Defining the hard-to-reach What exactly is meant by hard-to-reach is a matter of some debate. The term is inconsistently applied.

It will sometimes be used to refer to minority groups, such as immigrants, L !T people, or the homeless" it can be used to refer to hidden populations, groups of people who do not wish to be found or contacted, such as illegal drug users or gang members" at other times it may refer to broader segments of the population, such as the elderly, or young people, or people with disabilities. In the ser#ice context, hard-to-reach often refers to the underser#ed, certain minority groups, those slipping through the social safety net, and those who are deemed to be ser#ice resistant. $et another term used in this context is hidden populations, meaning those who are hidden from the point of #iew of research sampling. %idden populations may also acti#ely see& to conceal their group identity, as for example in the case of sniffers, in'ection drug users, L !T people who are in the closet, sexually acti#e teens, etc. The hard-to-reach are also called the seldom heard. The use of this term indicates that these are people who do not ha#e a collecti#e #oice and are often under-represented in consultation and in#ol#ement acti#ities about de#eloping ser#ices. %ard-to-reach suggests that there is something that pre#ents their engagement with ser#ices. (eldom heard emphasi)es the responsibility of agencies to reach out to excluded people, ensuring that they ha#e access to social care ser#ices and that their #oices can be heard. *ne of the chief difficulties in defining the hard-to-reach is the unintentional imputation of a homogeneity among distinct groups that does not necessarily exist. *r it may imply that the problem is one within the group itself and not within the approach. +ttempts at categori)ation can ha#e a stigmati)ing effect. %ard-to-reach audiences ha#e, with #arying degrees of pre'udice, been called obstinate, recalcitrant, chronically uninformed, disad#antaged, ha#enot, illiterate, dysfunctional, and information poor. +ssociati#e and ,onassociati#e In addition to these #arious ways to categori)e the hard-to-reach, we can distinguish between associati#e hard-to-reach populations, such as people at ris& of +I-(, and nonassociati#e hard-to-reach populations. those whose members do not normally ha#e contact with other members. ,onassociati#e populations share two primary characteristics. The first is demographic. There is no effecti#e centrali)ed information about them, and a large proportion of their members do not &now each other. The second is that their members share characteristics or attributes that ma&e it important for health and human ser#ices to ha#e information about them to inform ser#ice planning, policy, and deli#ery. In addition to these features, they are often low-fre/uency populations, and they might be sub'ect to stigma of #arious &inds. There has been a large amount of research on associati#e hard-to-reach populations, those whose members are socially networ&ed with each other and form a community 0with literally thousands of studies being done on populations at ris& of %I1 and +I-(, such as in'ection drug users2 3 but there ha#e been #ery few rigorous studies of nonassociati#e populations, particularly those that are less in the public eye, such as shut-ins. The central focus of my search strategy was to gather together information precisely on these nonassociati#e populations. I was loo&ing for groups defined by indi#idual attributes 0such as health or social status2 where there is often no o#erriding reason for withinpopulation sociali)ing and where a substantial proportion of population members do not ha#e strong social lin&s with other members and, indeed, might e#en resist such contact. These hard-to-reach groups must be ta&en into account in immuni)ation planning. ,o effecti#e %4,4 pre#ention strategy can exclude them.

+fter much effort I decided to include the following in my search strategy. 4. The homeless, the marginally housed, street people, and sex trade wor&ers 5. (helter residents 0including women and youth2 6. Inmates in the correctional system 0the incarcerated, parolees, the recently released, and those in half-way homes2 7. 8ersons with serious and persistent mental health issues, including dementia or addiction 9. %ousebound persons 0cystic fibrosis, arthritis2, shut-ins, and the disabled :. The linguistically isolated 0people with communication impairments, recent immigrants who are not fluent in ;nglish or <rench2 =. (elected recipients of <amily (er#ices and %ousing 0employment income assistance, go#ernment housing, children in care2 >. ?iscellaneous nonassociati#e groups 0transients, the uninsured, the socially isolated2 http.@@gossypiboma.wordpress.com@5AAB@AB@A9@hard-to-reach-hard-to-research@

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