Addi van Bergen

Cumulation of ill health and low agency 119 6 INTRODUCTION Changes in society and demographic trends are putting pressure on our health care system [1]. The ageing population is leading to an increase in multiple morbidities [2], while improved medical treatment is expanding the lifespan of individuals with these health conditions [3]. Over the coming years, health care expenditures in the Netherlands are expected to grow twice as fast as the economy [3]. Households in which social and medical problems accumulate bring in numerous professionals— often too late—and this puts pressure on municipal finances [3]. It is therefore more important than ever to deploy resources in health care, public health and social care in such a manner that the greatest health gains can be made. To help understand the needs of the population so that governances and services can be better planned and delivered, population segmentation and risk stratification are essential steps. In Western countries, a strong socioeconomic gradient in health has been observed. Health appears to progressively increase with socioeconomic position [4] and to decrease with higher societal inequality [5]. Traditionally, education, income and profession are used as indicators for socioeconomic status [6], but other social stratifiers have also been used. The World Health Organization summarises the 8 stratifiers that are the most frequently assessed in health inequality monitoring, namely, place of residence (rural, urban, etc.), race or ethnicity, occupation, gender, religion, education, socioeconomic status and social capital or resources (PROGRESS) [7]. We expected that social exclusion (SE) would also be a good or even better candidate than these traditional social factors to describe and analyse the social stratification of health. According to the World Health Organization (WHO), SE is rooted in an interplay of dynamic processes at the individual, household, community, country, and global levels. These processes are driven by unequal power relationships and lead to a cumulation of deprivations in the economic, social, cultural and political domains [8, 9]. There is ample evidence that SE impacts health and that, vice versa, ill health exacerbates social exclusion [10]. Mediation and moderation effects may also be in place [11-13]. In fact, health is so intricately linked to SE that it is considered by some as part and parcel of the concept itself [14] In this paper, we explored SE as a promising stratifier for both health and low agency. Agency refers herein to the human capability to influence one’s functioning and the course of events by one’s actions [15]. According to Link and Phelan [16], differential access to resources such as knowledge, money, power, prestige and beneficial social connections is an important, or even the most important, reason why interventions to improve health are consistently less effective in low versus high socioeconomic groups. So-called “high agent” interventions do not work for low socioeconomic groups because participants must use their personal resources or “agency” to benefit [17-19]. Population interventions that require individuals to use a low level of agency, for example, food manufacturers reducing the salt content of bread, smoke-free public places and so-called “nudge” interventions, are likely to be most effective and