Defining 'Hard to Reach': the Work of Health Visitors with Vulnerable Families
The term ‘hard to reach’ first appeared in the Health Visiting Review (Lowe 2007). This review claimed that the health visiting service was able and experienced in reaching the ‘hard to reach’. Yet there was a dearth of health visiting literature on what this concept meant and how it was interpreted in practice. A wide literature review was undertaken which examined government child health policies on reducing health inequalities and how the targeting of services to meet the needs of ‘vulnerable’, ‘disadvantaged’ or ‘hard to reach’ families had developed. The literature review identified how the concept of risk in relation to child health promotion had been defined and redefined since the 1970s. The latest shift involved the identification of ‘new social risks’ and the promotion of early intervention to prevent social exclusion and health inequalities. At the time of the study’s inception, health visiting was a service both in decline and under threat. In contrast, the development of new early intervention programmes such as Sure Start (National Evaluation of Sure Start 2005), On Track (Doherty et al. 2003) and intensive home visiting (Barlow et al. 2005) also led to the critical examination of the concept of ‘hard to reach’. In response to the lack of information on the concept of ‘hard to reach’ in health visiting, I set out to examine critically how Health Visitors (HVs) working in a disadvantaged area conceptualised and operationalised the concept of ‘hard to reach’. This qualitative ethnographic case study (Yin 2003), by using research methods of focus groups, participant observation of a Well-Baby Clinic and interviews, gathered perceptions and experiences of HVs and service users. Thematic analysis was guided by Gee’s (2005) method of critical discourse analysis and revealed how the term was contested by HV practitioners. It was considered a broad term that in practice could be applied widely and negatively as a label for non-engaging service users; yet themes emerged which also demonstrated how HVs related to and constructed the concept in their day-to-day practices of client engagement. The findings were categorised and a typology was developed in relation to the reach of health visiting within a predominantly deficit model of health. The typology consists of four types, all of which relate to the ‘reach’ of the health visiting service at the interpersonal level. The first type, the ‘easy to reach’ client, highlights the diversity of clients: not all clients living within a disadvantaged area were ‘hard to reach’. This category also identifies how some clients living within this disadvantaged area developed relationships with HVs. Including the type ‘easy to reach’ within the typology acknowledges the diversity of clients living within an area of disadvantage, and also the facilitators in HV/Client relationships. The second type identified was the ‘emotionally hard to reach’ client, and identifies characteristics of clients who had a tentative relationship with the health visiting service. Working with ‘emotionally hard to reach’ clients involved negotiation and the building of trust at each encounter. The third type, ‘physically hard to reach’, developed following the identification of a range of barriers that reduced access to vulnerable clients. The fourth type, ‘hard to reach services’, arose from the findings - and this type relates to barriers created by the organisation of the health visiting service in a disadvantaged area. The typology highlights the importance of both clients’ and HVs’ engagement in the development of working relationships. It recognises the organisational structures and discourses that act as barriers and facilitators to client engagement. It recommends that health visiting should take the opportunity offered in the Health Visitor Implementation Plan (DH 2011) to develop a health visiting service underpinned with a strengths-based model of public health.