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 — 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 — 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 — 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.
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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 empiric and grey literature searches were carried out as detailed above. A total of documents were included in the final scoping review. 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. 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 exploring the origin and background of each of the tools the following became apparent:. 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.
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 ]. 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 ].
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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. 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 — 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. 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.
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. This may have been because quantitative scores are easier to conduct and to repeat over time in busy clinical settings, and this is precisely where tools included were mainly intended for use. Significantly, none of the 22 individual tools discovered were specifically developed or used in general primary healthcare settings.
As primary healthcare is the point of initial contact the majority of people have with the health system and it includes such a wide variety of components, it can offer help for many health issues. Primary healthcare, and universal health coverage in particular, is discussed as part of the solution to many of the causes and end results of social exclusion.
It would therefore seem to be a logical place to try to assess and monitor social inclusion and social exclusion — but this does not yet appear to be the case. What is surprising, however, is that many tools omit domains that would seem to be important for any measure of social inclusion or social exclusion to cover. Having somewhere secure to live tends to be considered a fundamental need to be dealt with before more complex issues such as health problems can be addressed.
In addition, the fact that there are over thirty different domains mentioned across the 22 tools we investigated highlights the fact that work in this area is hampered by the lack of a consensus definition and agreement on the domains that should be accounted for in any measure. As stated, there are multiple definitions of both social exclusion and social inclusion across the published and grey literature. Several reports and papers tabulate and compare the various definitions [ 11 , 14 , 43 ].
These terms could be considered more optimistic and acceptable than the negative terms often used to explain the concept of social exclusion. This may explain why governments and others have adopted the positive language of social inclusion when developing policies or even establishing initiatives e. Definitions of social exclusion can be broadly categorised: some address the problems associated with exclusion [ 59 , 60 ], others detail what aspects of life people are excluded from [ 61 ], and others mention the various levels on which exclusion is seen to operate [ 8 ].
The strengths of this scoping review include the fact that a wide range of databases and grey literature sources were searched by the authors.
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Manual searches of the reference lists of included publications were carried out, and we attempted to contact all relevant tool authors. This resulting review also contains publications across a number of disciplines, and work from a variety of countries is included. We included a number of review papers, mostly looking at mental health, adding to the likelihood that all relevant individual measurement tools were included.
There were a number of limitations to this scoping review. Firstly, critical appraisal of the background papers or the resulting tools was not included as this was beyond the scope of this type of review. Some of the 22 tools included were previously validated and evaluated, others were not, and this was not taken into account for this publication. The authors were unable to contact all tool authors; this meant having to rely on secondary sources for descriptions of some tools, leaving some sections of the tables incomplete.
The searches carried out were limited to papers in English, and those published since the year This scoping review offers a comprehensive description of existing work on the measurement at the individual level in healthcare settings of social exclusion and social inclusion. We have firstly shown that there is a wide range of definitions of both terms in use, and they tend to focus on quite different aspects of social exclusion and social inclusion. Some definitions describe the problems associated with social exclusion, others mention the parts of life that people are excluded from, and others explain the levels that social exclusion operates on.
We have listed the measurement tools developed for use with individual patients in healthcare settings.
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These tools vary in the number of items they include, how scores are allocated and in how they are administered. The majority of these tools were designed for use in mental health settings.
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These tools cover a wide variety of domains, perhaps highlighting the differing views of researchers and practitioners on what exactly is meant by the terms social exclusion and social inclusion. There is apparently no measurement tool intended specifically for use in primary healthcare settings for the measurement and monitoring of changes in social inclusion or social exclusion status.
It would appear, therefore, that there is scope to develop a measurement tool for this purpose, or to modify an existing tool that covers most or all of the domains felt to be important in the context of primary healthcare. No external funding was applied for or used in the conduct of this research. Abbreviations of names of tools in Tables below are suggested; some have been suggested by the creators of the tools themselves, others have been originally used by previous review authors.
POD and KE developed the detailed plan for conduct of comprehensive searches. Any difficulties with search process arising were discussed with KE at regular intervals. All authors have reviewed the final manuscript for submission. All authors read and approved the final manuscript.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Electronic supplementary material. Khalifa Elmusharaf, Email: ei. National Center for Biotechnology Information , U. Int J Equity Health. Published online Feb 2. Author information Article notes Copyright and License information Disclaimer.
Corresponding author. Received Sep 10; Accepted Jan This article has been cited by other articles in PMC. Associated Data Data Availability Statement Data generated or analysed during this study are included in this published article, and in its Additional file. Abstract Background Social exclusion is a concept that has been widely debated in recent years; a particular focus of the discussion has been its significance in relation to health. Methods A scoping review of the peer-reviewed and grey literature was conducted to examine tools developed since that measure social exclusion or social inclusion.
Results Twenty-two measurement tools were included in the final scoping review.
Conclusions There are several definitions of both social inclusion and social exclusion in use and they differ greatly in scope. Electronic supplementary material The online version of this article Why relate social exclusion to health? Why relate social exclusion to primary healthcare? Identifying relevant studies 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. Selecting the studies For this review, final inclusion and exclusion criteria were developed as the searching and exploration of the resulting papers took place [ 37 ].
Table 1 Measurement Tools.
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Andy Steele's contribution on black young people is revelatory and Martin Pearl and Roger Zetter's report on asylum should be a wake-up call to ministers As a series of pointers to important issues in the nexus between housing and equality [this book] works. Author: ROOF This timely series of essays has been brought together by two professors with extensive experience of researching housing and ethnic relations The book makes a valuable contribution to current debates Its readers will be left feeling that this is a challenge for everyone to take up.
Author: Inside Housing From the dereliction of our worst social housing estates to the hidden poverty of the lower end of the private housing market, black and ethnic minority people are trapped in the worst living conditions as this collection makes clear. The authors throw light on a number of still-concealed discriminatory housing practices, such as social housing landlords failing to deal with racial harassment, institutional racism in the employment of staff and the central role that housing plays in the exclusion of refugees.
There are also sound analyses of the housing needs of people from ethnic minorities, including Asian elders. Author: Community Care. Along with Andy Steele, he also conducted an investigation into career opportunities for ethnic minorities in housing associations in the North West of England and is currently completing a similar national project. He has also published works on social exclusion issues. He has been responsible for studies of the housing needs of black and other minority ethnic groups. Would you like to tell us about a lower price? If you are a seller for this product, would you like to suggest updates through seller support?
Each chapter investigates a different aspect of the situation that black and other ethnic minority groups face, including: Their housing needs The procedure of the allocation of housing Patterns of housing settlement of black and other ethnic minority groups The employment of black and other ethnic minority staff in housing associations. Read more Read less. Review An important contribution to the body of knowledge on race and housing. Read more. Tell the Publisher! I'd like to read this book on Kindle Don't have a Kindle? Further, it sheds light on how those different dimensions reinforce one another.
Social deprivation, economic disadvantage, and democratic disqualification are interrelated and mutually reinforcing—but distinct—dimensions of the overarching phenomenon of social exclusion. Economic disadvantage refers specifically to constraints on how groups of people are able to participate as workers, consumers, and owners.
Democratic disqualification refers to the limits placed on the ability of certain citizens to have an equal say in the decisions of the nation or community. The complex of rules that govern each of these dimensions of social exclusion are enforced through laws, government policies, and the rules of private entities; informal practices and relationships; by police, state-sanctioned private violence, and bureaucracies.
These dimensions are mutually reinforcing. The history of social exclusion lays the groundwork for future social exclusion. So, economically and politically powerful people initially seeded racist ideas in order to justify the policies and power relationships of their time. When those ideas took root, they helped feed new policies that the powerful few developed, and so on. Even when people dismantle the policies, the pattern of social exclusion continues because of the foundation that was deliberately set.
For example, a white shopper reproaches a black woman in this case, me for not providing adequate assistance in finding an item on the assumption that the latter is a store employee. This exchange is not merely an innocent mistake; the first shopper has exposed unspoken rules about how I, as a black woman, am supposed to be in that space social deprivation. Those rules were not always unspoken, and are part of the legacy of laws segregating public places, housing, and access to robust work opportunities economic disadvantage.
In this way, social deprivation is the disciplinarian of the trio. It draws the lines of who belongs—in the broad national community and in very particular places—and how they belong there. It deliberately deploys racist ideas to justify and naturalize social exclusion—economic disadvantage, democratic disqualification, and even further social deprivation—in order to distract the public from who is responsible for inequality.
In his robust study of the history of anti-black, racist ideas, Ibram X. Kendi writes:. Time and again, racist ideas have not been cooked up from the boiling pot of ignorance and hate. Social exclusion is not just a concept or a complex of rules. Social exclusion is a set of decisions and actions. The economically and politically powerful few in the United States have deployed white supremacist and racist ideas to further concentrate their wealth and power.
They have deputized others—including people who are not white—to enforce the social exclusion of black people through simple and seemingly individual acts, as well as through sweeping rules.