Addi van Bergen

Chapter 7 144 SUMMARYAND MAIN FINDINGS The main aim of this dissertation is to develop a reliable and valid instrument to measure the multidimensional concept of social exclusion (SE) in public health surveys, more specifically as embedded in the Public Health Monitor conducted by the GGDs in the Netherlands. This can facilitate the systematic identification of population groups at high risk for ill health so that resources for public health can be used more efficiently and effectively and health inequalities can be addressed with appropriate health and social policies. We started in Chapter 1 with the observation that although SE appears to be a promising concept to help with understanding and tackling health inequalities, the concept has been ill defined in health research, a generally accepted measure was lacking, and the evidence base was not well developed. In the current project, we took significant steps towards improving the knowledge base: we carried out a systematic review on the association between SE and health (Chapter 2), we constructed and validated a multidimensional measure for SE, the Social Exclusion Index for Health Surveys (SEI-HS) (Chapters 3, 4 and 5), and we explored a possible application of the SEI-HS in public health (Chapter 6). In chapter 2, we described a systematic review of the evidence base for the association between social exclusion or social inclusion (SI) and health in EU and OECD countries. Six hypotheses were evaluated, i.e., that high SE/low SI is associated with (i) adverse mental health outcomes, (ii) adverse physical health outcomes and (iii) adverse general health outcomes in both (a) the general population and (b) populations at high risk of SE. We operationalised SE as the accumulation of deprivations in four dimensions, i.e., social, economic, political and cultural [1] and SI as the accumulation of involvement in these dimensions. Twenty-two observational studies were included in the review, both using a multidimensional operationalisation of SE or SI and testing the relationship between SE/SI and one or more health outcomes. In the general population, our study confirmed the association between SE/SI and mental and general health but not physical health. In groups at high risk of SE, we found clear confirmation for an association between SE/SI and mental health but not general health. For physical health, the evidence was inconclusive, both in the general population and in groups at high risk of SE. In chapter 3, we explored whether the multidimensional concept of SE could be validly approximated with items available in the Public Health Monitors (PHM) of the four major cities in the Netherlands: Amsterdam, Rotterdam, The Hague and Utrecht (G4). The Netherlands Institute for Social Research (SCP) social exclusion index of Hoff & Vrooman [2, 3] was used as the gold standard. This 15-item instrument measures the overall degree of SE in a single index score as well as scores on four dimensions of SE: 1) Limited social participation, 2) Material deprivation, 3) Inadequate access to basic social rights, and 4) Lack of normative integration. Analyses were performed