Existing research has shown that care leavers are one of the most disadvantaged groups in society and are at particular risk of experiencing negative long-term outcomes including unemployment, homelessness and mental health problems. This thesis makes a contribution to knowledge in this area by focusing upon a group of care leavers about whom very little is currently known: care leavers in higher education. These are young people who despite the odds, have succeeded educationally and are overcoming their early disadvantage to make a successful transition from care into adulthood. This thesis uses Bourdieu's theory on transformation and reproduction in society and the concepts of capital, field and habitus to explore care leavers' experiences of higher education. It considers how the support available to care leavers from their local authorities and higher education institutions has developed since Jackson and colleagues (2005) Going to University from Care study first highlighted deficits in the level of support provided to care leavers. This thesis also compares the experiences of care leavers with students from other disadvantaged backgrounds to understand where care leavers have specific support needs as a result of not being supported at university by their birth parents. Finally, this thesis considers the impact of the Buttle UK Quality Mark, developed in response to the findings of Jackson and colleagues (2005) and awarded to universities demonstrating a commitment to supporting care leavers.

Older Norwegian adults with an intellectual disability are today more integrated into society than earlier generations. Some represent the last of the generation that experienced and can talk about childhoods in central institutions and about living under the World War II Nazi regime. The closure of Norwegian institutions, which took place in the1990s, was based on social valuation theories. The post-closure situation for people with intellectual disabilities, their staff and local authorities was very different form what they had experienced previously, local authorities being responsible for providing person-centred services. This thesis examines whether life story work represents an effective approach to the person-centred support of older adults with an intellectual disability, through examining the impact of this work on services users (‘storytellers’) and their life story work supporters (‘interlocutors’). ‘The life story model of identity’ developed primarily by the American psychologist and professor Dan P. McAdams, is a major contribution to the thinking of this study. The model emphasises the importance of service providers’ understanding and knowledge of their service users’ life stories. A combination of critical realism and interpretative phenomenology analysis is advanced as a suitable joint philosophical framework for investigating the impact life story work has on both storytellers with intellectual disabilities (aged 45+) and on the interlocutors they personally chose from their staff group. The Delphi technique was used in a preparatory phase of interviews of six experienced life story workers from three different countries. A Participatory Action Research (PAR) approach was used to prepare the intervention, to develop the LSW programme and for pre- and post-interviews. 38 participants from day centres and residential settings in Norway took part in the study. The results indicate that even staff who had known storytellers for a long time learned new and valuable information. They came into possession of a better understanding of the service users’ behaviour and the interlocutors’ attitudes to service users were changed by the experience of carry out life story work with them. The interlocutors stated that they considered life story work to be ‘important’ in today’s services. The storytellers experienced increased feelings of safety and greater awareness of their abilities, life span (roots) and of themselves as a person (identity and personal development). They expressed pride in their life story work and appreciated the time they had spent talking and working alone with their interlocutors. Storytellers and interlocutors both said that life story work had brought them closer together and the love and appreciation they had for each other was a clear result of the time they had spent together. The eight week programme was, however, also challenging for the interlocutors who had problems finding the opportunity to conduct two hours work a week without interruption from other contextual influences.

An increasing proportion of people in the United Kingdom are living longer with long-term conditions. The National Health Service is facing the challenge of increased pressure on its service provision. A number of key health policy initiatives encourage individuals to make informed choices and purport to give them rights and control over their own health and healthcare. Within this context, people are actively encouraged to self-care, manage diseases, and make decisions and choices about healthcare in an informed way. To facilitate this, it is important to gain an understanding of the health information seeking behaviours of older people. Health information is available from various sources but little is known about the health information seeking behaviours of older people and what affects this. By exploring this, it helps to reveal how health information is sought regarding on-going health conditions and provides greater depth in understanding the health information seeking process. The study explores older people's experiences and views on their health information seeking behaviours and endeavours to gain a better understanding of these experiences and views. The study draws on constructivist grounded theory with two phases to data collection: Nine participants completed un-structured diaries over two months with follow up semi-structured interviews, a further twenty participants participated in semi-structured interviews. Major categories were inductively drawn from participant's responses. Strategies of health information seeking behaviours are not necessarily fixed, but subject to change over time. The analysis suggested three main categories that explained the health information seeking behaviours of older people. Three interrelated conceptual categories were identified: (1) Regulating self (2) Self managing and (3) Self-mobilisation. These categories formed the basis of the emergent substantive theory called 'navigating later life'. There were different patterns of behaviours between participants which captured variations in information seeking; these informed the development of a typology of health information seekers. Ageing in the 21st century is a complex process; with older people inhabiting a world of more choice, multiple sources of knowledge, changed healthcare roles and increased self-care undertaken within the home. The study provides important insights for healthcare professionals and raises implications for strategies aimed at improving older people's access to appropriate health information. The navigation model provides a potentially valuable tool for policy makers when considering the support older people require to self-care.

The demographic time bomb means that older people will become a major part of tomorrow's society. This has become an increasingly pressing issue for older people and government policy alike. ONS (2009) statistics suggest that past retirement age, the sense of quality of life (QoL) experienced by older people begins to decrease, with the fastest decline occurring after the age of 70. This research therefore began by investigating how ICT could be implicated in the social life of the older person and thus improve their QoL. Literature reviews of the field of older people's involvement with ICT indicated that there was very little research between the more general studies of ICT involvement (which include far more than the purely social aspects) and the very specific (which involve examining the social impact of just one piece of technology). This study therefore aimed to fill the gap between the two extremes. It also aimed to generate theory in an under-theorised area. The study began with a focus group and interviews asking questions around how people thought social life had changed with the advent of new technologies, how they experienced the technology, and how things could be improved in the future. The study was qualitative in nature and adopted a grounded theory approach in order to inductively generate theory. The study of the lived experience of ICT also contributed to a phenomenological approach. Comparative analysis of transcripts obtained in Phase One (Year One) enabled a set of Grounded Theory Categories to be created which accounted for what was happening in the data. A core category of identity was identified which influenced subsequent data collection in Phase Two (Year Two). Phase Two participants were then involved in more focused interviews around identity concepts. Further analysis in Year Two enabled a Schema of Subject Positions to be created concerning (digital) identities which accounted for all of the participants in the study and the ways in which they viewed and interacted with technology. The Categories were also subsumed within a Grounded Theory Model involving a tripartite identity schema aligned with Giddens theory of the reflexive project of the self. Findings suggest that participants are implicated in methods of identity involvement which can be playful or pragmatic; can be viewed in moral, immoral and amoral ways (leading to ideas of the authentic and the inauthentic); and can represent the individual or explore new identities. Identity construction can ultimately be implicated positively with the use of ICT, and may lead to a virtuous cycle of ICT usage which can improve quality of life by affirming better self-views or enabling the testing of new views of selfhood. Positive technology identities can be offered as identity role models for other older people to follow.

Social care and health services for older people in Cambridgeshire have been integrated since April 2004. This study examines the effect of the integration programme on service users. Previous research into health and social care integrations predominantly centre on process issues and pay much less attention to outcomes. No study has evaluated the impact of fully-integrated care services for the whole user group of older people. Theory-led programmatic approach was used in this study. Multi-method data collection and analysis were employed to uncover and examine the causal links, the contextual conditions, the implementation process, causal mechanisms, and intended and achieved outcomes of the integration programme. This study reveals an improvement in the physical functioning of one in three occupational equipment users; a rise in the level of satisfaction of 85% of occupational health and 82% of physiotherapy users; older people with complex problems and high-level needs were able to be helped to live at home; and waiting time for both assessment and for services within two weeks and four weeks were below the national achievement and the ministerial targets. It also reveals a lack of change outcomes in social care, and service users’ low level of satisfaction with social care services, which appear to be associated with the privatisation of long-term social care and the predominant aim in social work of achieving maintenance and prevention outcomes. The integration programme’s goals—unifying the care system, easier and simpler access to services and a single and quick assessment—were not fully reached, mainly because of users’ low awareness of the integration, incompatible ICT systems and lack of funding. This study contributes to knowledge on how the total integration in Cambridgeshire has benefited users and how theory-led programmatic approach can be used in this area and in the study of this kind of complex social programme.

Modernity has brought many benefits (e.g. technological advances, material comfort, longer life expectancy and improved health). However, it is argued that we are now experiencing 'diminishing returns‘ from and 'adverse effects‘ of a Modernist worldview (Hanlon et al 2011; 2012a; 2012b). Evolutionary theories and models of paradigm change (e.g. Beck and Cowan 2006; Senge et al 2005; Scharmer 2009; Wilber 2001) offer a way of thinking about how our worldviews emerge and shift in response to existential challenges and so called 'wicked problems‘ (Rittel and Webber 1973). This study aimed to explore people‘s experiences of co-production and wicked problems in the context of care for older people in light of theoretical perspectives of evolutionary paradigm change. Method: This study adopted a parallel process of a) an instrumental case study to explore the substantive topics of co-production and wicked problems in the context of care for older people and b) the development of an analytical lens informed by concepts associated with evolutionary theories of paradigm change, through which empirical case study findings were re-interpreted. The case was an older people‘s residential care service within a Scottish Local Authority. This encompassed 11 care homes for older people. 30 in-depth qualitative semi-structured interviews were undertaken with frontline Care Workers, Care Home Unit Managers, Senior Managers and Key Theoretical informants. A constructivist-grounded theory approach was taken to data analysis to produce narratives around care, change and problems. These narratives were then re-interpreted through an evolutionary paradigm change lens. Findings: Using an evolutionary paradigm lens enabled an exploration of the underpinning worldview that is giving rise to patterns of activity and way of organising care observed in the case study. It also led to a reframing of care for older people as an existential issue rather than a conventional wicked problem. Co-production was reinterpreted as a yearning for connection, humanity and aliveness within our health and social care services in response to the dehumanising tendencies and effects of the Modernist paradigm. However, it was found that the organisational response to this yearning was rooted in a dominant Modernist way of thinking, being and doing. Instances of so-called 'horizon capture‘ (Sharpe 2013) were witnessed, suggesting that the spirit of co-production could become thwarted and subsumed within mechanistic approaches. Conclusion: An evolutionary paradigm change lens yields ideas and novel perspectives which may be of use to those in the public sector who are seeking to navigate the uncharted territories inherent to being at the edge of an emerging paradigm.

Pour assister les aînés, les technologies apparaissent a priori comme des ressources intéressantes. Encore faut-il qu’elles soient acceptées. Les modèles théoriques d’acceptation des technologies existants s’ancrent difficilement dans les cadres disciplinaire et empirique de la gérontologie. L’objectif de cette recherche est donc de proposer une théorisation du processus d’acceptation des technologies qui tienne compte du vieillissement biopsychosocial. Une démarche scientifique empirico-inductive est mise en œuvre. Il s’agit d’une Théorisation Ancrée (TA) dans l’expérience vécue par des aînés associés à la conception d’un calendrier interactif (Amelis). Les études psycho-ergonomiques conduites pour la conception avant et pendant l’usage d’Amelis montrent que les AME ont plusieurs fonctions utiles pour les aînés. Mais des obstacles d’usage apparaissent concernant l’apprentissage, la crédibilité du système, ou encore ses sollicitations corporelles, émotionnelles et cognitives envers l’utilisateur. La compréhension de cette réalité vécue par les aînés assure l’ancrage empirique de la TA dont les résultats mettent en évidence la centralité du concept de temporalité. Ce concept se décline selon les dimensions chronologique, adaptative et axiologique du temps. Ainsi, dans un contexte gérontologique, l’acceptation d’une technologie se rapporte à des moments spécifiques, à des processus développementaux et adaptatifs mais aussi aux perceptions et valeurs accordées au temps. Intégrer le concept de temporalité et ses déclinaisons aux modèles d’acceptation des technologies renforcerait leur cohérence théorique et empirique avec le vieillissement. / Technologies may support older adults in their aging process. However, to be useful, they have to be accepted. Existing technology acceptance models are not well adapted into the gerontological context. These models probably neglect aging-specific acceptance factors. The aim of this study is to understand the technology acceptance process by the older people. We develop an inductive and empirical approach for conceptualising the acceptance dimensions related to the biopsychosocial experience of aging. We used an adaptation of the Grounded Theory (GT) methodology to investigate older participants’ experience during the participatory design of an interactive calendar called Amelis. Both the design studies and the usage studies highlight that Amelis can be useful for the elderly in different ways. Nevertheless, we identify barriers to the use of such technology. They are related to the learning process, the credibility of the electronic device, and various loads for users (i.e. cognitive, emotional, physical). Understanding user experience represents the empirical basis of the GT. The GT results emphasize that time is a key concept to analyze technology acceptance by the elderly. Three conceptual dimensions appear regarding time: chronological, adaptive, axiological. The gerontological context gives precise meaning to those dimensions. Accordingly, technology acceptance by the elderly especially depends on (1) specific moments (2) adjustment process regarding aging changes (3) time value. Underlining the importance of time provides directions for further research within the elderly. It also supports the evolution of professional practices as well as institutional choices.

Introduction : Peu d'études se sont intéressées aux aides à domicile dans l'accompagnement de la vieillesse et moins encore, dans celui concernant les conduites d'alcoolisation à cet âge. Dans cette thèse s'inscrit dans une approche intégrative incluant une méthodologie quantitative et qualitative. Ainsi, nous étudions les aspects psychologiques de ces aides à domicile tout en les comparant à celles accompagnant la maladie d'Alzheimer.Méthode : 99 aides à domicile recrutées en milieu écologique ont répondu à un questionnaire de données professionnelles de 62 items, une échelle d'estime de soi (EES), un questionnaire de satisfaction de vie professionnelle (ESVP), un inventaire d'épuisement professionnel (MBI) et une échelle évaluant la symptomatologie anxio-dépressive (HADS). Les participantes ont été réparties en deux groupes : celles soulignant des difficultés dans l'accompagnement de la maladie d'Alzheimer (n=63) et celles évoquant des difficultés dans l'accompagnement de conduites d'alcoolisation (n=36). Parmi elles, 18 ont accepté de participer à un entretien de recherche enregistré et analysé à l'aide du logiciel QDA Miner 4.Résultats : Les résultats des dimensions psychologiques sont statistiquement significatifs lorsqu'ils sont associés aux caractéristiques professionnelles. Dans l'accompagnement des conduites d'alcoolisation, lorsqu'elles connaissent le diagnostic de la pathologie, l'épuisement émotionnel est plus élevé et celui-ci est corrélé positivement avec l'humeur dépressive et négativement avec la satisfaction de vie professionnelle. L'accomplissement personnel est corrélé négativement avec la symptomatologie dépressive. La satisfaction de vie professionnelle est corrélée positivement avec la relation de satisfaction avec l'entourage. Dans l'accompagnement de la maladie d'Alzheimer, quand elles ne connaissent pas le diagnostic de la pathologie de la personne âgée, leur épuisement émotionnel est plus élevé et celui-ci est corrélé négativement avec la satisfaction de vie professionnelle et positivement avec la symptomatologie anxio-dépressive.Pour les conduites d'alcoolisation, le discours relatant des difficultés avec la personne âgée a un lien de similarité avec les représentations de la maladie, la progression de la maladie, les relations avec les familles et le sentiment d'impuissance de l'aidante face à la pathologie de l'aidé. Le discours sur les satisfactions a un lien de similarité avec ceux évoquant l'expérience pour accompagner, les représentations et les compétences pour parler de la maladie avec les âgés. Concernant la maladie d'Alzheimer, le discours relatant des difficultés avec la personne âgée a un lien de similarité avec ceux évoquant les représentations et la progression de la maladie, ainsi que les identifications de l'aidante face au vieillissement de l'âgé. Le discours sur les satisfactions a un lien de similarité avec l'expérience pour accompagner et les raisons pour lesquelles elles exercent ce métier. Cette étude permet de mieux appréhender les spécificités psychologiques des aides à domicile française et ouvre ainsi, des perspectives de recherche. Des implications cliniques pourraient voir le jour dans la prévention des aspects psychologiques auprès de cette population. / In France, few studies were interested by care social workers in the accompaniment of old age and less still, in that concerning the alcohol misuse at this age. In this thesis, we study the psychological aspects of these professional all while comparing them with those to support the Alzheimer's disease. 99 social care workers answered a questionnaire of 62 professional data, a scale of self esteem (EES), a questionnaire of job satisfaction (ESVP), an inventory of burnout (MBI) and a scale of anxio-depressive symptomatology (HADS). The professionals were divided into two groups: those with the difficulties in the support of the disease of Alzheimer (n=63) and those with the difficulties with alcohol misuse (n=36). Moreover, 18 of whom were interviewed. In the support of alcohol misuse, significant results show that when they know the diagnosis of pathology, emotional exhaustion is higher and this one is correlated positively with depressive mood and negatively with the job satisfaction. The personal achievement is correlated negatively with depressive mood. The job satisfaction is correlated positively with relatives' relations. In the support of Alzheimer's disease, when they don't know the diagnosis of the pathology, emotional exhaustion is higher and this one is correlated negatively with the job satisfaction and positively with anxio-depressive symptomatology. For the alcohol misuse, the interview of difficulties with the elder is related to similarity with those showing the representations and progression of the disease, the family's relations and the feeling of ineffectiveness for supporting the pathology. The discussion of satisfactions is related to similarity with those evoking the professional experience, the representations and skills to speak with the person about the disease. For Alzheimer's disease, the discussion of difficulties with the elder is related to similarity with those evoking the representations and the progression of the disease ¿ and that ¿ with the identifications of the senior. The discussion of satisfactions is related to similarity with those talking the professional experience and the evocation of the personal reasons to work. This study allows considering the specificities of French social care workers. It opens some research perspectives and could have a clinical implication in prevention of this population.

Dans les pays de l’OCDE, le vieillissement démographique et la prévalence croissante de maladies chroniques induisent un accroissement marqué des effectifs de personnes âgées dépendantes. Répondre à la préoccupation sociétale concernant l’accompagnement des personnes en incapacité dans un contexte de pression sur les finances publiques constitue un défi majeur pour les politiques publiques. Comment les dispositifs publics visant à financer les soins de longue durée affectent les aides formelles et informelles reçues par les personnes en situation d’incapacité ? La distribution des aides médico-sociales et des restes-à-charge est-elle équitable ? Comment améliorer l’efficience et l’équité des dispositifs publics ? Cette thèse apporte un éclairage sur ces questions en mobilisant les outils conceptuels de la microéconomie et les méthodes de l’économie appliquée. Elle rassemble quatre investigations empiriques menées à partir de données françaises et néerlandaises récentes. Les 3 premiers chapitres traitent du cas français. Le chapitre 1 étudie la distinction faite entre adultes handicapés et personnes âgées dépendantes. Il évalue l’effet de la « barrière des 60 ans » sur les aides formelles et informelles reçues. Les chapitres 2 et 3 se focalisent sur le dispositif-phare destiné aux personnes âgées dépendantes, l’Allocation personnalisée d’autonomie (APA). Le chapitre 2 estime les élasticités prix et revenu de la demande d’aide à domicile des bénéficiaires de l’APA. Le chapitre 3 évalue l’équité dans l’utilisation des aides et des restes-à-charge dans le cadre de l’APA. Le chapitre 4 évalue l’équité horizontale dans l’utilisation de soins de longue durée aux Pays-Bas. Les subventions sur l’aide à domicile induisent des ajustements dans la consommation d’aide via des effets de revenu et de substitution, ce qui a des implications pour l’efficience de ces dispositifs. Des iniquités sont détectées dans les deux pays. / Dans les pays de l’OCDE, le vieillissement démographique et la prévalence croissante de maladies chroniques induisent un accroissement marqué des effectifs de personnes âgées dépendantes. Répondre à la préoccupation sociétale concernant l’accompagnement des personnes en incapacité dans un contexte de pression sur les finances publiques constitue un défi majeur pour les politiques publiques. Comment les dispositifs publics visant à financer les soins de longue durée affectent les aides formelles et informelles reçues par les personnes en situation d’incapacité ? La distribution des aides médico-sociales et des restes-à-charge est-elle équitable ? Comment améliorer l’efficience et l’équité des dispositifs publics ? Cette thèse apporte un éclairage sur ces questions en mobilisant les outils conceptuels de la microéconomie et les méthodes de l’économie appliquée. Elle rassemble quatre investigations empiriques menées à partir de données françaises et néerlandaises récentes. Les 3 premiers chapitres traitent du cas français. Le chapitre 1 étudie la distinction faite entre adultes handicapés et personnes âgées dépendantes. Il évalue l’effet de la « barrière des 60 ans » sur les aides formelles et informelles reçues. Les chapitres 2 et 3 se focalisent sur le dispositif-phare destiné aux personnes âgées dépendantes, l’Allocation personnalisée d’autonomie (APA). Le chapitre 2 estime les élasticités prix et revenu de la demande d’aide à domicile des bénéficiaires de l’APA. Le chapitre 3 évalue l’équité dans l’utilisation des aides et des restes-à-charge dans le cadre de l’APA. Le chapitre 4 évalue l’équité horizontale dans l’utilisation de soins de longue durée aux Pays-Bas. Les subventions sur l’aide à domicile induisent des ajustements dans la consommation d’aide via des effets de revenu et de substitution, ce qui a des implications pour l’efficience de ces dispositifs. Des iniquités sont détectées dans les deux pays.In OECD countries, population ageing and the increasing prevalence of some chronic diseases cause a substantial increase in the number of the disabled elderly. Responding to both the societal concern for ensuring appropriate longterm care (LTC) to the disabled and the pressure on public spending is a major challenge for public policies. How do public LTC schemes affect the use of formal and informal care by the disabled? Are there socio-economic disparities in the use of formal care? Is the allocation of LTC services and of the out-of-pocket payments incurred by the disabled elderly equitable? Which features of LTC policies could be changed to make them more efficient and more equitable? My research sheds light on these questions, using conceptual tools from microeconomics and methods in applied economics. It brings together four empirical investigations led in the contexts of France and the Netherlands, which have contrasting LTC systems. I make use of recent administrative and survey microdata. The first three Chapters focus on French policies. Chapter 1 studies the distinction that is made between the handicapped adults and the dependent elderly in access to public LTC support. It assesses the effect of the “age 60 threshold” on the formal and informal care received by individuals with a disability. Chapters 2 and 3 concentrate on the main scheme accessible to the disabled elderly, the Allocation personnalisée d’autonomie (APA). Chapter 2 estimates the income and price elasticities of formal home care demand by APA beneficiaries. Chapter 3 assesses equity in the use and financing of home care within the APA scheme. Chapter 4 lands in the Netherlands and assesses income-related horizontal equity in LTC use. Home care subsidies trigger adjustments in the use of care through both substitution and income effects. This has implications for the efficiency of such policies. Some inequity is detected in both countries.

Les impacts du vieillissement de la population européenne ne peuvent se résumer aux modifications de la structure de la population. Aussi, les politiques publiques actuelles – nationales et européennes – se saisissent de ses enjeux sociaux et économiques dont le logement. Cette thèse étudie l’adaptation des logements aux enjeux du vieillissement dans les territoires européens en cherchant à comprendre la manière dont les personnes âgées et les politiques publiques prennent en considération l’impact du vieillissement individuel sur les conditions de logement et, plus largement, d’habitat. La mesure de l’adaptation du logement des 50 ans ou plus est réalisée en considérant la situation de logement (type, peuplement, équipements), celle de l’habitat (environnement de vie) et l’aide humaine reçue. Les cas danois, français et espagnols sont plus particulièrement étudiés, grâce aux données de l’enquête Survey of Health, Ageing and Retirement in Europe (SHARE). Trois questions y sont particulièrement traitées : dans quels pays l’adaptation se produit-elle ? Comment les individus y procèdent ? Qui y recourt et quand ? Chacune fait l’objet d’une méthodologie spécifique : typologies, étude des trajectoires et régressions logistiques. Elles permettent de mettre en évidence une adaptation globalement limitée et essentiellement centrée sur l’environnement. La manière dont elle se produit ne présente pas de schéma typique et peut répondre ou non à des besoins en termes de santé ou de taille du ménage. / The consequences of the ageing of Europe’s population ageing are not limited to changes in the population structure. National and European contemporary public policies have been tackling its social and economic implications, particularly in the field of housing. This PhD thesis studies the adjustment of housing to ageing in Europe. To do so, it examines the ways in which both the elderly and public policy-makers take into account the impact of individual ageing on housing and living conditions. Housing adjustments in individuals aged 50 were measured with a focus on housing conditions (type of housing, occupation, and amenities), living conditions and home care. The Danish, French and Spanish cases are most particularly analysed, based on data from the Survey of Health, Ageing and Retirement in Europe (SHARE). Three research questions are addressed : in which countries are adjustments made ? How do individuals adjust ? Who adjusts and when ? Each of these questions is answered with a specific methodology : clustering, trajectory analysis and logistical regressions. Adjustments are shown to be ultimately limited, and mainly focused on the environment. No typical adjustment scheme is identified ; adjustments may or may not be responses to needs in terms of health or household size.