Addi van Bergen

Cumulation of ill health and low agency 133 6 were measured with validated instruments, namely, the SEI-HS for SE [22] and the Kessler-10 scale for anxiety and depression symptoms [27], respectively. The items of the scales reflect the different underlying concepts. The SEI-HS items ask, for example, about having enough money to heat one’s home, missing the pleasure of the company of others, satisfaction with one’s housing, giving money to good causes, etc., while the K10 scale items specifically ask about feeling tired, hopeless, restless, depressed, nervous, worthless, etc. There are no overlapping items. The K10 scale was originally developed to measure psychological distress, which is a common underlying factor in severe mental illness, in the general population [27] and has since been used to screen for anxiety and, in particular, depression [29, 30]. A high score on the K10 scale may indicate the presence of an anxiety or a depressive disorder, as well as a response to a specific stressor or demand [31]. Persons in a situation of social exclusion are, by definition, facing multiple problems in different domains of life, including economic and social domains and the lack of access to basic social rights. The emotional, cognitive and psychophysiological manifestations measured with the K10 scale may thus be a reaction to the situation that socially excluded people are generally in [31], as well as the result of prolonged exposure to chronic stressors in the form of depression, generalised anxiety and other psychological disorders [32, 33]. This may explain some of the associations found in this study. In addition to differential exposure to stress, differences in coping mechanisms and resources may also influence the risk of psychosocial distress. SE citizens are exposed to more stressors, such as financial debts, loneliness, poor housing conditions and other social problems, and their coping mechanisms are also less effective than those of their counterparts. That is why the confirmation of the second hypothesis is crucial. People with a higher level of personal control may appraise themselves as being capable of coping with or controlling problems in their life and therefore may be less physiologically impacted by stressful events and ongoing situations [34, 35]. As they are more likely to view their health as controllable, they might exercise healthier behaviour and the better management of their health [35]. As almost 50 percent of the socially excluded citizens in the four Dutch cities reported low personal control, compared to 5.2% in the rest of the city population, this finding has implications for health care practice, public health interventions and social care in these cities. Regarding physical disorders (diabetes, high blood pressure, obesity), lifestyle factors (smoking, inactivity) and low SRH, the first hypothesis was confirmed for low household income and non-Western migration background but not for low education and low labour market position. Low education (no or elementary schooling) and low labour market position (unemployed, disabled for work and/or on social assistance) appeared to be stronger social stratifiers in this population thanwere low income (lowest quintile disposable household income) and non-Western migration background. In the Netherlands, educational level is commonly used as the standard indicator of socioeconomic status in health research [36]. Our analyses showed that neither the less