Older people from deprived areas, the oldest old and those from ethnic minorities engage less in health promotion interventions and related research, potentially generating inequities.

To explore and map the extent to which such ‘hard to reach’ groups of older people, are the focus of local health and well-being strategies in England.

Document analysis of current health and well-being promotion strategies in a purposive sample of 10 localities in England with high proportions of some or all of the three hard to reach groups. Documents were analysed using an interpretive approach.

A total of 254 documents were retrieved and reviewed. Much of the content of the documents was descriptive and reported the implications for resources/services of population ageing rather than actual initiatives. All localities had an Older People’s Strategy. Strategies to counter deprivation included redistribution of winter fuel payments, income maximisation, debt reduction and social inclusion initiatives, a focus on older owner occupiers and recruitment of village ‘agents’ to counter rural deprivation. The needs of the oldest old were served by integrated services for older people, a community alarm service with total coverage of the 85+ population, and dietary advice. The needs of black and minority ethnic (BME) older people were discussed in all localities and responses included community work with BME groups, attention to housing needs and monitoring of service use by BME older people. Three other themes that emerged were: use of telecare technologies; a challenge to the idea of ‘hard to reach’ groups; and outreach services to those at most risk.

Document analysis revealed a range of policy statements that may indicate tailoring of policy and practice to local conditions, the salience of national priorities, some innovative local responses to policy challenges and even dissenting views that seek to redefine the policy problem.

Achieving good response rates to population surveys from hard to reach groups in deprived areas can be challenging.

To explore and compare different approaches to improving response rates in an economically deprived multicultural area.

Following a lower than anticipated response rate in a pilot study for a postal questionnaire survey of chronic pain (79/653 (12%)), we conducted a second pilot involving a shorter postal survey and separate collection of more detailed information in a waiting room survey. The second postal survey used a shorter questionnaire, telephone data collection from non-responders by study team members rather than telephone reminders from practice receptionists, and involved a nested randomised-controlled trial (RCT) of hand-addressed versus printed-address envelopes. Both pilots involved subjects randomly selected from the practice registers.

The second pilot postal survey using shorter questionnaires yielded considerably more responses (240/642 (37%)). Our RCT showed that hand-addressed envelopes achieved a slightly higher response rate although not large enough to justify its use in our main study. The waiting room survey was successful in collecting more detailed data from lengthy questionnaires.

A range of methods of questionnaire administration may be required when conducting a survey with a hard to reach group in a deprived and ethnically diverse population. Postal and telephone administration can be used to collect a small amount of data. Face-to-face administration and recruitment can be successful for longer questionnaires.

Ongoing structured patient education, for those with type 2 diabetes, is a core requirement within diabetes health policy. Although type 2 education programmes are becoming established in the UK, a recent review reveals mixed results with little evidence to suggest whether or how such programmes might be directed, to achieve maximal benefit. Black and ethnic minority peoples, and poor and socially disadvantaged groups are especially vulnerable to the effects of the disease. What are the attitudes of these hard-to-reach groups towards diabetes learning?

Eight semi-structured interviews were carried out on participants from different cultural backgrounds. All were from the same primary-care setting, who had type 2 diabetes for more than 12 months. Potential participants were asked to opt in to the research process by invitation letter and in-house poster advertisement. Purposive sampling was undertaken on those who opted in. When recruitment proved difficult, targeted personal approaches were undertaken opportunistically, to increase the opt-in rate, and allow further purposive sampling. During analysis, themes and categories emerged inductively from participants’ dialogue, with no ‘a priori’ categories or themes. The themes were then linked into a map, which ultimately described the whole. The sample size was too small to be representative of the practice population and as such findings were not generalisable to a wider setting.

Diabetes education was highly valued, it was needed so that people felt well and alive; it had to be a respectful experience involving listening and being listened to. It was necessary for the learning to be personal, the desire coming from within. Previous learning related to employment had involved being shown the ropes and was viewed positively. Past diabetes learning had taken place in family settings, in informal meetings and within consultations with health professionals. These were generally preferred to formal classes. The quality of the learning experience was very important to participants. Stress and depression were barriers to learning and diminished capacity to change. The hard to reach are aptly named when trying to recruit for interview studies.