Reading guide

This web article is based on the Trend Scenario and the Thematic Foresight Studies. The substantiation for the texts, numbers and figures presented here can be found in these documents, unless indicated otherwise. The Trend Scenario and Thematic Foresight Studies show how our public health situation and health care sector will develop over the next 25 years if we pursue our current course and do not take any additional measures. This approach makes it possible to map out the societal challenges for the future.

Key message

Health problems and social issues often accumulate for vulnerable groups
Some of the older people are in a vulnerable situation due to an accumulation of chronic diseases and other medical and social issues. This group will continue to grow. People who have a lower socio-economic status often have an unhealthy lifestyle. They also have to deal with social issues more often, which are accompanied by stress. Negative effects resulting from labour market developments such as robot automation and digitisation primarily affect less skilled workers. This can exacerbate the social issues and stress among people with a lower socio-economic status. These underlying social issues often need to be resolved first, before creating room to work on a healthy lifestyle.

An accumulation of problems puts older people in a vulnerable position

The percentage of older people in the population is increasing. Older people often have several chronic diseases at the same time. We also refer to that as multimorbidity. Older people are also more likely to suffer from problems such as falling, memory problems, visual and hearing impairments, limitations in daily living, incontinence, depression, loneliness and poly-pharmacy (the use of multiple medicines at the same time). Some of the older people are in a vulnerable situation due to an accumulation of chronic diseases and other medical and social issues. They may be able to manage for now, but minor changes could be enough to unbalance their lives. There are various trends that will contribute to a future increase in the number of older people in vulnerable positions. This is not only because the number of older people is rising, but also because an increasing number of older people will reach very old age. In addition, older people will increasingly live independently, and are increasingly likely to live alone.

People are increasingly expected to take the lead in arranging their own social support and care, and many people do in fact want to do it themselves. However, there are also people who have difficulty doing it, or are unwilling to do so. Older people are more likely to feel like they do not have enough control over their own lives compared to other age groups. This also applies to people with chronic diseases (see figure). Due to the ageing population, the number of people who do not feel sufficiently in control of their own lives will increase as a result. This will lead to a situation in which there will be more older people with complex issues, and they will be expected to take a more active role in resolving these issues, even as the group of older people who have difficulty doing so will also be increasing. It should be noted that older people are not the only ones who have difficulty managing their own health care process. This issue occurs in all age groups, and at all levels of education. However, it is more common amongst older people than in other age groups. Older people who are facing an accumulation of problems may have particular difficulties expressing their preferences and needs clearly. The same applies to other vulnerable groups, such as older people who have a migrant background and older people who have cognitive limitations. The latter group will grow, since life expectancy for people with cognitive limitations is increasing.

Percentage of population aged 65 and over with and without a chronic condition that experience insufficient control over their own lives, 2016

Source: Health Monitor for adults, Public Health Services, Statistics Netherlands (CBS) and RIVM, 2016

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Indicator(s) used: Number of Dutch people (19+) who experience insufficient control over their lives.

Source(s) used (in Dutch): Health Monitor for adults, Public Health Services, Statistics Netherlands (CBS) and RIVM, 2016.

Unhealthy lifestyle and social problems are more common in people who are less well educated

People who have a lower level of education are more likely to have an unhealthy lifestyle than people who have a higher level of education. Looking at smoking, excessive alcohol use and overweight, 27 percent of people whose highest level of education is basic vocational school or junior general secondary school display none of these unfavourable lifestyle factors. For people with higher professional or university education, that figure is currently at 49 percent. People with lower levels of education often are more overweight and a combination of overweight and smoking occurs more often in this group. This pattern becomes even clearer when, in addition to educational level, we also take a closer look at differences between men and women. Nearly 60 percent of women who have attained higher education have none of these three risk factors; in case of women with lower levels of education, that figure is 25 percent. However, women with higher education are more likely to use alcohol excessively than women with lower levels of education (see figure). In general, however, men are more likely to use alcohol excessively than women.

People who have lower levels of education also more often have to deal with social issues, such as unemployment and poverty. A number of future developments in the labour market can intensify these issues, because they are expected to have a bigger impact on employees that have lower levels of education than on employees who have attained higher education. These trends mainly involve technological development, such as robot-based automation and digitisation. These increasingly complex technologies will create a bigger demand for employees with higher education, with new skills, while robots can replace the work of people with lower levels of education. The ongoing digitisation requires different competencies from employees, which also change rapidly. This makes lifelong learning a crucial necessity. Less skilled workers may find it difficult to meet these demands, as will older people, flex workers and people in poor health. 

These social issues will result in stress, which in turn might have a detrimental effect on lifestyle. In many cases, there will only be room to work on a healthier lifestyle when the underlying causes of this stress have actually been resolved. Interventions such as workforce mediation or debt counselling are therefore often a better starting point for improving health in these cases than addressing lifestyle factors. 

Adults with no, one, two or three risk factors by educational level, 2016


Source: Health Monitor for adults, Public Health Services, Statistics Netherlands (CBS) and RIVM, 2016


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Indicators used: Percentage of population aged 25 and over being overweight (Body mass index >= 25), being an occasional smoker (including daily smoking), and/or excessively using alcohol (more than 21/ 14 glasses of alcohol per man/woman per week), disaggregated by educational level (low, middle low, middle high, high).

Percentages might differ from those presented in the Trend Scenario due to the use of different sources.

Sources used: Source(s) used (in Dutch): Health Monitor for adults, Public Health Services, Statistics Netherlands (CBS) and RIVM, 2016. data processed by RIVM.

More mental problems amongst people who have a migrant background due to accumulation of risk factors

Dementia seems to occur more frequently amongst certain groups of people who have a migrant background. The number of older people with dementia who have a migrant background is likely to rise more rapidly in future than the number of older people with dementia who have a Dutch background. Other psychological problems and mental conditions, such as displacement, psychosis and depression, are also more prevalent amongst people who have a migrant background. This higher occurrence is likely due to an accumulation of risk factors, such as low income, low health skills, loneliness, and a higher frequency of cardiovascular diseases and diabetes. Stress resulting from the underlying causes of migration, such as war, and uncertain migration processes, also plays a role in this context.

Accumulation of problems also occurs at neighbourhood level; extensive clustering in the northeast of the Netherlands

An accumulation of problems plays a role not only in individual cases, but also in specific neighbourhoods. Neighbourhoods where people have a higher-than-average occurrence of smoking, excessive alcohol use and overweight are found all across the Netherlands. However, it is apparent that there are clusters in the northern and easternmost regions of the country. To gain a better understanding of areas that also have a high prevalence of social issues, it was assessed which neighbourhoods make extensive use of formal arrangements for workforce participation and income assistance. The neighbourhoods that display relatively frequent use of these arrangements are also distributed across the entire country, and again show clear signs of clustering in the northeast of the Netherlands (see figure). As a result, there is an overlap between neighbourhoods that see lots of social issues and neighbourhoods with a higher frequency of unhealthy lifestyles. Overlap primarily occurs between the use of social benefits and smoking and overweight. 

Neighbourhoods that are home to many people with lower incomes often show an accumulation of negative characteristics, such as air and noise pollution due to nearby roads and motorways, less well-insulated homes, a street plan which is less conductive to easy mobility, and a wider range of options for unhealthy food. Continuing urbanisation will cause people to be pushed to the fringes of the cities. Rising house prices, for instance, mean that only people with high incomes can still afford to have houses in the most coveted neighbourhoods, often in and around city centres. That will change the composition of these neighbourhoods, causing them to become less diversified. This trend reinforces the income-based division; there will be neighbourhoods which will be primarily occupied by people with higher incomes and neighbourhoods primarily housing people with lower incomes. This will also exacerbate the differences in health between neighbourhoods.

Accumulation of unhealthy lifestyle factors and social assistance plans, 2016
Opeenstapeling ongezonde leefstijl en Sociale regelingen

Source: SMAP data RIVM, in collaboration with Public Health Services and Statistics Netherlands (CBS), Waarstaatjegemeente.nl

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Indicator(s) used: Above-average occurrence of unhealthy lifestyle factors (smoking, excessive alcohol use, overweight), at neighbourhood level.  Percentage of households that use social assistance plans involving income support and workforce participation, at neighbourhood level.

Source(s) used (in Dutch): SMAP data Health Monitor for adults, Public Health Services, Statistics Netherlands (CBS) and RIVM, 2016. CBS, via Waarstaatjegemeente.nl