished woman “nya mininga” (2003 134)). Being menopausal is, according to Vincent, a condition for positions of power, such as becoming a woman leader in the secret societies of the village. This role makes the woman who endorses her an eminent person with strong responsibilities and real power.

On the symbolic side described by ethnologists, menopause implies, on the one hand, a lifting of multiple prohibitions, for example acts and words in public spaces, and, on the other hand, an opening of possibilities among others, access to certain foods, acquiring new roles in the community such as therapist, midwife, leader of rituals etc. These symbolic benefits are still often reported in rural areas, but are not so visible in the city, where a heterogeneous population coexists with great cultural diversity.

In everyday life, however, the women interviewed in Yaoundé point out different experiences for which the reported facts do not overlap with the realities described by some anthropologists. One explanation is obviously the gap between the traditional and rural spaces in which some research has been conducted and the city where traditional values are diluted in more a globalized, westernized and at the same time individualistic environment.

There remains the experience that is often individual in the face of menopause. The women we interviewed had 3 types of interlocutors that illustrate urban social reconfigurations. The first interlocutor for educated women is their gynaecologist. He is the first to answer questions about physiological changes and disruptions. For all that, women point out that they get mixed and unsatisfactory answers. As some research points out, the current discourse on menopause is highly medicalised and ambivalent.

A second type of interlocutor is constituted by friends or professional networks. Finally a third source of information is the internet for those who have access to it. However, knowledge of the menopause and its symptoms remains very low among women interviewed in Yaoundé. This seems to be the case in the rest of Africa. An Ivorian study conducted on 278 women in 2017[3] showed that the symptoms and risks of menopause are unknown by 73.68% of women. However, a test carried out for this purpose shows that the level of knowledge of menopause is related of the level of schooling. This also seems true in Yaoundé where educated women seem to have a better knowledge of menopause in general and are able to search on google for medical information.

Another important point is the use of medicinal plants to treat or prevent symptoms. A majority of women interviewed in Yaoundé used plants purchased from herbalists and other traditional healers. They are either in the form of a concentrated liquid, in powder or simply as fresh or dried barks. Depending on the quality and intensity of the symptoms, some women go to the hospital to see a general practitioner. These women are often discouraged by healthcare professionals who explain that menopause can not be truly treated.

It is known that modern medicine offers menopausal hormone treatments (HRT) to cope with discomfort with the advantage of eliminating many symptoms, the risk of cardiovascular disease and osteoporotic fractures. However, concerns regarding possible harmful side effects of HRT has impacted on its uptake by women.  Hormone Replacement Therapy is not accessible and available in many African countries, particularly Cameroon.

Today, women are turning more and more to other medicines and plants. This poses a problem in the context where the marketing of medicinal plants remains poorly controlled, despite the willingness of public health services to better regulate the practice of traditional medicine through recognition of the function and quasi-union organization created for these actors.

Reference

[1]Josiane Mbarga, « Regards de Suissesses et de Camerounaises citadines sur la ménopause : dépasser les dichotomies binaires », Anthropologie & Santé [En ligne], 8 | 2014, mis en ligne le 31 mai 2014, consulté le 21 mai 2019. URL : http://journals.openedition.org/anthropologiesante/1396

[2] VINCENT J.-F., 1976. Traditions et transition : Entretiens avec les femmes beti du Sud-Cameroun. Paris, ORSTOM Berger-Levrault ; VINCENT J.-F., 2003. « La ménopause, chemin de la liberté selon les femmes beti du Sud-Cameroun », Journal des africanistes, 73(2) : 121-136.

[3] See Kouamé A, Koffi Y., Piba S.,  et al, 2018, « Niveau de connaissance de la ménopause et habitudes alimentaires et médicinales des femmes en Côte-D’Ivoire », European Scientific Journal, Vol 14 Ju 2018,

Smartphones,’addictions’ and connections in Italy

By Shireen Walton, on 14 May 2019

Photo (CC BY) Shireen Walton

Last week during one of the women’s group activities at the Multicultural Centre I have been regularly attending in Milan I was asked if I could take a photo for one of the Italian women, Maria, in her early 70s, who volunteers at the Centre three days per week. Maria had just been found on Facebook by an old school friend and wanted to instantly send her a nice photo of herself ‘here and now’ on Facebook messenger to acknowledge and build the connection. Maria spent some minutes deciding where to pose, and how to fix her appearance, to the extent that it cut short in an abrupt manner the end of the meeting. Maria’s desire to connect across time/space there and then was so strong that the barries between the smartphone’s buzzing social universes and the physical social setting of the Centre had crossed over, with mixed responses by others present.

Centro Multiculturale, Milan. Photo (CC BY) Shireen Walton

Such examples of smartphone ‘intrusions’ into a social scene are not uncommon, and go hand in hand with a range of attitudes and judgements – that are often expressed and shared, ironically in smartphone-circulated memes, cartoons and photos. During my time in Italy a range of popular mantras reflect the alleged intrusion that digital connectivity feel poses to life: ‘we are all addicted!’ ‘just look at people on the metro – all face down, scrolling away, ignoring everyone and everything around them’, ‘at a party, no-one speaks to each other anymore, it’s crazy!’ and so on..

As an anthropologist, I find the worries and anxieties that some people have about smartphones – their over-reliance, seeming addiction or just about their general usage, part of the curiosity in exploring what the smartphone is, and how people describe it in relation to their everyday practices.  Peeling back the layers of these discourses, one sees the spectrum of practices that smartphones are implicated in in individuals’ lives, from connection with family, friends and community, to tools for navigating bureaucracy, citizenship, and health. All the while, the digital infrastructures that form and shape the basis for these interactions and practices (wifi, roaming data, connection speed…) form a part of people’s contextual and sited experience with their smartphone in daily life.

The notion of the ‘switched-on-self’, the boundaries between digital and non-digital lives has been a more general theme in my research and participant observation in my fieldwork with Italians and migrant groups in Milan. The correlation between being on/off in the person’s mind/body recalls and in some sense plays into wider global social trends like the flourishing of mindfulness and yoga that are posited by many people I speak with here as opportunities for peace – ‘places’ and practices to go to and do to ourselves and our bodies to ‘switch off’ from our busy, including constantly connected, digital lives.

Outdoor yoga in the park in the Milan fieldsite; moments for digital detoxing. Photo (CC BY) Shireen Walton

Throughout my research I have noticed how the issues of technology addiction and connection have been defined along age lines. At AUSER, a nation-wide NGO association for active ageing in Italy with a headquarters in my fieldsite, and Milan-based organisation Grey Panthers that is concerned with ageing and technology, what I have deduced is that while facilitating digital connectedness is a core policy concern aimed at older people (senior/anziani) [1], while policies and initiatives being designed to tackle digital addiction have been identified an issue prominent amongst the young (giovani) [2]. The ASSA project’s interest in middle-age has helped nuance these discourses about young and older populations by looking at how people live their lives with smartphones – including between ‘old’ and ‘young’ categories of age.

To take some examples. Alberto is 60, by policy standards he is neither old nor young. He still works full-time as a history school teacher at the local public school, and is an active volunteer in local community events. Reflecting upon his relationship with his smartphone Alberto describes how he does not consider himself particularly technologically savvy, nor up-to-date with regards to apps. However, from the moment he wakes up (first his alarm, followed by checking WhatsApp, Facebook and then email notifications from bed) he is attaccato (‘attached’) to his phone. He says he is mindful of his pupils’ usage, particularly in the classroom, but confesses to regularly checking his phone during school hours himself. He is in touch with his daughter in her 20s who is searching for work, as well as with the left-wing community organisations he co-runs with friends, monitoring Facebook pages dedicated to spreading awareness of local history and resistance to Fascism, particularly in light of the current policies of the present Interior Minister Matteo Salvini’s far-right anti-migrant stance. Alberto’s smartphone is a reflection of his social universe, and this visibly engagements and investments with this smartphone.

Photo (CC BY Shireen Walton)

Meanwhile Davide, 64, is retired, on a state pension. He volunteers running one of the community allotments in the neighbourhood several days a week. Davide uses his smartphone regularly. It is central to the way he runs the allotments, communicates with the community, and maintains his social life as a single, retired, socially-active man in his mid-60s. Davide also does not consider himself a tech-savvy person. Speaking about apps and app usage he, like many other people I find, explains: “I don’t have any apps really… I rarely use any…” We then discover together, by observation with the phone, that he does have a number of apps, and in fact uses a number of these frequently – many of the social media apps, an app for his gym, an app for the weather, apps that identify what certain plants are… He is not ‘addicted’, but he is reliant, reasonably heavily, on his phone.

Milan neighbourhood community allotment. Photo (CC BY) Shireen Walton

Smartphone practices for some like Alberto and Davide are involved in reflecting and shaping individual lives, social identities and wider offline practices. However, digital infrastructure and connecting to the Internet also plays a significant part in explaining smartphone reliance, and people’s conceptualisation of their phone. In some cases, loss of Internet connection (due to low reception or running out of credit) can be annoying, humiliating, and harmful.

Adla from Tanzana is in her mid 30s, and has a 1-year old daughter. She has been in Milan for a year and a half. Her daughter was born in the city, but has been told by authorities that her daughter is not yet old enough to attend nursery. Adla explains how she does not feel entitled to take part in certain social / support groups since her daughter is too young to go to school and she is uncomfortable attending the mothers groups in here area that are a big source of community life here but which are dominated by Arabic-speaking Egyptian women, which makes Adla feel like the ‘wrong kind of foreigner’ with the ‘wrong kind of languages’, being Tanzanian, speaking Swahili and some English, but limited Italian. Adla relies on her smartphone to navigate the geography of the city, including finding relevant administrative offices, using Google Translate to communicate in basic Italian, and maintain connection with her family – her sister in Sweden, her husband is working in another country in Africa, and the rest of her family are back in Tanzania. Adla does not have Wi-Fi in the one-bedroom apartment where she lives, so uses data roaming through her basic monthly social services allowance to access her familiar social universe. This connection to her smartphone as a physical thing holds intense meaning for her and her ability to navigate her way through each day. Even when the data has run out and it is not connected it is of comfort to Adla in the absence of physical, familiar, offline social life. Unlike Alberto or Davide, whose smartphones reflect their wider activity and presence in the neighbourhood, Adla’s smartphone life takes on heightened significance where her offline life is marred by insecurity and limited physical participation.

In a final example, an Egyptian family in the neighbourhood have been applying for a visa to visit their immediate family in the US who they have not seen for several years. The couple, in their mid-40s, work full-time in Milan as a baker and cleaner respectively, and their teenage children attend local public schools. Every year they apply for entry to the US via a lengthy application system. The family do not have WiFi at home and have limited data roaming on their phones. Upon receiving a letter in the post saying that they need to check the status of their visa application on the US state department website within a specific time period, the couple try to do this in the hours when they are not working, and due to their long working hours that leaves little time to stay for long periods of time in Internet cafes. The site keeps crashing and needs refreshing, and entering the application details in English, a language neither of them speak, is time-consuming. They repeat the process over and over again on their basic smartphones, at times in public free WiFi zones in the city, or at home with their limited data, to no avail. Upon learning about their experience with this process I become involved – the couple ask me to assist with internet access and English translation. Eventually, we discover that their application has been refused, to the couple’s stoic acceptance. It is but a small anecdote in this family’s larger experience of social stress, living on the margins of society in Milan as a close-knit ‘stranieri’ (foreign) family making do in their current set-up, where smartphones, Internet connections, are all part and parcel of broader lived realities; practices, experiences and desires.

In sum, the relationship between the smartphone, and what is often viewed as addiction or social rudeness – particularly amongst youth – are important themes to nuance further, along broader demographic lines. Understanding how and how much different people, of different ages and socio-cultural backgrounds, use and shape their lives around in a given context in relation to smartphones may well point to technological addiction, ill-health, and too much screen time, but it also highlights how central the phone is as a thing itself – for many, an object of attachment, including and beyond its switched on capacity for digital connection. A wide range of factors stemming from broader social contexts thus situate the smartphone holistically as an object of everyday life.

Notes and references:

[1] Auser’s mission statement is aimed at ‘promoting the active ageing of the elderly and enhancing their role in society’, which includes technological education and encouraged usage for wellbeing and for a positive impact on lifestyle. In the University of the Third Age for over 60s that Auser runs through a network of volunteers, ‘technological awareness’, as well as lectures on the dangers of data and privacy issues form a part of a broader curriculum on a wide variety of topics from horticulturalism to cooking to tourism and so on.

[2] De Pasquale, C., Sciacca, F., Hichy, Z. (2017). ‘Italian Validation of Smartphone Addiction Scale Short Version for Adolescent and Young Adults’ in Psychology 08(10): 1513-1518.

 

 

Older adults in Chile as digital immigrants: facing the ‘digital transformation’ towards a paperless world

By Alfonso Manuel Otaegui, on 22 April 2019

Photo by Alfonso Otaegui

Nowadays many bureaucratical procedures can be done online. In just a couple of years, however, online will be the nearly only option in Chile. This paperless trend represents a challenge for older adults, as it pushes them to access the internet for everyday tasks that were simpler for them on paper, such as paying the bills or getting information on free activities for seniors.

Older adults constitute a significant component of the Chilean population, as the aging process of this South American country has continued. According to the National Institute of Statistics (INE), the percentage of people aged over 65 years or more grew from 6,6% in 1992 to 11,4% in 2017 (2.003.256 people). If we extend the age range to 60 years or more, the figures get even more significant. According to the National Service for Older Adults (SENAMA), 16,2% of Chile’s population is 60 years old or older (roughly around 2.800.000 people) (‘Censo 2017 reveló que (…)’ 2017).

The Chilean Senate has recently approved the bill of  “Transformación Digital en el Estado” (“Digital Transformation in the State”). This law aims at modernizing the functioning of the State. “We are in 2018 and we still handle most of our bureaucratical procedures on paper”, said President Sebastian Piñera in the letter accompanying the law proposal (‘Mensaje de S.E. el Presidente de la República (…)’ 2018: 2). The president encourages the use of electronic resources based on two main arguments: saving time and sparing paper. One of the main points of the bill is that most State bureaucratical procedures will have to be done in electronic form. This bill takes into account the fact that some people lack access to the required technology, and it gives to those people the chance of doing bureaucratical procedures on paper. However, this possibility is strictly exceptional. While the electronic form is the rule, the paper is an exception that will have to be requested and duly justified (ibid. 7).

So, how does this government initiative affect older adults? This 16% of the population needs to access the internet to become part of this ‘Digital Transformation.’ According to the Chilean Sub-secretary of Communications, 84,8% of the access to the internet in 2018 was done through mobile devices (93,4% of these devices were smartphones) (‘Conexiones 4G se disparan 35% en 2018 (…)’ 2019). This situation implies that older adults will need to master the smartphone to keep up with the proposed changes in the administration.

Learning to use a smartphone implies a challenge for older adults, at least on two fronts. Firstly, it implies an adaptation to a new type of user interface (UI). Mobile devices’ UIs are radically different from the electromechanical UIs found in the older technologies more familiar to older adults. While in older technologies’ UIs most –if not all– of the system functionality is accessible at once through buttons and switches, mobile devices’ UIs imply navigating several screens and contextual menus that display only a fraction of the whole system at a time (Docampo et al. 2001).

Secondly, this learning process requires proper guidance. In the smartphone workshops I volunteer, I often ask my students about the main obstacles they encounter in their learning experience. By far, the factor they complain the most about is that their younger family members lack the patience to teach them. “My daughter bought this phone for me –says a 63 years old lady– and taught me [how to use it] on the first day. After that, if I ask something, she says ‘I already taught you’!”. “When you ask them how to do something –explains a 67 years old man–, they do it very fast on your phone, ‘pa, pa, pa, it’s done!’, but they don’t show you how to do it”. Elderly students require self-paced learning, as they experience greater anxiety and frustration while learning to use new technology (Fisk et al. 2009).

If the Chilean government wants to include this important sector of the population in this ‘Digital Transformation,’ then it should develop public policies to address the unique learning needs of older people properly. In all fairness, there are several state-run cultural centers and public libraries in Santiago that offer free lessons for older adults –as the ones where I’ve been teaching. They have two constraints, unfortunately. On the one hand, there is a very limited number of places: in some cases, students are allowed to attend a workshop only once, as they have to leave the place to new students. These workshops usually last one month (with one or two classes a week), which is not enough for students of this age, who need various exercises over more extended periods (Fisk et al. 2009). On the other hand, the teacher-to-student ratio is not as high as it should be. The diversity of UIs across the whole spectrum of Android phones requires personalized teaching, as any procedure explained in front of the entire class has to be repeated with each student, to apply minor –yet fundamental– tweaks to each case.

Chile is pushing forward the paperless trend. A well planned public policy of digital alphabetization for older adults with specialized teachers would be then of the utmost importance to help the older ‘digital immigrants’ (Leung et al. 2012) to join the trend.

 

References

Censo 2017 reveló que más del 16% de la población chilena es adulto mayor. (2017, December 27). Retrieved from http://www.senama.gob.cl/noticias/censo-2017-revelo-que-mas-del-16-de-la-poblacion-chilena-es-adulto-mayor

Conexiones 4G se disparan 35% en 2018 y abre expectativas de cara al despliegue de 5G. (2019, April 10). Retrieved from https://www.subtel.gob.cl/conexiones-4g-se-disparan-35-en-2018-y-abre-expectativas-de-cara-al-despliegue-de-5g/

Docampo Rama, M., De Ridder, H., and B. Ouma , H. 2001. Technology generation and age in using layered user interfaces. Gerontechnol. 1, 1, 25–40.

Fisk, A. D., Rogers, W. A., Charness, N., Czaja , S. J., and Sharit, J. 2009. Designing for Older Adults: Principles and Creative Human Factors Approaches2nd Ed. CRC Press.

Institituto Nacional de Estadísticas Chile. 2018. Síntesis resultados Censo 2017. Santiago: Instituto Nacional de Estadísticas Junio / 2018.

Leung, R., Tang, Ch., Haddad, Sh., McGrenere, J., Graf, P., and V. Ingriany. 2012. How Older Adults Learn to Use Mobile Devices: Survey and Field Investigations.ACM Transactions on Accessible Computing, Vol. 4, No. 3, Article 11.

Mensaje de S.E. el Presidente de la República con el que se inicia un proyecto de ley sobre trasnformación digital del sector público (2018, June 25). Retrieved from https://digital.gob.cl/doc/Proyecto-de-Ley-Transformacion-Digital.pdf