Addi van Bergen

Chapter 3 60 DISCUSSION AND CONCLUSIONS Our approach to construct a scale for social exclusion based on items fromroutine public health surveys was successful in all four cities as far as relevant items were available in the surveys. Data reduction with canonical correlation analysis yielded fairly similar selections of items consistently with the original SCP index. This corroborates the assumption that similar constructs were measured. Both the general indices and the underlying dimension scales had good internal consistencies, with the exception of the dimension scale ‘inadequate access to basic social rights’. In line with the SCP index, the internal structure of our indices reflected the multidimensional character of the concept social exclusion. Moreover, the indices demonstrated strong associations with risk factors and correlates, which may be considered as a confirmation of the construct validity of the indices. On the whole, Index3, based on the Utrecht dataset, performed most consistent due to better content validity in the dimensions ‘limited social participation’ and ‘inadequate access to basic social rights’. The OVERALS analyses demonstrated good generalisability to the other cities. The usability of the constructed instrument is not confined to the studied cities. The use of multiple datasets allowed us to replicate the measurement properties in other populations, which improved the generalisability of our findings beyond the population in which the instrument was developed. This makes it a promising instrument for other cities and countries as well. Further strengths of our study are the large sample size, the broad representation of the study population and the intensive approach of hard-to-reach high risk groups. A limitation of our study is that the routine public health surveys used in this study did not contain items on the dimension ‘lack of normative integration’. It has been reported previously that such items are not standardly available in (health) questionnaires [10]. Normative integration relates to the duties of social citizenship and is reflected in e.g. compliance with dominant values, social commitment and responsibility towards fellow citizens. Failure to comply with these obligations is as much a cause of social (self-)exclusion as are the rights associated with social citizenship [7]. As normative integration is considered an important theoretical dimension of social exclusion, we recommend to include in future research additional items from the validated SCP index, such as ‘giving to good causes’ and ‘sometimes doing something for one’s neighbours’ (Table 3). Although the other three dimensions were well represented in Index3, some improvements can be made. Items that could be included in the dimension ‘material deprivation’ are lack of basic goods and services and in the dimension ‘inadequate access to basic social rights’ items that refer to the actual lack of access to healthcare. Furthermore, we were not able to assess the concurrent validity of our indices. As the study was based on secondary data, we could not examine the agreement between the indices and the SCP index in the same dataset. However, the evidence suggests