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Sharratt et al. Plast Aesthet Res 2020;7:35 I http://dx.doi.org/10.20517/2347-9264.2020.99 Page 3 of 10

with these women being more likely to decide to continue their pregnancy than would have been expected
[6]
if such intervention was not received .

At the same time, the European Pillar of Social Rights states that “Everyone has the right to timely access
[7]
to affordable, preventive and curative healthcare of good quality” p.21 . There have been significant
improvements in health in Europe due to advancing healthcare systems; however, access to healthcare
remains uneven across countries and social groups, according to an individual’s socioeconomic status,
[8]
place of residence, ethnic group and gender . Furthermore, it has been established that the lack of coverage
and provision of certain types of care, such as cleft and craniofacial care, means that significant inequality
remains in Europe. It is extremely important to acknowledge, however, that this inequality is not just
between countries, but also within a country.

Inequalities are more present in socially marginalised groups; they are, for example (but not limited to),
individuals who are unemployed, experience mental health problems, migrants or refugees and have
disabilities. Belonging to a socially marginalised group also increases the risks of health inequalities,
poverty and social exclusion. In 2017, 22.4 per cent of the European population (112.8 million people) lived
in households at risk of poverty or social exclusion. In Bulgaria, Romania and Greece, more than a third of
[9]
the population was at risk . When it comes to children, figures for 2018 show they are the group at highest
[10]
risk of poverty or social exclusion in Europe .
A fundamental factor that explains inequalities in healthcare is that the lower the income of an individual
or family is, the more self-reported unmet healthcare needs they have. A descriptive example is that in
Greece those who are in the lowest income quintile report 34.3 per cent unmet healthcare needs while
[8]
those in the highest quintile report only 0.4 per cent . Currently, there exists evidence that large income
[11]
differences result in poorer health and more negative social consequences and health inequities are
[12]
increasing in many countries . One of the factors that contributes to belonging to a group that is at risk
[13]
of being in poverty and social exclusion is an individual’s level of education , since higher educational
[14]
attainment often correlates with higher employment rates and higher earnings . It also depends on which
[15]
region an individual resides, since the 2018 unemployment rates in EU regions vary from 1.3% to 35.1% .
At the same time, research shows that individuals with cleft are at an elevated risk of poor educational
outcomes in comparison to their peers [16-19] . This carries the potential to influence the long-term outcomes
for individuals with cleft, since they are then hypothetically at a higher risk of poverty and/or social
exclusion if they do not succeed in their education.

Experiencing inequality, poverty or social exclusion is also associated with mental health problems.
[20]
Currently, in Europe, more than one in six people experience mental health problems , and, when it comes
to mental health problems for individuals with cleft, there are population-based studies from Denmark
and Sweden that show a significantly increased risk for having psychiatric and neurodevelopmental
disorders [21,22] as well as increased risk for being prescribed psychotropic medication [23,24] .

When individuals with a cleft or craniofacial conditions are seen by their healthcare providers, based on
[25]
EU data for the general population, approximately 22 per cent are at risk for poverty or social exclusion .
However, the real figures are probably higher since the research introduced above shows that some
individuals with a cleft are at significant risk of not doing well academically and at risk of mental health
problems, which are associated with a higher risk of experiencing inequality, poverty and/or social
exclusion. The impact is also influenced by the access to healthcare, as well as the economic situation in the
country in which an individual with a cleft or craniofacial condition resides.