Addi van Bergen

Systematic review: social exclusion or inclusion and health 25 2 INTRODUCTION According to the World Health Organization (WHO), social exclusion (SE) is one of the driving forces of health inequalities [1-3]. SE refers to the inability of people to participate fully in society [4], while its antipode, social inclusion (SI) refers to the situation in which individuals are fully involved in the society in which they reside, including the economic, social, cultural and political dimensions of that society [5]. The pathways linking SE (and lack of SI) to poor health are complex and diverse[1]. The situation of SE encompasses deprivations in areas such as social relations, material resources, access to health services and housing, which are in itself well known determinants of health [6, 7]. In addition, pathways leading to poor health may occur via direct and indirect causation as well as through reverse causation. The experience of exclusion, e.g. low social standing, feelings of alienation and lack of belongingness may directly impact health and well-being via psycho-neuroendocrine mechanisms or work indirectly through stress-related unhealthy behaviours [8-10]. SE may also give cause to other deprivations e.g. poor labour conditions or poor nutrition, which also contribute to ill-health [1]. Reverse causation occurs when poor health and disability generate and reinforce exclusionary processes [2]. Although SE and SI have considerable public health significance from a theoretical perspective, the empirical evidence-base on this topic is still sparse. Literature reviews on social exclusion or inclusion and health mostly discuss the concepts, operationalisations and instruments used to measure SE or SI [2, 11-13] or describe characteristics of the retrieved studies (research design, country, year of publication etc.) [14, 15]. One study systematically reviewed the impact of interventions on SI in adults with intellectual disability [16]. None of these reviews reported systematically on the relationship between SE/SI and health. The lack of clarity and diversity of meanings associated with SE/SI, the wide variety of SE/SI measures used, the focus on only one dimension of SE/SI and the complexity and sheer magnitude of the literature, severely limited the inferences that could be made from these studies [2, 11-16]. In this study, we conducted a systematic literature review that addressed one of the main obstacles encountered in previous reviews i.e. lack of clarity and diversity of meanings. SE/SI represents a broad concept that, by its nature, can be defined and operationalised in various ways. Multidimensionality is one of the agreed upon characteristics [17], but the number and nature of the dimensions vary. Burchardt, for example, used four dimensions: consumption, production, political engagement, and social interaction [18]; others distinguished six [19] or even seven [20] elements or dimensions of SE/ SI. TheWHO defines social exclusion as “dynamic multidimensional processes driven by unequal power relationships interacting across four main dimensions - economic, political, social, and cultural - and at different levels including individual, household, group, community, country, and global levels” [1]. These processes may lead to a state of SE characterised by a cumulation of deprivations in multiple dimensions [1, 10, 21]. We choose the WHO definition and classification into four societal domains as a template for our study. To further improve homogeneity we made a distinction