Addi van Bergen

Summary and general discussion 151 7 concrete policy actions (instrumental use) but to aim for higher awareness and better understanding of the provided epidemiological results (conceptual use): ‘ Ultimately, if the conceptual use of research is high during the policy process and applies to multiple policy actors, this can eventually lead to more instrumental use.’ [28] However, instrumental use should not be the measure of success [30]. Epidemiological knowledge contributes to the improvement of the policy process if findings are taken into account and discussed, whether it leads to policy changes or not [30]. We recommend presenting a larger policy story of SE, aiming at a deeper understanding, rather than piecemeal approaches. The SCP SE framework presented in Chapter 1 can serve as an example here. In our experience, this model is well understood by professionals and policymakers and leads to insightful discussions on meso and macro risk factors that enhance individual problems and vulnerabilities and to ideas about how to tackle these [26, 27]. Barrier 3: Limited reach of the SEI-HS: additional research GGD epidemiologists play an important role in deciding whether to include the SEI- HS in the PHM [23]. The fact that the SEI-HS does not measure SE in high-risk population groups, such as people experiencing homelessness or living in institutions and undocumented immigrants, is perceived as a major barrier to its use by some GGD epidemiologists [23]. As such, this barrier is not due to the SEI-HS itself but to the exclusion of the mentioned groups from the PHM and applies equally to other health and social problems that are common among these groups, such as loneliness [31] and poverty [32, 33]. The people most affected are not included in the PHM or in population surveys in general and are usually excluded from mainstream policy as well. It is therefore important to supplement the PHM with additional research on high-risk groups, with, for example, register-based research [34], population estimates [35], on-site research [32, 33] or peer research [36]. This does not mean that the PHM does not provide valuable information. The qualitative interviews with socially excluded citizens in Utrecht, Amsterdam and The Hague showed that the PHM reached a diverse group of vulnerable people with non- institutional addresses, including persons leading very isolated lives, victims of violent incidents such as armed robbery or rape, people with drug addiction or aggression disorders, perpetrators of domestic violence, and people who have just been released from prison (Chapter 6). These are important target groups for public health policy and policies to prevent homelessness. Thanks to the SEI-HS, these otherwise invisible groups do not remain completely out of sight. ‘With the PHM, we do not reach the real vulnerable citizens, but the outcome measures visualise an image of the size of the group that is possibly vulnerable and can become vulnerable more easily [GGD epidemiologist].’[23]