+

Left out: Perspectives on social exclusion and inclusion across income

groups
Stewart, Miriam ; Reutter, Linda ; Makwarimba, Edward; Veenstra, Gerry ; Love, Rhonda ; . Health Sociology Review; Abingdon 17.1 (Jun
2008): 78-94.

- PDF 92

Headnote
ABSTRACT

The goal of this paper is to explore the experiences of exclusion and inclusion of both low and higher-income people within a 'social determinants of
health framework'. In the first phase of this research, individual interviews with 60 high-income and 59 low-income participants, and group interviews
with 34 low-income participants were conducted. During the second phase, 1671 higher and low-income participants were surveyed by telephone.
The findings revealed that inadequate financial resources, ill-health, and unwelcoming behaviours inhibited participation in community activities
among low-income respondents. Higher-income earners were more likely to engage in social and group civic activities. Participants in the low-income
category were less able to participate in desired activities due to user fees and poor health. Data revealed significant relationships between self-rated
health and measures of exclusion and inclusion. Based on the responses of participants, the paper concludes that structural rather than
interpersonal change contributes significantly to increased levels of social inclusion, and ultimately, improvements in health outcomes.

Received 23 March 2007 Accepted 16 August 2007

KEY WORDS

Social exclusion, social inclusion, poverty, low-income, participation, sociology

Introduction

Social exclusion' refers to deeply embedded societal processes whereby certain groups are unable to fully participate in and benefit from major
societal institutions (Galabuzi 2004, 2005; Labonte 2004), and experience economic, political and social deprivations and inequalities (UNICEF 2006;
Stickley 2005; Stevens et al 2003). Social exclusion may be linked to experiences of stigma and discrimination in the associational life of civil society
as well as in occupational, educational, political and justice spheres (Stickley 2005). Among other effects, experiences of social exclusion can
generate low self-esteem, internalisation of blame, and powerlessness that can often lead people to avoid engagement with community life.

Although there is undoubtedly wide variation in the processes and experiences of social exclusion across national and other contexts, women, ethnic
minorities, refugees, the elderly, disabled people and homeless people appear to be particularly vulnerable to social exclusion (Abbott and Sapsford
2005; Crombie et al 2005). Poverty is an important cause and product of social exclusion (Galabuzi 2004, 2005; Labonte 2004). Material deprivation
can generate experiences of social exclusion and isolation because of limited available resources for engaging in community, leisure and family
activities and accessing health and social services. In turn, processes of stigma and discrimination can limit opportunities in the workplace and the
labour market that can lead to material deprivation. Importantly, such deprivation, the related non-participation in community activities, and social
isolation, have all been linked to poor health outcomes. The social capital and health literature has demonstrated quite convincingly that meaningful
participation in formal and informal community activities and organisations is linked to good health (Mohan and Mohan 2002; Kawachi et al 2005;
Veenstra 2006). In addition, significant links have been demonstrated in many international contexts between low socioeconomic status and poor
health (Raphael 2007; Yngwe et al 2005; Reutter et al 2005; Cattell 2001; Wilkinson 1996). Poverty and poor health are also thought to be mutually
reinforcing problems which prevent many people from participating meaningfully in the community and wider society (Yngwe et al 2005; Mowafi and
Khawaja 2005; Santana 2002; Wagstaff 2002; Cattell 2001).

The complex interconnectedness of material deprivation and experiences of social exclusion warrants thorough exploration from a Social
Determinants of Health theoretical framework (Marmot 2007). Accordingly, this research investigated perceptions and experiences pertaining to
participation in community life, reasons for low levels of social inclusion, and the role of material deprivation in two urban centres in Canada. The
research aims to provide further insight into the interconnectedness of these social determinants of health, towards the ultimate goal of better
understanding and eventually ameliorating health disparities in Canada and elsewhere.

Background

>
The overall poverty rate for Canadians is 14.4%, marginally lower than it was two decades ago (National Council of Welfare 2004). Welfare incomes
across Canada fall well below the poverty line, possibly because of welfare cuts and inflation (Thompson 2004). Almost 25% of Canadian fulltime
workers earn less than two-thirds of the median earnings, compared with 13% in Germany and only 5% in Sweden (Myles 2005). Those most at risk of
falling below the poverty line include single parents, older unattached people, people with work-limiting disabilities and recent immigrants to the
country (Hatfield 2004; Papillon 2002). The poverty rate has increased in large Canadian cities (Lee 2000), accompanied by the separation of
neighbourhoods and people according to income (Seguin and Divay 2002). As is the case elsewhere (Kawachi and Kennedy 1997), the income gap
has also increased in Canada (Raphael 2007; Picot and Myles 2004).

The processes of social exclusion have intensified because of the restructuring of global and national economies and the deregulation of markets,
resulting in the decline of the welfare state (Raphael 2004; Galabuzi 2004, 2005; Labonte 2004). Increasing globalisation and the rising power of
corporations have led to changes in employment conditions, such as decreasing levels of job security and worker control within the workplace, with
corresponding affects on health and well-being (Marmot 2007; Raphael 2004). Increased levels of poverty and social disadvantage have also been
associated with higher levels of unemployment, restrictions on social expenditure, and dismantling of the provision of services by the state in the
market economy (Martin 2004; Room 1999).

There is a growing body of research on various aspects of social exclusion. Some research establishes that people living on low-incomes experience
social exclusion and are frequently prohibited from participating in individual, community and civic activities, with associated negative health
outcomes (Abbott and Sapsford 2005; Marmot 2002). Richardson and Le Grand (2002) examined the definitions of social exclusion among low-
income individuals. Other studies have also analysed social exclusion of particular sub populations or sub regions (for example see Pantazis et al
2006 in the United Kingdom), while Bittman (2002) focused on the limited conceptualisation of exclusion in Australia. Another study in Portugal
investigated the effects of poverty and social exclusion on health, specifically health care utilisation among selected disadvantaged populations
(Santana 2002). A more recent study conducted in the UK investigated social exclusion among older people (Abbott and Sapford 2005). In Australia,
some research has centred on the participation levels in social and civic community life among advantaged and disadvantaged populations (Baum et
al 1999).

In this paper, social exclusion and inclusion are examined in a broad social context that portrays the nature and effect of these concepts as intricately
intertwined with other determinants of health, specially focusing on income. This research situates these concepts within a social determinants of
health framework and a critical sociological perspective (Marmot 2007; WHO 2005; Raphael 2004, 2007; Labonte 2004; Galabuzi 2004, 2005;
Schofield 2007). A social determinants of health framework incorporates key concepts such as social exclusion/inclusion, income, employment, and
education. Each of these concepts are central to this research as well as intricately related to social determinants of health. The social determinants
of health approach looks beyond immediate causes of disease and illhealth to the 'causes of the causes', that is '... the fundamental structures of
social hierarchy and the socially determined conditions these create in which people grow, live, work, and age' (Marmot 2007:1). According to
Schofield (2007), the World Health Organisation (WHO) Commission on Social Determinants of Health approach reflects a sociological perspective.
For example, the social exclusion knowledge network (one of nine such networks) examines '... the relational processes that lead to the exclusion of
particular groups of people from engaging fully in community, social life' (Schofield 2007:112). A critical sociological approach:

... focuses on the dynamics of the social within local contexts and ... demands close and systematic investigation of how such dynamics work in
producing current health inequalities. It is also able to closely examine the social mechanisms by which policy interventions work in seeking to
redress and reduce such inequities (Schofield 2007:112).

Therefore, this paper employs a critical sociological perspective to examine the relational processes that lead to exclusion and inclusion, focusing
particularly on the role of income and its relationship to other pertinent social determinants of health. The research focussed on five key questions
from the perspective of low-income and higher-income participants:

1) How are inclusion and exclusion experienced?

2) What are the factors influencing or predicting exclusion and inclusion?

3) What are the perceived barriers to inclusion?

4) What is the impact of exclusion? and

5) What are the implications for policies and programmes that enhance inclusion?

Methodology

This study employed qualitative methods in the initial phase of the study, and a quantitative survey in the second phase. While each method provided
unique information, the methods were also complementary, in that the qualitative (individual and group interviews) data informed the design of
quantitative measures and enhanced the interpretation of survey data.

Two large urban sites, Toronto, Ontario (in central Canada), and Edmonton, Alberta (in Western Canada), were selected for the study. The social and
economic policy changes in these provinces have included substantial cuts to the social safety net. In Ontario, welfare rates were reduced by 22%
>in
1995, and these rates have remained unchanged. Funding cuts to public health programs have increased food bank use in this province (Community
Social Planning Council of Toronto [CSPCT] 2003). Welfare incomes in Alberta are also low, varying between 25-51% of the poverty line, depending on
family type and ability to work (National Council of Welfare 2005). The poverty rate in Edmonton and Toronto was 16% at the time of data collection
(Statistics Canada 2001).

The researchers sought participants from economically homogeneous and heterogeneous communities in these two cities. The criteria used to
select the eight neighbourhoods in this study were a) economic prosperity, to contrast wealthy and poor places, and b) variability in the degree of
economic heterogeneity, to contrast homogeneous places with those where different income groups co-exist. Specific neighbourhoods were selected
using the most recent census, in consultation with community partners. Each site obtained ethical approval from the appropriate university
committees in the respective provinces.

Phase I: Individual and group interviews of low-income and higher-income people

During the first phase of the research, participants were purposively sampled to represent varied lowincome situations (e.g. working poor, social
assistance recipients, unemployed, homeless), and key demographic characteristics (such as gender, ethnicity, and age) that may influence exclusion
and inclusion. To determine poverty status (low-income), Statistics Canada's Low- Income Cut Offs [LICOs] were utilised. At the time of our study,
families spending more than 54.7% of their income on basic needs fell below the LICO (Ross et al 2000).

This qualitative research is founded on individual and group interviews. Individual interviews, lasting from one, to one and a half hours, were
conducted with 59 low-income people and 60 higher-income people. Interview guides covered the following topics: perceptions and experiences of
exclusion and inclusion, participation in community and civic activities, and strategies to enhance inclusion for people living on low-incomes.1 Six
group interviews, each lasting about two hours, were conducted with low-income participants (n=34) to expand the breadth of the qualitative data
beyond the depth of the individual interviews. Key topics explored in the group interviews included: a) types of activities or groups which made
participants feel they were 'part of things', b) activities or groups that made participants feel 'left out', and c) strategies that could be used to make
lowincome people feel 'part of things'.2

Trained interviewers conducted both individual and group interviews, under the supervision of investigators. Investigators co-led group interviews
with these trained interviewers. Thematic content analysis was applied to the taped and transcribed qualitative data from the individual and group
interviews.3

Phase II: Survey of low-income and higher-income people

Phase two of the research was based on a survey of low and high-income English-speaking adults from the same eight neighbourhoods. Recruits
were randomly selected to participate in a telephone survey. The two-stage probability selection process included:

(1) selecting households by randomly identifying telephone numbers within the eight neighbourhoods using postal code data; and

(2) randomly selecting respondents from the selected households. Participants surveyed in both cities totalled 1,671 higher- and low-income people
(839 from Edmonton and 832 from Toronto).

The project included at least 200 surveys per neighbourhood to allow for neighbourhood and city inferences. Trained interviewers conducted
telephone interviews. Interviews lasted 25 minutes on average.

The conservatively estimated response rate was 58% (defined as the number of completed interviews divided by the estimated number of eligible
households). When the sample's demographic breakdown was compared to the 2001 national census by age, gender, educational attainment and
household income, the survey sample was better educated and a little wealthier than the general population from which the sample was drawn. The
survey instrument containing 110 items constructed by the investigators using relevant subscales from validated measures as well as new items was
developed to reflect the qualitative findings from the first phase of the research.

To assess social inclusion, survey participants were asked to indicate their involvement and, or membership in six civil (associational) networks, such
as a trade union, Parent Teacher Association [PTA], neighbourhood group, church group, voluntary association, social club or other group or
association. The research developed an index of participation in community groups that measured the number of different kinds of groups in which
respondents currently participate.4

For logistic regression modelling, additional variables were created to distinguish those respondents who participated in one or more community
groups from those who participated in none. Perceptions regarding barriers to participation were assessed by six items. One item asked participants
whether they would like to participate more in community activities. Five items were used to assess personal reasons for non-participation in
community events, including feeling unwelcome. To measure social exclusion, a new variable was created from the latter item for logistic regression
modelling to contrast people who did not participate in the community as they would like because they felt unwelcome, with those who did not
participate as much as they would wish, but did not cite this particular reason, combined with those who did participate in community events as
much as they wanted. Two questions assessed the impact of participation on health and community well-being, one question ascertained self-rated
health, and three items ascertained respondents' opinions regarding responsibility for supporting low-income people. (See Table 1 for descriptions of
items and their distributions in the sample.) >
 Variables such as poverty status and educational attainment, gender, place of birth, age and
neighbourhood of residence are invoked to explain variability in feeling unwelcome in community
events (exclusion) and participation in community groups (inclusion). Descriptive statistics were
performed for selected survey items and indices created from survey items.5 Association and
statistical significance were assessed using appropriate statistical tests and multivariate regression
models were developed.6

Experiences of inclusion

Table 1: Perceptions regarding barriers to
participation
The qualitative interviews provided insight into the nature of inclusion. Respondents participated
most in social, leisure, and volunteer activities; followed by work, physical, and family activities.
Approximately equal numbers of people from both groups participated in cultural and educational
activities. Although there was some overlap in activities for both low-income and higher-income
respondents, the latter were more likely to access activities which cost money, while the former
participated in subsidised activities or those with no user fees. To illustrate, low-income participants
socialised at community centres or agencies and with friends, while higher-income people
entertained at dinner and neighbourhood-organised parties, and engaged in activities/hobbies
involving substantial costs. While participants with low incomes met for coffee, those living on
higher incomes went to restaurants for dinner:

Our kids are involved in schools ... so through that we've ended up getting to know a lot of the parents around, so we end up doing some socialising
with the parents. Often that involves doing stuff like ... having play dates for our kids where we end up doing stuff together

(Higher-income participant).

[S]ometimes we ... go to the mall and just walk around, let the kids look at the toys, go by Wal-Mart ...or even ... just go for a little walk ... so the kids
can have air ... [W]e really take care on letting the kids not know that all we do is sit on the couch and eat potato chips ...

(Low-income participant).

Participation in social, leisure, volunteer, work, physical and family activities increased the participants' sense of belonging, control and happiness;
while engaging in activities that provided a 'common experience' fostered feelings of connection. Perceptions of personal contribution also enhanced
connectedness. However, there were differences in the frequency of experiencing these benefits, in that twice as many higher-income respondents
reported increased self-efficacy and inclusion resulting from participation. Indeed, fewer than half of those living on low incomes noted the positive
impact of their participation. Among higher-income people, a sense of community, rather than participation in specific activities, promoted a sense of
inclusion:

[W]hen I see the objective met, that helps me to participate in other things ... And there's a joy given to me, an accomplishment given to me, and even
sometimes a fulfillment of love and affirmation I feel from a relationship with people (Higher-income participant).

I'm really connected with [community outreach organisation] ... they help me out emotionally, financially, mentally, and physically. If I'm feeling down
in the dumps, they'll bring me back up ... It makes me feel really good, because at least I could phone somebody besides my family members

(Low-income participant).

Participants identified various structural and interpersonal factors that promote participation. Structural facilitators of participation, such as policies
of governments and agencies, were most often identified, followed closely by the availability of personal resources, such as financial resources, the
accessibility of amenities, and interpersonal factors. Community support and community size were also mentioned, wherein encouragement,
emotional and instrumental support, and smaller communities were considered facilitative. Although low and higher-income participants were equally
likely to describe structural facilitators, those living on low-incomes were much less likely to cite personal resources.

Low-income participants emphasised the importance of accessibility to amenities, particularly where accessibility meant no transportation expenses
would be incurred. They also described various strategies employed by governments and agencies which were of some assistance, and felt that these
affordable programs and quality services treated people with respect:

I can walk to [the centre's programs] because it's so close (Low-income participant).

Being on a low-income I find that the government is starting to see that we're here ... just programs out there for the low-income ... it's free ... They've
been throwing you money for... the kids ... twice a year they give you a big chunk of money for day care and stuff like that ...I would never move from
Canada, just because they do care about the little people, I think

(Low-income participant).
>
While most higher-income respondents had their own transportation to attend events outside their immediate communities, some also emphasised
the importance of accessible community facilities. The most frequently mentioned interpersonal factors promoting participation were 'similar values
and circumstances'. Higher-income respondents noted common interests offered through children:

I didn't ... have a connection ... until we moved into this neighbourhood, and probably until [my daughter] started going to preschool ... that's when I ...
started meeting people and getting involved

(Higher-income participant).

Relevant insights also emerged from the second phase of the research through the survey data. Survey participants were asked to specify their
participation in six types of community groups. The mean number of different kinds of community groups was 1.67 (scores ranging from O to a high
of 6). Respondents were most likely to belong to an arts/music/sports/social club (49.8%), union (33.6%), religious community (33.1%) or
volunteer/service organisation (30.5%), compared with only 11.2% and 9.2% who participated in a neighbourhood group or parent-teacher association,
respectively. The LICO (low-income cut-off) variable was strongly related to two kinds of civil participation: those with incomes above the low-income
cut-off were much more likely than their counterparts to belong to a union or professional organisation (38% versus 13%,) or to a club (53% versus
36%). A multivariate logistic regression model on a dependent variable distinguishing respondents who participated in one or more community
groups from those participating in none and containing age, gender, nativity (born in Canada or not), educational attainment, LICO and neighbourhood
of residence as independent variables showed that education remained a statistically significant marker for participation in at least one community
group after controlling for the other variables. LJCO did not make a statistically significant contribution to this model, however, perhaps indicating
interconnectedness of LICO with educational attainment as a predictor of participation in community groups.

Experiences of exclusion

Participants reported a variety of both physical and social activities in which they were not able to participate, however there were differences
between income groups in terms of the degree and nature of non-participation. Almost all low-income participants were unable to participate in work,
family, leisure, educational, and cultural activities, compared with about half of higherincome participants, exacerbating their sense of exclusion.
While low-income people did not participate in most physical activities that required financial resources to procure equipment or involved club dues
or user fees, people whose incomes were just above the poverty line also did not participate in these activities. One third of lowincome participants
could not take part in social activities (e.g. restaurants, dinner parties, events, dating, dances), because of financial constraints:

[B]ecause of the constraints of time and also the need to have finance to live on, I've not been able to do some of the community activities that I
would like to, such as learning bridge or making use of whatever other facilities are available there. But I believe that it would be worthwhile to do so,
because there are some good offerings at our community

(Low-income participant).

Well I can't really afford ... tickets to go to the theatre. I mean I really do love plays, and I feel a little sad sometimes ... when I see that there's
something on at the ... [Theatre] I'd really like to see and I don't have the money for it (Low-income participant).

Participants also reported being left out of social activities by friends, and excluded from socialising, games, and clubs, either because of costs or
being made to feel unwelcome:

I don't buy nothing else [sic]; I don't go out anywhere ...I don't drink. You don't get invited to a lot of things because [your friends] don't want to
embarrass you. They go on trips ... And purposely now they won't ask me because they don't want to put me on the spot you know. I find out [they've
been away after] they come back (Low-income participant).

[O]ur kids haven't skied and things like that. Our holidays are much more frugal than some of the holidays of our neighbours. We eat out less. So ... for
leisure activities we try and do free or inexpensive leisure activities

(Higher-income participant).

The role of work in experiences of exclusion was evident in both income groups, albeit in different ways. Although labour market participation can
reportedly make low-income people feel included, about a third of participants associated a lack of gainful employment with poor health and
disabilities. Some participants were excluded from jobs, and others were not able to work full-time:

I would like to work full-time. I had a job in demolition with some housing Agency ... eight hours a day for three weeks, and it killed me, I was
exhausted. I'm a different person ... [because of the medication I take]. I can't really work a full-time work

(Low-income participant).

I have a trade. Two years ago I paid to have a Class 1 as a truck driver ... there is no plan to give you experience. So they hire only people with two
years' experience. So ... everything is there, the money ... everything ... but they never really fix that gap. If they don't hire nobody you can't start the
experience >
(Low-income participant).

Some higher-income respondents with children, particularly single parents, experienced exclusion because of the nature of their work and perceived
gender and racial inequities. Others' work commitments were so overwhelming they were unable to participate in outside activities:

I guess in some ways I feel part of the financial services community because I've been working in it for a very long time. But in other ways I feel very
excluded from it because it's a very white male-dominated community

(Higher-income participant).

Work has always been my hobby ... because of the type of work ... I've done all my life it's been a 24-hour a day type of work ... and so you don't get as
involved in other things you should be involved in

(Higher-income participant).

Higher-income respondents were more likely to experience inclusion in the work community. Work activities engendered respect, fulfillment,
interpersonal connections, and financial resources to 'purchase' higher education, leisure and community activities:

With co-workers we actually work together so we'll actually get together and do ... peer case supervisions ...or train together so there's a sense of
belonging by working and learning together (Higher-income participant).

Income also determined participation in family activities. Low-income people were three times more likely not to participate in family activities than
higher-income people. Indeed, about one-quarter could not afford to host family events or were notinvited to such functions. On the other hand, some
respondents did not participate in family activities because of 'self-exclusion':

I feel kind of like an outcast from my family ... Well I don't get invited to a lot of family things ... they just don't invite me if there's a special family affair
(Low-income participant).

We have this really large mostly dysfunctional [extended] family that I don't really want to have a big influence on my kids' lives. So because of that,
they don't have access to a lot of family connections

(Higher-income participant).

Barriers to inclusion

Participants identified structural, personal, and interpersonal barriers to participation. Important structural barriers to participation included prejudice
and discrimination, the inaccessibility of amenities, bureaucracy/red tape, undemocratic structures, lack of opportunities, unsafe communities,
decreased funding for services, and insensitivity to the needs of lowincome people. People particularly perceived exclusion when agencies and
governments refused to provide supports (e.g. food, utilities, health care), or when those supports were terminated or withheld:

The social service system is set up to keep you reliant on them for euer ...I don't think it's set up to get people independent, to get people to work, to
get people feeling good about themselves, to have self-respect and ... dignity and ... the things you need to ... make some kind of a life for yourself

(Low-income participant).

People living on low incomes were three times more likely to describe a lack of resources and to link this with the high cost of basic necessities,
tuition, health maintenance, services not covered by health insurance, and social activities. Cost of transportation played a significant role by
preventing their participation in activities:

When I have no money to go out for coffee or anything I isolate myself because friends are always saying Oh come on out, don't worry about it I'll pay
for it'. But I don't feel comfortable with that on a regular basis

(Low-income participant).

In terms of income, we've got two vehicles, and the Kinsmen is very hard to get to by bus ... And also I've got the money to buy a pass for the
Kinsmen. It's not cheap to go there, for sure (Higher-income participant).

Respondents living on low incomes identified various personal factors leading to their nonparticipation. About half cited health obstacles linked to
pain from injuries, chronic illnesses, surgeries, disabilities, and depression. While some interviewees were unable to participate in family and
community activities due to these limitations, others experienced exclusion and discrimination in work environments, because of health problems:

They don't understand why I'm not working ... I've got a few things wrong with me where I can't work so you're damned if you do, you're damned if you
don't. If I get a job and I can't complete the task or /can't get there all the time because of my arthritis, then you're fired. And with arthritis I can't work
all the time and they [social assistance] expect me to walk around looking for jobs. And if you let them know you can't look for a job you're off the>
roll
(Low-income participant).
I wish [my husband] could do things with us; I just wish he wasn't in a wheelchair. I wish he could come on holidays with us ...

(Higher-income participant).

Social distancing was the key interpersonal factor inhibiting participation. Low-income participants noted avoidance by others as a barrier to
inclusion. Conversely, others distanced themselves (i.e. self-isolation) in order to cope with a 'hostile world':

I don't see my family very often. I could have gone home for Christmas this year. I did the year before, because my brother does a lot of travelling for
work and there's air miles. [I didn 't go] because I think I'm ashamed of being poor and not being able to do what I would like to do (Low-income
participant).

Exclusion was linked to unwelcome and unfriendly behaviours. Low-income interviewees felt excluded when others prejudged them, or shut them out
of social circles.

Several pertinent propositions were tested using survey data to determine key factors contributing to exclusion. Just over half the respondents
reported not participating in community events to the degree they would like to, with no differences between higher and lowincome respondents.
Time constraints and lack of awareness of available activities were dominant reasons cited for non-participation in community events.

There were, however, some significant differences in the applicability of such barriers to participation for low versus higher-income people. Lack of
time, the most frequently mentioned barrier to participation overall, was cited as an explanation more often by higher than low-income people.
Inadequate financial resources was three times more likely to be reported by low than higher-income people (63% vs 21%). Poor health as a perceived
barrier to participation was strongly associated with poverty. About a third of those living below the poverty line (33%) cited health problems as a
barrier compared with only 10% of those with incomes above the poverty line. Finally, being made to feel unwelcome was reported as a barrier to
participation by few respondents overall. However, unwelcoming excluding behaviours were cited by almost twice as many low-income as higher-
income respondents (18% vs 10%).

A multivariate logistic regression model on a dependent variable distinguishing respondents who did not participate in community groups as often as
they would like because of being made to feel unwelcome from the other respondents and containing age, gender, nativity (born in Canada or not),
educational attainment, UCO, and neighbourhood of residence as independent variables, showed that being younger, and born outside Canada, were
both associated with feeling unwelcome at community events after controlling for the other variables.

Impact of exclusion

Almost all participants living on low-incomes reported on the detrimental impacts of exclusion on their social and emotional well-being, and
eventually on their physical well-being. Some noted the influence of non-participation on their precarious mental health, while others contended that
the resultant stress exacerbated anxiety, loneliness, depression, shame, frustration, and feelings of inadequacy. Exclusion also created a sense of
apathy, hopelessness, and resignation among low-income participants:

It makes me feel useless. Why did I work all those years ... and now when I'm in need, I get rejected. So you know it makes you really feel lousy, less
than a human being because you're not being treated like a human being

(Low-income participant).

They kind of associate that you are less capable of doing well and achieving ... certain goals in your life. They associate you as having been less
educated. It makes me sick ...I always have a bad feeling in my stomach like when I consider this so I try to block this out as much as I can and try to
go on. But it's unhealthy ... That can be more damaging because it chips away at your self-esteem. It was stressful; it made me feel inadequate

(Low-income participant).

I've grown so accustomed to living this way that it's ... I've maybe grown numb from it really (Low-income participant).

In this study, insights into the linkages between health status and living on a low-income were revealed initially in Phase I, and these were
supplemented by analysing survey data on selfreported health from Phase II. Survey respondents were nearly unanimous in believing that
participation in community events and recreational activities is good for the health of the individuals participating and for the community (Table 1).
The views of low and higher-income respondents about the influence of participation on health did not differ along these lines.

Statistically significant relationships were established between self-rated health and measures of inclusion (number of different kinds of clubs and
associations) and exclusion (felt unwelcome at community events as a reason for participating less in such events than wished). In all cases, poorer
health was associated with lack of inclusion.

Implications for programs and policies

>
Participants, regardless of income status, focused more on structural strategies to reduce exclusion and increase inclusion than on interpersonal
strategies. Structura/strategies included expanded funding for programs and agencies, increased social assistance benefits, more information about
services and entitlements, comprehensive services (e.g. health coverage, subsidised housing, child care, transportation), elimination/reduction of
user fees, lower tax rates for the poor, decreased tuition fees, and higher minimum wages. Interpersonal strategies aimed at family, friends,
neighbours and the public included being less judgmental and paternalistic and providing emotional and practical support. Participants living on low-
incomes also desired respect and sensitivity to income barriers, while their higherincome counterparts suggested more outreach and stronger
support for the poor. In general, interviewees believed that low-income people should have a voice in developing programs for the poor.

Over half the survey respondents believed that governments should take the most responsibility for supporting people on lowincomes, while about
one quarter (28%) assigned the responsibility to family/friends. Very few mentioned charities. Overall, most respondents believed that governments
are spending too little on programs for low-income people. Far more believed that low-income people were better suited to designing programs for
other low-income people than were government representatives. Those living below the poverty line were slightly more likely to feel that governments
are spending too much on these programs (7% vs 3%).

In conclusion, it is noted that the study was conducted in eight neighbourhoods in two large urban areas, excluding rural populations that might have
different experiences or views. Nevertheless, the use of a representative sample in the second phase permits some degree of generalisability to other
Canadian urban centres. However, non-English-speaking people and those without land-line telephones were not included in the telephone survey.
Importantly, new immigrants in Canada, who are more likely not to speak English, are also more likely to be living in poverty (Hyman 2001) and our
data suggests that people not born in Canada are more likely to feel 'unwelcome'.

Discussion and conclusion

This study contributes unique insights regarding the influence of income on the experiences of social exclusion and inclusion. Comparing the
experiences of low and higher-income participants highlights significant differences in the nature, extent, and barriers to participation in community
life and health outcomes. Many studies have demonstrated the reciprocal relationship between social determinants of health, and social exclusion,
such as low-income, low education, unemployment, disability, discrimination, lone parenthood, inadequate transportation, homelessness, poor
housing, neighbourhood of residence, and ethnic minority status (Abbott and Sapford 2005; UNICEF 2006; Davies 2005). Quantitative data from this
research based on a representative telephone survey indicates a significant positive relationship between greater participation in community groups
(i.e. inclusion) and educational attainment, when controlling for other demographic variables. The qualitative data also revealed a connection
between higher-income and higher educational attainment and participation in more community groups.

The qualitative results also revealed that people living in poverty were less likely to participate in various activities due in part to economic and social
barriers. Although about half of all respondents indicated they would like to participate more in community events, the barriers preventing such
participation differentiated low-income people from those with higher incomes. A major barrier to positive health outcomes for low-income people
was related to financial constraints. For this reason, many researchers identify poverty as a cause and consequence of social exclusion, whereby lack
of money prevents people from fully participating in the social and economic activities of society (Kunz and Frank 2004). The user-pay systems for
many health-related activities was prohibitive for many low-income people, limiting community, physical, and leisure activities and exacerbating
exclusion. Lack of affordable transportation also posed a financial barrier (Abbott and Sapsford 2005; Bittman 2002).

Previous research points out the centrality of labour market exclusion (particularly unemployment) to social inclusion (Crombie et al 2005; Williams
2004). In this study, labour market exclusion was central due to disabilities and ill-health, primarily experienced by lowincome people, resulting in an
inability to maintain higher participation rates in employment. Other studies have indicated that the lack of gainful employment precludes the receipt
of a steady income to address basic and higher order needs, leading to social exclusion (Yngwe et al 2005; Williams 2004).

The role of health in inclusion and exclusion was explicated in both the qualitative and quantitative findings. The findings noted significant
relationships between self-rated health and the measures of inclusion and exclusion in this research. Health emerged as an important barrier to
participation, supporting other literature (Abbott and Sapsford 2005; Bittman 2002; Pantazis et al 2006; Baum et al 1999). Disabilities and illhealth
(i.e. health barriers) limited participation in the labour market and in leisure and social activities. Moreover, ill-health and poverty, while contributing to
exclusion individually, were often intertwined in their effect on participation. This was particularly evident for participants living on disability
government assistance, which was perceived to be inadequate to meet their basic needs. Some critical scholars (e.g. Schofield 2007) reject
piecemeal interventions such as government assistance, because these are centred on creating 'safety nets' instead of dealing with the real causes
of poverty.

In addition to 'causing' exclusion, ill-health can also stem from experiencing exclusion. Participation in informal community activities and
organisations has been linked to improved health chances (Mohan and Mohan 2002). Conversely, exclusion from participation in society's structures
of opportunity results in a loss of agency and self esteem (Abbot and Sapford 2005; Campbell and McLean 2002). One study reports that social
contacts and participation in community activities generated, 'a sense of achievement... beneficial to ... quality of life' (Cattell 2001:1511). According
to the qualitative data in this research, both low and higher-income people believed that participation in community activities increased their self-
efficacy and sense of accomplishment. More low-income people thought that nonparticipation had a detrimental impact on their psychological,
social, and physical well-being. Our findings go further than previous research by pointing out other negative health-related effects of non-
participation, such as apathy and hopelessness. >
Unwelcome behaviours and social distancing also contributed to exclusion from social relations through non-participation. Given that social relations
facilitate the establishment of social networks and the flow of support resources among community members; excluded populations are being
denied access to social support, a key determinant of health status, health behaviour and health services use (Finch and Vega 2003; Santana 2002;
Gottlieb 2000; Wilkinson and Marmot 1998). The protective factor of social support in enhancing feelings of belonging and mitigating isolation is
reported elsewhere.

The importance of 'time' as a barrier to participation overall is not unexpected. Bittman (2002) found that higher-income people tend to have adequate
resources for participation, but little time owing to work commitments. This observation was supported by our quantitative data. However, this
research also found that the lack of time was a significant constraining factor for low-income people; perhaps because they were so busy working in
multiple part-time, lowpaying jobs, and 'trying to make ends meet', that they could not participate in some financially accessible activities. In this
sense, low-income people are doubly excluded (Bittman 2002). Indeed, our qualitative data suggests that the experience of poverty requires the skill
of juggling many activities, which consumes considerable time.

This study revealed that the reduction of exclusion requires attentiveness to structural barriers, supporting other authors' views that as social
exclusion is multidimensional, societies/governments should create multisectoral alliances to enhance inclusion (Marmot 2007; UNICEF 2006;
Crombie et al 2005; Galabuzi 2004, 2005; Labonte 2004). Most participants supported initiatives to enable low-income people to have a voice in
designing programs to enhance social inclusion. Other authors also recommend participation and control by disadvantaged people in service design
and delivery (Davies 2005; McClure 2000; Mendes 2002). From the 'causes of causes' social determinants of health perspective, marginalised people
can be empowered through such policy interventions (Marmot 2007).

Efforts to reverse social exclusion have been implemented in Europe (Crombie et al 2003; Williams 2004), and social inclusion initiatives have been
filtering to other industrialised countries such as Canada (Guildford 2000; Ministry of Health and Social Affairs 2005). Effective and efficacious policy
interventions call for a critical sociological analysis and the elimination of exploitative and discriminatory structures that create barriers to equity, and
instead promote participation in civic, social, economic and political spheres. This will involve collaboration among a wide range of services, the
involvement of service users, and a multi sectoral approach (Crombie et al 2005; Davies 2005). As exclusion and low-income reinforce each other
(Hatfield 2004), they demand solutions that address the root causes, the unjust social structures and local processes that bring them about and
cause health inequities. The findings from this research emphasise the need for policies to reduce exclusion by tackling its structural causes, the
'upstream determinants of health' (Baum and Harris 2006; Schofield 2007; Marmot 2007), because income alone is not enough to guarantee
inclusion. Globalisation increasingly leads to employment insecurity, resulting in greater segmentation of the labour market, more part-time,
precarious and lowpaying jobs, and sometimes unemployment. Therefore, to create employment and improve incomes and working conditions -
prime social determinants of health (Raphael 2004) - policy makers need to restructure policies governing the flow of capital, global trade
agreements, and local policies governing wages. Such policies offer prospects for greater social cohesiveness and wellbeing because for most
people, living conditions are largely dependent on economic opportunity afforded by the labour market. Such intervention policies are more effective
than those that target the symptoms: the psycho-social strategies dealing with depression, isolation and low selfesteem among excluded groups.

Strategies that increase low-income people's involvement and engagement in social, civic, and economic activities could include, for example,
invitations to volunteer or join community agency boards, and free or subsidised membership in community centres and programmes. Increased civic
and political participation at the community level is needed to boost individual and community empowerment (Heenan 2004), and diminish the
feelings of apathy, hopelessness, and resignation prevalent among low-income people. At the local level, the social dynamics that create barriers to
participation and equity (Schofield 2007), such as 'unwelcoming behaviours' or 'social distancing', require interventions at a policy level. At national
and local levels, programmes should increase a structural awareness and understanding of poverty and its causes and effects; and reduce
judgmental and paternalistic attitudes, interactions, and practices.

From a critical sociological perspective, it is these local, national and international dynamics that cause health inequalities and inequities (Schofield
2007). Successful interventions in northern Sweden involved 'providing information resources for the expansion of professional networks and
supporting the rehabilitation of individuals who have been long-term unemployed' (Marmot 2007:5). Canadian scholars have similarly recommended
equipping people with skills that allow them to participate fully in the labour market (Voyer 2004). This research provides insights into the processes
and consequences of such exclusion; further research should explore how inclusion can be promoted through health-related policies and programs.

Acknowledgments

This study was funded by the Social Sciences and Humanities Research Council of Canada. We gratefully acknowledge the Institute for Social
Research at York University for their able administration of the questionnaire survey. We acknowledge with appreciation the invaluable research
assistance of Susan McMurray, Sylvia So, Christine Daum, Mary Jane Buchanan, Kate Hibbard, Zhi Jones, Jody Mackenzie, Sue McCoy, Tammy
Simpson, Jean WalrondPatterson and Edward Shizha in Edmonton, Saima Anto and Mary Louise Noce in Toronto, and Gail Low in Vancouver. We also
wish to thank our community partners in Toronto and Edmonton for sponsoring the research, members of the Community Advisory Committees for
their advice and participation, various community agencies for their assistance, and the study participants for sharing their personal experiences.

Footnote
Endnotes
>
1. Community advisory committee members provided input in the construction of the semistructured interview guides used in the individual
interviews, and an equal number of low-income (n=5) and higher-income (n=5) participants helped pilot-test the interview guides.

2. In this sample, 67.6% were female and 60.6% had a high school education or less. Almost half (44.1%) were 30-44 years of age, with no participants
younger than 20 years or older than 64 years. The main sources of income were welfare (41.2%) and employment (38.2%).

3. A coding framework derived from themes and sub-themes emerging from initial interviews was developed and modified as analysis continued.
Consistency across sites was enhanced by interrater reliability among coders, cross-site discussion of emerging themes, and the exchange of coding
summaries. Both sites used the QSR NUD*IST software package to manage qualitative data. Perceptions of low-income and higher-income people
were described and compared in relation to social exclusion, social inclusion, and recommendations for programs and policies. Common descriptors
of content areas in Phase I interview data were identified to inform the development of survey items in the second phase.

4. Survey item for participation in community groups:

Are you a member of a trade union or professional association?

Are you a member of parent-teacher associations?

Are you a member of a neighbourhood watch, neighbourhood improvement association, or any tenants' groups?

Are you a member of a church or any other religious groups?

Are you a member of charitable or volunteer organisations, or service clubs?

Do you participate in any art or music groups, social clubs, sports teams and so on?

Are you a member of any other groups or organisations that we have not mentioned?

5. Quantitative survey data (Phase 2) were analysed using SPSS 13.0.

6. Multivariate binary logistic regressions were used to determine the effects of demographic and socio-economic variables (i.e. age, gender,
neighbourhood, place of birth, education and poverty status) on the selected measures of social exclusion and inclusion.

References
References

Abbott, P. and Sapford, R. (2005) 'Living on the margins: Older people, place and social exclusion' Policy Studies 26:29-46.

Baum, F.E.; Bush, R.A.; Modra, C.C.; Murray, C.J.; Cox, E.M.; Alexander, K.M. and Potter, R.C. (1999) 'Epidemiology of participation: An Australian
community study' Journal of Epidemiological Community Health 54:414-423.

Baum, F. and Harris, L. (2006) 'Equity and the social determinants of health' Health Promotion Journal of Australia 17:163-165.

Bittman, M. (2002) 'Social participation and family welfare: The money and time costs of leisure in Australia' Social Policy and Administration 36:408-
425.

Campbell, K. and McLean, C. (2002) 'Ethnic identities, social capital and health inequalities: Factors shaping African-Caribbean participation in local
community networks in the UK' Social Science and Medicine 55:643-657.

Cattell, V. (2001) 'Poor people, poor places, and poor health: The mediating role of social networks and social capital' Social Science and Medicine
52:1501-1516.

Crombie, I.K.; Irvine, L.; Elliott, L. and Wallace, H. (2005) Closing the Health Inequalities Gap: An International Perspective WHO Regional Office for
Europe: Copenhagen.

Davies, J.S. (2005) The social exclusion debate: Strategies, controversies and dilemmas' Policy Studies 26:3-27.

Finch, B.K. and Vega, W.A. (2003) 'Acculturation stress, social support, and self-rated health among Latinos in California' Journal of Immigrant Health
5:109-117.

Galabuzi, G.E. (2004) 'Social exclusion' in Raphael, D. (ed) Social Determinants of Health: Canadian Perspectives Canadian Scholars Press: Toronto,
pp. 235-251.

Galabuzi, G.E. (2005) Canada's Economic Apartheid: The Social Exclusion of Racialized Groups in the New Century Canadian Scholars Press: Toronto.
>
Gottlieb, H.B. (2000) 'Selecting and planning support interventions' in Cohen, S.; Underwood, L. and Gottlieb, H. (eds) Social Support Measurement
and Intervention: A Guide for Health and Social Scientists Oxford University Press: Oxford, pp.195-220.

Guildford, J. (2000) Making the Case for Social and Economic Inclusion Population and Public Health Branch, Health Canada: Atlantic Region.
Available at: http://www.phac-spc. gc.ca/canada/regions/atlantic/pdf/social.pdf (Accessed on August 12, 2002).

Hatfield, M. (2004) 'Vulnerability to persistent low-income' Horizons 7:19-26.

Heenan, D. (2004) 'A partnership approach to health promotion: A case study from Ireland' Health Promotion International 19:105-113.

Hyman, I. (2001) immigration and Health Health Canada: Ottawa. Available at: http://dsp- sdcommunication.gc.ca/Collection/H13-5-01-5E.pdf
(Accessed on August 12, 2002).

Joseph Rowntree Foundation (2005) Policies Towards Poverty, Inequality And Exclusion Since 1997 Joseph Rowntree Foundation: York, UK.

Kunz, J.L. and Frank, J. (2004) 'Poverty, thy name is hydra' Horizons 6:4-8.

Kawachi, I. and Kennedy, B.P. (1997) 'Health and social cohesion: Why care about income inequality?" British Medical Journal 314:1037-1040.

Kawachi, O.K.; Courts, A. and Subramanian, S. (2004) 'Commentary: Reconciling the three accounts of social capital' International Journal of
Epidemiology 33:682-690.

Labonte, R. (2004) 'Social inclusion/exclusion and health: Dancing the dialectic' in Raphael, D. (ed) Social Determinants of Health: Canadian
Perspectives Canadian Scholars Press: Toronto, pp. 253-266.

Lee, K.K. (2000) Urban Poverty In Canada: A Statistical Profile Canadian Council on Social Development: Ottawa. Available at:
http://www.ccsd.ca/pubs/2000/up/(Accessed on November 5, 2000).

Marmot, M. (2007) 'Achieving health equity: From root causes to fair outcomes' The Lancet 370:1153-1163.

Martin, S. (2004) 'Reconceptualising social exclusion: A critical response to the neoliberal welfare agenda and the underclass thesis' Australian
Journal of Social Issues 39:79-94.

McClure, P. (2000) Participation Support For A More Equitable Society: Final Report Of The Reference Group On Welfare Reform Department of Family
and Community Services: Canberra.

Mendes, P. (2002) 'Excluding undesirables from the local community' Social Alternatives 21:48-54.

Ministry of Health and Social Affairs (2005) Sweden's Report On Measures To Prevent Poverty And Social Exclusion Government Offices of Sweden:
Stockholm.

Mohan, G. and Mohan, J. (2002) 'Placing social capital' Progress in Human Geography 26:191- 210.

Myles, J. (2005) Postponed Adulthood: Dealing with the New Economic Inequality New Social Architecture Series, Canadian Council on Social
Development. Available at: http://WWW.ccsd.ca (Accessed on April 4, 2006).

National Council of Welfare (2004) Poverty Profile 2001 Minister of Public Works and Government Services: Ottawa, Canada.

National Council of Welfare (2005) Welfare incomes 2004 Minister of Public Works and Government Services: Ottawa, Canada.

Pantazis, C.; Gordon, D. and Levitas, R. (eds) (2006) Poverty and Social Exclusion in Britain The Policy Place: Bristol.

Papillon, M. (2002) Immigration, Diversity and Social Inclusion in Canada's Cities Discussion Paper F/27, Family Network, Canadian Policy Research
Networks: Canada.

Peterson, N.A. and Hughey, J. (2004) 'Social cohesion and interpersonal empowerment: Gender as moderator' Health Education Research: Theory and
Practice 19:533-542.

Raphael, D. (2004) 'Introduction to the social determinants of health' in Raphael, D. (ed) Social Determinants of Health: Canadian Perspectives
Canadian Scholars Press: Toronto, pp. 1-18.

Raphael, D. (2007) Poverty and Policy in Canada: Implications for Health and Quality of Life Canadian Scholars' Press: Toronto.

Repper, J. (2000) 'Adjusting the focus of mental health nursing: Incorporating service users' experience of recovery' Journal of Mental Health 9:575-
>
587.
Richardson, L. and Le Grand, J. (2002) Outsider and insider expertise: The response of resident of deprived neighbourhoods to an academic definition
of social exclusion' Social Policy and Administration 36:496-515.

Richmond, T. and Saloojee, A. (eds) (2005) Social Inclusion: Canadian Perspectives Fernwood Publishing: Halifax.

Room, G.J. (1999) 'Social exclusion, solidarity and the challenge of globalisation' International Journal of Social Welfare 8:166-174.

Ross, N.A.; Wolfson, M.C.; Dunn, J.R.; Berthelot, J-M.; Kaplan, G.A. and Lynch, J.W. (2000) 'Relationship between income inequality and mortality in
Canada and in the United States: Cross sectional assessment using census data and vital statistics' British Medical Journal 320:898-902.

Santana, P. (2000) 'Ageing in Portugal: Regional inequalities in health and health care' Social Science and Medicine 50:1025-1036.

Santana, P. (2002) 'Poverty, social exclusion and health in Portugal' Social Science and Medicine 55:33-45.

Scharf, T.; Philipson, C. and Smith, A.E. (2005) 'Social exclusion of older people in deprived urban communities of England' European Journal of
Ageing 2:76-87.

Schofield, T. (2007) 'Health inequity and its social determinants: A sociological commentary' Health Sociology Review 16(2):105-114.

Seguin, A.M. and Divay, G. (2002) Urban Poverty: Fostering Sustainable And Supportive Communities Canadian Policy Research Networks: Ottawa.

Statistics Canada (2001) Incidence of Low Income among the Population Living in Private Households, Census Metropolitan Areas Available at:
http://statcan.ca/English/Pgdb/famil60i.htm (Accessed January 4, 2002).

Stevens, A.; Bur, A-M. and Young, L. (2003) 'People, jobs, rights and power: The roles of participation in combating social exclusion in Europe'
Community Development Journal 38:84-95.

Stickley, T. (2005) 'Developing a social inclusion strategy for people with ongoing mental health problems' Mental Health Practice 8:12-15.

UNICEF (2006) The State Of The World's Children 2006 UNICEF: Geneva. Available at: http://www.unicef.org/sowc06/fullreport (Accessed October 22,
2006).

Veenstra, G. (2006) 'Social capital and health in Canada: (Compositional) effects of trust, participation in networks and civic activity on self-rated
health' in Johnston, R. and Kay, F. (eds) Social Capital, Diversity, and the Welfare State UBC Press: Vancouver, pp. 249-275.

Voyer, J-P. (2004) 'Poverty and exclusion: New perspectives, new approaches' Horizons 6:1-2.

Wagstaff, A. (2002) 'Poverty and health sector inequalities' Bulletin of the World Health Organisation 80:97-105.

Watt, G. (2001) 'Policies to tackle social exclusion: Must deal with the iceberg and not just its tip; this is an issue for all society' British Medical
Journal 323:175-176.

Wilkinson, R.G. (1996) Unhealthy Societies Routledge: London.

Wilkinson, R. and Marmot, M. (eds) (1998) Social Determinants Of Health: The Solid Facts World Health Organization Regional Office for Europe:
Copenhagen. Available at: http://www.euro.who.int/document/e81384.pdf (Accessed September 28, 2000).

WHO (2005) 'Priorities for research to take forward the health equity policy agenda' Bulletin of the World Health Organisation 83: 948-953.

Williams, C. (2004) 'Access to justice and social inclusion: The policy challenges in Wales' Journal of Social Welfare and Family Law 26: 53-68.

Yngwe, M.A.; Fritzell, J.; Burstrom, B. and Lundberg, O. (2005) 'Comparison or consump-tion? Distinguishing between different effects of income on
health in Nordic welfare states' Social Science and Medicine 61: 627-635.

AuthorAffiliation
Miriam Stewart

Faculty of Nursing and School of Public Health

University of Alberta

Canada

Linda Reutter
>
Faculty of Nursing
University of Alberta

Canada

Edward Makwarimba

Social Support Research Program

University of Alberta

Canada

Gerry Veenstra

Department of Sociology

University of British Columbia

Canada

Rhonda Love

Department of Public Health Sciences

University of Toronto

Canada

Dennis Raphael

School of Health Policy Management

York University

Canada

: 9071
Copyright eContent Management Pty Ltd Jun 2008

ProQuest... ;

PDF
9 P

(10)
(4687)

>
Humber Libraries

Cookie
2017 ProQuest LLC

>