Addi van Bergen

Construction of a multidimensional measure for social exclusion 47 3 INTRODUCTION Social exclusion is generally considered as one of the social determinants of health and a major factor in the causation and maintenance health inequalities [1-3]. Social exclusion is a broad term that refers to the inability of certain groups or individuals to participate fully in society. The World Health Organization 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” [4]. Important features of social exclusion are multi-dimensionality, relativity (i.e. social exclusion is context specific) and agency [5]. Agency refers to the fact that the excluding is done by someone or something, which can be the government or private institutions, the social environment or the individual itself. It is common that exclusion processes in one dimension affect those in other dimensions [2,6,7]. For example the loss of paid employment may lead to loss of social contacts and loss of income, which in turn may result in debts, poor housing, insecure living environment or reduced access to health care [6]. All these factors increase the risk of health problems directly or indirectly. In addition the experience of being excluded affects health negatively [1,2]. Health risks thus tend to accumulate in socially excluded individuals and groups. In the Netherlands, Community Health Services are responsible for public health monitoring at the local level. At least once every four years they conduct routine public health surveys among the adult population. The questionnaires that are used for this cover a broad spectrum of health outcomes and determinants. In addition to mandatory questions on a national level, topics can be included to address local policy priorities. If available, validated and standardised measures are used [8]. Measurement of social in these health surveys is desired, but acceptable measurement instruments are lacking. Recently, the Netherlands Institute for Social Research|SCP (SCP) has developed an instrument to measure social exclusion in social and economic policy research [9,10]. Based on an extensive literature review, the SCP has first defined and then operationalised the concept of social exclusion [7]. The definition is rooted in two scientific traditions i.e. the French tradition, which focuses on the extent to which people are integrated into society and connected to others (socio-cultural exclusion); and the Anglo-Saxon tradition, which emphasises relative deprivation, the notion that people or groups consider themselves disadvantaged compared to others with similar characteristics (their reference group). Nowadays, research within the Anglo- Saxon tradition is focused on a more ‘objective’ approach in terms of social indicators that measure differences in socio-economic status and rights (structural-economic exclusion). [9]. The SCP definition of social exclusion distinguishes two forms of social-cultural exclusion: “lack of normative integration” and “limited social participation” and two