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Engaging hard-to-reach families and children

2. Background research

2.1 Defining hard-to-reach populations
2.2 Factors affecting engagement of hard-to-reach families
2.3 Summary

2.1 Defining hard-to-reach populations

Although the definition of hard-to-reach groups varies between programs and there are no clear criteria for defining who should be included as hard-to-reach, the term is usually used to refer to sections of the community who are eligible for services or programs but are difficult to involve in a given activity (Barrett 2008; Brackertz 2007; Coe et al. 2008). In early intervention and prevention, the term captures the following three groups, each of which also provides a different frame of reference for thinking about hard-to-reach families (Doherty, Hall & Kinder 2003).

Each of these groups includes people not being served, but who service providers and policy makers believe would benefit if they were more involved. These categories capture slightly different sources of marginalisation that may separately or together impact on vulnerable individuals and groups, so that some may be simultaneously hard-to-reach in the sense of being underrepresented, invisible or service-resistant (Barrett 2008; Doherty, Hall & Kinder 2003).

Critique of the term hard-to-reach centres on its complexity and potential to stigmatise. Researchers, service providers and advocates sometimes prefer not to use it in the latter sense, feeling a focus on individual service resistance detracts from barriers arising from the ways services are delivered (Barrett 2008; Doherty, Hall & Kinder 2003). Indeed, there is a growing body of research (summarised by Katz, La Place & Hunter 2007 and Sawrikar & Katz 2008) that indicates that potential client groups often perceive services as hard-to-reach because they are either irrelevant, inappropriate, inaccessible or stigmatising. Thus, the concept hard-to-reach is probably best understood in terms of the relationship and engagement between services and potential client groups, rather than as specific characteristics of either services or service users.

A further criticism of the concept of hard-to-reach is that it is usually constructed and controlled by practitioners, rather than being a concept with which service users would identify (Barrett 2008). Indeed, most studies of hard-to-reach populations, including this one, are limited by being based on practitioner rather than service user perspectives, in part because difficulties in providing services to marginalised groups also makes them difficult to involve in research.

The term engagement also requires further explanation. In the context of initiatives for hard-to-reach families and children, engagement generally refers to the processes for facilitating involvement in services (in other words the ‘front end’ of service provision: referral pathways, information and access to the service). However, as Katz, La Place and Hunter (2007) point out, engagement also consists of processes and systems that facilitate continuing participation in the program or service. Although the techniques are generally similar for both aspects of engagement, there are some differences, which are indicated in this report.

Typically the term hard-to-reach includes one or more of a number of disparate groups of families and individuals, including:

In the qualitative component of this study, we deliberately allowed service providers to define those client groups who are hard-to-reach, and have not therefore attempted to specifically address issues of engagement for all the groups mentioned above. This is not to say that these groups were not represented in the clientele of the SFCS 2004–2009 projects and initiatives. It is likely that attempts were made to engage with most of these groups in at least some of the hundreds of Communities for Children, Local Answers and Invest to Grow projects, services and initiatives.

Despite its complexity, the term hard-to-reach is maintained in the current study. However, the qualitative methodology provided participants scope to adopt and express their own definitions and understandings of hard-to-reach. Indeed, by recognising that the notion of hard-to-reach is socially constructed and fluid, the research allowed participants to demonstrate the frames, concepts and terminology prevailing in their service contexts, and themselves contribute evidence about who is hard-to-reach, and why, in different community, service and stakeholder contexts.

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2.2 Factors affecting engagement of hard-to-reach families

McCurdy and Daro (2001) set up a framework for understanding why target populations (or subsets of them) may not utilise support services on offer, and why, after enrolling in a service, engagement may be difficult to maintain. This framework distinguishes factors relating to individuals, providers, programs and neighbourhoods, but recognises that there is considerable overlap between these factors. Indeed, the precise combination of factors influencing service access and participation vary widely, given the heterogeneous nature of hard-to-reach populations and the complexity of the issues involved (Coe et al. 2008). Notwithstanding, McCurdy and Daro’s (2001) categories are used to capture the challenges and facilitators in engaging underrepresented, invisible or service-resistant families, as documented in previous studies.

Individual factors

In terms of individual factors, McCurdy and Daro (2001) posit that parents’ beliefs, attitudes and needs will directly affect whether they seek and accept services. Attitudes toward services may be determined by parents’ perceptions of risk and the potential costs and benefits of service involvement, along with readiness to change. In addition, McCurdy and Daro (2001) identify how willingness to engage with services can depend on experiences with other services in the past, and on family and friends whose approval or disapproval of services may influence service use. Indeed, Coe et al. (2008) found social isolation could make parents unlikely to seek out Sure Start services, and recommended using ‘befrienders’ or ‘parent ambassadors’ to improve take up among isolated families.

Information is also a critical determinant of individual attitudes to services and willingness to engage (Doherty, Hall & Kinder 2003). Others cite psychosocial concerns, such as:

Frequent and regular contact with service staff may also be difficult where families face daily stresses and have chaotic routines, especially for care givers in low-income families, sole parents and those with children with disabilities, or where parents are experiencing complex problems like depression or postnatal depression, poor literacy, learning or communication difficulties, mental health issues or substance abuse (Garbers et al. 2006; Unger, Jones & Park 2001). The transience of some groups, because of frequent changes of residence or involvement in criminal behaviour, may also make contact and engagement difficult (Doherty, Hall & Kinder 2003).

Individual refusal to use services is problematic, as those who are unwilling to engage are often those with the greatest needs. Indeed, Barlow et al. (2005) point to evidence that women refusing services tend to be younger, less well educated, less likely to use health services and more likely to have poor pregnancy outcomes in terms of birth weight, breastfeeding, and gestation time. Other reasons for refusal may include hostility to interventions by some family members. In On Track, a crime reduction program for children in the United Kingdom, some fathers were found to resist social services or agency involvement with their families, and refused to cooperate. This was highly problematic, especially where they were a source of risk for children (Doherty, Hall & Kinder 2003). Similarly, in Hawaii’s Healthy Start Program, family members’ or partners’ reluctance to have a service provider enter the home contributed to mothers’ refusal to be involved (National Committee to Prevent Child Abuse, cited in McCurdy & Daro 2001).

In terms of understanding resistance to, and readiness for, service interventions, McCurdy and Daro (2001) identified a five stage process:

  1. pre-contemplation (not thinking about using services)
  2. contemplation (considering using service)
  3. preparation (readiness)
  4. engagement (action)
  5. maintenance (sustaining involvement and preserving change).

Refusal and resistance to engagement are most common in stages one and two of the above process, although problems of engagement can arise at any point. Barlow and colleagues (2005) also point to some factors contributing to refusal to engage, finding many vulnerable families who refused were unable to understand information about service provision, while others felt too burdened by the complexity of their lives to be able to think about the possible benefits of a new service. Misperceptions and misgivings about services were also reasons to refuse, along with a lack of trust of professionals, and feeling family or other supports were sufficient (Barlow et al. 2005; Coe et al. 2008).

Provider factors

McCurdy and Daro (2001) identified the importance of awareness of, and sensitivity to, the cultural backgrounds of families, along with service delivery style—including communication style—and the manner in which service goals are framed to parents. Here we capture these, and provider factors arising from other studies, in terms of service promotion, outreach and entry points, staffing, relationship building and practice approaches.

Service promotion

In terms of service promotion to hard-to-reach groups, advertising in the usual ways such as through local newspapers has been found not to result in contact with those in most need (Howard & Chaplin 1997, cited in Stanley & Kovacs 2003). Promoting programs in positive terms, for example, as helping parents to raise happy and healthy children, may improve reach when compared with promotion strategies framing interventions as aiming to rectify parental deficit (Dumka et al. 1997, cited in Stanley & Kovacs 2003). Promoting interventions through less stigmatised (mainstream or universal) activities and agencies is also identified as a strategy for engaging vulnerable families (Watson 2005).

Outreach and entry points

For culturally and linguistically diverse groups, making first contact is recognised as potentially difficult. In Sure Start, having workers trained to reach special needs groups and perform outreach to these populations was recognised as important (Garbers et al. 2006). However, the ethnic matching of staff to the community is not universally perceived as an effective engagement strategy. For example, having workers with shared ethnic backgrounds has been found to give service users both a reason to use and a reason to avoid some Sure Start local programs, especially where communities are small and privacy may be compromised (Craig et al. 2007).

Barrett (2008) also comments that while similarities between parents and providers can increase the likelihood of engagement, this is not closely associated with better outcomes. Skills in listening and connecting with families have been found to be more important than demographic similarities (Barrett 2008). Others emphasise informality and flexibility at entry points (for example, accepting referrals from outside the area), and ‘starting from where people are at’ as particularly important factors at entry points for hard-to-reach populations (Doherty, Hall & Kinder 2003).

For those who are hard-to-reach in terms of ‘slipping through the net’ or being invisible or overlooked, engagement is understood to relate to provider recognition of user needs and capacity to innovate to meet unmet needs (Doherty, Hall & Kinder 2003). In On Track, providers used bridging strategies such as home visits, telephone reminders of appointments, and working out of hours; they also sought to put families’ and children’s needs above those of the organisation (Doherty, Hall & Kinder 2003).

Service venues have also been identified as important for ensuring that service provision is offered in places that are not stigmatising, and where clients are not required to travel extensively (Doherty, Hall & Kinder 2003). Indeed, locating services where parents are, such as through neighbourhood or home visits, is also seen as a way to improve reach and engagement, although bringing families into centres for parenting education is recognised as effective for breaking down isolation (Stanley & Kovacs 2003).

Staffing

Staffing is another challenge for providers working with hard-to-reach clients. This includes ensuring services have appropriately experienced staff with the skills required to effectively recruit and retain hard-to-reach groups. Problems recruiting and retaining staff may be exacerbated where risks of working with target groups are high, for example, where the safety of service providers is threatened, as this makes the work unattractive (Doherty, Hall & Kinder 2003).

For culturally diverse families, hiring bilingual staff and involving community leaders in outreach and engagement strategies is seen as important (Unger, Cuevas & Woolfolk 2007), although the ethnicity of service providers tends to be less important to engagement than the staff–client relationship in general (Forehand & Kotchick 1996). Indeed, work skill and style is more important than ‘fixed attributes’ (Katz, La Place & Hunter 2007; Moran, Ghate & van der Merwe 2004). For those working with men, specific engagement techniques may be required, although engaging fathers may not be prioritised in social work training where notions of men as threats, as irrelevant to family care, or as absent may dominate (Scourfield 2006).

As well as enhancing staff continuity and quality, staff-related strategies for improving engagement generally include fronting services with local community members or outreach workers to improve trust, and limiting the perceived distance between staff and service users, to ensure users feel comfortable (Doherty, Hall & Kinder 2003). Recruiting service users as workers has also been identified as a way to both engage users and improve the status, self-confidence and skills of service users who were initially hard-to-reach, facilitating their transitions (Barrett 2008).

Practice approaches

Practice approaches are also recognised as important provider factors. Relationships are critical to successful practice and recognised as the catalysts for successful engagement with vulnerable families (Barrett 2008), although building relationships with hard-to-reach populations is recognised as time intensive because it must be built in small increments. Stanley and Kovacs (2003) highlight the importance of engaging individuals directly and in person, as well as engaging all family members—especially male authority figures—and providing incentives like food and social activities.

Having the time and resources to build relationships prior to group interventions, for example, through one-to-one visits to parents, is understood to help service users to build self-esteem and help overcome anxieties about service participation (Avis, Bulman & Leighton 2007). Even reminder or follow up phone calls are important for helping to clarify the service process and address any emerging concerns before they prevent attendance (Moran, Ghate & van der Merwe 2004). Indeed, parents reported that personal communications were most effective in encouraging participation in Sure Start (Avis, Bulman & Leighton 2007). Time for one-to-one relationship building may also provide the insight necessary to build formal supports around informal networks, which is recognised as important to effective help and help-seeking (Katz, La Place & Hunter 2007).

As well as having time to build relationships early, low caseloads throughout the intervention will ensure providers have adequate time with families, as developing trust and relationships with hard-to-reach groups requires extra time (Stanley & Kovacs 2003). Flexible practice and program content is important, as is allowing participants to set their own goals. Doherty, Hall and Kinder (2003) also found some professionals preferred not to use structured assessment tools for hard-to-reach groups, as ‘pen and paper’ exercises were seen to alienate those with negative experiences of school and service provision.

In terms of supporting parents of disabled children, engagement strategies include focusing on parents’ own concerns and perceptions of their needs, recognising parents’ expertise, and building relationships with parents (Sloper 1999). Employing a staff member with expertise in this area has also been identified as a factor increasing access to relevant services and activities, with these workers best able to support families through transitions to early years settings, advise colleagues, and run specialist groups (Pinney 2007).

Program factors

Program funding

In terms of program factors, adequate and stable funding is identified as essential to accessing hard-to-reach groups as it promotes smooth service delivery and reduces staff turnover, thereby reducing service disruption and client disengagement (McCurdy & Daro 2001; Unger, Cuevas & Woolfolk 2007). Services under pressure to be more cost effective may adopt a one-size-fits-all approach, which risks compromising the flexibility required to meet diverse family needs (Unger, Cuevas & Woolfolk 2007).

Stanley and Kovacs (2003) also highlight how funding impacts on service characteristics, with underfunding contributing to staffing shortages, overworked staff, inflexible or restrictive opening hours, and an inability to provide the transport and child care necessary to promote access among the most vulnerable. Davies and Oke (2008) point out the importance of flexible funding, including access to brokerage to help highly vulnerable families avert chaos or crisis.

Barrett (2008) found funding constraints and short-term funding tend to hit hard-to-reach families harder than routine work with other client groups, with outreach work described as the first casualty. Managers find insufficient funding or a lack of continuity in funding arrangements impacts most on those with complex needs and those for whom relationships take a long time to develop, as these groups cannot be effectively helped by short-term measures.

Auspice

Auspice and the specialised character of services can also make a difference. McCurdy and Daro (2001) find parents will more willingly engage with services provided under non-profit than public auspices, especially if government departments are associated with statutory child protection. Their review of the US literature found that voluntary providers were perceived as closer and more in tune with local populations and their needs than government agencies who were feared because they were believed to have the agenda of removing children.

Targeting, specialisation and joined up services

In terms of the timing of engagement, pre-birth interventions are considered most effective, with parents thought to be more willing to accept advice and receive help in the prenatal months, especially early in the pregnancy (Larner, Halpern & Karkavy 1992, cited in McCurdy & Daro 2001).

In terms of generalist or specialist services, universal services have been found to fail to reach minority populations (Craig et al. 2007). Although targeted services may be more stigmatising than those aimed at the mainstream, they have been found to be more successful than universal services for reaching families with children with disabilities (Pinney 2007). On the other hand, however, specialist services have been perceived to be more distant from users, with those who have multiple, highly complex and interrelated needs being difficult for individual specialist services to reach (Doherty, Hall & Kinder 2003).

Indeed, people with needs that cut across traditional service boundaries may be better reached, engaged and served via ‘wraparound’, individualised service supports rather than a series of restrictive, categorical services (VanDenBerg & Grealish 1996). Indeed, Doherty Hall and Kinder (2003) also highlight the importance of multi-agency teams, blurring agency identity or specific agency roles, and adopting learnings from local voluntary groups. In terms of support for parents of disabled children, research points to a need for a holistic approach to needs assessment, and a single point of contact for the family (Sloper 1999). Discussing services for culturally diverse families, Unger, Cuevas and Woolfolk (2007) identify a need for increased collaboration and cooperation across agencies, as a way to increase capacity and leverage resources.

Pragmatic program factors

Koshinsky and Clipsal (2006) (cited by Barrett 2008) highlight how hard-to-reach status is constituted by pragmatic service provision factors, such as difficulty contacting families, poor transport provision, or poor match of schedules. For culturally and linguistically diverse groups, interpreter and translator services are obvious responses, as are celebrating important festivals and paying attention to dress and food requirements (Craig et al. 2007). Crèche facilities are also recommended, especially for parents with large families (Craig et al. 2007). In terms of engaging men, commentators are critical of female-dominated services which are only available during office hours, and suggested using dedicated practitioners focusing on fathering, and reaching fathers through fun and practical activities (Garbers et al. 2006). Brekke (1989) recommends using orientation sessions as pre-group preparation, especially for group work with men, as this helps weed out inappropriate group members and facilitate cohesion and bonding. For families in crisis, quick follow ups for referrals are important, with longer periods between contacts associated with attrition (Watson 2005).

Social and neighbourhood factors

Social norms and expectations

Scourfield’s (2006) discussion of the position of fathers in child protection highlights how willingness to engage with services relates to deep-seated norms and expectations around social roles. Some men may avoid health and social workers, perceiving child wellbeing and development as women’s business, or prefer not to face up to problems associated with their behaviour (Scourfield 2006). Similarly, service providers may also perceive fathers to be on the margins of family life and child protection practice.

Social disorganisation

In terms of neighbourhood factors, McCurdy and Daro (2001) perceive social disorganisation to contribute to unwillingness to engage with services, while social capital, which provides the neighbourhood with resources and environmental supports, improves parental engagement. This is problematic because those rich in social capital may be more willing to consider early intervention services ‘because the prevailing ethos in the area is one in which residents seek out and expect to use a broad array of formal supports’ (McCurdy & Daro 2001, p. 116). However, they may also have better access to informal or non-service supports.

Isolation and transport

Other neighbourhood factors relate to physical or social isolation of client groups, including transport and location. As Davies and Oke (2008) point out, in metropolitan areas service users report that public transport - or knowledge about using public transport—present major barriers to access, especially for mothers of small children with prams. This is more of a barrier in rural areas, where families may be particularly isolated and hard-to-reach if they lack transport and accessible community facilities within ‘pram pushing distance’ (Garbers et al. 2006). However, even when services have been locally-based, transport and physical access is particularly important, given the time constraints and complexity of circumstances among target families (Coe et al. 2008).

Service networks and initiative fatigue

In addition, in rural areas the absence of a network of services may make strategies to promote participation through referrals and other strategies for networking irrelevant (Garbers et al. 2006). A final neighbourhood-related barrier to participation is initiative fatigue, which may contribute to reluctance to become involved in some communities, where families are weary or suspicious of new services, especially where they are short-term (Doherty, Hall & Kinder 2003).

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2.3 Summary

This section has outlined how hard-to-reach populations have been defined in previous studies, and the challenges and facilitators identified to affect reach and engagement. The discussion outlined three groups of hard-to-reach clients: the underrepresented; the invisible or overlooked; and the service-resistant (Doherty, Hall & Kinder 2003). These suggest slightly different sources of marginalisation, although they may separately or simultaneously contribute to the circumstances of hard-to-reach groups.

In terms of the individual factors affecting service readiness and refusal, previous studies identify access to information, attitudes to help-seeking, fear, misperceptions about services, communication difficulties, hostility to interventions by family members and daily stresses and complexities. In terms of provider factors that make a difference to reach and engagement, previous studies identify how services are promoted, the appropriateness of outreach and entry points, staffing, and practice approaches that prioritise relationship building.

Funding proved to be a key determinant of services’ ability to engage hard-to-reach populations. Whereas adequate, stable and long-term funding promotes smooth service delivery and reduces staff turnover, short-term funding is found to disrupt processes of relationship building with hard-to-reach groups. Other factors include engaging clients early in a pregnancy, mixing specialist and generalist services or targeted and universal services, using single entry points, and ensuring practicalities are appropriate, such as transport, child care and scheduling.

Literature also identifies that neighbourhood and social factors affect service use for hard-to-reach families. Social norms and expectations, social disorganisation and social capital can impede engagement, as can social and geographical isolation and the associated transport difficulties, the absence of a service network, or initiative fatigue in a community. In addition some communities, especially remote Indigenous communities, lack the basic buildings or facilities to provide services and also lack trained staff to provide services. These are all significant barriers to service use by the local community.

To build on this small but growing evidence base, the following sections examine how activities funded under Local Answers, Invest to Grow, and Communities for Children have been reaching and engaging groups who may be considered hard-to-reach, using qualitative methodology (see Sections 3 to 7) and quantitative analysis (see Section 8).

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