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Reaching the Hard-to-Reach: Conceptual Puzzles and Challenges for Policy and Practice

Published online by Cambridge University Press:  22 March 2012

MHAIRI MACKENZIE ,
MAGGIE REID ,
FIONA TURNER ,
YINGYING WANG ,
JULIA CLARKE ,
SANJEEV SRIDHARAN ,
STEPHEN PLATT  and
CATHERINE O'DONNELL
MHAIRI MACKENZIE*
Affiliation:
Urban Studies, School of Social & Political Sciences/Institute of Health & Wellbeing, University of Glasgow, 27 Bute Gardens, G12 8RS, UK
MAGGIE REID
Affiliation:
General Practice & Primary Care, Institute of Health & Wellbeing, 1 Horslethill Road, Glasgow G12 9LX, UK
FIONA TURNER
Affiliation:
General Practice & Primary Care, Institute of Health & Wellbeing, 1 Horslethill Road, Glasgow G12 9LX, UK
YINGYING WANG
Affiliation:
General Practice & Primary Care, Institute of Health & Wellbeing, 1 Horslethill Road, Glasgow G12 9LX, UK
JULIA CLARKE
Affiliation:
General Practice & Primary Care, Institute of Health & Wellbeing, 1 Horslethill Road, Glasgow G12 9LX, UK
SANJEEV SRIDHARAN
Affiliation:
Keenan Research Centre, St. Michael's Hospital, 30 Bond Street, University of Toronto, Toronto, Ontario, M5B 1W8, Canada
STEPHEN PLATT
Affiliation:
Centre for Population Health Sciences, School of Clinical Sciences & Community Health, The University of Edinburgh, Teviot Place, Edinburgh, EH8 9AG, UK
CATHERINE O'DONNELL
Affiliation:
General Practice & Primary Care, Institute of Health & Wellbeing, 1 Horslethill Road, Glasgow G12 9LX, UK
*
email: Mhairi.mackenzie@glasgow.ac.uk
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Abstract

The concept of systematic inequalities in social and health outcomes has come to form part of contemporary policy discourse. This rhetoric is deployed even in the face of policy decisions widely viewed as iniquitous. Moreover, there is a widespread view, expressed across the political spectrum, that those in more deprived circumstances are less likely than their more affluent counterparts to be in receipt of optimal public services. Such individuals and communities are variously described as excluded, disadvantaged, underserved or hard to reach. Across countries and policy domains the term ‘hard to reach’ is used to refer to those deemed not to be in optimal receipt of public sector services which are intended to increase some aspect of material, social or physical wellbeing. It is increasingly used in health policy documents which aim to address health inequalities. However, it is an ill-defined and contested term. The purpose of this paper is two-fold. First, it offers a critical commentary on the concept of hard-to-reachness and asks: who are viewed as hard to reach and why? Second, using a case-study of a Scottish health improvement programme that explicitly aims to reach and engage the ‘hard to reach’ in preventive approaches to cardiovascular disease, it tests the policy and practice implications of the concept. It finds that a lack of conceptual clarity leads to ambiguous policy and practice and argues for possible theoretical refinements.

Type
Articles
Information
Journal of Social Policy , Volume 41 , Issue 3 , July 2012 , pp. 511 - 532
Copyright
Copyright © Cambridge University Press 2012

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References

Barlow, J., Kirkpatrick, S., Stewart-Brown, S. and Davis, H. (2005), ‘Hard-to-reach or out-of-reach? Reasons why women refuse to take part in early interventions’, Children and Society, 19: 199–210.CrossRefGoogle Scholar
Bastagli, F. (2009), ‘Conditionality in public policy targeted to the poor: promoting resilience?’, Social Policy and Society, 8: 1, 127–40.CrossRefGoogle Scholar
Bauld, L., Day, P. and Judge, K. (2008), ‘Off target: a critical review of setting goals for reducing health inequalities in the United Kingdom’, International Journal of Health Services, 38: 3, 439–54.CrossRefGoogle Scholar
Baum, F. E., Begin, M., Houweling, T. A. J. and Taylor, S. (2009), ‘Changes not for the fainthearted: reorienting health care systems toward health equity through action on the social determinants of health’, American Journal of Public Health, 99: 11, 1967–74.CrossRefGoogle Scholar
Benach, J., Malmusi, D., Yasui, Y., Martinez, J. M. and Muntaner, C. (2011), ‘Beyond Roses's strategies: a typology of scenarios of policy impact on population health and health inequalities’, International Journal of Health Services, 41: 1, 1–9.CrossRefGoogle Scholar
BMA Scotland (2010), General Practice in Scotland: The Way Ahead – Final Report, Edinburgh: BMA Scotland Public Affairs Office.Google Scholar
Brackertz, N. (2007), ‘Who is hard to reach and why?’, Institute of Social Research Working Paper, Swinburne University of Technology Institute of Social Research, Victoria.Google Scholar
Burchardt, T., Le Grand, J. and Piachaud, D. (2002), ‘Degrees of exclusion: developing a dynamic, multidimensional measure’, in Hills, J., Le Grand, J. and Piachaud, D. (eds.), Understanding Social Exclusion, Oxford: Oxford University Press.Google Scholar
Cabinet Office (2009), ‘Context for social exclusion work’, http://www.cabinetoffice.gov.uk/social_exclusion_task_force/context.aspx (accessed 22 July 2009).Google Scholar
Carpentier, V. and Lall, M. (2005), Review of Successful Parental Involvement Practice for Hard-to-Reach Parents, London: Institute of Education, University of London.Google Scholar
Connell, J. P. and Kubisch, A. C. (1998), ‘Applying a theory of change approach to the evaluation of comprehensive community initiatives: progress, prospects and problems’, in Fulbright-Anderson, A., Kubisch, A. C. and Connell, J. P. (eds.), New Approaches to Evaluating Community Initiatives: Theory, Measurement and Analysis, Washington, DC: Aspen Institute.Google Scholar
Conservative Party (2010), Invitation to Join the Government of Britain: The Conservative Party Manifesto 2010, London: Conservative Party.Google Scholar
Crane, M. and Warnes, A. (2001), ‘Primary health care services for single homeless people: defects and opportunities’,Family Practice, 18: 3, 272–6.CrossRefGoogle ScholarPubMed
Department of Health (2007a), Health Inequalities: Progress and Next Steps, London: Department of Health.Google Scholar
Department of Health (2007b), Systematically Addressing Health Inequalities, London: Department of Health.Google Scholar
Department of Health (2008), Putting Prevention First. Vascular Checks: Risk Assessment and Management, London: Department of Health.Google Scholar
Dixon-Woods, M., Kirk, D., Agarwal, S., Annandale, E., Arthur, A. and Harvey, J. (2005), ‘Vulnerable groups and access to health care’, Report for the NHS Service Delivery and Organisation Programme, NCCSDO, London.Google Scholar
Dorling, D. (2010), ‘All in the mind? Why social inequalities persist’, Public Policy Research, 16: 4, 226–31.CrossRefGoogle Scholar
Freeman, G. K., Horder, J., Howie, J., Hungin, A. P. S., Hill, A. P. and Shah, N. C. (2002), ‘Evolving general practice consultation in Britain: issues of length and context’, British Medical Journal, 324: 880–2.CrossRefGoogle ScholarPubMed
Galdas, P. M., Cheater, F. and Marshall, P. (2005), ‘Men and health help-seeking behaviour: literature review’, Journal of Advanced Nursing, 49: 6, 616–23.CrossRefGoogle ScholarPubMed
Goddard, M. and Smith, P. (2001), ‘Equity of access to health care services: theory and evidence from the UK’, Social Science and Medicine 53: 1149–62.CrossRefGoogle ScholarPubMed
Graham, H. (2007), Unequal Lives: Health and Socioeconomic Inequalities, Maidenhead: The Open University.Google Scholar
Judge, K., Platt, S., Costongs, C. and Jurczak, K. (2006), ‘Health inequalities: a challenge for Europe’, Discussion paper, UK Presidency of the EU, London, http://ec.europa.eu/health/ph_determinants/socio_economics/documents/ev_060302_rd05_en.pdf.Google Scholar
Klein, R. (2006), The New Politics of the NHS: From Creation to Reinvention, 5th edition, Oxford: Radcliffe Publishing.Google Scholar
Kovandzic, M., Chew-Graham, C., Reeve, J., Edwards, S., Peters, S., Edge, D., Aseem, S., Gask, L. and Dowrick, C. (2011), ‘Access to primary mental health care for hard-to-reach groups: from “silent suffering” to “making it work”’. Social Science and Medicine, 72: 5, 763–72.CrossRefGoogle Scholar
Krieger, N. (2008), ‘Ladders, pyramids and champagne: the iconography of health inequities’, Journal of Epidemiology and Community Health, 62: 12, 1098–104.CrossRefGoogle ScholarPubMed
Labonte, R. (2006), ‘Social inclusion/exclusion: dancing the dialectic’, Health Promotion International, 19: 1, 115–21.CrossRefGoogle Scholar
Labour Party (2010), The Labour Party Manifesto: A Future Fair for All, London: Labour Party.Google Scholar
Levitas, R. (1998), The Inclusive Society? Social Exclusion and New Labour, Basingstoke: Palgrave-Macmillan.Google Scholar
Lindsay, C. (2011), ‘Welfare that works?’, in Yeates, N., Haux, T., Jawad, R. and Kilkey, M. (eds.), In Defence of Welfare: The Impacts of the Spending Review, Social Policy Association, http://www.social-policy.org.uk/downloads/idow.pdfGoogle Scholar
Lynch, J., Davey Smith, G., Kaplan, G. and House, J. (2000), ‘Income inequality and mortality: importance to health of individual income, psychosocial environment, or material conditions’, British Medical Journal, 320: 1200–4.CrossRefGoogle ScholarPubMed
Mackay, D. F., Sutton, M. and Watt, G. C. M. (2005), ‘Deprivation and volunteering by general practices: cross-sectional analyses of a national primary care system’, British Medical Journal, 331: 1449–51.CrossRefGoogle ScholarPubMed
Mackenzie, M., Turner, F., Reid, M., Wang, Y., Clarke, J., Sridharan, S., Platt, S. and O'Donnell, C. (2011), ‘What is the “problem” that outreach work in primary care seeks to address: seeking theory in an anticipatory care programme’, BMC Health Services Research, 11: 350, doi:10.1186/1472-6963-11-350.CrossRefGoogle Scholar
Marmot, M., Atkinson, T., Bell, J., Black, C., Broadfoot, P., Cumberlege, J., Diamond, I., Gilmore, I., Ham, C., Meacher, M. and Mulgan, G. (2010), Fair Society, Healthy Lives: The Marmot Review, London: University College London.Google Scholar
Mathieson, J., Popay, J., Enoch, E., Escorel, S., Hernandez, M., Johnston, H. and Rispel, L. (2008), Social Exclusion: Meaning, Measurement and Experience and Links to Health Inequalities: WHO Social Exclusion Knowledge Network Background Paper 1, Lancaster: WHO Social Exclusion Knowledge Network.Google Scholar
Mercer, S. and Watt, G. C. M. (2007), ‘The inverse care law: clinical primary care encounters in deprived and affluent areas of Scotland’, Annals of Family Medicine, 5: 6, 503–10.CrossRefGoogle ScholarPubMed
NESS Research Team (2004), Characteristics of Sure Start Local Programmes 2001/2, London: DfES.Google Scholar
NHS Health Scotland (undated)online, ‘Anticipatory Care Programmes’, http://www.healthscotland.com/anticipatory-care/programmes.aspx (accessed 01 June 2011).Google Scholar
NICE (2011), ‘About the Quality and Outcomes Framework’, http://www.nice.org.uk/aboutnice/qof/qof.jsp#What (accessed 01 June 2011).Google Scholar
Osborne, G. (2008), An Unfair Britain: Why Labour Have Failed on Fairness. London: Conservative Party.Google Scholar
Royal College of General Practitioners (2004), ‘General practitioner workload’, RCGP Information Sheet No. 3, RCGP, London.Google Scholar
Sassi, F (2009), ‘Health inequalities: a persistent problem’, in Hills, J., Sefton, T. and Stewart, K. (eds.), Towards a More Equal Society? Bristol: Policy Press.Google Scholar
Scottish Executive (2005), Delivering for Health, Edinburgh: Scottish Executive.Google Scholar
Scottish Government (2008a), Equally Well: Report of the Ministerial TASK Force on Health Inequalities, Edinburgh: Scottish GovernmentGoogle Scholar
Scottish Government (2008b), Equally Well Implementation Plan, Edinburgh: Scottish Government.Google Scholar
Scottish Socialist Party (2011), Holyrood Election Manifesto, Edinburgh: Scottish Socialist Party.Google Scholar
Shiner, M. (1995), ‘Adding insult to injury: homelessness and health service use’, Sociology of Health and Illness, 17: 4, 525–49.CrossRefGoogle Scholar
Thomas, B., Dorling, D. and Davey Smith, G. (2010), ‘Inequalities in premature mortality in Britain: observational study from 1921 to 2007’, British Medical Journal, 341: c3639.CrossRefGoogle ScholarPubMed
Tudor Hart, J. (1971), ‘The Inverse Care Law’, The Lancet, 1: 405–12.CrossRefGoogle Scholar
Wang, Y., O'Donnell, C., Mackenzie, M., Reid, M., Turner, F., Clark, J., Sridharan, S. and Platt, S. (2010), ‘Effect of deprivation on reach and engagement in general practice’, Policy and Practice Paper No. 7, Edinburgh: NHS Health Scotland.Google Scholar
Watt, G. C. M. (2002), ‘The inverse care law today’, The Lancet 360: 252–4.CrossRefGoogle ScholarPubMed
Watt, G. C. M. (2011), ‘Anticipatory care in very deprived areas’, British Journal of General Practice, 6: 584, 228.Google Scholar
Yeandle, S. and Pearson, S. (2001), New Deal for Lone Parents: An Evaluation of the Innovative Pilots, Sheffield: Sheffield Hallam University.Google Scholar
Yeates, N., Haux, T., Jawad, R. and Kilkey, M. (eds.) (2011), In Defence of Welfare: The Impacts of the Spending Review, Social Policy Association, http://www.social-policy.org.uk/downloads/idow.Google Scholar