This thesis is concerned with the experiences and understandings of young people as they move from their final two years of compulsory education into a range of post-16 destinations including Further Education, work, apprenticeships and unemployment. The participants were all identified as being ‘hard to reach’ by school practitioners. The research responds to a need to deepen understanding of such young people ahead of the age of participation in education and training in England being raised to 18 in 2015. The research was conducted in the South West of England. The empirical research was undertaken between January 2008 and April 2010 and comprised semi-structured interviews with 51 young people who were interviewed between one and three times during that period. The data presented in this thesis is focused on 11 of those young people who were each interviewed on three occasions. The findings suggest similarities between the post-16 transition experiences of the young people participating here and those of young people in this age range, not identified as ‘hard to reach’. Notwithstanding these parallels, the research revealed that young peoples’ post-16 transitions and the aspirations they hold are often more nuanced than has been theorised in previous research. The findings raise questions about the implications of labelling young people, and 14-19 policy predicated upon assumptions regarding those who do not participate post-16. In conclusion it is suggested that at a time of continued economic uncertainty and UK youth unemployment approaching one million , young people need more flexibility in the school and post-16 experiences that are available and actively encouraged, rather than increased levels of constraint.

The term 'hard to reach' first appeared in the Health Visiting Review (Lowe 2007). This review claimed that the health visiting service was able and experienced in reaching the 'hard to reach'. Yet there was a dearth of health visiting literature on what this concept meant and how it was interpreted in practice. A wide literature review was undertaken which examined government child health policies on reducing health inequalities and how the targeting of services to meet the needs of 'vulnerable', 'disadvantaged' or 'hard to reach' families had developed. The literature review identified how the concept of risk in relation to child health promotion had been defined and redefined since the 1970s. The latest shift involved the identification of 'new social risks' and the promotion of early intervention to prevent social exclusion and health inequalities. At the time of the study's inception, health visiting was a service both in decline and under threat. In contrast, the development of new early intervention programmes such as Sure Start (National Evaluation of Sure Start 2005), On Track (Doherty et al. 2003) and intensive home visiting (Barlow et al. 2005) also led to the critical examination of the concept of 'hard to reach'. In response to the lack of information on the concept of 'hard to reach' in health visiting, I set out to examine critically how Health Visitors (HVs) working in a disadvantaged area conceptualised and operationalised the concept of 'hard to reach'. This qualitative ethnographic case study (Yin 2003), by using research methods of focus groups, participant observation of a Well-Baby Clinic and interviews, gathered perceptions and experiences of HVs and service users. Thematic analysis was guided by Gee's (2005) method of critical discourse analysis and revealed how the term was contested by HV practitioners. It was considered a broad term that in practice could be applied widely and negatively as a label for non-engaging service users; yet themes emerged which also demonstrated how HVs related to and constructed the concept in their day-to-day practices of client engagement. The findings were categorised and a typology was developed in relation to the reach of health visiting within a predominantly deficit model of health. The typology consists of four types, all of which relate to the 'reach' of the health visiting service at the interpersonal level. The first type, the 'easy to reach' client, highlights the diversity of clients: not all clients living within a disadvantaged area were 'hard to reach'. This category also identifies how some clients living within this disadvantaged area developed relationships with HVs. Including the type 'easy to reach' within the typology acknowledges the diversity of clients living within an area of disadvantage, and also the facilitators in HV/Client relationships. The second type identified was the 'emotionally hard to reach' client, and identifies characteristics of clients who had a tentative relationship with the health visiting service. Working with 'emotionally hard to reach' clients involved negotiation and the building of trust at each encounter. The third type, 'physically hard to reach', developed following the identification of a range of barriers that reduced access to vulnerable clients. The fourth type, 'hard to reach services', arose from the findings - and this type relates to barriers created by the organisation of the health visiting service in a disadvantaged area. The typology highlights the importance of both clients' and HVs' engagement in the development of working relationships. It recognises the organisational structures and discourses that act as barriers and facilitators to client engagement. It recommends that health visiting should take the opportunity offered in the Health Visitor Implementation Plan (DH 2011) to develop a health visiting service underpinned with a strengths-based model of public health.

Background: This thesis reflects upon a heuristic study of a Storytelling Programme which took place in a KS3 Pupil Referral Unit. Previous experiences in the field, as a community storyteller, revealed the power of stories to calm and engage young people. In my community work I had seen that storytelling particularly engaged those considered ‘hard to reach.’ This research was designed to explore the storytelling process further with the aim of understanding more about the impact of the process and to understand the key components as identified by the young people themselves. Methodology: A heuristic research methodology was adopted within this study. The Storytelling Programme was delivered to twelve young people at a Pupil Referral Unit in the North West of England. Five of these participants were interviewed along with their teacher, and their reflections were integrated with my own to create a crystallized understanding of the storytelling process, whilst also remaining true to the unique experiences of each participant. Findings: Heuristic analysis of the Storytelling Programme revealed that young participants developed new personal narratives that reflected new ways of being and thinking. Change was demonstrated by the young people expressing a more positive sense of self. A striking finding, echoed by all participants, was the significance of the relationship in facilitating the therapeutic change process. Discussion: Whilst some of the changes could be linked to particular stories, the participants could not articulate whether their increased sense of well-being came from the stories or more generally from the programme or my ‘way of being’ (Rogers, 1980). It appears that stories and the therapeutic relationship intertwine within the storytelling process to create opportunities for therapeutic change. The findings of this study suggest that story is a particularly useful indirect medium to engage ‘hard to reach’ young people who have disorganised attachment styles. Storytelling offers the opportunity to place the intersubjective relationship as central, fostering an implicitly nurturing and co-regulating dyad that can offer reparation as well as the opportunities for catharsis and the development of emotional literacy through the processing of the story material. Conclusion: It appears that storytelling intertwines the interpersonal relationship with the stories to create a process which is both interpersonal and intrapersonal. The storytelling process appears to facilitate dyadic co-regulation, which may be an essential first step in the therapeutic change process. Once in a state of calm the young people could connect to the story stimuli and develop new ways of being and thinking. Whilst stories appear to promote changes at both the relational and semantic level, the findings from this study suggest that the implicit relational changes had primacy in facilitating significant therapeutic change.

Sex work is one of the rare elements of our society that is both accepted and stigmatized. Ironically enough, it is stigmatized without being studied in depth. The truth is we know very little about sex work and even less about pornography—the most legal of genres. While researchers have spent a great deal of time determining the effects that pornography has on viewers, particularly juvenile viewers, little research has been done on the men and women who make pornography. A 43 question survey was created and disseminated to those in the pornographic film industry, both amateur and professional, resulting in 210 respondents from all walks of life. The results of the inquiry show that social scientists know relatively little about working in pornography, having a profound impact on the current discussion and future research. Additionally, this investigation presents a new and creative method for surveying hard to reach, hidden, or sensitive subject populations that will aid in aspects of future research on sex work and other stigmatized behaviors.

Parent engagement in children’s developmental rehabilitation services is thought to be a fundamental component that is needed for children to reach their potential. This is especially true in the approach known as family-centre services – an approach that positions parents as partners in their child’s services. However, service providers and organizations can have difficulty engaging those parents who often miss their child’s appointments. These families are typically referred to as ‘hard-to-reach’, however this label may ascribe ‘blame’ to parents and lead service providers, researchers and policy makers to overlook the social, organizational, and economic barriers that can limit families’ use of services. Chapters 2-4, explore multiple avenues to contextualize parents’ attendance and engagement in children’s therapy services by applying family centred service tenants, Family Stress Theory, and ethical principles. These chapters lay the foundation for the grounded theory study presented in Chapter 5. This study, conducted with parents of children who use developmental rehabilitation services, describes the conditions that affect parent engagement and presents The Phoenix Theory of Parent Engagement to illustrate how parents attend, participate and engage in their child’s therapy service. These results are presented as a metaphorical journey through children’s developmental rehabilitation services in pursuit of child health and happiness. The implications of this theory are presented as they might be relevant to service providers, organizational leadership, and policy makers. These ideas are offered in an effort to inspire a coordinated effort to improve access and excellence in the provision of developmental rehabilitation services for children and families. / Thesis / Doctor of Philosophy (PhD) / Children’s developmental rehabilitation services are thought to be most effective when parents consistently attend, participate and engage in the service. When families do not consistently attend, participate or engage in services they can be labelled as ‘hard-to- reach’. Little is known about why families are hard-to-reach, if there are organizational barriers to service use, and how to promote engagement. This thesis provides a foundation for understanding parent engagement by exploring the clinical application of family-centred service, Family Stress Theory, and ethical principles. A grounded theory study is presented to contextualize parent engagement and explain how parents engage in their child’s developmental rehabilitation services. Service providers, organizational leadership, and policy makers can apply this theory to promote access and engagement in children’s developmental rehabilitation services.

Yes / This chapter is based on detailed qualitative research into the working lives of low-paid workers in multiple employment. We discuss the research design and practicalities of researching a ‘hard to reach group’ of workers. The emotive and sensitive issues that emerged for both the researchers and participants are also assessed.

En France, depuis les années 80, les personnes sans domicile ont fait l’objet de nombreux dénombrements, d’enquêtes tentant de les caractériser et de comprendre le phénomène d’exclusion afin d’orienter les politiques publiques d’assistance. Cependant rares sont les enquêtes réalisées avec un souci de représentativité et plus rares encore sont celles qui tentent d’évaluer l’état de santé des personnes sans domicile de manière objective, alors que la privation de logement est connue pour impacter durablement la santé. Ceci peut s’expliquer par le fait que les personnes sans domicile constituent une population au « contour flou », très hétérogène, évoluant constamment (en nombre et profils), dispersée et très mobile sur le territoire francilien mais également entre la rue et les différentes formes d’hébergement possibles. Ces particularités constituent autant de contraintes et difficultés à chaque étape de la réalisation d’une enquête dont les résultats se veulent extrapolables à une population donnée.Ce travail de thèse présente l’état des connaissances et le dispositif d’aide aux personnes sans domicile en 2007 et son évolution jusqu’en 2016. Il compile des connaissances sur l’état de santé et les conditions de vie des personnes sans domicile en Île-de-France, grâce à des enquêtes épidémiologiques, menées par l’Observatoire du Samusocial de Paris, s’intéressant à la santé mentale, les ectoparasites ou encore l’anémie. Il détaille les principaux obstacles, méthodologiques et pratiques, rencontrés lors de ces enquêtes et les solutions retenues pour les surmonter. Enfin, il conclut à la possibilité de faire des estimations de prévalences raisonnables et fiables en santé. / Since the 80’s, many surveys have been carried to count and describe homeless people, and to understand the exclusion’s phenomenon to advice French public assistance policies. However, only a few surveys have been done ensuring representativeness and even fewer attempted in assessing the health status of homeless people in an objective way, whereas housing deprivation (homelessness) is known to have a durable impact on health. This can be explained by the fact that this population is difficult to define, as it is very heterogeneous and constantly evolving (number and profile wise). The homeless are also scattered and highly mobile within the Ile-de-France territory, and also between streets and different forms of accommodation. These particularities are all constraints to epidemiological surveys among homeless people, and the generalization of their results.This PhD thesis presents the state of knowledge on homelessness and what has been done in order to give support to this population between 2007 and 2016. It compiles knowledge on the health status and living conditions of homeless people in Ile-de-France based on epidemiological surveys carried out by the Observatoire du Samusocial de Paris focusing on mental health, ectoparasites or anemia. It details the main methodological and practical obstacles encountered during these investigations, the solutions chosen to overcome them and concludes by affirming that reasonable and reliable estimates of prevalence can be produced in the field of health.

Le virus de l'hépatite C (VHC) est un problème majeur de santé publique dont les usagers de drogues (UD) constituent la principale source de contamination en France. Réaliser des enquêtes séro-épidémiologiques auprès de cette population pour suivre la dynamique du VHC s'avère difficile notamment en raison de leurs pratiques illicites. Cette population est en partie accessible par les lieux d'enquêtes et en partie "cachée" car ne fréquentant aucun lieu répertorié. Pour enquêter chaque partie, nous avons considéré l'échantillonnage lieux-moments (TLS) puis l'échantillonnage conduit par les répondants. Après avoir formalisé le TLS dans le cadre d'un sondage indirect, nous avons proposé un estimateur pour un total et une proportion, qui tient compte de la fréquentation multiple et hétérogène des lieux d'enquêtes. Nous recommandons cette méthode pour estimer la prévalence d'une maladie dans des études auprès de populations fréquentant des services, même en cas d'erreurs sur les fréquentations déclarées par les participants. L'enquête ANRS-Coquelicot réalisée en 2004 auprès des UD fréquentant des centres dédiés, puis répétée en 2011, a permis d'estimer la prévalence du VHC à 43,7%. A partir des deux enquêtes, nous avons ensuite estimé l'incidence du VHC par âge et en fonction du temps en construisant un modèle mathématique reposant sur la formulation d'une relation entre la prévalence et l'incidence. Ce modèle consistait en la combinaison d'un modèle compartimental et d'un modèle de régression. L'incidence du VHC a ainsi été estimée à 4,4/100 personnes-années en 2011. Cette approche est une alternative satisfaisante pour estimer l'incidence d'une maladie à partir d'enquêtes épidémiologiques transversales en l'absence de cohorte ou de tests biologiques permettant d'identifier les infections récentes. Compte tenu de la baisse de la prévalence, des mesures de réduction des risques et des avancées thérapeutiques, une diminution de l'incidence du VHC devrait se poursuivre malgré une potentielle augmentation des comportements à risque des UD. / Hepatitis C virus (HCV) is a public-health issue that drug users (DU) remain the major source of contamination in France. Conducting seroepidemiological surveys among this population to assess the HCV dynamic is difficult particularly due to their illicit practices. This population can be accessible through survey locations or can be hidden (who does not visit any location). To survey each part, we presented time-location sampling (TLS) and respondent-driven sampling. We presented TLS in the context of an indirect sampling and proposed a design-based inference taking into account the frequency of venue attendance (FVA) to estimate a total or a proportion. We recommend this method for estimating the prevalence of a disease in surveys among hard-to-reach populations, even if errors occur in the FVA reported by the participants. The ANRS-Coquelicot survey carried out in 2004 among DU attending centres providing services to drug users, then repeated in 2011, allowed us to estimate the HCV prevalence at 43.7%. Using these two surveys, we estimated age- and time-dependent HCV incidence from a mathematical model linking prevalence and incidence. This model consisted in combining a compartmental model with a regression model. The HCV incidence was thus estimated at 4.4/100 person-years in 2011. This method is an alternative approach to estimate incidence of a disease from cross-sectional epidemiological data in the absence of cohort or biological tests to identify acute infections. The decline in HCV incidence is to be expected given decreasing prevalence, recent developments in harm reduction measures and new therapeutic approaches despite a potential increase of at-risk behaviors.

The transition towards a sustainable and low-carbon future requires significant changes in energy behaviour among energy consumers. However, the question remains about how, by whom, and what changes are necessary to achieve this transition. While many policies have been implemented to overcome these barriers, current policies focus on technology market development and market failures. Policies that address behavioural anomalies are limited, leading to a lack of engagement and awareness among many energy consumers. This issue is particularly prominent among hard-to-reach (HTR) consumer groups, which can be found in both the commercial and residential sectors (Rotmann, Sea, 2019). The impact of HTR energy consumers on energy efficiency measures and the achievement of climate neutrality remains largely unexplored. It is necessary to identify and understand these groups to address this gap. By doing so, it is possible to help them change their energy consumption behaviour towards a more sustainable and low-carbon future (Rotmann, Sea, 2019).This project aims to provide insights into HTR energy consumers in Sweden and assess their impact on achieving climate neutrality. The primary objective is to identify the most common HTR groups, their main barriers, and the potential drivers that could help change their energy consumption behaviour. A detailed literature review is conducted to gather information on practical and theoretical cases globally to achieve these objectives. After the literature review, a semi-quantitative data analysis has identified and classified HTR energy user in Sweden, by using modelling software like Mental Modeler. A qualitative analysis was carried out to analyze the HTR groups, identify their main barriers and potential drivers, and to understand their energy behaviour better. From the literature review, it was found that high income, low income, and elderly are hard to reach, and there is a research gap of their behavior, needs and how to address their challenges to energy consumption. The findings revealed that high energy prices, subsidies, economic conditions, and energy production were key driver components that could not be controlled by individual energy consumers. Therefore, policymakers must implement policies that address these root causes, such as investing in renewable energy sources, increasing competition in the energy market, and offering targeted subsidies for energy-efficient products and services. Additionally, policies that promote economic growth and stability can help to improve energy efficiency by reducing the financial strain on households. Overall, this study highlights the need for comprehensive energy efficiency policies that target both the demand and supply side of energy consumption to promote sustainable and affordable energy use in households, which is crucial for achieving long-term energy and climate goals. / Övergången till en hållbar framtid med låga koldioxidutsläpp kräver betydande förändringar i energibeteendet bland energikonsumenter. Frågan kvarstår dock om hur, av vem och vilka förändringar som krävs för att uppnå denna övergång. Även om ett stort antal policyer har implementerats för att övervinna dessa barriärer, fokuserar nuvarande policyer främst på teknikmarknadsutveckling och marknadsmisslyckanden. Policyer som tar itu med beteendeavvikelser är begränsade, vilket leder till bristande engagemang och medvetenhet bland många energikonsumenter. Denna fråga är särskilt framträdande bland svåråtkomliga konsumentgrupper, som finns i både kommersiella och bostadssektorer (Rotmann, Sea, 2019). De svåråtkomliga energikonsumenters inverkan på energieffektivitetsåtgärder och uppnåendet av klimatneutralitet är fortfarande i stort sett outforskad. För att komma till rätta med denna klyfta är det nödvändigt att identifiera och förstå dessa grupper bättre. Genom att göra det kommer det att vara möjligt att hjälpa dem att ändra sitt energikonsumtionsbeteende mot en mer hållbar framtid med låga koldioxidutsläpp (Rotmann, Sea, 2019). Detta projekt syftar till att ge insikter om HTR energikonsumenter i Sverige och bedöma deras inverkan på att uppnå klimatneutralitet. Det primära målet är att identifiera de vanligaste HTR-grupperna, de huvudsakliga hindren de möter och de potentiella drivkrafterna som kan bidra till att förändra deras energiförbrukningsbeteende.En noggrann litteraturöversikt genomförs för att samla information om praktiska och teoretiska fall globalt för att uppnå dessa mål. Efter litteraturöversikten har en semi-kvantitativ dataanalys identifierat och klassificerat HTR-energianvändare i Sverige genom att använda modelleringsprogramvara som Mental Modeler. En kvalitativ analys utfördes för att analysera HTR-grupperna, identifiera deras huvudsakliga hinder och potentiella drivkrafter och för att bättre förstå deras energibeteende. Från litteraturgenomgången framgick det att höginkomsttagare, låginkomsttagare och äldre är svåra att nå, och att det finns en forskningslucka vad gäller deras beteende, behov och hur man kan hantera deras utmaningar i energikonsumtionen. Resultaten visade att höga energipriser, subventioner, ekonomiska förhållanden och energiproduktion var viktiga drivkomponenter som inte kunde kontrolleras av enskilda energikonsumenter. Därför måste beslutsfattare genomföra politiska åtgärder som adresserar dessa grundorsaker, såsom investeringar i förnybara energikällor, ökad konkurrens på energimarknaden och erbjudande om riktade subventioner för energieffektiva produkter och tjänster. Dessutom kan politiska åtgärder som främjar ekonomisk tillväxt och stabilitet hjälpa till att förbättra energieffektiviteten genom att minska den ekonomiska belastningen på hushållen. Sammanfattningsvis betonar denna studiebehovet av omfattande energieffektivitetspolitik som riktar sig mot både efterfråge- och tillförselssidan av energiförbrukningen för att främja hållbar och ekonomiskt överkomlig energianvändning i hushållen, vilket är avgörande för att uppnå långsiktiga energi- och klimatmål.