Social determinants

Pilot projects funded by the European Parliament


A pilot project is an initiative of an experimental nature designed to test the feasibility and usefulness of action. It is meant to develop evidence-based strategies to address a problem, identify good practices, and provide policy guidance for the benefit of possible future initiatives in the area of health inequalities.

The European Commission's contracts with various contractors are based on their approaches in the chosen proposals and provide them with the necessary scope for their execution. Boards of scientific experts have been set up from a variety of disciplines for each project to provide robust guidelines for the project intervention and to validate its tools including the project websites which reflect the views of the authors and not necessarily the official opinion of the Commission.

Feel free to browse the ongoing projects below

VulnerABLE: Improving the health of those in isolated and vulnerable situations

This European initiative shall increase our understanding of how best to improve the health of people who are living in vulnerable and isolated situations across Europe.
The project targets specific vulnerable and isolated populations such as children and families from disadvantaged backgrounds; those living in rural/isolated areas; those with physical, mental and learning disabilities or poor mental health; the long-term unemployed; the inactive; the 'in-work poor'; older people; victims of domestic violence and intimate partner violence; people with unstable housing situations (the homeless); and prisoners.

Due to their circumstances, these groups may be more at risk of poor health and/or face barriers in accessing healthcare services. The project will assess their particular health needs and challenges, as well as identify best practices to support them and ultimately improve their health.

The concept of vulnerability is a social phenomenon, affected by multiple processes of exclusion that can lead to or result from health problems. Individuals can be more or less at risk of being in a vulnerable situation, depending on personal (inborn or acquired) and societal and environmental factors. The more personal resources (good mental and physical health, good coping skills, etc.) and environmental support a person has, the less likely that person is to be at risk of vulnerability.

Over its two-year lifetime, the 'VulnerABLE' project will involve:

  • Interviews with individuals and organisations who work first-hand in the field of health inequalities (such as the World Health Organisation and local authority networks);
  • Detailed research into the health needs of people in isolated and vulnerable situations, including a face-to-face survey and in-depth focus groups with them;
  • Bringing together the leading thinkers in this area and enabling them to contribute to future strategies to prevent isolation and vulnerability;
  • Training materials and capacity-building workshops for national and regional authorities who are active in delivering healthcare services and who have a vital role to play in tackling health inequalities;
  • Regular news updates, direct communication with experts and a one-day conference to spread awareness of the project's findings amongst national and regional authorities; public health experts; health professionals; and other non-governmental organisations (NGOs).

Main health challenges facing vulnerable people and policies responses pulled together in the VulnerABLE scientific report

The VulnerABLE two year project delivered its final report: it is  a scientific report  which pulls together the main health challenges facing vulnerable people across the EU and policy responses that address these issues.

The key findings include:

  • Widespread inequalities remain in health and access to healthcare within and between Member States. For example, there is a gap of 8.5 years between the Member State with the lowest life expectancy (Lithuania) and the Member State with the highest life expectancy (Spain). The European Commission is addressing this issues through its communication on ‘Solidarity in Health: reducing health inequalities in the EU’ with the aim to facilitate the exchange of best practices between Member States and share understanding about the effects of social exclusions;
  • The cost of treatment (in 2015) was the most common reason for unmet healthcare needs across Europe. Member States are starting to focus on improving access to healthcare, for example Greece’s National Health Strategy (2014-2020) aims to improve healthcare access for all vulnerable groups, particular those with lower levels of education or income;
  • Multi-faceted strategies are needed to effectively target vulnerable groups, where health is a key component. Anti-poverty strategies in the UK and Portugal are good practice examples of how health issues need to be addressed alongside employment, housing, income and other poverty related issues.

The VulnerABLE conference on the 7th November gave stakeholders a chance to reflect on the projects findings and share best practices examples across sectors, organisations and Member States.


Health inequalities are unnecessary, avoidable, and unjust - Findings of literature review

Unmet needs in healthcare still very much exist across the European Union (EU) for people living in vulnerable and isolated situations. The pilot project assessed their health challenges by analysing relevant literature, data, and policy documents. It found that although there has been an increase in health across the EU in recent years, this has not been experienced equally between and within Member States. Life expectancy, the prevalence of ill health, and the level of unmet needs vary across different population subgroups, according to the latest data.

Key findings:

  • In 2014, 6.7% of Europeans reported having unmet healthcare needs, with the most common barrier being cost (reported by 2.4% of Europeans).
  • Data from the Survey of Health, Ageing and Retirement in Europe (SHARE) show that in older people socioeconomic factors such as a lower level of education and lower income increase the likelihood of older people experiencing limitations to their mobility, and the prevalence of eyesight, hearing and chewing problems.
  • Those living in rural areas are less likely than urban residents to seek the healthcare they need because of cost, distance, and/or a lack of health facilities and professionals. In some Member States, pharmacies, essential medicines as well as specialised services are more difficult to access. In Romania there were three times as many pharmacies reported in urban than rural areas, despite the fact that a large proportion of the population lives in rural areas.
  • Most prisoners have pre-existing vulnerabilities, such as substance abuse and mental health needs, which overcrowding and poor hygiene in prison may make worse.
  • Those with lower levels of education are more likely to have a lower life expectancy. Data from Bulgaria show that the average life expectancy, at age 25, of men educated to lower secondary level or below (ISCED 0-2) was 40.8 years in 2013, compared to 52 years for men with a tertiary education (ISCED 5-8). A similar gap was seen in women.
  • Long-term unemployment and inactivity is associated with a range of poor health outcomes, including premature ageing, poor mental health, negative health behaviours and worse self-reported health. When healthcare is reliant on in-work benefits or insurance coverage, un-employment is a major barrier to access.


Improving the health of vulnerable and isolated groups: Exploring most effective strategies from across Europe

The case study inventory , produced as part of this pilot project, contains 31 quality scored and highest ranked case studies of existing initiatives from across the European Union, covering 19 EU Member States. All the case studies aim to improve access to health care for one of the nine target groups of the project[1]; to address inequalities in health status; or both. Specific approaches include:

  • ŸSetting up mobile health and outreach services to reach out to vulnerable groups;
  • ŸReforming the delivery of healthcare to make it more appropriate to the needs of vulnerable groups (for example, by sensitising professionals);
  • ŸTackling the lifestyle factors that contribute to poor health;
  • ŸAddressing the root cause[s] of poor health for a particular group;
  • ŸRaising awareness and engaging communities to empower individuals to take greater control of their health; and
  • Improving general understanding of the needs of particular groups (through research and engagement)

The case study of this inventory is two-fold:

ŸFirstly, it is a resource for policy-makers and healthcare professionals who wish to promote health equity and deliver a more inclusive service, by learning from the approaches identified;

ŸSecondly, it is an important foundation for subsequent stages of this pilot project, as it supports the following outcomes:

  • Capacity-building activities at regional and national level to spread awareness of the practices among officials and health professionals; and
  • Inform policy guidance on pre-conditions for effective approaches in improving access to and quality of health for vulnerable groups.

[1]: Children and families at risk of poor health, including lone parents; Those with physical, mental and learning disabilities or poor mental health;  In-work poor;  Those living in rural/isolated areas;  Long-term unemployed and inactive;  Older people;  People with unstable housing situations (homeless); Prisoners; - Victims of domestic violence and intimate partner violence.


High cost of healthcare facilities is the biggest barrier for vulnerable and isolated people – Insights from VulnerABLE survey

This pan-European survey conducted in 12 Member States (France, Germany, Greece, Italy, Lithuania, Netherlands, Poland, Romania, Slovakia, Spain, Sweden and the UK) provides insights into the particular health needs and risk factors of all nine target groups of the project. The largest number of the over 4,000 respondents had physical, mental and learning disabilities, followed by the long term unemployed/inactive.

The questionnaire explored their experiences with access to and quality of healthcare, causes of health problems and factors that may prevent access to care.

Key results:

  • Vulnerable and isolated people often deal with health issues, largely attributed to their lack of money or the feelings of stress. More than half of the respondents reported a long standing illness, disability or physical/mental weakness, and more than a quarter of respondents experienced feelings of psychological stress, such as feeling tense, lonely and depressed most or all of the time.
  • Vulnerable and isolated people often find it difficult to obtain the healthcare they need. High cost of healthcare facilities was the biggest barrier to accessing care, alongside long waiting times and inability to get an appointment with a healthcare professional. Furthermore, respondents with lower education levels and lower income levels found it more difficult to understand health information provided by healthcare professionals.
  • Access to healthcare varies across the different target groups. Vulnerable families, people living in rural or isolated areas, and vulnerable older people reported the most problems with accessing healthcare. People with physical, mental and learning disabilities were consistently less affected by the costs of healthcare.
  • Satisfaction with health services is lower for people with greater healthcare needs. Nearly half of the respondents who reported having bad health were dissatisfied with their medical treatments due to long waiting times, scepticism that the treatment improved their health, high treatment costs, and the attitude of healthcare professionals. Prisoners, people living in rural and isolated areas, and isolated older people had the lowest satisfaction levels.
  • Education and financial situations are key factors affecting health, access to healthcare, and satisfaction with healthcare services. Respondents with only a basic education reported having mental health issues more often. Respondents in difficult financial situations reported problems with stamina, breathing or fatigue. Level of education and financial status were linked with psychological stress, for example respondents in a difficult financial situation experienced fewer instances of waking up well rested.

The survey also highlights areas for future research, e.g. around causes of specific health needs, barriers to access to healthcare, differences between target groups, and the role education and financial status play in health and access to healthcare.


IRIS – opening eyes to domestic violence and abuse in General Practices

IRIS (Identification and Referral to Improve Safety) is a domestic violence and abuse (DVA) training support and referral programme in the UK. The VulnerABLE literature review and Focus Group discussions identified it as interesting case study on the UK Strategy to end violence against women and girls (VAWG).

IRIS wants to help professionals to better identify and support persons experiencing DVA from a current partner, ex-partner or adult family member by

  • Ongoing training and support to general practice teams;
  • Electronic prompts on patient records to remind healthcare professionals to ask about DVA and record data safely;
  • Creating local clinical champions to co-deliver training and peer support to other colleagues;
  • Health education resources for practices and patients;
  • Advocacy for patients through the support of an advocate educator;
  • Named contact for patient referrals through enhanced care and referral pathways.

Primary care and third sector organisations specialising in violence against women and girls work together in IRIS. An advocate educator is linked to general practices and based in a local specialist service. He/she works in partnership with a local clinical lead to co-deliver the training to practices.

IRIS has proven to be a cost-effective intervention. It was the first European randomised controlled trial to improve the healthcare response to DVA. It took place in Bristol and Hackney in 48 practices during 2007-2010; 12 control practices and 12 intervention practices each were evaluated. Results showed that, in interventions practices:

  • Women were 22 times more likely to have a discussion with a clinician about referrals;
  • Women were 6 times more likely to be referred to an advocate;
  • Women were 3 times more likely to have DVA identified on their medical records.

Outcomes were based on the number of referrals to domestic violence agencies providing advocacy, and the level of disclosure of domestic violence in patient’s medical records. There is also a range of other evidence available on IRIS' positive outcomes.

The IRIS model has been up scaled nationally and is commissioned in 34 parts across the UK. The national IRIS team provides support and guidance to areas who wish to implement the model. Commissioning guidance is available and a training for trainers programme is delivered locally.

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HEPP – Maintaining a focus on health inequalities

This pilot project will contribute to maintaining an EU and Member State focus on health inequalities and help to mainstream measures to address them. The project has a particular focus on alcohol, nutrition and physical activity, related to the socio-economic gradient and disadvantaged areas. The pilot project works closely with

  • the previous Joint Action on Reducing Alcohol Related Harm (JA RARHA),
  • the Joint Action on Nutrition and Physical Activity (JANPA), and 
  • the EU Expert Group on Social Determinants and Health Inequalities.

The project, by sharing knowledge and developing policy guidance, will have an impact on better understanding what can be done to address health inequalities related to alcohol consumption, nutrition and physical activity in the European Union. It will also help Member States to better address the associated behaviours and risks, and their drivers (‘ the causes of the causes’). It will train countries to overcome barriers to inter-sectoral action through information exchange and collaboration between experts in research, policy and practice.

HEPP prepared two scientific reports to update the evidence on the status of health inequalities in Europe concerning:

  • Nutrition and physical activity (and sedentary behaviour)
  • Alcohol consumption

For each EU Member State it will also produce a fact sheet on health inequalities relating to the above determinants.

HEPP will analyse the data of Joint Action RARHA from a health inequalities perspective.

To ensure the outcomes are useful and appropriately focused as well as effectively disseminated, HEPP works with organisations and individuals recognised as European experts in those fields, to keep interested experts and policy makers engaged in the project.

HEPP will develop a range of detailed case studies to showcase effective action, and the strategies and skills needed to implement them. It will provide up-to-date advice and support to Member States in their policy development and implementation process to ensure its high impact.

Similarly HEPP will identify suitable Member States with a specific focus to hold training workshops. Those workshops will develop capacity within the Member States involved, and will also pilot the on-line training resources.

HEPP will later compile all information in short ‘policy briefs’ to clearly outline the rationale for action. The potential costs and benefits of a focus on health inequalities in relation to alcohol, nutrition and physical activity will also be analysed.

This work will be finalised in 2018 ahead of a high-level conference in Brussels.

If you would like to find out more please contact

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Health4LGBTI: Reducing health inequalities experienced by LGBTI people

This pilot project will increase our understanding of how best to reduce specific health inequalities experienced by lesbian, gay, bisexual, transgendered and intersex (LGBTI) people, focussing in particular on overlapping inequalities stemming from discrimination and unfair treatment on other grounds (e.g. older, younger, refugee, immigrant, disability, rural, poverty).

The project will explore the particular health needs and challenges faced by LGBTI people and analyse the key barriers faced by health professionals when providing care for LGBTI people. The aim is to raise awareness of the challenges and provide European health professionals with the tools that give them the right skills and knowledge to overcome these barriers and contribute to the reduction of health inequalities.

The Health4LGBTI project commenced in March 2016. Over its two-year lifespan, activities will include:

  • A state‐of‐the‐art review of the health inequalities experienced by LGBTI people and the barriers faced by health professionals in providing healthcare for LGBTI people;
  • Two focus group studies in 6 geographically diverse EU Member States (Poland, Italy, UK, Belgium, Bulgaria, and Lithuania) to map the barriers faced both by LGBTI people and health professionals. A further aim of the focus group studies is to generate data including stimulus materials to inform the development of training module(s) for healthcare professionals; 
  • Development of training module(s) aimed at increasing the knowledge, attitudes and skills of healthcare professionals when providing healthcare to LGBTI people.  The module will be developed in such a way so as to be potentially replicable across the EU; 
  • Piloting of the training module(s) in the same Member States where the focus groups will be conducted, in order to fine-tune and finalise the modules;  
  • A final European conference, and wide dissemination and communication targeting civil society organisations representing or working with key population groups, healthcare professionals, European health organisations including the EU as well as national, regional and local policy and decision makers in the area of health.

There is substantial evidence demonstrating that LGBTI people experience significant health inequalities that have impact on their health outcomes. LGBTI people continue to experience stigma and discrimination combined with social isolation and limited understanding of their lives by others, leading to significant barriers in terms of accessing health and social care services. These experiences can translate into a risk of alcohol abuse, depression, suicide and self‐harm, violence, substance misuse and HIV infection. Depression, anxiety, alcohol and substance misuse are at least 1.5 more common in LGBTI people, with lesbian and bisexual women at particular risk of alcohol abuse.

One of the most common issues for LGBTI people in accessing health and social care services is that many healthcare and other professionals commonly assume that LGBTI people’s health needs are the same as those of heterosexual people, unless their health needs are related to sexual health. LGBTI people have unique healthcare concerns which frequently go unacknowledged by service providers. A further significant barrier in accessing health services by LGBTI people concerns disclosure of identity, as many LGBTI people fear that if they disclose their sexual orientation or gender identity status to a healthcare worker they will experience discrimination and/or poorer treatment.

Whereas lots of attention has been paid to describing and measuring the problem of health inequalities within and across Europe, relatively little attention has been paid to how most effectively reduce health inequalities in populations. Clearly, there is a need both at Member State and European levels to tackle these inequalities experienced by LGBTI people, as the right thing to do to support some of the most vulnerable populations within our societies, but also as a work towards the development of high quality health services across the Union that are equally accessible to all.

For more information, please contact Massimo Mirandola, Verona University Hospital ( 

'Health4LGBTI' focus groups discussed barriers to equal access to healthcare

The first focus groups of the EU funded pilot project met in Brighton and Warsaw to explore the barriers faced both by LGBTI people and health professionals, when seeking and providing healthcare respectively.

The first of the series took place in June in Brighton, UK, and brought together eight health and social care professionals, some of whom are involved in promoting LGBTI health in their respective fields. At their meeting, health professionals presented specialist perspectives in working with LGBTI patients and identified knowledge gaps in LGBTI health issues amongst health and social care professionals. They also discussed the need for improved training in LGBTI health. In a second focus group, also in Brighton, LGBTI people themselves discussed the barriers and provided examples of challenges they encounter when seeking healthcare.

Two focus group discussions each are being organised in Poland, Italy, UK, Belgium, Bulgaria, and Lithuania. The next ones are scheduled to take place in Ghent, Vilnius, Verona and Sofia in the coming two months, Warsaw having made a start already on 7th September.

For further information contact Massimo Mirandola

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GenCAD: Gender-specific mechanisms in coronary artery disease in Europe

This European pilot aims to improve the understanding of sex and gender differences in chronic diseases, using coronary heart disease (CAD) as an example to highlight these differences regarding treatment and prevention activities in European countries.

As with other chronic diseases, CAD differs significantly in women and men throughout Europe, in age distribution, risk factors, prevention, clinical manifestation, response to therapies and outcomes. However, the existing evidence regarding sex and gender differences is sometimes incomplete and the existing findings are frequently not convincingly presented to the medical community and public.

Our target audiences are healthcare professionals, gender-based organisations, policy makers and the general population.

The GenCAD project commenced in February 2015. Over its three-year period, the GenCAD project aims to:

  • Analyse existing knowledge about gender differences in CAD risk factors, disease mechanisms, clinical manifestations, treatment options, access to health care, as well as management and outcomes.
  • Assess awareness of health professionals and general population to identify the most effective practices to raise awareness about sex and gender manifestations of CAD, its specific risk factors and available treatments in the member states using two types of surveys.
  • Develop information material based on the outcomes of the studies, surveys, and comprehensive needs assessment. Easily understandable factsheets will be disseminated in all official 24 EU languages.
  • Communicate & disseminate results of the surveys and the resulting factsheets to different target audiences and the health care community in all member states at various workshops and international conferences.

The GenCAD project will investigate published information, European databases and existing health policies in different countries to provide novel insights as to how and why different forms of CAD affect women and men, which preventive approaches are most effective in a gender-specific context and how this is already integrated into health policies. Also to be included are social determinants of health contributing to the inequalities between women and men, potentially affecting CAD outcomes. It will assess awareness of different groups of the population on these facts and use this knowledge to optimize structured information in factsheets for target groups and to develop the best strategies to raise awareness at all societal levels.

The project aims to ensure long-term sustainability and transfer of the results and products into practice by encouraging the use of its results by national stakeholders.

For this purpose, the project is organizing conferences and will disseminate its findings to all stakeholders in all Member States.

Long-term availability of the produced factsheets will be assured through this website and, international societies and institutions. A report will also be made available focusing on gender aspects in CAD and its prevention that assembles the European activities, highlights, gaps and opportunities.

If you are interested in joining the GenCAD project, you can get involved in the conferences and workshops by contacting Nicholas Alexander, Institute for Gender in Medicine, Charité Universitaetsmedizin Berlin (info[a]