Addi van Bergen

Chapter 1 12 Social exclusion and health Social exclusion is one of the structural drivers of health inequities and forms part of the WHO Social Determinants of Health framework [3, 16, 43]. Inequities in health arise because of the circumstances in which people grow up, live, work, and age and the systems put in place to deal with illness [43]. The conditions in which people live and die are shaped by political, social, and economic forces [43]. The individuals involved are not necessarily passive victims of these social processes; they may actively resist exclusionary processes and the ensuing negative consequences [17]. Several theories exist about ow social determinants impact health. Brunner and Marmot propose a link between social structure and health through material, psychosocial and behavioural pathways, in combination with genetic, early life and cultural factors [44]. Diderichsen identifies three main processes: differential exposure (e.g. residential conditions and physical environment), differential vulnerability (e.g. clustering and interaction of other risk factors and earlier exposures) and differential disease consequences (e.g. barriers to access to care and the job market) [45]. The WHO Social Exclusion Knowledge Network specifies two pathways linking SE to health: constitutive and instrumental. The constitutive perspective looks at the intrinsic value of social inclusion: the experience of inequality and exclusion tends to have pronounced psychological effects and negatively impacts health, well-being and agency [19, 46-49]. The instrumental perspective looks at the circumstances associated with SE: material deprivation, social isolation, poor housing – often in deprived neighbourhoods – and reduced access to care all have a negative impact on health. Additionally, disease and ill health can themselves generate and reinforce exclusionary processes [17]. The relationship between SE and health is theoretically well founded but lacks systematic empirical evidence. A number of literature reviews have been published on SE or social inclusion (SI) and health [17, 38, 50-53], but due to a general lack of clarity and diversity of the meanings ascribed to SE/SI, the wide variety of SE/ SI measures and the complexity and sheer magnitude of the literature, no inferences could be made. Most reviews have therefore been limited to describing and discussing the concepts, operationalisations and instruments used to measure SE or SI [17, 38, 53, 54] and/or the characteristics of the retrieved studies, e.g., research designs, countries, years of publication [51, 52]. One study systematically reviewed the impact of interventions on SI in adults with intellectual disabilities [50]. None of the reviews reported systematically on the relationship between SE/SI and health. In short, the relationship between SE and health is theoretically well founded but lacks systematic empirical evidence.