IntroductionThe Utrecht Health Profile was published in February 2018. It provides an overview of the health of Utrecht’s population and the factors that affect this. Some of the more important conclusions are that Utrecht residents are on average getting older and that most Utrecht residents perceive their health as good. Utrecht children are living healthier and obesity rates are declining.
However, there are also groups that are not doing so well in our city: Utrecht residents facing problems in multiple life areas. These residents have medical, psychological, social and/or societal problems. These multiple problems are often complex and unpredictable and can put someone in a vulnerable position. The municipality is making every effort to also make this city a healthy and pleasant place to live for this group of Utrecht residents.
The Scientific Council for Government Policy recommends that this group is given priority because there is great potential for health gains. Especially if the prevention of health problems starts at an early age1. This means we will not only focus on adults but also children. We share background information for anyone working with Utrecht residents facing multiple problems. In addition, this information can help to put important issues on the agenda, with the aim of improving the health of this particular group.
Public Health Monitor UtrechtThe Public Health Monitor Utrecht is a tool for the municipality of Utrecht and its partners to continuously monitor the health of Utrecht residents. Once every four years we take stock of the situation in the Utrecht Health Profile. We look at remarkable developments, at what is going well or less well, and at disparities between population groups or districts that require attention. For this purpose, we use many data sources and we conduct interviews in the city to interpret this data. In the process, we look at health indicators as well as factors affecting health, such as lifestyle, social environment, care services, social participation and living environment. In addition to the Utrecht Health Profile, we regularly issue special editions, in which we focus on a specific theme or target group.
Various data sourcesAn important source of information for the Public Health Monitor Utrecht is the health survey. This is a biennial survey conducted among adult Utrecht residents, in which we ask about their health, lifestyle, well-being, social contacts and living environment. The Youth Monitor Utrecht is an important source for information about children. This is a biennial survey conducted among pupils aged 10-12. An annual survey is also conducted among the members of the ‘Meetellen in Utrecht’ panel. This is a panel for people who need extra support or help in life. For example, people with mental health problems, who are suffering from addiction or people who have experience with homelessness. In addition to surveys, we use data records, such as Keten Registratie en Informatie Systeem (KRIS). This is a client tracking system for Utrecht residents in refuge facilities or supported housing. And lastly, we also use other research in the Netherlands and in Utrecht as a source.
Utrecht residents facing problems in multiple life areas can be identified in different ways. The simplest way is to look at accumulation. This means that we count the number of areas of life in which a person scores poorly in the survey. For adults we use the health survey and for children we use the Youth Monitor Utrecht. We consider the following domains: physical health, mental health, daily functioning, dealing with stress, access to care, obesity, nutrition and exercise, substance abuse, physical living environment, social contacts, social participation, financial situation and level of education/family affluence.
Identifying people with multiple problems
In addition, we use the indicator for social exclusion based on the Health Survey. Social exclusion occurs when adults are unable to participate, or can only participate partially in society. This could include a lack of meaningful social contacts, limited financial resources, insufficient access to care and services and reduced social involvement in society. Answering more questions in the negative in the survey means more problems and a higher social exclusion score.
The survey does not identify people who live in supported housing or who use the refuge facilities in Utrecht, such as night refuges, crisis refuges and domestic violence refuges. In general, this group also has complex multiple problems2,3. Additional data has therefore been collected about this group, based on the registers kept at the various supported housing and refuge facilities.
How many residents are we talking about and who are they?
How many adults are involved?23% of Utrecht adults (19 years and older) have accumulated health risks or problems in four or more areas of life. This equates to approximately 60,000 adults4. In 2012 this percentage was 24%. The absolute number of Utrecht residents facing an accumulation of at least four areas of life has remained more or less the same. This is due to the growth of the city.
7% of Utrecht adults (also) have a high social exclusion score. This equates to almost 18,000 Utrecht residents. Compared to 2012, this percentage has remained the same. 16% of Utrecht adults are faced with an accumulation of problems, but do not score high on social exclusion4.
What are the characteristics of these groups?Utrecht residents facing an accumulation of problems or a high score on social exclusion perceive their health to be quite a lot lower than the average in Utrecht. They are more likely to be 40 years of age or older and are more likely to have a migration background. They are also more likely to have VMBO as their highest degree.
And among the youth?Among children (age 10-12) in Utrecht, 4% have unfavourable scores in at least four areas of life6. In 2009 this was still 7%7. Accumulation is more likely to occur among children from families with a low family affluence*. Accumulation is also more likely in children with a Turkish background.
* Family affluence is determined on the basis of six questions about possessions and financial possibilities within the family.
Utrecht residents staying in refuges or supported housing2,726 adults in Utrecht stayed in refuge facilities or lived in supported housing in 2016. The number of adults staying in night refuges and crisis refuges is comparable to previous years. In night refuges, 85% of the users were male and in crisis refuges this percentage is 59%. In 2016, 86 children also stayed in crisis refuges. Almost half of the 199 children who stayed in domestic violence refuges were under the age of four.
Financial situationIn addition to providing the figures, interviews have been conducted with professionals, volunteers, policymakers and residents of the city on the health of people facing multiple problems. Both the figures and interviews show that these people nearly always have financial problems. Financial problems are discussed in almost all the interviews. The resulting picture is that financial problems occur among almost all Utrecht residents facing multiple problems. Professionals often link financial problems to having a poor diet and few social contacts. Furthermore, financial worries are also a major source of stress. Scientific research shows that poverty seems to demand so much mental effort that there is less room for thought about anything else. This can lead to taking decisions that inadvertently increase the problems. There is also a risk that too much is asked from people with financial worries, for example when they are asked to fill in long forms or answer difficult questions. It is important to prevent this from happening or offer support12.
“Almost everyone comes to us because of their financial situation. This situation is a terrible burden for people and makes them very vulnerable. Some people will never be able to resolve their situation. The question remains what came first: debt or excessive burden and vulnerability."
In addition to the relationship between financial problems and stress, the figures show a clear link between financial problems on the one hand and physical and mental health problems, participating in society and social contacts on the other hand. Utrecht residents who find it difficult to make ends meet are more likely to have mental health problems, are more likely to report chronic physical conditions and are more likely to contact their GP or medical specialist. Parents with children under the age of 18 who have difficulties making ends meet, are three to five times more likely to have one or more mental health issue(s) than parents with sufficient financial resources.
Growing up in poverty has a negative effect on children. Two-thirds of children growing up in families with little money are also stressed13. Family poverty can have a negative effect on the children’s physical and mental health as well as their living situation, school performance, social environment and the relationship with their parents. These children are also more likely to feel excluded13.
“For many people, it’s all about surviving. Rents are high, insurances are expensive. Some people don’t have enough to meet their basic needs, these are often families with children that are still living at home. It does happen that they have to skip a meal in order to make ends meet."
Many households live on low incomesIn 2016, 25,900 households in Utrecht lived on low incomes (up to 130% of the statutory minimum income). This is 18% of the total number of households in the city: a percentage that has remained virtually unchanged since 2014. There are 9,500 children in these households. This number of children has dropped ever so slightly in recent years.
More children are growing up in a household with a long-term income around the threshold for obtaining income support1,500 children grow up in a household that has lived on an income around the threshold for obtaining income support (up to 101% of the statutory minimum income) for four years or more. In 2014 this was as still 1.9%. In 2016, this increased to 2.4% of Utrecht children14.
Debt is very commonThe population survey 2017 shows that 8% of households have problematic debts15. 87% of the people using night refuges said they were in debt. This percentage is 94% in crisis refuges3.
What is being done in Utrecht with regard to the financial situation?The municipality of Utrecht wants all Utrecht residents to be able to live without debts and to be able to participate in society. There are various schemes that offer support for this, such as the U-polis (collective health insurance for low-income residents), the U-pas (free participation pass offering many discounts on activities and items) and income support such as individual income support and crisis payments. The municipality ensures that these schemes are accessible to all Utrecht residents that need them, including those who are working on low incomes.
Various steps have already been taken in Utrecht to prevent debts and to help Utrecht residents who are already in debt. Examples include Jongerenfonds, a pilot scheme for early debt detection and the transfer of access to debt services to the community teams. The municipality is also making plans to give a major boost to tackling debt and poverty in the coming years.
In addition to providing the figures, interviews have been conducted with professionals, volunteers, policymakers and residents of the city on the health of people facing multiple problems. The interviews mainly reveal that there are concerns in the city about access to care.
Access to care
Concerns about access to care for Utrecht residents facing multiple problems are regularly reported in these interviews. Utrecht residents sometimes find asking for help too complicated. Because of all the changes in care provision, it can be difficult to find the way to get the correct care and support. This is extra difficult for this group of Utrecht residents because they have multiple care and support needs at the same time. Because contacts are increasingly taking place digitally, this can increase the feeling of confusion. It is also difficult to clarify your own care needs if you have a lot of problems that are interrelated, or if you are suffering from stress. This is also mentioned in Schmidt’s study among Utrecht residents facing multiple problems16.
“Policy makers and care workers are signalling that the system is already complicated, even for the more educated residents who are involved with it through their work. Let alone for less educated or low-literate residents, residents who do not have access to a PC, residents who do not speak the language or do not speak it very well and who are also in the middle of a difficult phase of their lives. A government shouldn’t underestimate its citizens, but it shouldn’t overestimate them either."
Costs, for example in the form of an excess or personal contribution, are also a reason why some people choose not to access care services. In the Health Survey, 15% of Utrecht adults with accumulated problems in four or more areas of life, reported that either they themselves or a family member needed medical or dental treatment, but did not receive it. The average percentage in Utrecht is 7%. Nearly half of them did not seek treatment because of the cost4.
“A lot of people have to visit their GP often and their personal contribution to medical expenses is a major barrier. That leads to the dilemma: can I afford to go or not?"
The interviews in the city also revealed that there is a certain lack of trust. Trust has to be built up slowly. This takes time and effort.
Some people do not understand the language well enough to get the help they need. If someone is not able to clearly indicate what is wrong, they are more likely to be referred to the wrong type of care service. This requires language skills that, for example, Utrecht residents with a migration background or low-literacy skills do not always have.
“When I was ill, or when my children were ill, I would use the dictionary first to write down the words that I had to say to the GP. Sometimes I would show that note to the GP."
What is being done in Utrecht with regard to care?A lot has changed in the provision of care services since 2015 in the Netherlands, including in Utrecht. As a result of changes in legislation, long-term care services and youth care services have come under the responsibility of the municipality. The municipality of Utrecht wants everyone to be able to participate in society and be given the opportunities to develop their talents and skills. It does this by investing in the basic services that help adults, young people and children to get a firm foothold in life. Residents facing problems that they cannot solve themselves or with help from their community, can rely on low threshold, easily accessible care services and support. These are provided by the community teams, if necessary, by supplemented by specialist care. The care and support take the residents’ own capabilities into account and are aimed at strengthening their independence and resilience, if necessary with the help of co-residents and volunteers.
In addition to providing the figures, interviews have been conducted with professionals, volunteers, policymakers and residents of the city on the health of people facing multiple problems. Those involved have expressed their concern that problems usually pass from one generation to the next.
From generation to generation
If parents have multiple problems, this can also have consequences for their children. Patterns are often passed on from generation to generation. It is therefore important to also pay attention to the conditions under which these children grow up and what effect that has on their development. In interviews in the city, it has been mentioned that people are concerned about this.
“A lot of vulnerable people have been facing these kinds of problems for generations. They don’t see that it’s not normal to have to survive like this. That’s why they are not asking for help."
“Their only concern is: how do I get through this day. Because of the level of stress about money and generally not feeling comfortable in themselves, people don’t know what is available. There are lots of concerns about the children."
The Ombudsman for Children warns of the lifelong effect that growing up in poverty can have on the rest of children's lives13. The transfer from one generation to the next is also described by Donkers17*. She reports that there are parents in refuge facilities who themselves lived in refuge facilities as children.
“Unfortunately, this intergenerational transfer is the reality for many clients staying in refuge facilities: they have not managed to break the circle of violence and neglect." Donkers, 2015
A major risk factor is experiencing dramatic events at a young age. National research has shown that children in care or refuge facilities have experienced an average of seven dramatic events. Almost all children in care or refuge facilities are likely to have suffered traumas17.
Children who have experienced dramatic events often feel less fit and healthy. Think of sleep problems, concentration problems, anxiety, socio-emotional problems, mental health problems and behavioural problems17. They are also more likely to have health problems in adulthood. These can include cardiovascular disease, obesity, depression and addictions. The more dramatic the life experiences are that children have experienced, the more health problems they will have later on, even in adulthood18,19.
How are we doing?
How are we doing in the area of mental health?Mental health problems are relatively common among Utrecht residents with a high social exclusion score: more than twice the average4. Nine out of ten people in refuge facilities have mental health problems. Multiple problems also cause major stress. This is true for adults, as well as the children involved.
“My health is bad. I’m tired often, I have a lot of complaints and I don’t really feel like doing anything. Sometimes I feel that there is no one who can help me. My GP doesn’t understand me. My friends are helping me, I can talk to them about it."
How are we doing in the area of physical health?Physical problems are more common among Utrecht residents with a high social exclusion score. They are twice as likely to have cardiovascular diseases and three times as likely to have diabetes as city average4. Two-thirds of people in refuge facilities say that they have physical problems3.
“No, I'm not really healthy. I suffer from migraines, I have pain in my knees and hips and I have high blood pressure. Yes, there are a lot of things wrong with me."
How are we doing in the area of care?29% of Utrecht residents with a high social exclusion score reported having had contact with the community team in the past year. On average, 7% of adults in Utrecht have reported this4. Two-thirds of ‘Meetellen in Utrecht’ panel members, contacted a community team. 69% were happy with that20. Utrecht residents with a high social exclusion score are also more likely to visit a GP or medical specialist. However, they are less likely to visit the dentist4.
How are we doing in the area of lifestyle?Utrecht residents with a high social exclusion score generally have a less healthy lifestyle than the average in Utrecht. For example, more than half of them are overweight. 6% drink alcohol excessively, this is actually lower than the average in Utrecht. One possible explanation for this is that a large percentage of Utrecht residents with a high social exclusion score have a migration background. They are less likely to drink alcohol than the average in Utrecht4.
Visitors to the night refuge during the cold weather arrangement* consume on average 15 glasses of alcohol on the days they drink. A large proportion of them use drugs, especially cannabis21.
“People sometimes honestly don't know what a healthy diet is. They think that eating French fries with green beans every day constitutes a healthy diet.”
“I like to have a beer and a cigarette, nothing else. But only 10 a day, I'm not an alcoholic!"
Visitor of the night refuge during the cold weather arrangement*
* In case of persistent frost during the day and night, the cold weather arrangement starts in Utrecht. This means that all homeless people are then entitled to a free place to sleep, even if they are not from the Utrecht region. Once every two years, we interview visitors of the night refuge during that period.
How are we doing in the area of life skills?It is estimated that one in five people in Utrecht has low-literacy skills or a mild intellectual disability22. People staying in refuge facilities are more likely to have indications of low-literacy or intellectual disability3. More than one in five members of the ‘Meetellen in Utrecht’ panel reported being partially or completely unable to cope independently in society23.
“Most people [with multiple problems] cannot cope very well. They cannot read letters, need help with basic things. For example, they don’t know how to apply for benefits."
How are we doing in the area of social participation?Utrecht residents facing multiple problems are less likely to be socially active than the average. They are less likely to be in paid employment and are less likely to do volunteer work. Many members of the ‘Meetellen in Utrecht’ panel do volunteer work. In a study of the ‘Meetellen in Utrecht’ panel, the panel members emphasize that doing (volunteer) work can be very positive. They gain useful experience, gain confidence and learn new skills. Paid and voluntary work is also a lot of fun, it provides social contacts and improves the daily routine24. The percentage of informal caregivers among Utrecht residents with a high social exclusion score is about the same as the average in Utrecht4.
“Being healthy means being able to do whatever you want. I can’t do that anymore [...]. I’m able to do what I want with volunteer work, but I wouldn’t be able to get a paid job. I'm glad I can still do this."
How are we doing in the area of social contacts?Utrecht residents facing multiple problems often have a small social network. A quarter of Utrecht residents staying in refuge facilities have no contact with family and friends3. Approximately one-third of Utrecht residents with a high social exclusion score have little contact with family and friends or acquaintances4. More than three quarter of the members of the ‘Meetellen in Utrecht’ panel reported feeling lonely. Half of the members of the panel would like to have a larger, more diverse and stronger social network25.
“There are quite a few people who live alone and don’t have any contact with their neighbours."
Main conclusionsBy deepening the Utrecht Health Profile 2018, we provide an overview of how Utrecht residents facing multiple problems are doing. What are the main concerns and risk factors when it comes to their health and that of their children?
Nearly a quarter of adults in Utrecht have accumulated health risks or problems in four or more areas of life. This equates to approximately 60,000 adults. 7% of Utrecht adults also have a high social exclusion score. In addition, more than 2,700 Utrecht adults and 285 children are using Utrecht’s refuge facilities or supported housing. In general, they also have multiple problems. The size of these groups has remained more or less the same in recent years.
Financial worries are an important issue for this group. The picture that emerges from interviews is that financial problems are experienced by almost all Utrecht residents facing multiple problems. Many households in Utrecht live on low incomes and Utrecht residents facing multiple problems are more likely to be in debt. There is a clear link between financial problems and health. This is also true for children who grow up in a family with money worries.
In the city, there are concerns about access to care services. Finding the right help and asking for the right care services and support is complicated, especially for people with multiple problems.
If parents have multiple problems, this can also have consequences for their children. It is therefore important to also pay attention to the conditions under which these children grow up and what effect that has on their health and development. Children staying in refuges have often experienced dramatic events that can also have a long-term effect on their health and development.
In almost all areas of life, Utrecht residents facing multiple problems are not doing as well as the average in Utrecht. They are more likely to have mental health and physical problems. They are also more likely to have low literacy skills and a mild intellectual disability. They are less likely to be socially active and have a smaller social network. They are more likely to have contact with a community team, GP and medical specialist.
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