Addi van Bergen

Social Exclusion Index-f or Health Surveys (SEI-HS) 71 4 BACKGROUND Socioeconomic inequalities in health are one of the major challenges in the field of public health today. Social, material, cultural and political conditions shape our lives and our behaviours and thereby influence our health [1]. Social exclusion (SE) is understood to be one of the drivers of inequalities in health [1-3]. SE refers to the inability of certain groups or individuals to participate fully in society due to personal and societal factors. SE is a multidimensional concept, involving cumulative disadvantages in the social, economic, cultural and political domains [4-7]. The concept of SE is regarded as a promising entry for addressing health inequalities [6- 8]. Not only do the circumstances associated with SE such as poverty, poor housing, few social contacts and reduced access to care, have a negative impact on health, also the actual experience of exclusion may impact negatively on health status via psychosocial stress mechanisms [2, 7, 9, 10]. Poor physical and mental health, in turn, can be a barrier to social and economic participation [11]. To address health inequalities at local or national level, it is important to gain insight into the prevalence and nature of SE and its relationship with health. However, a generally accepted measure of SE does not yet exist in public health research [6, 8, 12- 15]. Health research typically focuses on a single dimension of SE, such as poverty, labour market exclusion or access to services [6, 8, 16]. Other limitations include the lack of theoretical grounding [16-18], conceptual justification for indicator choice and overall measurement validation [6, 8]. SE measures that have been validated are, to our knowledge, not particularly suited for use in public health surveys. These measures were developed for use in specific target populations instead of the general population [19-29], are too lengthy for use in population surveys [20, 30], do not allow for self-report [26-28] or measure health as a constituent part of SE [15, 31]. The lack of a suitable measure for SE prompted us in a previous study to develop our own instrument using existing routine public health survey data of the four major cities in the Netherlands [32]. As the gold standard we used the social exclusion index of the Netherlands Institute for Social Research|SCP (SCP) [33, 34], which was developed for use in social and economic policy research. This index does not suffer from the above limitations: it is multidimensional, theoretically sound, thoroughly validated, designed for use in the general population, brief, with only 15 items, suitable for self- report, not including a health domain and providing an overall index [33, 34]. The SCP index is the result of a decade of research and reflection [5, 35]. It is rooted in two main theoretical conceptualisations of SE: the French scientific tradition, in which SE refers to the socio-cultural aspects of people’s lives, the extent to which people are integrated into society and their connection with others; and the Anglo- Saxon line, in which SE is associated with structural-economic aspects of people’s lives, with relative deprivation and unequal access to income, basic goods, public services and citizen rights [5], [33], cf. e.g.[17, 36-39]. The SCP index is composed of two dimensions that concur with the French tradition i.e. (lack of) Social Participation