Addi van Bergen

Chapter 5 98 Particularly high levels of SE were observed in adults of non-Western background measured with the SEI-HS in 2012. One in five adults (21.0%) of non-Western background was classified as moderate to strong SE, while the prevalence rates in adults of native Dutch and western migration background were 2.7% and 6.5% respectively [28]. Differences in SE might be expected given that risk factors for SE, such as low educational level, low income, low labour market position, linguistic problems and poor health [20], tend to occur more frequently in non-Western immigrant groups than in native Dutch and western immigrant groups [29, 30]. The magnitude of the differences was so large, however, that suspicion has been raised on a potential cultural bias of the SEI-HS. The leading question for the present study was whether the strong SE among adults of Surinamese, Moroccan and Turkish background compared with native Dutch citizens in the four largest cities in the Netherlands, can be explained by shortcomings in the cross-cultural validity of the SEI-HS. To answer the research question, a mixed methods approach was chosen. In addition to quantitative testing of the cross-cultural validity through confirmatory factor analysis and differential item functioning (DIF) analysis [31], qualitative interviews were conducted with socially excluded respondents of immigrant background and native Dutch origin. Qualitative data contribute insight into the individual experience of socially excluded people and can be used to explore whether items sufficiently represent the same content across cultures [32]. MATERIALS AND METHODS Mixed methods design The present study has a sequential explanatory mixed methods design consisting of a dominant quantitative and a less dominant qualitative phase [33, 34]. Fig 1 shows the sequence, priority and integration of the two phases. In phase I survey data were collected on SE in the general population. In phase II, data from phase I were used to select a sample of socially excluded persons of Surinamese, Moroccan, Turkish and native Dutch origin. Semi-structured interviews were conducted on the perspective of the respondents on their situation and responses on the SEI-HS. The Medical Ethics Review Committee of the AMC confirmed that under Dutch law, medical ethics approval was not required for phase I (AMC, W12_146 no. 12.17.0163) nor for phase II (AMC, W13_311 # 14.17.0007) as participants were not subjected to any intervention or treatment.