How does social exclusion affect health




















Hunger and the welfare state: Food insecurity among benefit claimants during COVID This report looks in detail at food insecurity among benefit claimants using YouGov surveys of the The Child Poverty Scotland Act set stretching targets for child poverty reduction. Our upcoming webinar series will bring together a range of experts to explore the context of There is a need for the development of a tool for measuring social inclusion or social exclusion in primary healthcare settings.

Politics, sociology, health and economics are just a few fields that have explored this complex idea and adapted it. There are many definitions of social exclusion but generally it describes the state of disadvantage faced by particular groups who are felt to be removed from mainstream society, and who cannot fully participate in normal life [ 1 ].

The government of the United Kingdom UK had also championed the idea of focusing on exclusion, establishing a specific Social Exclusion Unit SEU in , which became part of the Office of the Deputy Prime Minister to drive this agenda across government departments and policymaking activity [ 3 , 8 , 9 ].

Many international bodies, such as the World Bank and the International Labour Organization, have also adopted the concept of social exclusion for use in their spheres of influence [ 10 , 11 , 12 ]. The widespread adoption of the term has been met with scepticism by others who have been critical of the move from focusing mainly on low levels of income as the primary cause of disadvantage; saying that now much of the blame for being socially excluded rests with the individual themselves, conveniently shifting the focus away from those with power and influence in society [ 14 , 15 , 16 ].

In Ireland, the term social inclusion has been adopted widely and appears frequently in policy documents across various sectors, particularly in health. The precise definitions of both social exclusion and social inclusion are highly contested. There is a growing body of literature that seeks to clarify the nuances of each term and the implications the various definitions have for corrective action and policymaking [ 4 , 8 , 10 , 14 , 19 , 20 ]. In recent years media reports and newspaper articles have begun to use these terms more frequently and without adequate explanation when reporting on a wide variety of societal problems and this seems only to add to the confusion around this terminology [ 23 , 24 ].

Social exclusion is often mentioned as one of the social determinants of health. Actions to alleviate this state or the processes of exclusion are seen as crucial in addressing the health needs of all, and the health needs of marginalised groups in particular [ 7 , 25 ].

Groups that are commonly mentioned in the context of social exclusion and health include people who experience homelessness, people who are problem drug users, people who engage in sex work, Gypsies and Travellers and people with disabilities [ 27 , 28 ]. Other sources mention numerous additional groups at risk of social exclusion: people who are unemployed, people who are migrants and refugees, people with mental health problems, women and children, older people, rural dwellers, people leaving institutions and single parent families [ 3 , 29 ].

This report and the subsequent WHO Europe report reinforced the significance of the role that health systems and primary healthcare have in addressing social exclusion and improving the health status of populations [ 26 ]. Possibly the clearest discussion of the links between social exclusion and health took place in preparation for the WHO Commission on Social Determinants of Health. A subgroup of the Commission, called the Social Exclusion Knowledge Network SEKN , was established in to investigate and report definitively on the relationship between these two concepts.

This continuum results in health inequities. Social exclusion influences health directly through its manifestations in the health system and indirectly by affecting economic and other social inequalities that influence health. This detailed explanation clearly sets out that social exclusion, the problems that cause it, and those that derive from it, critically affects the health of individuals and populations.

This SDG mentions the effective management of conditions such as HIV and substance abuse and the introduction of universal health coverage among other targets. This reflects the suggestion that improving the health status of such socially excluded groups may improve the health of the population as a whole. This also overlaps with the argument from some authors that health should be considered a human right and that a rights framework should be used to set appropriate standards and allocate responsibility for the improvement of the health status of certain groups in society [ 32 ].

The field of primary healthcare is the ideal place to seek to document and analyse social exclusion in relation to health. Primary healthcare has wide population coverage in most countries.

Primary healthcare services, such as general practice, work to alleviate many of the causes and ill effects of social exclusion on a daily basis — primary healthcare professionals understand that to cure or attempt to resolve the health problems of many of their vulnerable patients, they often need to find solutions to the exclusionary processes being experienced by those patients, as well as dealing with the actual medical issues.

The advent of commissioning [where local health trusts in England and Wales plan and purchase services locally based on evidence of need] as a method of planning and funding community health services there has seen a focus on developing the case for service provision to groups traditionally described as socially excluded.

Evidence is used to generate reports clearly outlining poor health outcomes for socially excluded groups when compared to the general population and then proposals are sought for possible interventions or adaptations to services in primary healthcare settings in order to attempt to close these health gaps [ 27 , 28 ]. In , Dr. The conclusion that she and other authors have reached is that primary healthcare professionals, who work in such proximity to many socially excluded groups, have an onus to advocate and act on behalf of these patients [ 34 , 35 , 36 ].

For example, a GP may see and treat a person with community-acquired pneumonia using antibiotics and advise when to return if symptoms worsen.

If that same person with the pneumonia is a person who injects drugs and who is rough sleeping, then the GPs advice and management may be different. He or she may attempt to secure hostel accommodation for that person, give information on where to obtain meals, help to locate an addiction support worker for the patient, discuss the safe storage of medications and possibly plan an early clinical review of the patient.

Existing measures of success in primary healthcare interventions with marginalised patients are generally limited to the traditional disease mortality and morbidity outcomes; but there is the possibility that these do not capture the essence of life and health as a socially-excluded person. Bearing these factors in mind, we are seeking to discover if the degree of social exclusion a person is experiencing — in all its complexity and with the ambiguity associated with the terminology — could be an appropriate measure for use in primary healthcare settings.

This scoping review was therefore developed to address the following specific questions: how are social exclusion and social inclusion defined in relation to health, and how are social exclusion and social inclusion measured at the individual level in healthcare settings.

Measuring the degree of social exclusion of a person attending a healthcare service could allow their status to be monitored over time, and potentially show that certain healthcare interventions reduce social exclusion. This may demonstrate that health policies and health system interventions aimed at marginalised and socially excluded groups have tangible benefits.

A scoping review allows us to summarise the characteristics of measures of social exclusion and social inclusion that have previously been developed, and highlight any gaps in the extant evidence. Scoping reviews do not typically involve detailed critical appraisal of the included work, thereby allowing a variety of both peer-reviewed and grey literature to be included.

The steps include i identifying research questions, ii identifying all relevant studies, iii selecting significant studies, iv charting the relevant data, and then v summarising and reporting the results.

To find publications related to these research questions we searched electronic databases, reference lists and key websites for both peer-reviewed papers and grey literature. The search strategy for these databases included three rows of search terms to be applied to the titles and abstracts of publications. For this review, final inclusion and exclusion criteria were developed as the searching and exploration of the resulting papers took place [ 37 ].

Criteria included work published in English between January and January from any country. Publications to be included were peer-reviewed research, published reports, editorials, commentaries and PhD theses.

Publications for inclusion had to relate primarily to social exclusion or social inclusion and their measurement in relation to health. For the exclusion criteria documents such as conference abstracts and book reviews, publications not relating primarily to social exclusion or social inclusion and its measurement in relation to health and publications reporting on biological or physiological responses to exclusion were omitted.

The lead author was responsible for screening the titles and abstracts of all document using the agreed inclusion and exclusion criteria. The co-authors were then consulted at regular intervals during the review process to discuss the emerging results, and to resolve any issues arising in the search process. For the results, we focused on measurement tools looking at social inclusion or social exclusion at the individual patient level, and their supporting publications. The details of each of the measurement tools included in the final scoping review are displayed in Table 1 under the headings of i name of the tool, ii whether it mentions primarily social exclusion or social inclusion, iii the target population group for the tool, iv the purpose of the tool, v a brief background on the tool, vi the number of items included in the tool, vii how the tool reports results, and viii how it is administered to participants.

A number of review papers were discovered during the searches and these are noted on the table in Additional file 1. A sample of the definitions of social exclusion and social inclusion referenced in the background papers for each of the twenty-two tools is also included in Tables 3 and 4. The empiric and grey literature searches were carried out as detailed above. A total of documents were included in the final scoping review. From these documents, 22 tools or measures for the assessment of individual-level social inclusion or social exclusion, or the measurement of very closely related concepts, were identified and charted in Table 1.

Additional file 1 provides details on the background literature linked to each of the 22 tools described in Table 1. Having located the background literature naming each tool, attempts were made to contact the authors of each tool by email. They were asked to provide a copy of the original tool for scrutiny.

One row of Table 1 is incomplete as we were unable to obtain the original Human Givens HG tool [ 40 ], and we had to rely on scant secondary information to describe this measure [ 41 ]. We have therefore used the denominator 21 rather than 22 tools when describing characteristics of the tools. Instead, they looked at the closely linked concepts of participation, integration, recovery and vulnerability.

There were no scales or tools found that were developed for the measurement of social exclusion alone. When reviewing the administration of the tools, the number of items or questions included in each tool varied; with questions asked in the long version of the SCOPE too, compared to four questions in the measure of Multidimensional Social Inclusion MSI.

Each of the 22 measurement tolls has been included in Table 2 below, displaying the domains covered in their questions. The most common domain seen was Social Networks referred to in some way in all 22 tools ; which included all aspects of interaction with family members and friends, and feeling accepted by them.

The Other category was utilised for domains that arose only once or twice when analysing the tools; including themes as diverse as political engagement, hopefulness and offending.

There are a wide variety of definitions of both social exclusion and social inclusion documented in the literature. Several review papers list some of the many definitions, and compare the elements that these definitions do and do not include [ 9 , 14 , 42 , 43 ]. Additional file 1 summarises the background literature relating to each of the 22 tools selected for this scoping review.

It is notable that many of the papers cited in Additional file 1 do not have a clear definition of what is meant by social exclusion or social inclusion, despite discussing the measurement of these concepts. Some authors did not definitively choose any one definition and instead listed a number of existing ones, while others combined elements of various definitions in an effort to provide clarity [ 41 , 44 , 45 ].

Of the papers that did set out a clear definition at the outset, it was one from the World Bank that appeared most often [ 46 ]. One paper included a definition of social inclusion apparently composed by the authors themselves [ 47 ].

A selection of the definitions cited in the papers is included in Table 1 , Additional file 1 and other commonly cited definitions are listed in Tables 3 and 4 below. This scoping review found that the concepts of social inclusion and social exclusion, while often described as abstract and lacking clarity, have both been discussed and measured at the individual level in relation to health.

This review identified 22 relevant measurement tools across the peer-reviewed and grey literature. The majority of these tools were developed for measuring these concepts in mental health settings, and it is not clear why this field predominates. It is also unclear as to why there are so many of these measurement tools, even in relation to mental health.

The tools that are listed have been developed and utilised in a number of different countries, and by researchers from various backgrounds and disciplines. The number of tools that have been created since the year is striking. It is likely that the lack of agreement on definitions and the domains that should be included for measurement are factors. The background papers reported in Additional file 1 highlight that the work associated with these tools has been published in a wide variety of research areas including journals relating to psychiatry, general mental health, occupational therapy, disability, rehabilitation, development, homelessness and social inclusion itself.

This highlights the point that the concepts of social inclusion and social exclusion are felt to be relevant to researchers and practitioners across many disciplines, but this may have led to duplication when it came to the development of measurement tools.

It is obvious that the concepts of social inclusion and exclusion are of great importance to mental health researchers and clinicians. The measurement of social inclusion status and its changes over time in patients who are engaging with treatment for mental health problems are seen as tangible outcomes in mental health clinical settings; they are considered useful alongside the more traditional measures of symptom control.

Encouraging the social inclusion and reintegration of people with mental health problems into society has also become an important policy goal internationally [ 51 , 52 ]. One possible reason for this is recognition of the immense, and increasing, economic and social burden of mental ill health worldwide [ 53 , 54 , 55 ].

The basis for this goal is the idea that an individual with mental illness who receives appropriate and timely treatment will eventually become more engaged and included in society, making it more likely that they will be able to re-enter the workforce and contribute.

The literature pertaining to two of the tools in particular, the SCOPE and the LCQ, highlighted that the authors had conducted extensive searches for existing measures of social exclusion and social inclusion prior to beginning their own work. The researchers conducted qualitative studies on the meaning of social inclusion in that country and then altered the domains and questions asked as part of the tool accordingly.

The LCQ was a tool produced by adding questions on topics such as housing and physical health to the existing APQ-6 tool following feedback from relevant groups. It is notable that none of the tools stated that its aim was to measure only social exclusion.

Fourteen of the tools described their aim was to measure social inclusion, and one the EPQ indicated it was meant for the measurement of both social inclusion and exclusion.

It is unclear why social exclusion is a less frequently used term in this context: it may be related to variations in the language used around the concepts of social inclusion and social exclusion, or the perception that social exclusion is more difficult to measure when compared with social inclusion. This implies that inclusion and exclusion are the opposites of each other.

This may then lead to the presumption that if you measure social inclusion, you have assessed both social inclusion and social exclusion status. There are a number of concepts very closely aligned with social inclusion and exclusion that were measured by seven of the 22 tools described. For example, the SIS tool for patients in mental health settings with schizophrenia focuses on the concept of social integration. When we look more closely at this tool, all of the domains it covers overlap with those of other social inclusion measures described in Table 2.

While the definitions of social inclusion and social exclusion themselves are unclear, the fact that authors and policy makers also use other similar, but equally ill-defined, terms in discussion of these complex concepts may add to the confusion around the issue.

Other tools included in Table 1 seek to assess concepts such as participation, recovery and vulnerability. The domains these tools cover are also very similar to the domains covered by those tools explicitly stating that they are measures of social inclusion. The SEKN report was critical of the approach taken by many researchers and policy makers who had discussed social exclusion as a state, rather than focussing on the exclusionary processes that led to and perpetuated that vulnerable state [ 8 ].

The work of the SEKN could have offered some clarity on questions relating to the concept of social exclusion, and yet there is little mention of the report in the background literature of the tools that were published after Subsequent research on social exclusion measurement did not seem to rely on the SEKN report for reference or a definition of the concept of social exclusion.

This may have been because the SEKN team only discussed the measurement of exclusion at global, regional and country level; there was no analysis of individual level measurement.

More recently, some authors such as Adam and Potvin have taken the work of the SEKN and adapted it to focus more on individual level social exclusion [ 58 ]. This statement highlighted possible confusion around the many factors that may lead to social exclusion, compared with those that may have resulted from it.

The association between high SE and poor MH came most clearly to the fore in people with severe mental illness and substance use disorder. Through the implementation of recovery-orientated services, the mental health sector can contribute to the SI of their clients.

These need to be addressed by social and economic policies, 36 involving not just the health sector but a range of sectors and services such as housing, employment, education, income support, debt counselling and community building. Preliminary evidence was promising.

Key points Social exclusion is generally regarded as an important social determinant of health, yet, its evidence base is still weak. In this systematic review, we operationalised social exclusion as the cumulation of deprivations in four dimensions, i. Evidence was found for the interconnectedness of social exclusion and inclusion and health.

Available evidence is stronger for mental and general health than for physical health. There is need for the development and use of validated multidimensional, and preferably composite, measures for social exclusion and inclusion.

References 41—62 are given in Supplementary file S6. Understanding and Tackling Social Exclusion. Geneva : World Health Organization , Google Scholar. Google Preview. Social Exclusion.

A Review of Literature. Millar J. Social exclusion and social policy research: defining exclusion. Multidisciplinary Handbook of Social Exclusion Research. Ottawa, Ontario, Canada : Senate , Courtin E , Knapp M.

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Jehoel-Gijsbers G. Methodological quality assessment tools of non-experimental studies: a systematic review. Ann Psychol ; 28 : — The concept of social exclusion implies a focus on causes of poverty and inequality. An examination on causation and macro-micro linkages is central to the understanding of social inequalities in health. A commonality exists, alongside problems, when it comes to exploring the links between social exclusion and health inequalities:.

Similarities do exist, such as over the abuse of power in social relationships impacting on health and well being. Other deprivations are caused such as low income, disease and ill-health. Therefore the power to restrict participation in economic, social, political and cultural relationships as a result of the abuse of power, leads to health inequalities.



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