Reaching the hard-to-reach? : conceptual, policy and practice puzzles

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