Background: In recent decades, improvements in medical treatment, public health, technology and education have resulted in people living much longer. This includes people with learning disabilities, the fastest growing sector being the over-70s, and those who are women. There have been a limited number of studies exploring ageing in the population of people with learning disabilities, and very few of these have studied ageing from the perspectives of women. Aim: To develop a contemporary perspective of the lived experiences of older women with learning disabilities. Objectives - To identify how women with learning disabilities construct the experience of ageing, through the lens of an asset theoretical framework - To examine how older women with learning disabilities experience the wider cultural and socio-political influences, and how these impact on their lives - To utilise a narrative approach that integrates stories and photo elicitation to facilitate a more in-depth understanding of their experiences - To indicate how a refined model could be developed to improve policy and practice in the provision of services for older women with learning disabilities An inclusive methodology is central to this thesis, with an expert reference group of four women with learning disabilities working in partnership with the researcher. The expert reference group ensure that this work is grounded in everyday experience, providing both support and challenge. Ten women over 55 with mild or moderate learning disabilities were purposively invited to take part. Narrative methods integrated with photograph elicitation captured their lived experiences, facilitating a more in-depth 3 understanding of their experiences of ageing. In methodological terms this offered a number of strengths in helping the women to engage with the research process and provided a visual reference that promoted a more inclusive and flexible approach to capturing the lived experiences of older women with learning disabilities. Findings The findings identify how a group of older women construct their experiences of ageing. The equanimity and positive outlook on life is interpreted and understood through developing and understanding their protective health assets. A central theme is the importance of friendships and relationships, providing a buffer during adverse times and helping the women to feel supported and valued by their local community. Conclusion In its contribution to service development and knowledge, this thesis provides a contemporary perspective of the lived experience of women with learning disabilities as they age. Furthermore, mapping the narrated assets of these women introduces a new and alternative model for representing individual experiences that challenge the mainstream perspective that has been central to UK policy and practice during the 21st century. This thesis has begun to address a gap between policy and the reality of the lived experience, and presents an alternative asset-based relationship framework (Fig 30 p. 248) that has the potential to guide and shape future learning disability practices. Finally, this appears to be the first study to apply an asset theoretical framework to underpin research with women who have learning disabilities, offering an alternative perspective that challenges social care policy and professionally-defined integration and social inclusion indicators.

Ungdomars försämrade psykiska hälsa är ett stort folkhälsoproblem bland ungdomar i Sverige. Forskning visar att ungdomars sociala kapital kan ses som en hälsotillgång samt att skyddsfaktorer, som familj och vänner, har betydelse för den psykiska hälsan. Distriktsköterskor i elevhälsan har en viktig roll i att arbeta med individens friskfaktorer för att främja den psykiska hälsan. Syftet med studien var att beskriva om det finns ett samband mellan psykisk hälsa och socialt kapital, såsom socialt nätverk, social förmåga och känsla av tillhörighet bland flickor och pojkar i åldern 14-16 år. Tvärsnittsstudien genomfördes i en mindre stad i sydvästra Sverige. Total deltog 461 stycken ungdomar i åldrarna 14-16 år. Data om den självskattade psykiska hälsan och uppfattningen om socialt nätverk, den sociala förmågan och känslan av tillhörighet samlades in med hjälp av mätinstrumentet Minneapolis Manchester Life of Quality (MMQL). Både flickor och pojkar skattade psykisk hälsa och socialt kapital högt. Det fanns inget tydligt samband mellan psykisk hälsa och socialt kapital i form av socialt nätverk, social förmåga och känsla av tillhörighet. Socialt kapital skulle kunna belysas som en hälsotillgång av distriktssköterskan i det hälsofrämjande arbetet. Det behövs fler longitudinella studier för att få mer kunskap om effekten av socialt kapital på psykisk hälsa, samt vilken roll sociala medier har i ungdomars sociala kapital. / The increasing mental health issues among adolescent in Sweden is a major public health issue. Research shows that the social capital of young people can be seen as a health source, and that protection factors, such as family and friends, have an impact on mental health . District nurses in school health service have an important role in their work with individual's health factor to promote the mental health. The aim of this study was to describe whether there is a relationship between mental health and social capital, as social network, social ability and sense of belonging among girls and boys aged 14-16 years. The cross-sectional study was performed in a smaller town in southwest of Sweden. A sample of 461 adolescents aged 14-16 years participated. Data for the self-rated mental health and the perception of social network, social ability and sense of belonging were collected from the instrument Minneapolis Manchester Quality of Life (MMQL). Both girls and boys rated their mental health and social capital high. There was no clear connection between mental health and social capital, in forms of social network, social ability and sense of belonging. Social capital could be highlighted as a health addiction by the district nurse in health promotion. More longitudinal studies are needed to gain more knowledge about the effect of social capital on mental health, as well as the role of social media in youth social capital.

Este trabalho se propõe analisar a relação entre o investimento em saúde e desenvolvimento dos estados brasileiros - medido pelo Índice de Desenvolvimento Humano- (IDH) mediante a utilização da tecnologia de produção denominada FDH (Free Disposal Hull - Fronteira com livre descarte de recursos). Para os estados não eficientes, serão identificados os percentuais de alteração dos insumos necessários para que estados sejam eficientes. Na seqüência, são selecionados os estados eficientes e com baixo índice de desenvolvimento, para serem utilizados pelos governos estadual e federal como prioridade em uma política de desenvolvimento para o Estado brasileiro, uma vez que, esses estados, por serem eficientes, com o aumento de investimento em ativos de saúde, aumentarão seu índice de desenvolvimento. Em suma, tem-se que os resultados permitirão algumas considerações sobre a eficiência em alocação de recursos nos diferentes ativos de saúde, possibilitando auxiliar a tomada de decisão do gestor público, no que diz respeito à alocação dos recursos disponíveis para área da saúde. / In this work it has attempted to appraise, quantitatively, the efficiency levels of the brazilians states. It is analyzed the relationship between output (development) and inputs (Health Assets) by constructing nonparametric efficiency frontiers. The technique of efficiency analysis were used to determine this frontier is the FDH approach. For the not efficient states, the percentages of alteration of inputs will be identified (Health Assets) necessary so that states are efficient. In the sequence, the efficient states and with low index of development will be selected, to be used for the state and federal governments as priority in one politics of Brazil development, a time that, these states, for being efficient, with the increase of investment in health asset, will increase its index of development. The results will be provided useful insights into the assessment of the administrative efficiency Health Assets.

Este trabalho se propõe analisar a relação entre o investimento em saúde e desenvolvimento dos estados brasileiros - medido pelo Índice de Desenvolvimento Humano- (IDH) mediante a utilização da tecnologia de produção denominada FDH (Free Disposal Hull - Fronteira com livre descarte de recursos). Para os estados não eficientes, serão identificados os percentuais de alteração dos insumos necessários para que estados sejam eficientes. Na seqüência, são selecionados os estados eficientes e com baixo índice de desenvolvimento, para serem utilizados pelos governos estadual e federal como prioridade em uma política de desenvolvimento para o Estado brasileiro, uma vez que, esses estados, por serem eficientes, com o aumento de investimento em ativos de saúde, aumentarão seu índice de desenvolvimento. Em suma, tem-se que os resultados permitirão algumas considerações sobre a eficiência em alocação de recursos nos diferentes ativos de saúde, possibilitando auxiliar a tomada de decisão do gestor público, no que diz respeito à alocação dos recursos disponíveis para área da saúde. / In this work it has attempted to appraise, quantitatively, the efficiency levels of the brazilians states. It is analyzed the relationship between output (development) and inputs (Health Assets) by constructing nonparametric efficiency frontiers. The technique of efficiency analysis were used to determine this frontier is the FDH approach. For the not efficient states, the percentages of alteration of inputs will be identified (Health Assets) necessary so that states are efficient. In the sequence, the efficient states and with low index of development will be selected, to be used for the state and federal governments as priority in one politics of Brazil development, a time that, these states, for being efficient, with the increase of investment in health asset, will increase its index of development. The results will be provided useful insights into the assessment of the administrative efficiency Health Assets.

Public health policy and practice principally acknowledge a needs-based approach when developing, implementing, and evaluating community health programs. This needs-based perspective receives criticism because it focuses too heavily on what is missing or wrong with communities as opposed to building on their strengths. As a result, community members are perceived as passive recipients, which is disempowering, and ultimately risks creating unsustainable and ineffective programs. In recent years, there has been a growing interest in achieving a balance between the needs-based approach and the asset-based approach, which accentuates positive capabilities. While the amount of literature discussing the benefits of this latter perspective has grown substantially, accompanying evaluation required to sustain continued investment has been limited. Compared to needs-based research, there is less literature on asset-based evaluation. Emphasis on such research could contribute to the progression of evaluation methodologies and theories, ultimately encouraging their use. The purpose of this study is to apply an existing public health evaluation framework – the RE-AIM model (Glasgow, Vogt, and Boles, 1999) – to asset-based community health interventions and to examine the utility of such an evaluation structure across a variety of asset-based health projects. A multiple case study design facilitated comparison of the applicability of the RE-AIM model dimensions – Reach, Effectiveness, Adoption, Implementation, and Maintenance across three cases in the East London borough of Tower Hamlets, United Kingdom. These included the Local Links Asset-mapping project, the Healthy Early Years Project, and the Good Moves project. The RE-AIM framework is additionally guided by principles of the Realist Evaluation approach (Pawson and Tilley, 1997). This research study contributes to asset-based research by providing a guideline and conceptual framework to support asset-based intervention evaluation theory and practice.

Contexte. La démence est un problème de santé publique important. Toutefois, les stratégies actuelles en matière de santé publique ne tiennent pas compte des approches visant à renforcer les facteurs de protection pour en réduire le fardeau. Cela peut s’expliquer par le fait que le renforcement des facteurs de protection est un domaine de connaissance émergent. Son vocabulaire et ses notions de base sont encore en phase d’exploration et de définition. Parmi les termes et les notions à développer, citons la « santé positive » comme résultat du renforcement des facteurs de protection et les « atouts de santé », en tant que déterminant positif de la santé. Le développement de ces termes en promotion de la santé et leur adaptation pour les études sur la santé du cerveau contribueront à une meilleure compréhension des mécanismes permettant aux aînés de préserver leur santé cognitive, et donc ouvriront les portes à de nouvelles stratégies pour réduire le fardeau associé aux démences. L’objectif. Cette thèse vise à proposer un modèle pour l’étude de la santé cognitive des personnes âgées et à le tester dans une large base de données populationnelle. Pour atteindre cet objectif, nous avons i) dérivé la signification du terme de santé positive en examinant systématiquement la façon dont le concept est défini/utilisé par différents auteurs dans des publications sur la promotion de la santé ; ii) révisé les modèles existants de déterminants « positifs » de la santé (« modèles d’atouts de santé ») et proposer un nouveau modèle d’atouts de santé ; iii) discuté l’utilité du modèle pour la recherche sur la santé cognitive des personnes âgées, et iv) évalué l’apport indépendant des atouts de santé dans la probabilité d’une santé cognitive positive chez les personnes âgées, à l’aide du model développé. Méthodes. Un examen de la portée a été effectué pour atteindre les objectifs 1 et 2 ; une revue narrative a été réalisée pour atteindre les objectifs 3. L’analyse secondaire des données de l’étude de cohorte longitudinale « Survey on Health, Aging, and Retirement in Europe », vagues 5 et 7, a été réalisée pour atteindre l’objectif 4. Dans cette étude, les déterminants positifs avaient un effet indépendant sur la santé cognitive si i) leurs variables étaient statistiquement significatives dans le modèle entièrement ajusté et ii) ces variables améliorent significativement l’ajustement de la qualité du modèle. Résultats. 1) Aucun consensus sur la définition de la santé positive n’a été trouvé dans la littérature. Parmi les définitions proposées, il y a « bien-être », « extrêmement bonne santé », « résilience » et « capacités ». Nous avons proposé de définir la santé positive comme une réserve en capacités, permettant une plus grande résistance face aux agents pathologiques/adversités et un plus grand bien-être en leur absence. 2) Dans la littérature, des déterminants de la santé positive sont regroupés autour de traits individuels ou de caractéristiques environnementales. Nous avons proposé un nouveau cadre pour les atouts de santé. Dans ce cadre, les caractéristiques individuelles, les actions (orientées vers l’autodéveloppement ou le développement communautaire), les environnements (physique and social) et le soutien social (informel et institutionnalisé) sont interconnectés. Chaque composante précédente contribue à la suivante et à une santé positive. 3) L’état actuel des connaissances sur la santé cognitive permet l’opérationnalisation de la définition de la santé positive cognitive ainsi que du modèle des atouts de la santé. 4) Les variables de trois des quatre groupes d’atouts de santé (caractéristiques individuelles, actions et environnements) démontrent une contribution indépendante à la probabilité d’une santé cognitive positive chez les personnes âgées. L’inclusion des atouts de santé améliore significativement la qualité de l’ajustement du modèle : le pseudo-R-carré a augmenté de 0,31 à 0,33 ; l’aire sous la courbe ROC a augmenté de 77,8 % à 79,5 %, p<0,0001. Cela signifie que les atouts de santé expliquent davantage la probabilité de santé cognitive positive. Conclusion. L’étude sur les facteurs renforçant la santé cognitive pourrait aux nouvelles opportunités pour la diminution du fardeau de démence. Une validation plus poussée du modèle est nécessaire. Premièrement, des indicateurs plus spécifiques d’atouts de santé doivent être trouvés. Deuxièmement, les relations entre les groupes d’atouts de santé devraient être clarifiées. / Background. Dementia is a significant public health challenge; however, current strategies on public health hardly consider the potential of reinforcing protective factors to diminish its burden. A possible reason for this is that reinforcing protective factors represent an emerging field of knowledge. Its vocabulary and basic notions are still under development. Among the terms and notions needing further discussion are “positive health” as the outcome of these reinforcing protective factors and “health assets” as positive health determinants. Advances in the development of these terms in health promotion and their further adaptation to the realm of studies on cognitive health will contribute to a better understanding of how older adults maintain it, which, in turn, could open the doors to new strategies aimed at reducing the burden of dementia. Objective. This dissertation proposes a model for studying cognitive health in older adults and testing it in a large populational database. To achieve this objective, i) we derived the meaning of the term positive health by systematically reviewing how the concept is defined/used by different authors of publications in health promotion; ii) we revised existing models of “positive” determinants of health (“health assets models”) and proposed a new model of health assets; iii) discussed the utility of the model for research on cognitive health of older adults, and iv) we assessed the independent input of health assets into the probability of positive cognitive health among older adults, using developed model. Methods. A scoping review was conducted to achieve objectives 1 and 2, and a narrative review was conducted to achieve objective 3. Secondary analyses of the longitudinal cohort data “Survey on Health, Aging, and Retirement in Europe” data, waves 5 and 7, were performed to achieve objective 4. In this study, determinants were considered as having an independent effect on cognitive health if i) their variables were statistically significant in the fully adjusted model and ii) these variables significantly improved the model’s fit quality. Results. 1) No consensus on the definition of positive health was found in the literature. Among proposed definitions, there were “well-being,” “extremely good health,” “resilience,” and “capacities.” We proposed to define positive health as a reserve in capacities, enabling higher resistance in the face of pathologic agents/adversities and increased well-being in their absence. 2) In the literature, the determinants of positive health are grouped around individual traits or environmental characteristics. We proposed a new health assets framework. In it, individual characteristics, actions (directed to self-development or community development), environments (physical and social), and social support (informal and institutionalized) are interconnected. Each component contributes to the others and positive health. 3) The current state of knowledge on cognitive health allows operationalizing the definition of cognitive positive health and the elements of the health assets model. 4) Variables of three out of four groups of health assets (individual characteristics, actions, and environments) had independent relationships with the probability of cognitive health in older adults. Including health assets significantly improves the model’s fit statistics: pseudo-R-square increased from 0.31 to 0.33; area under ROC rose from 77.8% to 79.5%, p <0.0001. It means that positive health assets bring additional information on the probability of positive cognitive health in older adults. Conclusion. Studying health assets could open the doors to strategies to reduce the burden of dementia. Further validation of the model is required. Firstly, more specific indicators of health assets need to be found. Secondly, the relationships between health asset groups should be clarified.