Firstly, the title of this blog is misleading. No group is unreachable. A better term is ‘hard to reach’ as this implies the possibility that they can be reached. Why are they hard to reach? Here are two suggestions. Firstly, the very nature of society and our norms, values and practices exclude certain people so they become removed from participation in society. For example the common belief that poor people are poor due to their own personal failing; notably the belief that “they” are lazy, addicted to drink and drugs and don’t manage their money properly (See the OXFAM 2013 Truth and Lies debate on Poverty for more on this) perpetuates how individuals respond to those who are poor and how society responds to poverty elimination. Secondly, if we are not reaching certain groups we are probably using the wrong approach and are unable to engage these groups in a meaningful way. Both of these arguments are not a criticism of individual healthcare workers but they are the result of the way society responds to socially excluded and minority groups. In turn this influences the ways we work and respond to the diversity of need in these groups at all levels of practice, from the healthcare university curriculum to the allocation of healthcare resources at national level.
Groups that are perceived as unreachable are those that are hard to engage in a meaningful way. In healthcare this may be people who disengage with treatment, are lost to follow-up or who do not follow preventive care or advice. It may also be people who find it difficult to access healthcare services, do not know about services available, or do not perceive a need to engage with or access healthcare. They are often groups who are a minority group in relation to their culture, ethnicity, language or social circumstances. For example, in the area of TB hard to reach groups include homeless, substance misusers, prisoners, vulnerable and migrants. NICE (2012) note that these groups are hard to reach as they are difficult to engage in treatment, have low levels of compliance and high levels of non-completion of drug regimens.
Unreachable groups may also experience multiple barriers in accessing health care and following healthcare advice. Structural barriers include transport, cost, time, language or culture. There may be individual knowledge deficits, conflicting beliefs, misperceptions of healthcare, negative experiences of healthcare or lack of confidence and support in changing behaviour. This is not a problem specific to the UK and many of the debates around unreachable groups are the same across the globe. For example a study on the ‘unreachable poor’ in Bangladesh note that lack of awareness of healthcare services, inconsistency in services, not living in close proximity to services and perceptions that services do not meet needs were cited as reasons for non-access (Ahmed et al. 2006). These reasons are no different to what people might say about non-access of healthcare in the UK.
As practitioners we need to reflect on our practice, and consider how to include those who are ‘unreachable’ into the scope of our healthcare discipline. With this idea in mind what follows is a list of nine ideas to help turn unreachable into reachable.
- You are the right person
Who you are should not stop you from reaching out to groups, you just need to go about it in the right way so do not let it be a barrier just because you might be demographically or socially different. Look around you for ideas; for example there are also some great internet handbooks available such as the FPA (2007) handbook for people working with refugees and asylum seekers in the area of sexual health.
- Positive connections
To engage people you need to find what it is that motivates them to connect to what you are saying. Asking encouraging, open ended questions can facilitate discussion and remember the context in which people live as this can help make connections with people. Go to the places where people live, consider what they are interested in, what they like and what they do. Look at what resources are available in the area as this will give you a much better understanding of the situations facing people and will help you to make connections.
- Review what you are offering
The marketing term AIDA (Attention, Interest, Desire, Action) may be useful to frame what you would like people to do and how you encourage them to do this. You need to engage their attention (A), keep their interest (I) Explain what it is they need to achieve and how this is going to help them in a meaningful way (D) Be very clear about the action you want people to take (A). The more you understand the circumstances in which a person lives, the more you can tailor this to their individual needs.
- Use your target group
The more you involve your target group in what you want to do the better. Whether this is how a new service should run, what a leaflet should look like, when a clinic should open or how to reach people; involvement of the target group is essential. Netto et al. (2013) and Corcoran (2011) provide guidance on cultural tailoring to specific ethnic groups as a starting point.
- Use diverse settings
Social spaces may be better locations to provide services than healthcare facilities. The main bonus being that they are situated in the communities they serve; hence the rationale behind mobile breast-screening units in supermarket car parks or sexual health clinics in shopping centres. Cafes, hairdressers, barbers, clubs or places of worship all have elements that are inclusive and reach groups who may not traditionally access healthcare facilities. They have partnership potential, a community focus, they may offer supportive relationships or have useful facilities i.e. space (Moorley & Corcoran 2014). A good example is the Black Barber shop programme (Releford et al. 2010) in the US which offers blood pressure checks and lifestyle advice in barbershops.
- Use Gatekeepers
Those who are living in a local community and who have a degree of respect within that community are in a good position to advocate and mediate for change. A good example in the context of healthcare are ‘promotores de salud’ or community health workers in the US who work with Hispanic groups who traditionally lack access to healthcare; they live in the communities they work and share many of the characteristics of their target groups (CDC 2004). Other gate-keepers include key people who may be a focus for a group gathering, for example church leaders, pro-active service users, influential peers or those running community groups. They may also have access to groups who are less visible, i.e. housebound, or specific ethnic groups.
- Judgments and stereotypes
It can be easy to stereotype people into categories based on their culture, ethnicity or appearance. Don’t do it! Never make an immediate assumption about someone based on what you see or your previous experiences. Everyone is different and will therefore respond to you differently so try and keep an open mind and be flexible in your approach.
- Know you area
Back up what you say by what is happening around you. You cannot tell a patient to take up swimming if there isn’t a local swimming pool nearby. The patients’ that you see live in the local area so have an idea of what exists to support them in their preventive and curative behaviours. What assets do they have as individuals? Having a dog (can help increase exercise), a friend in a similar situation (peer support) is just as important as community support groups, weight loss classes, safe places to exercise or social groups.
- Learn from others
Take a moment to think about this; who do you listen to and why do you listen to them? AND who do you talk to and why do you talk to them? Communication is a two way process. What others do that encourages you to listen and talk should be emulated in your own practice. In addition those we label as ‘unreachable’ have much to teach us, so if we talk ‘with’ them (not ‘to’ them) and listen to their voices, this will help us to develop our understanding and skills in working with hard to reach groups.
These ideas are really only starting points and the reason that I chose nine points instead of ten. There is much that could be added and I am hoping that our journal club discussion will be able to come up with the tenth point. So if you have any ideas or examples of working with hard to reach groups join the debate on this topic in the: Evidence Based Nursing twitter journal club on Wednesday 06th 2014: 20.00-21.00 #ebnjc and add any more ideas or experiences to the list.
Participating in the EBN Twitter Journal Chat
To participate in the EBN twitter chat, if you do not already have one, you require a Twitter account; you can create an account at www.twitter.com. Once you have a Twitter account contributing is straightforward:
- You can follow the discussion by searching for links to #ebnjc or @EBNursingBMJ in Twitter
- Or contribute to the discussion by sending a tweet starting with @EBNursingBMJ and ending with #ebnjc (the EBN chat hashtag).
- NB not including #ebnjc means people following the chat won’t be able to see your contribution.
Corcoran N (2011) Working on Health Communication Sage, London
CDC (2004) Community Health Workers/Promotores de Salud: Critical Connections in Communitieswww.cdc.gov/diabetes/projects/comm.htm
FPA (2007) Sexual health, asylum seekers and refugees; A handbook for people working with refugees and asylum seekers in England available at www.fpa.org.uk/sites/…/sexual-health-asylum-seekers-and-refugees.pdf
Moorley C & Corcoran N (2014) Defining, profiling and locating older people: An inner city Afri-Caribbean experience. Editorial. Journal of Clinical Nursing 23 2083-2085 available at http://onlinelibrary.wiley.com/doi/10.1111/jocn.12487/full
Netto G, Bhopal, R, Lederle N, Khatoon J & Jackson A (2013) How can health promotion interventions be adapted for minority ethnic communities? Five principles for guiding the development of behavioural interventions. Health Promotion International 25 (2) 248-57. Abstract available at www.ncbi.nlm.nih.gov/pubmed/20299500
NICE (2012) Identifying and managing tuberculosis among hard to reach groups PH37 available at http://www.nice.org.uk/guidance/ph37
Oxfam (2013) Trust and lies about poverty available at http://policy-practice.oxfam.org.uk/publications/truth-and-lies-about-poverty-ending-comfortable-myths-about-poverty-306526
Releford BJ, Frencher SK, Yancey AK, Norris K (2010) Cardiovascular disease control through barbershops: Design of a nationwide outreach program. J Natl Med Assoc. Apr 2010; 102(4): 336–345. Abstract available at www.ncbi.nlm.nih.gov/pmc/articles/PMC3758504/