POWERED BY PSO- CLEAR REPORT

Transcription

1 POWERED BY PSO- CLEAR REPORT Published 12 September 2018

2 Contents Executive Summary... 3 Introduction...4 About this Report... 5 Methodology Details...6 Key Learnings: For many people, living with psoriasis means constant flare-ups and a high impact on their happiness Achieving clear skin would improve perceived levels of well-being Achieving clear skin is seen as not possible by 2 out of 3 people living with psoriasis The type of treatment seems to influ ence the out look on achieving clear skin; those who have used biologics and systemics were the most positive...23 Better emotional and social lives with clear skin Summary and Conclusions...33 Appendix: Sample Details...34 LEO Innovation Lab in cooperation with The Happiness Research Institute, All rights reserved. Any part of this report can be reproduced only with the explicit acknowledgement of the copyright owner. The following reference should be included: LEO Innovation Lab, The Happiness Research Institute (2018), PsoClear Report 2018 Available at 2

3 Executive Summary The PsoClear Report aims to highlight the impact that achieving clear skin would have on the subjective well-being of people living with self-reported psoriasis. Input from 7,644 people living in 12 European countries has been analysed and the findings are presented in detail in this report. The core finding of the report is that achieving clear skin would improve perceived levels of happiness by 49%. We define the difference between current levels of reported happiness and levels of happiness in an imaginary period of clear skin (i.e. no signs of psoriasis) as the clear skin happiness differential. Key findings in this report: When evaluating their current happiness, 2% of the respondents chose 10 (on a scale from 0 (min happiness) to 10 (max happiness)). When asked about their happiness with skin free of psoriasis, 24% reported that their happiness level would be 10. The highest clear skin happiness differential (the difference between self-reported levels of happiness now and if clear skin would be achieved) was reported in the UK: 72%. Most countries show a clear skin happiness differential between 40% and 50%. On average, respondents reported they would be 49% happier if they achieved clear skin. Overall, 65% of people living with psoriasis found it completely impossible or very unlikely that they would achieve clear skin. 22% of respondents with self-perceived severe psoriasis reported that they would gain at least 2 hours on average per day, from the time fred from treating their skin, having more energy to do things, etc. This totals 730 hours per year, the equivalent of an entire month. 4 of the respondents have lived with psoriasis for more than 15 years, with only 8% saying they ve lived with psoriasis for less than a year. On average, 62% reported that their psoriasis has been diagnosed by a dermatologist. 24% of respondents have never experienced clear skin. 39% reported they always have a flare-up. 46% of the respondents estimated that a flare-up has a high impact on their emotional well-being. 3

4 Introduction Psoriasis is a serious noncommunicable disease 1, with more than 125 million people affected worldwide 2. Psoriasis has serious mental health consequences, with psychosocial comorbidities at least as severe as those seen in people with other serious diseases, such as heart disease, diabetes, kidney failure, cancer and liver diseases 3. The complex factors of living with psoriasis result in a significant happiness gap, as large as -3 for people living with self-perceived severe psoriasis 4. PsoHappy is the first survey initiative to focus on exploring the impact psoriasis has on quality of life by employing subjective well-being methodologies as advocated by OECD and the United Nations on a global scale. More than 230,000 completed surveys, made available through have been gathered from people living with psoriasis all over the world. Employing methodologies like the Cantril Ladder, PsoHappy benchmarks the levels of happiness of people living with psoriasis against the happiness levels of the general population as specified in the World Happiness Report. It explores different aspects of living with psoriasis, with an aim to offer a complete image of priorities and possible policy making interventions for improving the quality of life of those affected by psoriasis. 1. WHO, Resolution WHA67.9. Geneva, World Health Organization, Accessed July Accessed July Moeller AH, Ernstoft S, Vinding GR, Jernec BCE. A systematic literature review to compare quality of life in psoriasis with other chronic diseases using EQ-SD-derived utility values. Patient Relat Outcome Meas. 2015; 6: LEO Innovation Lab, The Happiness Research Institute (2017), World Psoriasis Happiness Report

5 About this Report The objective of the report was to explore what achieving clear skin, meaning skin that is completely free of lesions and symptoms like itchiness and scaling means for people living with psoriasis and what impact that has on their levels of happiness and subjective wellbeing. The report covers survey responses collected from 7,644 respondents in 12 European countries. The survey combined validated models that explore mental well-being aspects, original methodologies and open-ended questions that capture the experiences and emotions of respondents living with psoriasis. The learnings of the report highlight the importance of getting access to the correct diagnosis and treatment for people living with psoriasis, as achieving clear skin is perceived as having a significant impact on overall well-being and happiness. Declaration of interest The PsoClear Report has been paid for by LEO Pharma A/S and conducted by LEO Innovation Lab, an independent unit of LEO Pharma A/S, in collaboration with the Happiness Research Institute. 5

6 Methodology Details Survey delivery and data collection The responses associated to the option I don t have psoriasis were excluded The PsoClear Survey was delivered from the analysis. online using the PsoHappy platform, available at Target population between 21st of April and 17th of May Local translations of the survey were provided for all countries included in the final selection. The data analysed in this report covers the answers gathered from 7,644 respondents, with ages between 15 and 80 years old (y/o), living with psoriasis of The survey was promoted through notifications to those who previously participated in our other surveys, thereby opting-in to our database and consenting to receive all severities in 12 European countries: Austria, Belgium, Czech Republic, Denmark, France, Germany, Greece, Italy, Norway, Portugal, Spain and United Kingdom. targeted advertisements and posts on social media, primarily Facebook, as well as Twitter, Instagram and LinkedIn. The map in Fig. 1 illustrates the number of respondents for each country included in the analysis, and the color Anybody living with self-reported psoriasis, regardless of their treatment bar indicates numbers of participants in each country as depicted in the figure. or severity, could access the web app and answer the surveys. The application also allowed participants to drop off The average age of respondents was 40.2 y/o, median 40 y/o. and come back later to answer a new survey. In order to ensure participants were genuinely real people living with psoriasis, several qualifying questions were presented during the first survey. A detailed overview of the data set such as gender, age, work and social status can be found in the appendix of the report. 6

7 1,376 United Kingdom 238 Belgium 356 Norway 418 Denmark 628 Germany 485 Portugal 408 Spain 1,273 France 722 Italy 351 Austria 507 Greece 832 Czech Republic Fig. 1: PsoClear survey respondents by country 7

8 Severity We asked the respondents to evaluate the self-reported severity of their psoriasis in two ways. Firstly, we asked them how would they rate their psoriasis: mild, moderate or severe. Secondly, we asked them to estimate how much of their skin is affected by psoriasis, using the palm of their hand as a reference point as the body surface area (BSA) 5. Fig. 2 shows the percentages of answers for both of these questions. 28% evaluated their psoriasis severity as mild, while 45% noted the BSA as less than 4 palms, which is considered mild. This suggests that people tend to over-evaluate the severity of their psoriasis in comparison to the clinical evaluation, which has been confirmed by other studies 6. 'How would you rate the severity of your psoriasis?' 'How much of your skin would you estimate is effected by psoriasis?' (The palm of you hand can serve as a reference point) Severe 20% (1,412) Mild 28% (1,964) > 10 palms 16% (1,056) > 4 palms 45% (3,032) Moderate 51% (3,534) 4-10 palms 40% (2,677) Fig.2: Self-reported psoriasis severity and BSA When we refer to severity and run analysis by severity we have used the selfdeclared severity: mild, moderate or severe. 5. Lebwohl et al. J Am Acad Dermatol 2014;70: Idem 8

9 The composition of the samples collected among the 12 countries included in this report shows some differences. The United Kingdom and France stand out as countries where a large proportion of respondents evaluate their psoriasis severe (30% and, respectively, 2) and very few evaluate it mild (15% in both countries). On the other hand, 69% of the respondents in the Czech Republic evaluate their psoriasis as mild, with Greece also reporting higher percentages of people living with mild psoriasis (41%). Severe Moderate Mild 10% (28) 49% (137) 41% (116) 21% (42) 60% (123) 19%(39) 10% (58) 21% (128) 69% (423) 20% (80) 2 (325) 13% (79) 12% (56) 54% (213) 58% (695) 5 (339) 46% (215) 25% (100) 15% (174) 29% (173) 41% (192) Austria Belgium Czech Republic Denmark France Germany Greece 16% (112) 53% (337) 31% (221) Italy 19% (68) 51% (177) 30% (105) Norway 19% (87) 52% (234) 29% (130) Portugal 23% (85) 53% (196) 25% (92) Spain 30% (392) 54% (700) 15% (199) United Kingdom Fig. 3: Self-reported psoriasis severity by country 9

10 Analysis Limitations of methodology For each country, a minimum sample of 384 respondents 7 was deemed to be eligible for statistical analysis. Austria, Belgium and Norway did not record the minimum sample but they have still been included in the analysis 8. Similarly, This study is based on self-perceived diagnosis of psoriasis and severity. For this reason, the findings of this report can t be cited or referred to as if they were based on clinical diagnosis confirmed by healthcare specialists. some of the questions recorded less than 384 responses. The number of responses for each question are noted as n= in all the graphs in this report. All data is collected through selfadministered internet-based questionnaires. As such, we must consider coverage limitations, where we To produce different perspectives on the data, we employed different analytical approaches. We primarily used descriptive analysis, as well as fail to reach certain segments that do not use the internet or specific online channels that we have employed for recruitment of participants. partial correlations. The respondents were predominantly This approach allows us to determine key connections between different aspects of well-being for people with psoriasis, with a central theme around achieving clear skin and its impact on levels of happiness. women (76%), which introduces a gender bias that needs to be taken into consideration when going through the learnings. The graphs where the data was gender weighted have this specified. Where relevant, we have also included the analysis by gender and we note any significant differences. 7. Representative sample requires a size of 384 units ( 5% margin of error and a 95% confidence level) SS = (Z-score) 2 * p*(1-p) / (margin of error) 2 SS = (1.96) 2 * 0.5*(1-0.5) / (0.05) 2 SS = * 0,25 / SS = The margins of error for a 95% level of confidence for the countries with samples lower than 384 are: Norway: 5.18%, Austria: 5.23% and Belgium: 6.23% 10

11 For many people, living with psoriasis means constant flare-ups and a high impact on their happiness Regarding my life situation or daily stress, I m affected by my psoriasis in such a way that I m never without symptoms. [...] Most days I m more tired than I d admit... I m affected in a sub-psychosocial way... and it s not always easy to notice, by myself or someone else. Woman, 50 y/o, Norway Key findings 21% of respondents report my skin never got better since I got diagnosed, with the highest. percentage recorded in UK (32%) A further 35% report my skin hasn t got better every year, but there are The majority of participants (4) lived with psoriasis for more than 15 years, with only 8% saying they ve lived with psoriasis for less than a year. This indicates that psoriasis is a chronic condition that people might manage for many years. times I see improvements. 39% of the respondents say they always have a flare-up, with a further 9% reporting there is less than a month in between their flare-ups. 46% defined the impact of flare-ups In terms of which healthcare professional diagnosed their psoriasis, we see a lot of variation by country, reflecting the different healthcare setups in the surveyed geographies. on their emotional well-being as being high. How many years have you lived with psoriasis? Less than a year 8% (544) Between 1 and 5 years 15% (1,010) Between 5 and 10 years 15% (1,003) Between 10 and 15 years 15% (992) More than 15 years 4 (3,102) Fig. 4: Number of years living with psoriasis 11

12 On average, most of the respondents 'Has your psoriasis been diagnosed by:' (62%) reported that their psoriasis has been diagnosed by a dermatologist, while 26% have been diagnosed by personal doctor or GP (general practitionist). reported that their psoriasis has not been diagnosed by a doctor. (Fig. 5) I haven t been diagnosed by a doctor (396) My personal Doctor/GP 26% (1,548) A nurse 1% (36) Greece reported the highest percentage of people diagnosed by a dermatologist: 91%, while Czech Republic attributed A dermatologist 62% (3,757) Fig. 5: Diagnosis by type of healthcare professional only 28% of the diagnosis cases to a dermatologist. In the UK, less than half, 46%, of diagnosis is delivered by dermatologists, with almost half of the respondents saying that their GP has diagnosed their psoriasis. (Fig. 6) Greece Spain Italy Norway Denmark Portugal Germany Belgium France Austria United Kingdom Czech Republic 11% (33) 10% (64) 6% (15) 18% (44) 16% (59) 10% (36) 1 (63) 21% (108) 10% (19) 8% (14) 19% (35) 8% (90) 32% (353) 10% (23) 11% (25) 23% (54) 49% (570) 25% (124) 13% (64) 91% (365) 83% (251) 82% (514) 75% (188) 75% (270) 70% (259) 71% (358) 63% (144) 5 (633) 54% (125) 46% (540) 31% (157) 28% (140) Has your psoriasis been diagnosed by: Other I haven t been diagnosed by a doctor A nurse My personal Doctor/GP A dermatologist Fig. 6: Who has diagnosed the psoriasis by country 12

13 Despite a high number of people having been diagnosed by a specialist, 1 in 5 respondents report my skin has has the highest percentage of people whose skin never got better since the diagnosis (32%). never got better since I got diagnosed and a further 1 in 3 report my skin hasn t got better every year, but there are times I see improvements. (Fig. 7) People living with psoriasis in the Czech Republic have the highest percentage of people who see an improvement of their skin almost every month, By country, we see that the percentage of people who report my skin hasn t got better every year, but there are times I see improvements is higher in Norway which might be related to the higher percentage of people living with selfperceived mild psoriasis that have taken the survey in this country. (Fig. 8) (42%) and the UK (40%). The UK also Since you ve beed diagnosed with psoriasis, how many times a year, in average, have you experienced clear skin, meaning skin that is completely free of lesions and symptoms like itchiness and scaling? My skin gets better almost every month 8% (427) My skin gets better 3-4 times a year 12% (688) My skin gets better only once or twice a year 18% (977) My skin hasn t got better every year, but there are times I see improvements 35% (1,967) My skin has never got better since I got diagnosed 21% (1,175) Other 6% (328) Fig. 7: Perceived skin improvements per year Since you ve beed diagnosed with psoriasis, how many times a year, in average, have you experienced clear skin, meaning skin that is completely free of lesions and symptoms like itchiness and scaling? Austria Belgium Czech R. Denmark France Germany Greece Italy Norway Portugal Spain UK My skin gets better almost every month 16% (25) 9% (12) 19% (41) (24) (71) 6% (33) 14% (54) 9% (58) 6% (20) 10% (39) (24) 2% (26) My skin gets better 3-4 times a year 16% (26) 12% (17) 9% (20) 10% (34) 12% (119) 12% (64) 18% (69) 20% (127) 11% (33) 14% (52) 13% (44) (83) My skin gets better only once or twice a year 15% (24) 18% (25) 20% (42) 1 (58) 1 (176) 6% (88) 23% (87) 20% (124) 1 (54) 23% (88) 19% (63) 13% (148) My skin hasn t got better every year, but there are times I see improvements 29% (46) 38% (52) 21% (48) 38% (128) (376) 30% (158) 26% (98) 35% (225) 42% (132) 33% (123) 3 (120) 40% (463) My skin has never got better since I got diagnosed Other 19% (30) 6% (10) 18% (25) 5% (7) 16% (34) 15% (32) 21% (71) (25) 22% (221) (47) 2 (143) (36) 11% (43) (28) 11% (71) 5% (30) 19% (60) 4% (13) 13% (49) (27) 1 (57) 6% (18) 32% (371) 5% (55) Fig. 8: Perceived skin improvements per year per country 13

14 To further explore how people perceived achieving clear skin, the survey also asked questions around flare-ups. 39% of the respondents say they always have a flare-up, with a further 9% reporting that there is less than a month in between their flare-ups. Looking at the average periods of time in between flare-ups by gender, we see that the percentage of women reporting I always have a flare-up is slightly higher than the percentage of men reporting the same (40% women and 35% men). Overall, there are no significant gender differences in terms of estimated time between flare-ups. What is the average period of time in between your psoriasis flare-ups? I always have a flare-up Less than a month Between 1 and 3 months Between 3 and 6 months Between 6 months and a year More than a year My skin doesn t flare-up 9% (511) 15% (867) 13% (743) 11% (645) 6% (361) 6% (367) 39% (2,222) Fig. 9: The average period of time in between flare-ups Almost half of the participants in the survey (49%) defined the impact of flareups on their emotional well-being as being high (8 to 10 on a scale from 1 to 10). On average, 50% of women report that flare-ups have a high impact on their emotional well-being, with 41% of men reporting the same. Most men report a medium impact (4 to 7 on a scale from 1 to 10). This finding shows that women might see their flare-ups affecting emotional well-being more significantly. This is linked to previous findings that the impact of living with psoriasis is significantly higher for women than men 9 (Fig. 10 and Fig. 11). 9. LEO Innovation Lab, The Happiness Research Institute (2017), World Psoriasis Happiness Report

15 On a scale from 1-10, 1 being no impact at all and 10 being maximum impact, how does a flare-up impact your overall emotional well-being? Medium impact (4-7) 45% (2,341) High impact (8-10) 46% (2,606) Low impact (1-3) 9% (413) Fig. 10: Impact of flare-ups on emotional well-being (data weighted for gender) On a scale from 1-10, 1 being no impact at all and 10 being maximum impact, how does a flare-up impact your overall emotional well-being? Female High impact (8-10) 50% (2,190) Medium impact (4-7) 43% (1,863) Low impact (1-3) (303) Male High impact (8-10) Medium impact (4-7) 41% (405) 48% (468) Low impact (1-3) 11% (108) Fig. 11: Impact of flare-ups on emotional well-being by gender 15

16 The country spread of how the respondents perceive flare-ups impact their well-being is relatively even, with the UK and Spain reporting the highest impact (54% and, respectively, 52% of respondents reporting scores of a high impact). Greece has the highest percentage of people reporting a low impact of flareups on their emotional well-being (1-3 on a scale from 1 to 10). These differences are not statistically significant, suggesting a rather similar outlook across the surveyed countries. On a scale from 1-10, 1 being no impact at all and 10 being maximum impact, how does a flare-up impact your overall emotional well-being? Austria Belgium Czech R. Denmark France Germany Greece Italy Norway Portugal Spain UK High Impact (8-10) 60% 40% 40% (59) 43% (52) 39% (55) 40% (146) 48% (465) 45% (245) 3 (155) 43% (291) 45% (144) 45% (167) 52% (176) 54% (651) 20% 0% Medium Impact (8-10) 60% 40% 49% (64) 48% (61) 51% (64) 49% (153) 46% (467) 46% (228) 50% (176) 48% (283) 44% (140) 4 (174) 38% (119) 39% (412) 20% 0% 60% Low impact (1-3) 40% 20% 0% 11% (14) 8% (9) 10% (11) 11% (35) 6% (60) 9% (37) 14% (50) 9% (56) 11% (31) 8% (27) 10% (22) (61) Fig. 12: Impact of flare-ups on emotional well-being by country (data weighted for gender) 16

17 Please tell us more about how you think clear skin would improve your life My confidence would boost, I d be able to wear what I wanted without embarrassment, wear my hair loose, get close to my partner without feeling self conscious... Also the thought of not itching even for a minute is amazing. I would save time and a lot of money on treatments and just generally feel happier and healthy! Woman, 29 y/o, UK I haven t worn a t-shirt for example outside since I was 17 and diagnosed. Now being 31, with a wonderful fiancée and 2 children, I feel the impact come back around when the boys ask me to play in the paddling pool, or go swimming with them. To be able to wake up and not get immediately dressed, or at least covered up around the problem areas so my fiancée doesn t have to see the state of me. Man, 32 y/o, UK I would feel better with myself, I would look better in the mirror and I would go out more, it would improve my quality of life emotionally above all. Woman, 25 y/o, Spain I would find my joy of life and could go to the pool or the beach without feeling the eyes of people and especially I could dress as I want Woman, 49 y/o, France I wouldn t have to worry about what clothes to wear, especially during the summer when I tend to cover up. I wouldn t have to worry about flakes falling on my clothes which makes me look messy. I think I would be able to look in the mirror and not be critical or upset with myself. I wouldn t have to vacuum my house as much. I also think that if my skin cleared up for an extended period I would just be happier in myself because I wouldn t be itching constantly or in pain when I don t moisturize enough. I wouldn t get as stressed or as upset as I do now because it would be a great weight off my mind. Life would be so much easier if I had clear skin. Woman, 30 y/o, UK I would not be ashamed because people look at me like I have a plague. Woman, 53 y/o, Italy 17

18 Achieving clear skin would improve perceived levels of well-being Having clear skin is like having a kind of freedom. You don t have to think about your skin being unsightly to yourself or your loved ones, and you don t have to worry about those people who can upset you with their ignorance or put you in a difficult position. Man, 22 y/o, Greece Key findings Achieving clear skin would increase perceived levels of wellbeing significantly. The clear skin happiness differential - the increase in perceived happiness level now and with the possibility of achieving clear skin - varies between 30% in Austria to 71% in the UK. When evaluating their current happiness, 2% of the respondents chose 10, the maximum score on a scale from 0 to 10. When asked about their happiness with their skin free of psoriasis, 24%, a significant increase, reported that their happiness level would be a maximum 10. Some of the most interesting findings came from the questions we asked around how life - and levels of wellbeing - would improve, should the respondents achieve clear skin. The answers capturing current levels of well-being 10 follow the shape of a bell curve, indicating normal distribution; most of the answers sit under 4 and 7 on the scale from 0 to 10. The answers capturing levels of well-being in case of achieving completely clear skin are, on the other hand, skewed towards the upper levels of the scale, with 71% of respondents noting levels of 8, 9 and 10 on the scale from 0 to 10. The perception of how well-being would improve with clear skin is skewed towards the highest levels of the scale. (Fig. 13 and Fig. 14) 10. We use the Cantril Ladder to capture happiness / well-being: Imagine a ladder with steps numbered from zero at the bottom to 10 at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you. On which step of the ladder would you say you personally feel you stand at this time? with a variation to capture perceived well-being for achieving clear skin: On which step of the ladder do you feel you would stand if your skin would be completely free of psoriasis? 18

19 Imagine a ladder with steps numbered from zero at the bottom to 10 at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you. On which step of the ladder would you say you personally feel you stand at this time? % of distribution 23% (1,529) 20% 10% 5% 1% (93) 2% (151) 4% (284) 10% (652) 13% (859) 1 (1,145) 16% (1,049) 8% (529) 3% (184) 2% (160) 0 (Worst possible) (Best possible) Fig. 13: Distribution of perceived levels of current happiness Imagine a ladder with steps numbered from zero at the bottom to 10 at the top. The top of the ladder represents the best possible life for you and the bottom of the ladder represents the worst possible life for you. On which step of the ladder do you feel you would stand if your skin would be completely free of psoriasis? % of distribution 30% 20% 15% (794) 2 (1,415) 24% (1,261) 20% (1,039) 10% 5% 0% (22) 0% (21) 0% (17) 1% (50) 2% (92) 5% (275) 6% (321) 0 (Worst possible) (Best possible) Fig. 14: Distribution of perceived levels of happiness should clear skin be achieved 19

20 We call the difference in reported levels of well-being now and with the possibility of achieving clear skin the clear skin happiness differential. The happiness differential among the countries surveyed vary, with respondents in the UK seeing the highest jump in their happiness, with a 71% increase in their reported levels of well-being. Most of the countries show a clear skin happiness differential between 40% and 50%. Across all 12 countries, the clear skin happiness differential average was 48%. (Fig. 15) Centril normal vs clear skin gap/country - gender - weighted Percentage difference between current happiness and potential happiness with clear skin. UK France Norway Belgium Portugal Germany Greece Italy Denmark Spain Austria Czech R. 39% (326) 3 (302) 33% (144) 28% (192) 51% (948) 49% (294) 48% (133) 48% (347) 4 (487) 41% (350) 39% (600) 72% (1,073) Fig. 15: The clear skin happiness differentials (data weighted for gender) Women report higher increases in their happiness in the case of achieving clear skin. Women living with psoriasis are significantly less happy and more affected by psoriasis than men 11 so it is not surprising to see that they would report higher levels of well-being should they achieve clear skin. (Fig. 16) Percentage difference between current happiness and potential happiness with clear skin. Female Male % of distribution 45% (1,004) 52% (4,167) Fig. 16: The clear skin happiness differential by gender 11. LEO Innovation Lab, The Happiness Research Institute (2017), World Psoriasis Happiness Report

21 Achieving clear skin is seen as not possible by 2 out of 3 people living with psoriasis It just seems to be getting progressively worse. Plus having researched extensively it doesn t seem that uncommon to never achieve clear skin. Woman, 50 y/o, UK Key findings 63% of respondents think it is completely impossible or very unlikely that they would achieve clear skin. completely impossible or very unlikely to achieve clear skin. Women tend to be more pessimistic: 66% of women, compared to 59% of men. Happiness and the possibility of achieving clear skin are linked, as average levels of perceived happiness decrease as the belief that clear skin is achievable decreases. Moreover, happiness and hope - thinking it is possible to achieve clear skin - are linked. People who believed that it was impossible or almost impossible to achieve clear skin reported lower levels of happiness, with an average of 4.7 on the Cantril Ladder. People who think it is possible to achieve clear skin report higher average happiness levels of 5.2. It The perceived increase measured by the clear skin happiness differential is not supported by equally strong beliefs that achieving clear skin is possible. should be kept in mind, however, that a causation can t be tested here; it could also be that unhappiness promotes hopelessness. 63% of the survey participants found it On a scale from 0 to 10, 0 being totally impossible, 10 being totally possible how possible do you think it is for you to achieve completely clear skin? Avg. happiness level % % % 5.2 Fig. 17: Perception of hope (thinking it is possible to achieve clear skin) and happiness level. (data weighted for gender) 21

22 Self-perceived severity and thinking it is possible to achieve clear skin were not related. Relatively equal percentages of people across different severities reported they did t believe they could achieve clear skin. Hope, or the lack of it, affects all people living with psoriasis equally. Mild Moderate Severe % (104) 66% (417) 63% (210) % (41) 23% (145) 22% (67) % (23) 12% (72) 15% (42) Fig. 18: Possibility of clear skin by severity (data weighted for gender) Women tend to be more pessimistic in higher percentages. 66% of women, compared to 59% of men, thought it was impossible or nearly impossible to achieve clear skin. On a scale from 0 to 10, 0 being totally impossible, 10 being totally possible how possible do you think it is for you to achieve completely clear skin? Avg. Happiness level Female % % % 5.2 Male % % 5.2 Fig. 19: Happiness levels and possibility of achieving clear skin by gender 22

23 The type of treatment seems to influence the outlook on achieving clear skin; those who have used biologics and systemics were the most positive I ve never had lesion free skin. The best it gets is a pinkish colour rather than the scaly angry appearance during flare ups. Woman, 26 y/o, UK Key findings 53% of respondents have used prescription topical treatments, 11% light therapy, 9% systemic therapies (pills or injections) and biologic therapy (injections). the most positive outlook on their possibility of achieving clear skin - more than 1 in 5. People on light therapy reported the highest percentage of not thinking achieving clear skin was possible: 70%. Regardless the type of treatment, 30% of the respondents said they have not seen an improvement in their skin since being diagnosed. 5% of people on prescription topical treatment reported their skin gets better almost every month, while the highest percentage was recorded for people on biologic therapy: 16%. Biologics and systemics were the treatments that were correlated to the largest proportion of people having Fig. 20 shows the split among the different types of treatment. The respondents had the possibility to choose multiple responses, as they might use more than one treatment at a time. The totals therefore do not amount to 100%, but show the percentages of how many people use a specific treatment. Overall, more than 50% of the respondents use prescription topical treatments for their psoriasis. 23

24 'Which of the following forms of treatments are you currently using (you may use more than one)?' Prescription topical treatment (medical creams or ointments) Over-the-counter topical treatment (creams lotions or ointments) None of the above / not in treatment Light therapy (sunlight or ultraviolet) Systemic therapy (pills or injections) Biological therapy (injections) Don t know Distribution 1% (76) 13% (783) 11% (657) 9% (533) (395) 3 (2,171) 53% (3,116) Fig. 20: Type of treatment used Among the countries surveyed, the UK reported the highest percentage of people using a prescription topical treatment:6, while Greece reported the lowest percentage: 34%. (Fig. 21) When asked how often they have seen improvements of their skin, only 5% of people on prescription topical treatment reported their skin gets better almost every month. 16% of people on biologic therapy saw their skin getting better almost every month. More than 30% of people in any different kind of treatments said their skin hasn t got better every year, but there are times they see improvements. (Fig. 22). Prescription topical treatment (medical creams or ointments) Over-the-counter topical treatment (medical creams or ointments) None of the above / not in treatment Light therapy (sunlight or ultraviolet) Systemic therapy (pills or injections) Austria Belgium Czech Denmark France Germany Greece Italy Norway Portugal Spain Republic 4 (82) 38% (66) 14% (25) 1 (29) (12) 53% (80) 36% (55) 13% (19) 19% (29) (11) 34% (90) 49% (129) 9% (24) 9% (25) 9% (16) 51% (182) 43% (152) 13% (45) 11% (40) 10% (36) 54% (574) 29% (309) 19% (204) 9% (100) 6% (60) 44% (237) 50% (274) 14% (74) 1 (93) 9% (48) 34% (137) 34% (138) 21% (86) 6% (25) 14% (55) 46% (308) 34% (224) 14% (91) 9% (62) (48) 64% (210) 41% (136) 9% (28) 12% (40) 16% (54) 59% (236) 28% (112) 9% (37) 6% (26) (28) 53% (181) 33% (114) 13% (46) 9% (29) 13% (44) UK 6 (799) 39% (462) 9% (104) 13% (159) 10% (121) Biologic therapy (injections) Don't know (13) (12) 5% (7) 2% (3) 2% (5) 11% 29) (26) 1% (4) 6% (65) 1% (10) 6% (34) 1% (3) 6% (23) 6% (43) 1% (4) 8% (27) 11% (44) 1% (4 ) 8% (28) 1% (4) (80) 0% (3) Fig. 21: Type of treatment by country 24

25 Prescription topical treatment Over-thecounter topical treatment Biologic treatment (injections) (medical crems) (crems lotions...) Systemic treatment (pills or injections) Light treatment (sunlight or ultraviolet) None of the above/ not in treatment Don t know My skin gets better every month 5% (154) 8% (156) 16% (61) 8% (39) 5% (31) (53) 2 (14) My skin gets better 3-4 times a year 12% (360) 12% (251) 11% (42) 9% (46) 11% (69) 9% (63) 8% (4) My skin gets better only once or twice a year 18% (530) 1 (352) 1 (63) 1 (88) 20% (126) 15% (108) 8% (4) My skin hasn t got better every yerar, but there are times I see improvements My skin has never got better since I got diagnosed Other 38% (1,131) 23% (688) 4% (124) 3 (756) 22% (447) 4% (87) 30% (114) 13% (50) 13% (50) 40% (205) 18% (94) 8% (40) 3 (232) 22% (140) 5% (32) 3 (261) 22% (159) 9% (65) 18% (9) 6% (3) 33% (17) Fig. 22: How often people perceive their skin gets better by type of treatment A comparison among the different types of treatment shows that biologics and systemics are the treatments that were correlated to the largest proportion of people having the most positive outlook on their possibility of achieving clear skin - more than 1 in 5. However, more than half (54% - 55%) of the people on these treatments still didn t deem it possible, while for the other treatments 66-70% of people thought it was impossible to achieve clear skin. People on light therapy reported the highest percentage of not thinking achieving clear skin is possible: 70%. Biologic therapy (injections) Light therapy (sunlight or untraviolet) None of the above/not treatment Over-the-counter topical treatment (creams lotions or ointments) Prescription topical treatment (medical creams or ointments) Systemic therapy (pills or injections) 21% (10) 25% (12) 54% (26) 10% (13) 20% (27 ) 70% (94) 11% (17) 22% (34) 6 (105) 11% (47) 23% (99) 66% (283) 11% (73) 22% (147) 6 (444) 20% (18) 26% (24) 54% (49) Possiblility of clear skin scales Fig. 23: How possible is to achieve clear skin by type treatment 25

26 Please tell us more about how you think clear skin would improve your life That would be the itch away. No bloody sheets in the morning. No glances and questions about job vacancies. Sleep through at night. Woman, 52 y/o, Germany Psychologically and emotionally, as I often enter a vicious circle between poor psychology, stress and psoriasis exacerbation. Woman, 40 y/o, Greece Skip people staring; little children do not bother me much (they usually ask what it is), but adults who just look and sometimes whisper (like they point). Not having people watching my face (hard to cover still) and then refuse to sit next to me (would rather stand), let all the good recovery and poor you comment! Woman, 50 y/o, Norway Psoriasis is always present, I try to ignore this fact, but it is a constant concern, because it itches and I, I can not scratch, it is constantly flaking, and when I can cream. No psoriasis was wonderful!. Man, 52 y/o, Portugal A very important aspect for the human being is his exterior, that is, his physical aspect. It affects us, conscious or unconscious. When we feel good about our body we have another type of behavior, we feel more secure and able to face everything and everyone. When I am not in a bad phase of psoriasis, I feel more beautiful, unhindered, freer. This has a lot of influence on my emotional state, which influences all the other aspects of my life. Woman, 25 y/o, Portugal It would be like getting rid of a background noise that continually persists, suddenly silence, peace, calm and serenity!. Woman, 59 y/o, Italy 26

27 Better emotional and social lives with clear skin The quality of life would be better. You gain self-confidence, no burning and itchy skin or pain in the joints. You don t have to hide because you don t have to be afraid that somebody will look at you strangely or be disgusted. Woman, 26 y/o, Austria Key findings 55% of respondents chose emotional life as the aspect most improved by achieving clear skin. Self-confidence, free and positive were the top 3 words selected by both men and women to best describe the feeling of having clear skin, but they When exploring what achieving clear skin would mean in everyday life terms, 55% of the respondents prioritised their emotional lives as seeing the highest improvement. Social life with 51% and physical functioning with 36% were the next in top 3 life aspects that would improve. (Fig. 24) were prioritised slightly differently. 28% said they would socialise more, while 25% reported they would have more time for themselves. More than 1 in 5 people living with self-perceived severe psoriasis reported that they would gain at least 2 hours, If we take a look at it by gender, there were some nuances: women chose emotional life as benefiting the most, with 58%, while men put their social life as the aspect that would see most improvement, with 54%. (Fig. 25) on average, per day, if their skin would be free of psoriasis. This sums up to 730 hours per year, the equivalent of an entire month. 27

28 If your skin would be completely free of psoriasis, which aspects of your life would improve the most? (Users were able to choose 3 options. Numbers show percentage of users choosing a particular option.) Emotional life 55% (3,087) Social Life (friends and active...) 51% (2,737) Physical functioning 36% (2,030) Sexual intimacy 31% (1,640) Family life 19% (970) Professional career 16% (835) Other 5% (259) Educational life 2% (93) Fig. 24: Life aspects impacted by clear skin. (data weighted for gender) If your skin would be completely free of psoriasis, which aspects of your life would improve the most? (Users were able to choose 3 options. Numbers show percentage of users choosing a particular option.) Female Emotional life 58% (2,561) Social life (friends and activities) 49% (2,170) Physical functioning 38% (1,665) Sexual intimacy 30% (1,305) Family life 1 (750) Professional career 15% (649) Other 5% 209) Educational life 2% (69) Male Emotional life 50% (526) Social life (friends and activities) 54% (567) Physical functioning 35% (365) Sexual intimacy 32% (335) Family life 21% (220) Professional career 18% (186) Other 5% (50) Educational life 2% (24) Fig. 25: Life aspects impacted by clear skin by gender These insights are supported by the words selected by the respondents to describe the feeling of having clear skin. While self-confidence, free and positive were top 3 worlds selected by both men and women, they prioritised them differently. For men, positive was top choice, with 1 of respondents selecting it as one of the 3 words, while for women the top choice was free. A special note has to be made for normal, which was selected by 10% both for men and women. Coupled with many of the stories and answers we have collected in the open questions fields, we see that living a life without social stigma, being able to do the normal things like going to the beach or wearing short sleeves on a hot day are deemed as a dream by many people living with psoriasis. (Fig. 26) 28

29 What are the 3 words that best describe the feeling of having clear skin? (Users were able to choose 3 words/options.numbers show percentage of users choosing a particular option.) Female Positive 14% (1,543) Self-confident 16% (1,784) Free 16% (1,856) Normal 10% (1,095) Happy 9% (1,042) In control (769) Sexy 8% (903) Hopeful 6% (674) Carefree 6% (631) Full of life 3% (349) Full of enery 2% (211) Proud 1% (147) Strong 1% (122) Determined 1% (67) Indifferent 1% (63) Other Male Positive 1 (453) Self-confident 15% (397) Free 13% (331) Normal 10% (269) Happy 10% (248) In control 8% (198) Sexy 6% (155) Hopeful 6% (168) Carefree 5% (130) Full of life 3% (84) Full of enery 2% (50) Proud 1% (34) Strong 1% (26) Determined 1% (24) Indifferent 1% (22) Other Fig. 26: Top 3 words selected by gender When we looked into the country differences for this question, the UK and Greece stood out with the highest percentage of people who chose self-confidence (21% and, respectively, 20%), while in the Czech Republic sexy made top 3 words. Greece also reported the highest percentage of people saying that normal would best describe their feeling of having clear skin, with 15%. (Fig. 27) What are the 3 words that best describe the feeling of having clear skin? (Users were able to choose 3 words/options.numbers show percentage of users choosing a particular option.) Austria Belgium Czech R. Denmark France Germany Greece Italy Norway Portugal Spain UK Free 15% (58) 22% (72) 11% (49) 15% (130) 19% (490) 1 (230) 13% (103) 19% (304) 1 (130) 15% (137) 1 (129) 12% (360) Self-confident 14% (54) 9% (29) 16% (71) 11% (101) 10% (256) 16% (215) 20% (162) 1 (263) 15% (117) 16% (144) 16% (123) 21% (652) Positive 14% (53) 16% (52) 15% (67) 16% (141) 15% (376) 14% (194) 15% (122) 16% (251) 15% (115) 12% (110) 14% (108) 16% (488) Normal 8% (32) 8% (27) 12% (55) 10% (89) 10% (251) 12% (158) (54) (111) 14% (113) 11% (97) 10% (76) 13% (401) Happy 11% (41) 11% (37) 14% (64) 6% (54) 9% (240) (101) 5% (39) 8% (131) 8% (66) 6% (55) 8% (60) 10% (302) Sexy 10% (37) 6% (20) 6% (28) 9% (76) 8% (209) (92) 9% (74) (102) 6% (45) 9% (83) (54) 8% (236) In control Hopeful Carefree Full of life Full of energy Proud Strong Determined Indifferent 9% (35) 5% (20) 2% (29) 2% (7) 2% (8) 1% (3) 1% (5) 1% (2) 0% (1) 5% (18) 8% (28) 4% (12) 3% (11) 2% (7) 3% (9) 2% (6) 1% (3) 6% (27) 6% (25) 5% (24) 4% (17) 2% (10) 1% (3) 1% (4) 0% (2) 5% (43) 6% (56) 9% (84) (66) 2% (21) 1% (12) 0% (3) 0% (1) 1% (8) 6% (146) 8% (200) 3% (88) 4% (99) 2% (47) 3% (74) 1% (33) 1% (25) 1% (20) (91) 5% (72) (92) 3% (45) 2% (29) 1% (13) 2% (24) 0% (2) 0% (4) (59) 9% (76) 6% (49) 3% (22) 3% (22) 0% (3) 1% (10) 0% (4) 1% (12) (102) 4% (62) 6% (89) 3% (54) 3% (49) 1% (11) 1% (19) 1% (8) 1% (9) (52) 6% (44) (54) 2% (13) 2% (15) 1% (10) 1% (9) 0% (2) 0% (1) 6% (55) (68) 9% (83) 3% (28) 1% (13) 2% (14) 1% (10) 2% (15) 0% (3) (51) 5% (35) 8% (62) 3% (22) 2% (12) 2% (14) 1% (7) 1% (8) 1% (4) 9% (282) 5% (145) 2% (73) 2% (51) 1% (29) 1% (33) 0% (9) 0% (15) 1% (19) Fig. 27: Top 3 words selected by country 29

30 When asked what type of situations would best describe their lifestyle if they d achieve completely clear skin, 29% of people said there wouldn t be any changes in their lifestyle. This may made top 5 with 19% of the responses, supporting some of the answers in the open questions mentioning that people with psoriasis had to spend more time cleaning skin scales. (Fig. 28) be interpreted as an argument that most of the changes people perceive should they achieve clear skin are emotional, with limited impact on their daily activities. 28% said they would socialise more, with a further 22% saying that they would go out more. 25% reported they would have more time for themselves. I d vacuum less There were no significant differences between men and women for this question, except perhaps that a slightly larger proportion of men would socialize more, whereas more women selected the options that their lifestyle wouldn t change and that they would have more time for themselves. (Fig. 29) What are the 3 situations that would best describe your lifestyle if you d reach completely clear skin? (Users were able to choose 3 options. Numbers show percentage of users choosing a particular option.) My lifestyle wouldn t change I d socialize more I d have more time for myself I d go out more I d vacuum less I d have more sex I d spend more time with family I d do more sports I d focus on my hobbies I d date more I d focus on my job Other I d start an education / focus more on my studies 3% (140) 2% (111) 29% (1,507) 28% (1,492) 25% (1,340) 22% (1,162) 19% (990) 18% (935) 18% (926) 15% (796) 12% (606) 9% (490) 9% (486) Fig. 28: Lifestyle changes driven by clear skin What are the 3 situations that would best describe your lifestyle if you d reach completely clear skin? (Users were able to choose 3 options. Numbers show percentage of users choosing a particular option.) Female Male I d socialize more 13% (1,156) 15% (331) My lifestyle wouldn t change 14% (1,241) 12% (259) I d have more time for myself 13% (1,106) 10% (226) I d go out more 11% (944) 10% (213) I d vacuum less 9% (780) 9% (205) I d spend more time with family 8% (703) 10% (215) I d have more sex I d do more sports I d focus on my hobbies I d date more I d focus on my job / a better job I d start an education / studies 9% (740) (594) 5% (471) 4% (381) 4% (378) 1% (94) 1% (17) 9% (192) 9% (200) 6% (132) 5% (106) 5% (106) Fig. 29: Lifestyle changes driven by clear skin by gender 30

31 It s interesting to note the differences among the surveyed countries for this question. A 25% majority of the respondents in Greece said that their lifestyle would not change, whereas this option was chosen by only 6% in the UK. In the UK, people would go out, socialise more and vacuum less. A relatively larger proportion of people in the Czech Republic would spend more time with family and friends if they had completely clear skin. (Fig. 30) lifestyle. We got 4,050 responses across the 12 countries surveys that can be grouped in several themes: Better sleep Less stress Better focus and concentration Socializing more No itchiness and pain Being able to wear different clothes, shorts, t-shirts, etc, going out without covering up Enjoying the beach and swimming pools The survey also asked an open question related to these topics, encouraging people to tell us more about how they Not having to think about psoriasis Not having to explain and talk about it to others. think clear skin would improve their Austria Belgium Czech R. Denmark France Germany Greece Italy Norway Portugal Spain UK My lifestyle wouldn t change 15%(43) 1(45) 11%(43) 13%(93) 1(314) 14%(145) 25%(151) 20%(235) 10%(64) 15%(108) 1(103) 6%(163) I d socialize more Have more time for myself Go out more Vacuum less Have more sex Spend more time with family Do more sports Focus on my hobbies Date more Focus on my job / a better job Other I d start an education / studies 10%(28) 16%(47) 11%(32) 9%(26) 8%(23) 10%(29) 6%(17) 5%(14) 3%(10) 3%(9) 3%(8) 0%(1) 11%(29) 11%(29) 8%(22) 13%(33) 8%(20) (18) 11%(29) 6%(15) 3%(9) 3%(9) 1%(3) 11%(42) 15%(58) 13%(50) 8%(32) 5%(20) 14%(55) 5%(18) (26) 4%(16) 5%(20) 1%(3) 12%(83) 12%(82) 9% (59) 10%(68) 11%(76) 8%(58) 8%(54) 5%(34) 5%(36) 4%(25) 2%(11) 2%(12) 12%(222) 14%(252) 11%(191) 8%(142) 8%(142) 6%(100) (127) 8%(139) 4%(65) 4%(70) 2%(27) 1%(9) 9%(89) 12%(123) 13%(135) 8%(86) 9%(89) 9%(89) 8%(86) 6%(62) 4%(38) 5%(49) 1%(12) 0%(4) 12%(71) 13%(79) 6%(38) 5%(28) 9%(56) (43) 8%(45) 3%(18) 4%(24) 5%(29) 1%(8) 1%(4) 12%(146) 11%(131) 8%(94) 8%(89) (85) 4%(51) 8%(92) 6%(70) 6%(71) 5%(60) 2%(23) 2%(26) 18%(119) 9%(59) 11%(70) 10%(65) 9%(57) 9%(59) (46) 4%(24) 6%(41) 4%(25) 1%(6) 1%(5) 15%(111) 14%(102) (53) (54) 6%(47) (52) 8%(56) 6%(44) 5%(36) 6%(45) 2%(11) 1%(8) 16%(97) 16%(99) 9%(57) (42) 6%(39) 5%(31) 8%(51) 6%(38) 3%(17) 5%(28) 2%(10) 1%(7) 1(455) 10%(279) 13%(361) 12%(325) 10%(281) 11%(291) 6%(175) 4%(122) 5%(127) 4%(117) 1%(24) 1%(29) Fig. 30: Lifestyle changes driven by clear skin by country 31

32 On a practical level, we also wanted to know how people with self-perceived psoriasis estimated the number of minutes they would gain back in a day if their skin was free of psoriasis (because of spending less time on treatments, having more energy to do things etc). More than 1 in 5 people living with self-perceived severe psoriasis reported that they would gain more than 2 hours on average per day. This sums up to 730 hours per year, the equivalent of a full month. A further 1 of people living with self-perceived severe psoriasis estimated that they would gain back between 1 and 2 hour, while 26% said they would gain between 30 minutes and an hour. Even those living with self-perceived mild psoriasis would gain back noticeable time; almost half reported they would gain back 10 minutes, the equivalent of two and a half days in a year. (Fig. 31) If your skin would be completely free of psoriasis, how many minutes, on average per day, would you say you d gain back? (due to less treatment needed, more energy to do things etc) Mild Moderate Servere 10 minutes 20 minutes 18% (223) 49% (627) 21% (623) 18% (534) 9% (102) 12% (137) 30 minutes 13% (164) 20% (582) 15% (178) Between 30 min and 1 hour 11% (139) 23% (672) 26% (310) Between 1 and 2 hours More than 2 hours 4% (57) 5% (59) 9% (626) 8% (245) 1 (202) 22% (260) Fig. 31: Average minutes gained back per day per severity 32

33 Summary and Conclusions The findings highlighted by this report show that achieving clear skin would have a positive impact on the perceived well-being of people living with psoriasis. The clear skin happiness differential showed significant improvements in reported perceived happiness, from 39% in Austria to 71% in the UK. Moreover, a majority of the participants in this survey reported that different aspects of their life, mainly their emotional life, would be improved by achieving clear skin. 21% of people with self-perceived severe psoriasis estimated they would gain back at least an entire month in a year due to time fred from less treatment needed and more energy to do things. The stories and responses that people shared in the open questions also draw a vivid picture of everyday lives that would be improved, from the mundane to the deeply emotional: the act of choosing a piece of clothing, going to a job interview or to the beach with the children, right through to having the self-confidence to be intimate with a partner. However, the survey shows that 2 in 3 people living with psoriasis didn t think this was possible, making it clear that more needs to be done in terms of building awareness of what it means to live with psoriasis and making sure those affected find the right treatment for them in due time. A wider dashboard of disease outcomes, including subjective well-being and selfperceived happiness levels, could contribute to a better understanding of the impact psoriasis has and of how to ensure long-term mental and physical well-being. 33

34 Appendix: Sample Details 23% of the respondents were men and 76% women. 55% of the respondents were aged between 30 and 50 years. 18% were less than 30 and 26% were more than 50 years old. Age n = 7, (2%) 109 (1%) 437 (6%) 1,237 (16%) 1,474 (19%) 2,114 (28%) 2,091 (2) Gender n = 7,235 Male 1,655 (23%) Other 71 (1%) Female 5,509 (76%) Fig. A Age and gender sample composition. 61% of respondents were married or in a civil partnership and 29% were single. What is your civil status? Single 29.3 (2.095) Other 9.31% (664) Married or partnership 61.32% (4.373) Fig. B: Sample composition by civil status 34

35 The majority of the respondents, 59%, are employed for wages. 10% are selfemployed and 5% of the respondents declared that they are unable to work. The detailed split by work status is shown below. What is your current job status?' Employed for wages Self-employed Out of work and looking for work A homemaker A student Retired Unable to work Out of work and not looking Fig. C: Sample split by work status. 10% (641) 8% (541) 8% (415) 6% (372) 5% (348) 5% (342) 2% (128) 59% (3,939) To evaluate the perceived socio-economic status of the respondents, we used a question similar to the Cantril Ladder, with the lowest level being worst off and the highest level being best of. The detailed country spread is shown below. Think of a ladder with 10 steps representing where people stand in your country. At step 10 are the people who are the best off those who have the most money, the best education, and the most respected jobs. At step 1 are the people who are worst off those who have the least money, least education, and the least respected jobs or no job. Where would you place yourself on this ladder? 13% (37) 12% (25) 4 (135) 30% (86) 11% (32) 50% (105) 34% (70) Austria Belgium 16% (110) 51% (357) 1 (123) 16% (113) Czech Republic 12% (49) 4 (185) 32% (126) 9% (36) Denmark 13% (154) 60% (723) 23% (271) France 13% (76) 62% (370) 24% (144) Germany 8% (39) 59% (279) 30% (142) Greece 8% (57) 58% (423) 31% (229) Italy 19% (66) 51% (177) 26% (90) Norway 10% (44) 58% (266) 26% (119) Portugal 53% (200) 40% (151) Spain 18% (229) 66% (856) 15% (195) United Kingdom Fig. D: Sample configuration by perceived socio-economic status by country. 35

36 Skip people staring, little children do not bother me much (they usually ask what it is), but adults who just look and sometimes whisper (like they point). Not having people watching my face (hard to cover still) and then refuse to sit next to me (would rather stand), let all the good recovery and poor you comment!. Woman, Norway, 50 yo