Addi van Bergen

Chapter 6 134 educated nor the other three social groups are homogeneous. We identified segments within these groups as those with higher and lower risks of ill health related to SE. Educational level, income and occupational status are good predictors of differences in (perceived) health but are not necessarily also the explanatory factors or the direction of solution [37]. Dutch health policies are now mainly aimed at compensating for a lack of knowledge through information, strengthening individual skills and promoting healthy behaviours, which is not enough to reduce health inequities [37]. The third hypothesis was confirmed only in terms of RRs. As SE is the strongest stratifier, combining SE with one of the four social factors did not lead to an increase in RRs. PAF is dependent not only on RR but also on the prevalence of exposure in the population. The proportion of people with SE and/or, for example, low education (16.7%) or low labour market position (19.4%) is of course higher than with SE alone (10.3%). The choice of whether to target a small group with a high RR or a larger population segment with a lower RR will depend on policy goals, opportunities and political values [38]. In-depth analyses per city can provide guidance here. From a population health perspective, one should consider the potential impact on those with different levels of risk for disease within a population, including those in underrepresented or underserved groups [39]. Implications for policy, practice and research We see a number of ways in which health care practice, public health interventions and social care services could be adapted to realise health gains for this population segment based on disease patterns and characteristics that influence the interaction with health and care services. The first direction is taking agency into account in health care, public health and social care. In health care, a tailor-made and pro-active approach informed by data [40] could make a difference for persons with low agency, as could patient-centred care [41]. A promising development is DIABLEND, which is an integrated approach utilised in two deprived neighbourhoods in The Hague for personalised lifestyle optimisation in people with type-2 diabetes [42]. In public health, the focus for this group should be on the development and implementation of interventions that require little agency and explicitly enhance self-esteem and effective coping mechanisms [17, 43, 44] and increase social support as an important contributor to feelings of personal autonomy [45]. Good examples here are the Amsterdam Healthy Weight Programme that promotes a healthy food environment in which the healthy choice becomes the easy choice [46] and the municipality of Utrecht facilitating local support groups working together on building self-confidence, self-determination, healthy social relationships, meaningful roles and skills [47]. In social care too, agency should not be taken for granted. Pathways to Empowerment (Krachtwerk) is a good example, of a programme that is successfully applied in social and women’s shelters in the G4. This programme aims to improve the quality of the daily lives of persons who experience loss of control in their lives by focusing on their strengths and stimulating their personal agency, participation in society, and self-direction in life [48].