Xuxi Zhang

The aim of this thesis was to study health promotion for frailty as well as chronic conditions. Following the public health framework, we: (1) defined problems (surveillance), (2) identified the cause or risk and protective factors for the problems, (3) determined how to prevent or control the problems and (4) implemented effective interventions and evaluated their effect. In this thesis, we aim to answer the following research questions: 1. What are the associations between physical, psychological and social frailty and health ‐ related quality of life (HRQoL) among community ‐ dwelling older adults? (Step 1 of Public Health Framework) 2. What are the longitudinal associations between physical activity and frailty as well as the association between a 12 ‐ month change in physical activity and frailty among community ‐ dwelling older adults? (Step 2 of Public Health Framework) 3. What are the reliability and validity of the Tilburg Frailty Indicator (TFI) in five European countries? (Step 3 of Public Health Framework) 4. How does the Urban Health Centres Europe (UHCE) approach perform in terms of specific process components? (Step 3 of Public Health Framework) 5. What are the effects of peer support on glycemic control for adults with type 2 diabetes (T2DM) and the characteristics of effective peer support? (Step 3 of Public Health Framework) 6. What are the effects of interventions targeting modifiable risk factors on diabetic retinopathy (DR) for adults with T2DM and the characteristics of effective interventions? (Step 3 of Public Health Framework) 7. Could the Social Engagement Framework for Addressing the Chronic ‐ disease ‐ challenge (SEFAC) intervention be effective to promote the self ‐ management of chronic conditions and a healthy lifestyle? (Step 4 of Public Health Framework) In this chapter, the main findings of the studies reported in this thesis will be discussed (9.1). The methodological issues that could have affected the findings will be addressed (9.2). Finally, recommendations for future research, policy and practice will be outlined (9.3). 9.1 MAIN FINDINGS AND INTERPRETATION Health promotion for people with frailty The first step of the public health framework is to define the problem. Frailty is a major health condition associated with ageing. 1 Improvement of health and quality of life is an objective of health promotion. 2 Therefore, understanding the association between frailty and health ‐ related quality of life (HRQoL) among older adults could help us identify the problem and could provide insight needed for further development of effective interventions to improve HRQoL (See Figure 9.1.1). However, studies on the association between frailty and HRQoL are relatively scarce and show contradicting results. In Chapter 2 , the association between frailty and HRQoL were studied. The results show that frailty had a negative association with both physical and mental HRQoL. This is in line with previous studies reporting that frail people have a poorer physical and mental HRQoL than not frail people. 3 ‐ 7 We also analyzed the 9 221 General discussion