Addi van Bergen

Cross-cultural validity of the Dutch version of the SEI-HS 97 5 INTRODUCTION Social exclusion (SE) refers to the inability of people to participate fully in the society in which they live [1]. It is characterised by an accumulation of disadvantages on multiple dimensions: 1) social e.g. sense of belonging and social support; 2) economic e.g. material deprivation; 3) political e.g. lack of access to housing and health care; and 4) cultural e.g. acceptance of values, norms and ways of living [2, 3]. SE has a profound impact on people’s lives. Socially excluded persons report feelings of loss and shame, alienation, powerlessness and insecurity [4-6] resulting in loss of aspirations [4], withdrawal [7, 8], reduced self-confidence [6, 8] and high risk behaviour [9, 10]. SE is considered as one of the driving forces of health inequalities [2, 3, 11, 12] and is particularly relevant in the context of immigrant health [13, 14]. In the past decades, the number of immigrants living in Western Europe has increased significantly [15]. In the Netherlands on average 13 per cent of the population is of non-Western origin, with higher representation in urban areas [16]. In the four largest cities, Amsterdam, Rotterdam, The Hague and Utrecht, one in three citizens is of non-Western origin (34%), with first and second generation immigrants of Surinam, Morocco and Turkey constituting the largest groups (7.3%, 7.7% and 6.1% respectively). Immigration from Morocco and Turkey was initially labour-related dating back to the 1960’s, while the Surinamese immigration is related to the colonial past and had its highest influx in the period before Surinam’s independence in 1975 [17]. The Netherlands is one of the few EU-countries with a strong record of monitoring immigrant health and health related factors [18]. The Dutch Public Health Monitor (PHM), a four-yearly national health survey that routinely includes data on migration background, employs a large stratified sample, includes strategies to enhance response rates in cities with a diverse ethnic makeup and makes use of culturally validated questionnaires [19-23]. In 2012 we developed an index to measure the four dimensions of social exclusion: the Social Exclusion Index for Health Surveys (SEI-HS) [24]. It was developed as an embedded measure using items from the PHM and where the PHM fell short, supplemented with items from the Social Exclusion Index of the Netherlands Institute for Social Research|SCP [20, 24]. The SEI-HS was validated for the adult population of the Netherlands, including 5.2% respondents with a non-Western origin [24], but it was not validated specifically for immigrant groups. In cross-cultural research group differences may result from systematic biases in the way people from different cultures respond. Response style behaviour is reported to differ between cultural groups, with non-Western immigrants showing higher acquiescence and midpoint responding [25] or preferring extreme categories more than other groups [26]. Additionally, items that contain content or language that is differentially familiar or has a different connotation for various groups may compromise the cross-cultural validity [27].