Addi van Bergen

Systematic review: social exclusion or inclusion and health 35 2 and MH. The hypotheses that high SE/low SI is associated with adverse MH outcomes are supported by studies with various designs, sample sizes and settings, in both the general population and high-risk groups. Conflicting evidence was only found in two studies [39, 49], in which the relation between SE/SI and MH appeared to be mediated by other factors. This review also found support for the association between SE/SI and GH in the general population. The outcomes included some that are widely used in public health monitoring such as self-assessed health, presence of any chronic disease, and limitations due to health problems. Two aspects deserve closer attention. First, the results are confined to the social and economic dimensions of SE/SI. The cultural and social rights dimensions were not well presented and little or no significant relations with these dimensions were found. Second, none of the studies used a composite measure for SE/SI, and only one study provided insight into the cumulative impact of the underlying dimensions [41]. Our review failed to confirm or refute a direct association between high SE/ low SI and adverse PH in the general population. The wider literature provides ample evidence for associations between aspects of SE/SI and PH outcomes, for example, between social relations and mortality [6] and between neighbourhood characteristics and cardiovascular health [7]. We expected that a cumulation of these aspects would also be associated with adverse PH outcomes. One reason for the absence of association may be the much broader spectrum of PH outcomes included in this study, ranging from headache and obesity to severe obstetric complications. Another reason may be that these studies use other terms such as deprivation or precariousness and did not get included in this review. Lastly, as our review identified only a few studies focusing on the relation between SE/SI and PH or GH in high-risk populations, no conclusions can be drawn about the hypotheses on PH and GH in high-risk groups. Causality and directionality The studies we found employ different assumptions about the relationship between SE/SI and health. Some authors consider SE as a cause of adverse health [42-44] while others regard SE as a consequence of adverse health [33, 51, 53] or as a mediator [37]. The observational design of these studies does, however, preclude firm causal inference. The few longitudinal studies give us some insight in directionality. One longitudinal study showed that SE preceded negative health outcomes i.e. mortality in Japanese elderly women [43]. A second longitudinal study [41] points to a reverse directionality; long-term sickness absence was associated with a deterioration of the economic and social dimensions of SE in women, independent of their earlier situation. A reciprocal relation was found in two longitudinal studies [46, 53]. Further longitudinal studies may contribute to unravel the dynamic relation between SE/SI and health.