Introduction

In recent decades, there has been an international focus on reducing social inequalities in health [1,2]; nonetheless, inequalities with regard to health appear to be increasing [2]. The problem involves individuals with poor connections to the labor market and transfer income; these individuals are often more vulnerable to poor health outcomes [3]. The Danish Health Authority has defined these individuals as marginalized groups [4]. Marginalized people often live in deprived neighborhoods. A “deprived neighborhood” is defined as a geographically bounded area with a high proportion of adults with low socioeconomic status, characterized by indicators such as unemployment, low income, low education and low-paid jobs [5]. Within health science disciplines, the field of research on neighborhood conditions and their impact on individuals has grown. This area has attracted substantial interest among researchers in recent years [6]. It has been demonstrated that the health of individuals varies according to neighborhood characteristics, and several studies have proven that socioeconomically poor areas have higher morbidity and mortality rates than other areas [7–11]. Furthermore, studies have shown that those who live in deprived neighborhoods are less likely to participate in health programs and in health research compared to the majority of society, which have a higher socioeconomic status. [12–16]. The challenges within deprived neighborhoods vary substantially and involve financial or transport-related barriers, distrust or fear of authorities, communication difficulties, and lack of information and awareness in relation to health programs [14,16]. A systematic review by Bonevski et al. (2014) that involved several different recruitment approaches found no clear strategy that could improve the participation rate, though the best method did appear to be involvement in the community in an attempt to reach marginalized groups. The groups of interest were described as socially, culturally or financially disadvantaged groups compared to the majority of society. Involvement in the community should be in collaboration with groups and organizations in the community and should involve community members in the design of the health interventions [16]. Another review emphasized the lack of evidence regarding which recruitment approaches for residents living in deprived neighborhoods increase participation in health programs [12].

From 2010–2014, 12 municipalities in Denmark were involved in a national government-funded project, Forebyggelsesindsatser i nærmiljøet (FIN) (Prevention efforts in the local community), which aimed to strengthen health and wellbeing among marginalized groups in deprived neighborhoods. The Danish Health Authority committed these municipalities to work with predetermined risk factors of mental health, smoking and physical activity as well as either diet or alcohol use. Testing of methods for recruitment of the marginalized groups was also part of the project’s framework [4].

The knowledge gained from FIN and the limited evidence and research on the recruitment of marginalized groups provides a strong argument for further research on how to recruit marginalized groups from deprived neighborhoods in an attempt to increase participation in local health-promoting interventions. Thus, the aim of this article is to understand how recruitment approaches can promote participation in health programs within deprived neighborhoods to reach marginalized groups. We investigated this issue through a document evaluation of the 12 participating municipalities’ experiences with the recruitment of marginalized groups during the 2010–2014 period.

Method

The empirical setting

In 2010, the Danish Health Authority invited the Danish municipalities to apply for participation in and subsidies by the FIN project. The target group was residents who lived in deprived neighborhoods. The neighborhoods were either a deprived area in a larger town, a smaller town or an area composed of two or three small villages in rural areas. A selection criterion was that the municipalities could document the need and potential for interventions in a neighborhood with many marginalized people. Additional criteria were the establishment of new preventive and health promotion interventions, the geographical spread of the municipalities, previous experiences with interdisciplinary interventions, the potential for maintenance, and municipal co-financing [4]. Of the 98 municipalities in Denmark, 45 applied, and 12 municipalities were selected based on their applications.

The types of the interventions were not specified in advance by the Danish Health Authority. Therefore, the project employees had an open framework to shape the local interventions as long as they were aimed at the predetermined risk factors: mental health, smoking, physical activity, and diet or alcohol. The local interventions ranged widely, including exercise classes, smoking cessation courses, cooking teams and other social activities. Other interventions were more creative; for example, one municipality used activities with art to promote mental health.

As part of participation in the FIN project, the municipalities were required to conduct a local cross-sectional survey in the neighborhood. The survey was designed to obtain a better understanding of the individual neighborhoods. Furthermore, the survey made it possible to identify more specific target groups among the residents in the neighborhoods and by this develop health interventions. All municipalities identified target groups that had health problems, though few of the municipalities used these data in relation to design the recruitment of the residents. Some municipalities decided to work with all residents—as an unitary target group and some municipalities prioritized the most vulnerable groups in the neighborhoods based on the findings from the survey. The vulnerable groups often scored high on parameters such as loneliness, low attachment to the labor market, and had both physical and mental health problems according to the survey.

A comparison of the 12 deprived neighborhoods included in FIN (anonymized and termed A-L) showed that they had certain common characteristics: a higher proportion of residents with a low educational level, with lower incomes and who received social assistance compared to residents in other parts of the municipalities. Diversity was also present in the 12 neighborhoods, as illustrated in Table 1. The number of households ranged from 203–3,190, the number of residents ranged from 491–6,376, the percentage of immigrants or descendants ranged from 2%-52%, and the locations included nine urban and three rural areas. This diversity illustrates the different possibilities and working conditions for the project employees in the 12 neighborhoods.

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Table 1. Neighborhood characteristics.

https://doi.org/10.1371/journal.pone.0158079.t001

Data collection of documents

The data materials in our study were collected in the spring of 2015. Contact with the 12 municipalities was made through email, and we requested documents in the form of project descriptions as well as midterm and final evaluations. Because the project description was a mandatory document, it was possible to obtain 12 project descriptions. Project evaluation was not mandatory for the municipalities, and it was only possible to collect three midterm and 10 final evaluations. Additionally, six documents from researchers or external evaluators were included. The collected documents consisted of 1,500 pages of written material. An overview of the documents and their content, including whether the municipalities described, evaluated and adjusted the recruitment approach, is shown in Table 2. The project descriptions are included in the analysis to identify recruitment approaches, and the evaluations are included to assess recruitment strategies.

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Table 2. Overview of documents and content.

https://doi.org/10.1371/journal.pone.0158079.t002

Ten municipalities (A, B, C, D, E, F, H, I, J, K) evaluated approaches in relation to recruitment, and only three (E, J, K) provided a description of which residents were recruited to determine whether the residents belonged to one of the marginalized groups in the neighborhood. Municipality E described a special focus on three target groups: immigrants and their descendants, residents experiencing economic hardship and the lonely, who are mentally vulnerable. These groups were estimated to constitute approximately 40% of the 1,700 residents over 18 years of age. In municipality J, the most vulnerable populations are described as men of Danish origin who had indicated that they felt lonely in the survey, residents with an ethnic background other than Danish who are outside the labor market, and residents with chronic pain and health problems. Municipality K was not as specific in the evaluation as E and J. It divided the group of residents into two general categories based on project employees’ experience: vulnerable and resourceful. Two municipalities (G, L) did not compose an evaluation. Seven municipalities (A, B, C, D, E, F, J) described adjustments to the recruitment approach in their evaluations.

Data analysis

FIN ended in 2014. Therefore, it was possible to conduct a summative process evaluation of the municipalities’ work with recruitment to provide an understanding of why and how the municipalities' interventions did or did not work [22]. We analyzed the documents through a qualitative content analysis, defined as an interpretation of the content of text data through the systematic classification process of coding and identifying themes or patterns [23]. Authors MR, EKP and ASR conducted the content analysis. To ensure consistency and quality throughout the analysis process, all documents from one municipality (F) were coded individually and subsequently reviewed and discussed by all three authors. This approach aimed to produce a shared systematic review of the documents to ensure that nuances in the analysis of the documents were initially coded individually before being summarized in a joint process.

A comparison of documents from the project description, the midterm and the final evaluations provide insight into the development of the municipalities’ work with recruitment from start to finish. This approach made it possible to analyze whether the purpose, ideas and interventions at the beginning of the project were reached at the end [22]. We carefully analyzed the documents, looking for patterns, themes, and regularities as well as contrasts, paradoxes, and irregularities. The “negative” exceptions as well as the “positive” patterns were highlighted [24]. By comparing and analyzing experiences across municipalities, it was possible to generalize experiences from the individual municipality. The data analysis process is shown in Fig 1.

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Fig 1. Data analysis process.

Illustration of the steps in the data analysis process from reading documents to identifying themes.

https://doi.org/10.1371/journal.pone.0158079.g001

The identification of themes or patterns was a circular process. As the themes emerged, it was sometimes necessary to return to the documents and focus on an individual municipality’s experience with recruitment. Authors CKB and TMK are experienced researchers in deprived neighborhoods and qualitative methods, respectively. MR, EKP and ASR discussed the analysis process and the identified themes with CKB and TMK throughout the entire process and linked the findings to prior knowledge in the fields of recruitment, marginalized groups and deprived neighborhoods.

Results

Through the content analysis, we identified the recruitment approaches in the municipalities. Two main themes emerged in relation to recruitment. One theme included challenges with recruitment, and the other included positive experiences.

Discussion

The study revealed both positive experiences and barriers when recruiting marginalized groups in deprived neighborhoods. The barriers included challenges with the target group and geographical difficulties, and both depended on the particular context. The challenges with the target group involved distrust, language barriers in neighborhoods with many different nationalities, and a lack of ability to cope with new situations in vulnerable groups. Distrust and a lack of coping abilities might cause residents to lack the courage and desire to participate in the health program, whereas the language barrier can make it difficult for residents to read the written material that provides information about the activities. Geographical difficulties involved rural areas due to the lack of a local meeting point and distance to the activities. Furthermore, participation was challenged due to issues of time and money required to access the activities. The positive experiences included maintaining a local presence and face-to-face contact, which can improve the relationships and trust between the project employees and the marginalized groups and thereby increase participation in interventions. Residents’ recruitment of each other also improved participation. Furthermore, adjustments to the recruitment strategy based on continuously identifying and recognizing the target groups’ needs while the health program was in progress seemed to be an effective way to improve participation. The analysis showed that adjustments succeeded if the project employees continuously identified which groups of residents they did not reach and then targeted the recruitment approach to these groups.

Other studies are in line with our findings of a positive experience based on a personal and proactive recruitment approach. A study by Macleod et al. (2013) examined recruitment approaches for overweight or obese post-partum women living in a deprived area in Tayside, Scotland, which partly might be comparable to the neighborhoods in Denmark. The results showed that the most effective method for recruiting was visiting community groups; accordingly, that project staff’s visibility in the area was an advantage [25]. Similar results were reported in a review by Koopmans et al. (2012), which indicated that more active and personal approaches yielded greater participation in prevention programs in General Practice than passive approaches did among individuals from deprived areas [12]. A randomized controlled trial by Heinrichs (2006) examined payment as a recruitment approach. Although payment is not included in FIN, the study by Heinrichs is interesting as the context is comparable to the Danish deprived neighborhoods. The study showed that paying residents for participation in an intervention concerning improvements to parenting skills was effective in increasing participation for at least one session. Once the participants experienced the benefit of the intervention, they seemed to become self-motivated to attend regularly, and payment was less pertinent. The study was more effective among families from deprived neighborhoods than among families from more affluent neighborhoods [26]. Therefore, the use of payment might be considered to improve recruitment among marginalized groups in deprived neighborhoods in Denmark.

International studies and researchers focusing on deprived neighborhoods and health emphasize the importance of a socio-ecological approach [27–29]. The socio-ecological approach involves the understanding that health is created in the interaction between citizens and the environment in which they live [28]. Trickett emphasizes problems with the use of decontextualized knowledge when conducting primary prevention projects and highlights that the focus should be not only on the intervention but also on the context in which the intervention is conducted [27]. Therefore, when choosing or planning a recruitment strategy, it is important to consider the context in which interventions should be implemented. Our analysis identified several examples of how the context influenced the choices made in relation to the recruitment strategy. One example was hiring a bilingual employee in a neighborhood where many of the residents were immigrants (E). Furthermore, it might be worth testing whether free transport in rural areas can increase participation due to the distance barriers for many residents (F, H, I).

In the documents, there was a lack of evaluation and follow-up concerning the target group. This might be explained by the lack of requirements and support from the Danish Health Authority in terms of documentation and evaluation of the interventions. This lack of requirements might be a reason for the general trend of municipalities not describing in detail the recruitment process and the adjustments they made throughout the process. International research suggests using an iterative approach when working with health interventions [28]. This approach involves continuous evaluations and adjustments of the interventions and recruitment approaches to reach the target group as well as to handle unexpected changes in the environment. The iterative approach requires knowledge about the socio-ecological condition, an ongoing evaluation and a systematic approach using theory, evidence and experience in the specific practice [28]. A systematic review by Bonevski et al. (2014) emphasized the importance of acknowledging the need for an extended time frame, higher resource needs and operation via community partnerships in an attempt to access hard-to-reach-groups [16]. Our study showed that limited resources, such as economic limitations, lack of time, and lack of experience and knowledge with systematic working in practice, might present challenges in relation to adjusting the recruitment approaches to the target group’s needs. We also observed that three municipalities that involved researchers or external evaluators were more systematic in their documentation and were the only ones that evaluated recruitment in relation to marginalized groups. The involvement of researchers throughout the entire process is also recommended [28].

Our study’s results are based on the fact that only 10 municipalities developed evaluations of recruitment, and only three evaluations provide a description of which residents were recruited to determine whether the residents belonged to one of the marginalized groups in the neighborhood. Some municipalities’ documents were more useful in the analysis than others because these municipalities had been more systematic and diligent in their description and evaluation of the recruitment of the target group. The defective documents made it difficult to determine whether the recruitment process had succeeded. Our method may not capture all of the useful experiences of FIN, and it could have been supplemented with interviews with project employees or residents, who may have different perspectives than those represented in the documents.

Conclusion

This study provides important information on the process of recruiting marginalized groups in deprived neighborhoods for health interventions. Positive recruitment experiences involve the establishment of trust between the residents and the project employees. Trust can be achieved through the employees’ presence in the neighborhood, face-to-face contact and residents’ recruitment of each other. Furthermore, adjusting some of the interventions and the recruitment strategy increased participation. Further research is necessary to determine effective recruitment approaches to health interventions among marginalized groups. We recommend a systematic process of evaluation to examine which approaches are effective under which circumstances in relation to marginalized groups. Moreover, the collection of data during the recruitment process must include both qualitative methods that explore project employees' and residents' experiences and quantitative measures that assess participation development.