What is the 'problem' that outreach work seeks to address and how might it be tackled? Seeking theory in a primary health prevention programme

Abstract

BackgroundPreventive approaches to health are disproportionately accessed by the more affluent and recent health improvement policy advocates the use of targeted preventive primary care to reduce risk factors in poorer individuals and communities. Outreach has become part of the health service response. Outreach has a long history of engaging those who do not otherwise access services. It has, however, been described as eclectic in its purpose, clientele and mode of practice; its effectiveness is unproven.Using a primary prevention programme in the UK as a case, this paper addresses two research questions: what are the perceived problems of non-engagement that outreach aims to address; and, what specific mechanisms of outreach are hypothesised to tackle these.MethodsDrawing on a wider programme evaluation, the study undertook qualitative interviews with strategically selected health-care professionals. The analysis was thematically guided by the concept of 'candidacy' which theorises the dynamic process through which services and individuals negotiate appropriate service use.ResultsThe study identified seven types of engagement 'problem' and corresponding solutions. These 'problems' lie on a continuum of complexity in terms of the challenges they present to primary care. Reasons for non-engagement are congruent with the concept of 'candidacy' but point to ways in which it can be expanded.ConclusionsThe paper draws conclusions about the role of outreach in contributing to the implementation of inequalities focused primary prevention and identifies further research needed in the theoretical development of both outreach as an approach and candidacy as a conceptual framework.

Outreach programmes for health improvement of Traveller Communities: a synthesis of evidence

“…For Traveller Communities and other socially excluded groups who have multiple and complex needs, engagement with and access to preventative care may be afforded a low priority. 66 Mainstream health service provision is often ill adapted to the complicated everyday lives of these groups, for which flexibility and co-ordination across different health-and social-care systems is required. 20 Outreach has, therefore, been utilised as a key strategy to engage those who, through processes of social exclusion or socioeconomic deprivation, occupy a position on the margins of society and are considered 'hard to reach'.…”

“…20 Outreach has, therefore, been utilised as a key strategy to engage those who, through processes of social exclusion or socioeconomic deprivation, occupy a position on the margins of society and are considered 'hard to reach'. 66 While outreach approaches have, in general, been endorsed in commissioning guidance for improving the health of marginalised groups, 67 at present, little detail is given around the specific strategies that are likely to make outreach effective in different contexts.…”

“…68 Such characteristics pose challenges for articulating 71 and documenting the processes of outreach, 74 thereby placing it at odds with the emphasis on standardisation in clinical trials. 75 As Mackenzie et al 66 summarise:…”

“…Mackenzie et al 2011, 66 p. 352 There is, therefore, a need for greater theoretical development on the particular approaches and underpinning mechanisms of outreach most likely to lead to positive outcomes in particular contexts. 66,68,76 In doing so, there appears to be a need to achieve a balance between the generalisation and specificity of understandings of outreach across different contexts. …”

“…In addition, following MacKenzie et al, 66 outreach was considered to involve the alleviation of both 'physical as well as ideological gaps between services and users' (p. 2).…”