Addi van Bergen

Chapter 1 16 relevance of the topic for local public health, the length of the questionnaire and need to avoid unnecessary overlap with the mandatory national set. These are the challenges tackled by this dissertation. In short, the PHM is the best vehicle to measure social exclusion, given its wide coverage and prominent place in the preventive care cycle at the national and local levels. Aim and outline of the dissertation The aim of this dissertation is threefold: a) to systematically review the evidence base for the association between the multidimensional concept of SE, as defined in this study, and health; b) to develop a reliable and valid instrument to measure social exclusion in public health surveys, more specifically in the Public Health Monitor conducted by the GGDs in the Netherlands; and c) to explore the potential use of this instrument for public health research and policy. In Chapter 2, we start with a systematic review into the association between SE and health. As we saw above, the relationship between SE and health is theoretically well founded but still lacks systematic empirical evidence. The problem is not that there are no studies on SE and health; the opposite seems more the case. It is the wide variation in the concepts used and the operationalisation of SE that severely limit the synthesis of the evidence in these studies. To circumvent this obstacle, we confine our review to only one concept and operationalisation of SE and of its antipode, social inclusion (SI). In Chapter 3, we explore, as a first step in the development of a reliable and valid instrument to measure SE in routine public health surveys, whether the multidimensional concept of social exclusion can be validly approximated with items that are already used in the PHM. In Chapter 4, we describe the construction and validation of the Social Exclusion Index-for Health Surveys (SEI-HS). In this step, we address the limitations of our previous study. We requested that GGDs include an extra set of items in their 2012 PHM questionnaire and used these data to construct a national index. In Chapter 5, we examine whether the stronger SE among adults with Surinamese, Moroccan and Turkish backgrounds compared with native Dutch citizens in the four largest cities of the Netherlands (G4) can be explained by shortcomings in the cross-cultural validity of the SEI-HS. In this study, we use a sequential explanatory mixed methods design, combining quantitative analyses of 2021 PHM data and interviews with respondents with a high score on the SEI-HS from different migration backgrounds.