Addi van Bergen

Chapter 1 8 Introduction People living in the Netherlands and other Western countries are living longer, better educated, more self-reliant and healthier than ever before [1, 2]. This, however, does not apply equally to all citizens. In general, the lower a person’s socioeconomic position is, the poorer his or her health and shorter his or her life is [3, 4]. Health inequalities in Western countries are persistent and possibly even worsening over time [5-8]. Some groups at the bottom of the social ladder are seriously lagging behind. They rely on food banks or support from churches [9, 10], experience homeless [11], suffer from severe mental illness without access to specialised care [12], and endure severe loneliness [13] or marginal positions in society [14]. Social exclusion (SE) is considered one of the driving forces of health inequities [15-18]. People have become isolated from the opportunities that mainstream society has to offer and lack the ability to fully participate in society, which may lead to a loss of control over their lives and ultimately even to homelessness [19, 20]. Measuring SE in routine public health surveys may help to identify and quantify at-risk groups and gain better insight into their characteristics and health risks. Reliable information obtained thusly, would help policy makers develop more effective policies to tackle health inequities, provide a baseline from which to monitor and assess the effects of policies and programs, and raise the profile and visibility of socially excluded groups and their problems [16, 17]. The introductory chapter of this dissertation starts by elaborating on the concept of social exclusion, its use in social exclusion policies, definitions and models of SE and the measurement of social exclusion. This is followed by an outline on the relation between social exclusion and health and an introduction to the Dutch Preventive Care Cycle and public health monitoring in the Netherlands. Finally, the aim and outline of this dissertation are presented. The concept of social exclusion In general, social exclusion refers to the inability of people to participate fully in the society in which they live. The question ‘what exactly constitutes full participation?’ is, however, answered in different ways at different times. The historical origins of the concept of social exclusion go as far back as Aristoteles. He introduced the concept of an impoverished life, i.e., a life without the freedom to undertake important activities that a person has reason to choose and to take part in the life of the community [21]. In recent history the concept was rediscovered by the French Secretary of State, René Lenoir [22]. His book, ‘Les Exclus’, published in 1974, is widely regarded as the origins of the modern conception of social exclusion within the context of European social policies [23-25]. Lenoir uses the term ‘excluded’ for groups at the margins or at the bottom and fringes of society, such as mentally and physically handicapped individuals, those with substance abuse issues, those who commit crimes and those living in multi-problem households [22, 25].