Background
Despite sustained reductions in coronary heart disease (CHD) incidence and mortality over the last decade, CHD remains the commonest cause of premature death in men and women in Scotland [
1]. Research has suggested that a significant proportion of incident CHD is attributable to modifiable risk factors such as smoking, diet and level of physical activity [
2]. This recognition that CHD is a largely preventable disease has focused health policy, both in the UK and elsewhere, on primary prevention [
3,
4].
Research has also shown that socioeconomic deprivation (SED) is associated with excess CHD morbidity and mortality [
5]. For the most deprived populations in Scotland, premature mortality from CHD actually increased over the period 2003-2006 in contrast to other groups [
1]. This excess risk is partially mediated through the distribution of known CHD risk factors in deprived populations [
5] and it has been estimated that equal uptake of effective primary prevention across all socioeconomic groups in the UK would eliminate almost 70% of the excess CHD mortality experienced by socio-economically disadvantaged individuals [
6]. However, prevention interventions that fail to engage with deprived populations may actually serve to widen health inequalities. This presents policy makers and health care practitioners with the challenge of trying to implement effective primary prevention interventions that engage and recruit across all socio-economic strata.
The elements of health promotion strategies that are most effective for recruiting and engaging participants are not well understood [
7,
8] and, in particular, there is a paucity of good quality research examining the most effective strategies to engage 'hard-to-reach', deprived populations in preventative medicine. Yancey et al [
9] conducted a general assessment of the available literature and identified a number of issues that make studies challenging to compare and findings difficult to generalise. These include differences in the reporting of recruitment, enrolment, and retention information; inconsistencies in the use of terminology across studies and the complexity of the literature which covers disparate samples of socio-demographic compositions, different diseases and study types. Literature specifically concerning recruitment into CHD primary prevention is especially scarce. Fitzgibbon et al [
10] report the labour-intensive nature of effective recruitment within underserved communities in two separate CHD primary prevention programmes. Neighbourhood canvassing, presentations and telephone recruitment methods were cited as successful approaches; however the authors stress the importance of tailoring recruitment efforts to the needs, experiences and environment of the target population. In another CHD primary prevention programme, King et al [
11] adopted two recruitment efforts; a random-digit-dial telephone survey and a community media campaign. This study reports few differences in the demographics of the recruitment yield from each approach; however the telephone survey recruitment was particularly successful in recruiting smokers and persons with other cardiovascular risk factors. Furthermore, counter to expectations, subsequent programme adherence rates did not differ by recruitment source.
The primary prevention element of the Have a Heart Paisley (HaHP) study offered risk screening to individuals aged 45-60 years old, without a prior history of heart disease and registered with a general practitioner (GP) in Paisley, in the West of Scotland [
12]. The programme employed two approaches to engage with the community (a) a widespread social marketing campaign and (b) a community development project adopting primarily face-to-face canvassing. In this paper we present the results of a qualitative study that employed focus groups to explore the perceived barriers and facilitators experienced by individuals from a socio-economically disadvantaged population to engaging with a CHD primary prevention intervention.
Results
The focus group discussions highlighted a number of reasons for the lower uptake of risk screening in response to the social marketing campaign amongst individuals living in areas of high SED and a number of ways in which the community development project overcame these barriers. These have been categorised into four main themes: (1) processes of engagement; (2) issues of understanding; (3) design of the screening service and (4) the priority accorded to screening. In the results, presented below, the authors have edited some of the respondents' West of Scotland dialect for presentational purposes and ease of understanding.
Processes of engagement
The most immediate barrier to recruitment for many residents of Ferguslie Park was that the initial letter inviting them for screening did not reach them, as a result of inaccurate address information. The majority of focus group participants acknowledged this difficulty and spoke frankly about why individuals living in Ferguslie Park might be difficult to locate; citing escaping debt and committing benefit fraud as reasons:
Folk like that are not wanting to be on any list, anywhere, they think they're all after them for whatever it is - debt, giros, so they're not going to go for anything like this. They probably think you're wanting to get them off the (state) benefits (laughter of group) (Respondent 5, Group 1)
There was also consensus that mass mailings are ineffective in Ferguslie Park; being perceived as 'junk mail' to be immediately discarded:
If you get a letter in you just go 'oh more junk mail' and you throw it in the bin (Respondent 5, Group 1)
In contrast, interviewees suggested that social networks, extending beyond that of the immediate family, were highly effective methods for communication and for dispelling mistrust and misunderstanding of new services in the area:
Aye you just have to bang the jungle drums to get the word out there- best way! (laughter) (Respondent 2, Group 1)
Both focus groups were very positive about the processes of engagement employed by the community development project, which included on-street interviewing, door-to-door calling, peer referral and involvement of the outreach workers in local events. Participants repeatedly suggested that it was the face-to-face nature of the community development project that was pivotal to their engagement and recruitment:
I think we all came because of the approach, yeah (Respondent 4, Group 1)
In particular, participants felt that the enthusiasm of the outreach workers and their ability to establish rapport and engender trust with the target population was essential to recruitment:
Meeting the woman (community outreach worker) she was great, I wouldn't have bothered otherwise (Respondent 3, Group 2).
They made you feel comfortable the lassies (community outreach workers) (Respondent 4, Group 1)
What made me come along to the screening was that I got to know the workers (Respondent 3, Group 1)
Issues of understanding
Focus group participants expressed a lack of knowledge and understanding about both CHD and their individual risk of developing it. Several participants stated that they did not engage with the initial (mailed) invitation to screening because they felt they were in good health and did not require risk screening:
I just didn't feel I needed it, (screening) I just didn't feel... ill (Respondent 4, Group 2)
The information contained within the social marketing mass mailing failed to overcome these general issues of knowledge and understanding regarding CHD. In addition, participants felt there was of a lack of clarity in the information provided in terms of the process and value of screening. In particular, participants suggested that they were left unclear as to what participation would involve and what the benefits of screening would be for those who accepted the invitation:
I didn't know what it was about, I didn't know if they'd have me on a treadmill or anything like that and I wasn't wanting that (Respondent 1, Group 1)
In contrast, the direct face-to-face contact employed by the community development project meant that the community outreach workers were able to explain to prospective participants what was involved and what the participant could expect from the screening service, as well as the potential benefits to the participant. This was recognised in both groups as being vital to recruitment:
The fact that you were getting everything explained to you so it didn't matter that you couldn't read the glossy leaflet (social marketing material) (Respondent 3, Group 1)
Design of the screening service
In order to accept and take-up the invitation for screening, participants were required to make an appointment over the telephone and then attend the screening location at this time. Focus group participants felt that this procedure was demanding, inflexible to individual needs and placed too much responsibility on the individual:
It was too much hassle, trying to arrange all that and go up to town (screening location), to take time off your work and that (Respondent 3, Group 1)
I couldn't make the appointment and didn't know if I could get another (Respondent 5, Group 2)
These issues were considered to be particularly acute for individuals, such as residents of Ferguslie Park, with a range of competing issues (for example housing, violence, drug abuse and addiction) that may be of higher priority than organising a screening appointment:
There's so many issues in Ferguslie, in people's lives, whether it's the drugs, the alcohol, violence (Respondent 1, Group 1)
I got the stuff through and I actually called up and got an appointment through but it wasn't a good time for me, I couldn't commit to the appointment time, not with what I've got on my plate (Respondent 5, Group 1)
In contrast, the community development project ran a series of drop-in sessions where appointments were not required. Focus group participants indicated that this flexible approach was more suitable to the competing priorities of the local residents and had a major impact on recruitment, retention and quality of care:
Ye need a variety of times, you're maybe watching the grand weans (grandchildren) because something mental has happened the night before (Respondent 5, Group 2)
In addition, both focus groups identified the importance of the longer appointment times available through the community development project which allowed participants the time to receive, understand and ask questions about the results of their risk screening:
It wasn't like the doctors they chase you out the door. Because you were there for as long as you wanted (Respondent 2, Group 1)
Participants in both focus groups also discussed their prior negative experiences with both primary and secondary care services, describing how traditional healthcare settings made them feel uncomfortable. These experiences were directly cited as reasons to be sceptical of the screening service:
You're uncomfortable, it's the way they (doctors and nurses) fire questions at you (Respondent 2, Group 1)
You're on eggshells the whole time (when with doctor) aren't you? (Respondent 5, Group 1)
The community development project used an informal (non-health service) location for screening, overcoming the issues that some participants may have with traditional healthcare settings and staff. In particular the staff were repeatedly described as non-judgmental and non-patronising:
The fact that it's not formal and you were never getting lectured to (Respondent 3, Group 1)
You could actually speak to them (community outreach workers and project nurses). When I go up the hospital- the nurses and that talk to me, I'll say anything to them (Respondent 2, Group 1)
I think you never felt as though you were being patronised (Respondent 3, group 1)
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
IF, HS and CH conceived of the study. HS conducted and recorded the focus groups. CH, RS and MG performed the thematic analysis of the transcribed focus groups. CH drafted the manuscript with significant input from MG and RS. PD performed quantitative analysis of recruitment yields. KM, AS, CM, FM, HC, PD, PM and IF participated in the study design, coordination and helped draft the manuscript. All authors read and approved the final manuscript.