1. Measuring Social Inclusion
Where are we up to?
Measuring Social Inclusion
Peter Huxley PhD
King’s College London
Institute of Psychiatry
Social Care Workforce Research Unit

2. Measuring Social Inclusion
What is social inclusion?
Social inclusion can be measured within life domains
Social inclusion can be measured subjectively
Social inclusion can be measured objectively
(independently verifiable)
My brief is to consider issues in the measurement of social exclusion and where we are up to in its measurement. Obviously, in order to measure it one must have a clear idea of what one is trying to measure, so I begin with a definition of social inclusion which will determine my approach to measurement.
I will argue that social inclusion relates to many different life domains, and that measurement should relate to these different aspects of life.
I will suggest that we should approach its measurement from both subjective and objective perspectives. Here I shall be using objective in the sense of self-reported, but independently verifiable information.
I will show you some of our experience in measuring it subjectively, and explore the way in which I think existing national survey data can be used to benchmark the achievements of services in social inclusion terms

3. Measuring Social Inclusion
Social inclusion can be defined in terms of the success of one or more of the following four systems of 'integration':
the democratic and legal system which promotes civic integration;
the labour market which promotes economic integration;
the welfare state system promoting social integration;
and the family and community system, which promotes interpersonal integration.
This definitions comes from Commins, (12 years ago)
It shows the multi-dimensional nature of social inclusion and defines it in terms of integration.
Commins has four systems of integration; you could argue for more, but these seem to be fairly central to any society – that is the democratic system, the labour market, the state support system, and family and community.

4. Measuring Social Inclusion
  “One’s sense of belonging in society depends on all four systems. Civic integration means being an equal citizen in a democratic system. Economic integration means having a job, having a valued economic function, being able to pay your way. Social integration means being able to avail oneself of the social services provided by the state. Interpersonal integration means having family and friends, neighbours and social networks to provide care and companionship and moral support when these are needed. All four systems are therefore important. In a way the four systems are complementary: when one or two are weak the others need to be strong. And the worst off are those for whom all systems have failed”
(Commins, 1993, p4).
Commins goes on to say…
And we know from previous work and presenters today, that people with mental health problems often face the failure of all four systems.

5. Measuring Social Inclusion
Social inclusion – “the extent to which people are able to participate fully in the institutions of society” – by choice
Quality of life domains - choice
Work – open employment
Housing – independent living, suitable accommodation
Finances – high income, maximum benefit
Family relationships – level of contact
Social relationships – choice of friends
Leisure activity – community participation
Safety – not at risk
Physical and mental health – access to care, met need
It is important to recognise that the participation involved in social inclusion is by choice. No-one should be forced to participate in things that they do not wish to. Many examples spring to mind, like voting and line dancing.
We have looked at inclusion using QoL measures – these tap into what users/consumers feel are the most important areas of their lives, - the areas in which they wish to see improvement, or to maintain the status quo, and the areas which they think services ought to adopt as outcome indicators.
The QoL domains that reflect aspects of social inclusion are:
Work, where open employment is the choice of many consumers, or something meaningful to do during the day
Housing – where independent living and suitable accommodation are the goals
Finances where either improving ones lot or accessing entitlements are usually the objectives
Family – where one wants to be able to choose who to see and how often
Social relationships – one wants to be able to choose ones own friends
Leisure – what wants to choose the level of participation in community activities
Safety – one wants to live in as safe a community as one can
And in terms of health care one wants access to it when one needs it, and if possible to have ones needs met.
As one commentator said, where service users are making extensive use of service provision, the quality of that provision is itself an important aspect of inclusion, and as we have seen, Commins defines the welfare and state support system as one of the key systems of inclusion.
Subjective appraisal of the NHS, does therefore qualify as an aspect of inclusion; however, this is not out main area of interest, and there are many other people (eg Picker Inst) who are employed by the NHS to look at its quality from the user perspective.

6. Measuring Social Inclusion
Social inclusion and access to services
Empowerment (self-esteem, mastery, information and consultation)
Participation in design and review of services delivered to self and others
Users employed in the service
The NIMHE social inclusion resource pack includes proformas for reviewing services in terms of their inclusive activity in most of these life domains and include these suggestions for the measurement of social inclusion in relation to service access. To what extent do services aim to produce empowerment, and to what extent do service users participate in the design and delivery of services.
I don’t plan to look at these areas in any detail in this presentation today, since others are covering/have covered these areas. I am more concerned to day with the second area in the NIMHE SIRP…..

7. Mean gross monthly income by levels of financial well-being
Which is, (the second area in the NIMHE social inclusion resource pack) standard of living, in which there are several domains, and the first of these is income level.
In general terms there is a reasonably close association (but not a perfect one) between subjective measures of satisfaction and objective income level. This slide shows the association.
The slide uses the Delighted –Terrible scale from 1 (terrrible) to 7 (delighted) which we and others use in measures of Quality of Life.

8. Figure 2: GHQ mean scores by levels of financial well-being (1 = Terrible, 7= Delighted)
This slide shows that there is a strong relationship between feelings about income level and mental health. Without going into the endless debate about whether money produces happiness,or the direction of the relationship in this slide, it seems pretty clear that people who feel that they are excluded from the opportunity to access a reasonable income show high levels of anxiety and depression.

9. Measuring Social Inclusion
The group who had housing improvements (cf those who had not) had higher subjective well-being after 22 months in:-
living situation (p<0.001)
finances (p<0.01)
physical health (p<.001)
and in overall well-being (p<0.001)
Another life domain which is an important aspect of social inclusion is having access to appropriate and suitable housing. We did a survey In south Manchester which looked at community mental health following urban regeneration, and we found that people who had had housing improvements, such as new roofs, windows, bathrooms etc had improved subjective quality of life in self-reported physical health, finances, living situation and overall well-being ( using the delighted-terrible scale).

10. Individual QoL Profile: 3
So inclusion can be measured within life domains, and you can look at the results at the individual as well as the community level. Here is such a profile, the red line being the first assessment and the blue line the second assessment some time later. This young man got work, and therefore more money, and he moved so his work rating, his home rating, his finance rating and his overall rating improved.
However, his subjective mental health rating declined and his GHQ score remained the same. It may be that he was experiencing some stress as a result of working, and reducing his leisure opportunities, which as you can see declined markedly.

11. Individual changes showing the effect of intervention
For those of you interested in measuring this kind of change in relation to a service intervention here is another example.
The orange line are his subjective scores when he was in a hostel
The blue line are his scores when he was moved to a group home
And the red line was when he was moved to an adult placement scheme and lived with a family
This graph shows that objective changes in circumstances are accompanied by improved feelings of well-being, and also that where the life domain is not the subject of any specific intervention, as in the family ratings here, which remained at 4 throughout this period, it is unlikely that any subjective improvements will occur.

12. Measuring Social Inclusion
Why use objective social indicators?
[Objective - independently verifiable]
Demonstrate inclusion
Improvement over time
Valued social goals
Compare with the general population
Assess service performance
Support funding arguments
While we can clearly use subjective indicators like these I have shown you to measure the outcomes for service users, subjective indicators alone are very rarely accepted as adequate evidence. To cut a long story short, in general it seems to be the case that both subjective and objective indicators are desirable.
Objective indicators here means independently verifiable; that is the source could be someone other than the person themselves, but in our work we trust the judgement of the individual and use self-reported information. This is exactly the same technique used in all national social surveys pertaining to inclusion, such as the Labour Force Survey, and all ONS data collection, and the SE unit report on mental health. Such surveys are used to make judgements about the ‘state of society’ and about things such as social inclusion and the nature and extent of social capital.
My argument here, is that we can use the findings of these surveys against which to judge the status of groups of people with mental health problems and the success of services in delivering the social inclusion agenda.
So, objective indicators can be used to demonstrate inclusion, to show increasing or decreasing inclusion over time,
to show the extent to which socially valued goals (such as independence) are achieved.
We can compare the levels of integration (or inclusion) with those in the general population
and we can compare service performance in the extent to which integration or inclusion are achieved.
Performance in these terms can be used a a powerful aide in seeking continued or improved resources.

13. Measuring Social Inclusion
Issues in the use of social indicators
Cultural diversity
Language
Locality
Gender and age
Phraseology issues
Disability issues
Coding issues
Don’t necessarily map onto individual goals
Of course this is easier said than done, and there are a number of issues to deal with in attempting this approach. There is quite a list, but I don’t believe this should stop us trying.
Obviously, in a diverse society there are different norms and values, and these somehow have to be incorporated into our efforts to measure inclusion. In the development of the QuiLL, a QoL measure for older people, we included a large number of Asian respondents, and found that, given a free choice, they found the existing life domains worked for them, and they could not add any new ones. I should add that in the development of the quill a ‘spiritual’ or ‘religious’ domain emerged from older white UK citizens as well; this domain did not emerge in the adults of working age QoL instruments. It does show however, that religion and spirituality are important to some people and not others. There are clearly also age and gender differences, issues around the way questions are asked, appropriateness for people with disabilities, and technical issues such as coding – unless responses are coded in the same way comparisons may become impossible.
Obviously, in many life domains, what the person wants to achieve may not be ‘normative’ in the statistical sense. This goes back to the choice issue mentioned earlier, and it raises the question of the relationship between individual goals and valued roles. However, many of the social surveys can be disaggregated by these subgroups so that what an individual wants to achieve in terms of inclusion or integration is close to their cultural norm. In other words one can compare like with like.

14. Measuring Social Inclusion
Social contact
Visits with friends, family or neighbours
Mental health problems – 80%
No mental health problems – 87%
(Baum et al 2000)
Visits with friends last week
Mental health problems – 71%
No mental health problems – 78%
(ESRC 2001)
We all have different ideas about our own optimum level of contact with others, and we all have periods when we do not want our friends to visit and vice versa, and sometimes social contact is bad for our mental health and sometimes isolation is bad; nevertheless, individuals , service users as well as professionals use precisely these terms when describing aspects of recovery – our recent pilot evaluation of STR workers showed exactly these kinds of changes in inclusive activity – presented by both users and workers as signs of ‘improvement’ or aspects of recovery.
In terms of visiting with others, Baum, in an Australian epidemiological study found that 80% of people with mental health problems visited people in the last week compared to nearly 90% of those without mental health problems. In similar, but not directly comparable data, because this was about visiting friends only, we found exactly the same difference between the groups, of 7% - which is not very substantial. This may reflect what I said earlier, that at some points,perhaps when most unwell, people do not want to have the social contacts that they would normally enjoy. Equally it might reflect the fact that people with fewer social contacts of this sort are more at risk of becoming unwell. Whatever the direction, the frequency and type of social contact can be measured as one aspect of inclusion.

15. Measuring Social Inclusion
Social contact
no-one to turn to for help - 33%
have no close friend - 4 X national average
no close friend - 36%
(Turton 2002; Huxley and Thornicroft 2001)
Here is another example. In surveys of people with mental health problems, one-third of people said that they had no friends to turn to for help. If they did have someone to turn to for help they had a greater number of close friends (5 compared to 2).
The rate of people with mental health problems having no close friend is four times the UK national average (at about 36%) which we regularly get from national social surveys. If people do have a close friend then their social network is twice the size (20 cf 11) and they have three times the number of acquaintances (3 cf 1).
This shows a higher degree of exclusion among people with mental health problems. But it shows us another very fundamental point that we must not lose sight of… when measuring inclusion you still need the answer to the question, do you want more friends, or do you want someone to turn to for help. Here is another example.

16. Measuring Social Inclusion
People with severe illness or long term unemployment spend about 60% of their time alone
People with severe illness spend only1% of their waking time in contact with paid helpers
50% of waking hours (ex eating etc) watching TV
2.5 times (more than the LTU) people with severe illness want to do things alone (24%)
(Turton 2002)
Returning to people with severe mental health difficulties, Neil Turton (using a diary method) compared people with severe mental health problems with people who were in long term unemployment. Both groups spent about 60% of their time alone. Interestingly, and significantly, people with severe illness only spent 1% of their waking time in contact with paid helpers. This is probably a good thing.
They spent 50% of their waking hours watching TV. This is probably not a good thing.
And more than twice as many of them (than the long term unemployed wanted to do things alone (about a quarter).
To go back to the choice issue again, some of this isolation was by choice so it might not be social exclusion, rather a matter of ordinary individual preference. The way to identify which is it, is to ASK THE USER.

17. Figure 1: Experience of crimes of violence *British Crime Survey
Turning briefly to another life domain, safety. Another aspect of exclusion, mentioned earlier, is the opportunity to live in a safe neighbourhood. Here are data from the UK700 case management trial in Manchester and London, compared to the same data from the ESRC urban regeneration study in Manchester (Qualcomm) and the British crime survey average. This slide shows, contrary to the media presentation, that people with mental health problems experience much higher rates of crimes of violence against them than people in deprived areas or on average in the UK.

18. Measuring Social Inclusion
Employment
employment level of psychiatric patient populations rarely reaches more than 10%
when working they work fewer hours (Self-reported mental health problems in the LFS - total weekly 25; ONS PMS – 28; compared to 38 average)
at a lower hourly rate
(Self-reported mental health problems in the LFS – Hourly rate £6.60: ONS PMS <£4; compared to £7.30 average)
(Meltzer et al , 1995; Evans and Huxley, 2000; Labour Force Survey 2004).
Open competitive employment is again not a goal for everyone, but where it is there are clearly exclusion problems. The same may be the case with other forms of meaningful activity during the day.
Employment levels of people receiving mental health treatment rarely rises above 10%
In those services where vocational rehabilitation makes a difference, people do not work as long hours as the national average (ONS PMS data), and people with self-reported mental health problems in the LFS also report lower hours worked
and when they are working they are in low paid jobs. (and the self-reported mental health problem group also earn less than the average, according to the last LFS).

19. Measuring Social Inclusion Employment rates
Region
Highest
Lowest
North East
Alnwick (78%)
Easington (57%)
North West
Rossendale (87%)
Manchester (60%)
London -
Newham (52%)
E Midlands
Melton (89%)
Nottingham (60%)
Wales
Flintshire (78%)
Port Talbot (62%)
I will use employment to show the importance of knowing what the local circumstances are. Assume for a moment that a mental health service wants to maximise open employment among service users. The first thing to understand is that employment figures are based on only those people who are economically active, that is, there will always be a proportion of people who are counted as economically inactive. Even among the economically active, there are large variations between localities in the employment levels. Some service users and the services in their area will be faced with much more difficulty in achieving open employment. Here is a selection of regional highest and lowest employment rates. Finding work in Newham may be almost twice as difficult as in Melton. If you subdivide this further by ethnicity you find the Newham figure is 46% for BME groups.

20. Region Highest Lowest North East North West London Wales
Measuring Social Inclusion Job related training in the last 4 weeks National figure = 16%
Region
Highest
Lowest
North East
Wear Valley (24%)
Berwick u T (10%)
North West
S Lakeland (22%)
Warrington (10%)
London
Greenwich (23%)
Islington (8%)
Wales
Cardiff (20%)
Monmouth (13%)
Even if you are in work, there are other important matters that differ by locality. For instance the take-up of job-related training in Islington is almost three times less than in Greenwich and half the national average figure.

21. Highest Lowest Easington (59%) Ribble Valley (87%) Knowlsey (60%) -
Measuring Social Inclusion Achieving NVQ2 or equivalent National figure = 70%
Region
Highest
Lowest
North East
Chester-le Steet (81%)
Easington (59%)
North West
Ribble Valley (87%)
Knowlsey (60%)
London -
Barking & Dag ( 59%)
Wales
Ceredigion (73%)
Blaenau Gwent (47%)
Achieving qualifications tells a similar story, with chances of achieving NVQ2 more than the national average in Ceredigion, but a bit more than half in Blaenau Gwent.

22. Measuring Social Inclusion In ‘adult learning’ National figure = 76%
England
St Albans (91%)
Easington (60%)
Wales
Powys (74%)
Blaenau Gwent (50%)
For those in work or not, the proportion in adult learning, which is of considerable relevance to people with mental health problems who may have been out of the workforce for many years, the figure is huge – 76% (in the past 3 years). The Welsh figure is in the last year, Powys reaching the national average but Blaenau Gwent again being the lowest.

23. Measuring Social Inclusion
(In the past three years) have you attended any courses or received any instruction or tuition in driving, in playing a musical instrument, in an art or craft, in a sport or in
any practical skill? (include all courses and periods of instruction or tuition, however short)
 (In the past three years) have you attended any evening classes?
(In the past three years) have you deliberately tried to improve your knowledge about anything, taught yourself
As an aside, why are there so many people participating – well it is partly because of the wide definition in use in the surveys. Services which provide this kind of help, would need to use the same definition of adult learning in order to make a valid comparison between their users and the local population. (Unhelpfully, there is a difference between the English and Welsh definitions, in that the English one counts the last 3 years but the Welsh data only the last year).

24. Measuring Social Inclusion
(In the past three years) have you been on any taught courses designed to help you develop skills that you might use in a job? (include all courses however short)
(In the past three years) have you carried out any learning which has involved working on your own package of materials provided by an employer, college, commercial organisation or other training provider?
These are the job-related training questions.
I show you the questions because it is important to use the same questions if one is going to make this kind of comparison in order to assess the extent of exclusion, and the achievements of greater inclusion over time.

25. Measuring Social Inclusion
1 degree level qualification including, foundation degree, graduate membership of a professional institute or PGCE, or higher
2 diploma in higher education
3 HNC/HND
4 ONC/OND
5 BTEC, BEC or TEC
6 SCOTVEC, SCOTEC or SCOTBEC
7 teaching qualification (excluding PGCE)
8 nursing or other medical qualification
9 other higher education qualification below degree level
10 A-level/Vocational A Level or equivalent
12 NVQ/SVQ What is your highest level of full NVQ/SVQ? (level 1 – 5; don’t know)
13 GNVQ/GSVQ Is your highest GNVQ/GSVQ at advanced, intermediate, foundation, don’t know
14 AS-level
17 SCE standard
18 GCSE/Vocational GCSE
20 RSA
21 City & Guilds
22 YT Certificate
23 any other professional / vocational qualification / foreign qualifications
26 National Qualifications (Scotland)
27 Don’t Know
It is also important to use the same coding system. This is the code list for the qualifications question. You can of course reduce the number of codes so long as you keep a record of how you aggregate the different units.

26. Measuring Social Inclusion Participation
Political parties
Trade unions (including student unions)
Environmental groups
Parent-teacher association or school association
Tenants' or residents' group or neighbourhood watch
Education, arts, music or singing group (including evening classes)
Religious group or church organisation
Charity, voluntary or community group
Group for elderly or older people (eg lunch club)
Youth group (eg scouts, guides, youth club)
Women's institute or Townswomen's Guild or Women's group
Social club (including working men's club, Rotary club)
Sports club, gym, exercise or dance group
Other group or organisation
If you are looking at community participation, then here is the code list for participation used in the General Household Survey.

27. Measuring Social Inclusion
Participation: 100 service users compared to the local population
feel leisure opportunities are restricted (cf 64)
83 want a more active social life (cf 62)
47 want to participate more fully in family activities (cf 28)
56 not a member of community groups ( cf 47)
Satisfaction with leisure activity 3.7 (cf 4.3) (p<0.001)
And here is an example, based on South Manchester, of how this information might inform service providers. Say the service is provided to 100 service users, then the number who want to improve their leisure activity is about 80%, however, in the local population 62% want an improvement. So the service will be doing well if it reduces the proportion to this level, and even better if it goes beyond it. The same can be said of membership of community groups. The level is 56 in the service and 47 in the population.
Subjective well being in this domain is lower than in the local population and so helping people to feel better about their leisure activity also could be used as an indicator of improved social inclusion.

28. Measuring Social Inclusion
Service users in South Manchester
compared to the local population
5% employed compared to….. 61%
Average working week 24 hours compared to.. 38 hours
Average monthly income £755 compared to….£369
53% seen a friend in the last week compared to…. 80%
57% have a close friend compared to ……95%
16% contact with relatives less than monthly….3%
Here is a summary of some of the findings regarding the objective inclusion problems among the South Manchester population. These figure come from the UK700 case management trial, and the Urban Regeneration study.

29. Measuring Social Inclusion Conclusions
Subjective measures
Objective measures
Comprehensive inclusion
Domain specific inclusion
Individual goals and valued roles
Local comparisons
Questions and codes
Ease of access
Disaggregation
Interrogation
Not all services may want or have the capacity to measure inclusion in the terms I have suggested here. Some may want to use some specific domains, such as the last one, for instance on community participation. If services are to be compared, or progress to be assessed, or judgements made about the extent to which the service users are enabled to achieve valued goals, then the comparisons must use the same questions and the same codes.
Happily, many of the surveys that can be used are in the public domain, although, as my research for this talk has revealed that does not mean (a) that they are easy to access or (b) they can be disaggregated to the local level you need by the categories you need. For some you can only access the outputs and not the raw data.

30. Measuring Social Inclusion Sources
General Household Survey
GHS Social Capital Module
British Crime Survey
Home Office Citizenship Survey
Labour Force Survey
British Social Attitudes Survey
Health Survey for England
Psychiatric Morbidity Survey
National Adult Learning Survey
Census
These are some of the surveys one can use. They are routinely up-dated and so need to be re visited for the most current figures. Much of the content is not relevant, and much is too detailed. The questions from each survey is usually accessible through the Question Bank (ref) and the data itself accessible (if you have a huge memory on the computer) through the UK data archive to registered users. A list of sources and their coverage is in the NIMHE social inclusion resource pack.
I am continuing work on this idea, and I am prepared to work with services who want to operate any part of what they do in this way – from Kings College – addresses attached.

31. Measuring Social Inclusion
The Question Bank
The UK Data Archive