Programme aims: why purpose drives recruitment
Key drivers for recruitment are the aims and objectives of programmes. In general, the data indicate that the less programmes are driven to capture specific populations, the less targeted the recruitment drive. Health walks programmes – ‘specifically designed and carried out to improve one's health’ [33
] – seek out particular population groups based on health criteria. ‘Walking-focused’ programmes (on the other hand, as typified by those run by Agency A, seek out individuals based on walking criteria. Although as a subscription-driven walking charity Agency A now cites the promotion of social welfare (incorporating health) within its aims, historically it was formed to promote access to the countryside and the ‘right to roam’. These are aims which still predominantly define the way open walking programmes are structured within the organisation.
"the problem they have is, some of their traditional members have a lot of discomfort with promoting the urban walking agenda…I think they see it as detracting from the core stuff about footpaths…"
"Respondent 5, Case study A (Agency A)"
Data from the six Agency A walking leaders who provide ‘open to all’ programmes, showed that the typical demographic of recruited members is white, middle class, and retired. Given that such programmes are not seeking to recruit from specific groups, non-targeted recruitment methods are typically employed, e.g. placing promotional material in community spaces and/or local media in order to engage anyone interested in walking from the population at large.
Data from the health walks programme leaders on the other hand, show recruitment strategies driven in part by health aims. Typically programmes had pre-identified target groups (e.g. sedentary people, people living in areas of deprivation) defined within their aims, which led to targeted recruitment strategies. Although most respondents did mention the use of promotional material, it was recognised that this type of recruitment would not engage those for whom lifestyle changes were a necessary precursor.
"To me that’s not the target group that we want [those that read posters] because obviously if they’re out and about they’ve seen them anyway, so they are getting out and about. We prefer to try to get to the people that need to walk."
"Respondent 17, (Agency B)"
Commonly adopted strategies were clearly linked to working in face to face contexts.
"Our mission statement is to get more people more active more of the time…When you’re targeting a certain group of people [i.e. the inactive] they’re not going to read something in a health and fitness magazine, they’re not necessarily going into a leisure centre to pick up information from there. So rather than waiting for them to come to us, we’re going to them."
"Respondent 15, (Agency B)"
The majority of respondents who worked within programme aims which targeted ‘hard to recruit’ groups e.g. Black and Minority Ethnic (BME) or vulnerable children and family groups, mentioned the need to work in partnership with those organisations and agencies currently working with those groups.
"[Agency A have] not really [got] the expertise or contacts to do it with children or families. So we needed help in that direction and [named children’s agency] have got that national spread of working with children and contact through family centres throughout the country”"
"Respondent 3, Case Study B (Agency A)"
In terms of actually recruiting to walking programmes those from ‘hard to recruit’ groups who had never walked, there was a recognition that engagement is largely achieved through the trust and motivation which partner organisations build up with their clients. Recruitment at this level was typically observed as inter-personal – intensive face-to-face, word-of-mouth prompting.
"Walk leader: I don’t know if it would have been possible [to run the programme without the help of a partner], because all the BME groups that I’ve run, I’ve always had some sort of community worker attached to them… [without that] they probably didn’t know who Agency A were, they wouldn’t have heard of [named walking programme]."
"Community Programme Manager: …my Assistant has worked her socks off to get them women…The day before you’re ringing, you’re sending letters out, ringing the morning before, you’ve got to really motivate [the Asian women to participate in the walking sessions]…"
"Group interview, Case Study C, (Agency A)"
To summarise this finding, programme aims which require targeting of specific groups adopt more specific recruitment methods.
Recruitment processes: what guides the activity of recruitment?
A key principle which guides recruitment is the conceptual framework, if any, underpinning each programme. Of the 28 walking programmes, only 5 (all with health aims) were working within a conceptual framework which established recruitment strategy. Of these, 3 programmes were staffed by paid coordinators, where the remit was to work with partner organisations and community groups to reach ‘hard to recruit’ groups. These were guided by the adoption of actively targeted approaches as described above.
Two other programmes operated under theoretical models which informed the recruitment process. One was a health walks programme guided by the Stages of Change model [34
], which led to the provision of walking interventions of differing intensities designed to cater for the needs of the local population at differing stages of engagement. Here, longevity was perceived as facilitating effective ‘word of mouth’ recruitment. The other, a walking programme run by a drug addiction team, operating under a bio-psychosocial model [35
] to bring about mental and physical health improvement, used ‘word of mouth’ recruiting firstly via therapy sessions and encouraging clients to bring others. These programmes indicate at least some kind of formative evaluation through participatory planning with other stakeholders [36
]. Data from the remaining 23 programmes indicated the decision about which recruitment methods to adopt was largely the responsibility of walking programme coordinators, who operated under no guiding conceptual framework.
Having established that most respondents had no conceptual framework to guide their recruitment activity, we now examine which recruitment methods were selected. Figure categorises the methods according to two types of recruitment approach – ‘passive’ and ‘active’.
Recruitment methods used by projects.
Passive methods are defined as ones which require the potential programme participant to make the first contact with the programme. Active methods are defined as ones which require a programme representative to make the first contact with the potential participant. The data show a fairly even distribution between passive and active methods used, although the only active method used by ‘open to all’ programmes was ‘word of mouth’. Programme leaders were then asked to nominate the method thought to be the most and least effective. Figure shows that active methods – particularly ‘word of mouth’ – were overwhelmingly believed to be the most effective.
Effectiveness of recruitment methods used.
Despite the popularity of the use of fliers and posters shown in Figure , only a small number of programme leaders believe them to recruit effectively, with some regarding them negatively. The data seem to indicate a mismatch between the methods respondents believe to be effective and the ones they actually adopt. Other than the ‘open to all’ Agency A groups, who typically used the fewest number of recruitment methods (typically programme fliers and word of mouth), the majority of respondents, none of whom were guided by presence of a conceptual framework, used a ‘belt and braces’ approach encompassing as many methods as their capacity allows.
"Everything can work. You just have to try everything."
"Respondent 27, (Agency C)"
Three respondents with a personal background in marketing were identified during interviewing. Notable was their adoption of ‘what works’ recruitment, all favouring active ‘word of mouth’ community-based approaches. In this sense their recruitment activity appeared to be more strategic than many other respondents, where the start-point focused on recruitment outcomes (how best to recruit the target group) not recruitment processes (how many potential recruitment methods could be employed). In explaining why respondents were so process- rather than outcome-focused in their recruitment, the data indicated the influence of resource availability. Although respondents thought of active recruitment methods as more effective, they described them as time-intensive and draining of human resources.
"…we have no budget for advertising or promotions or anything. It was purely salary-based…We’re doing a lot of social and community promotions…Which is actually quite labour intensive"
"Respondent 15, (Agency B)"
Of the 28 programmes, none worked within a specific recruitment budget, although a few possessed a ‘publicity’ budget. Funded post respondents commonly spoke of recruitment being under-resourced. For example, those programmes which fell under the Agency B umbrella – typically gathering meagre funding from multiple sources – tailored to their recruitment methods according to resource capacity which drove them to adopt the cheapest methods.
"Yes, it is NHS [National Health Service] funding, if you classify my wages as funding. Other than my time to coordinate the scheme, the other funding pot comes from the [named] Council. They will print my timetable for me but then it’s down to me to distribute that. There’s no other funding set aside for the walking scheme as such…with regards to targeting the population groups and the ways in which we do it, because I’ve got no budget I’m restricted to leaflets…"
"Respondent 18, (Agency B)"
To summarise this finding, without the guiding principles of a conceptual framework for recruitment method selection, very few recruiters are strategic in thinking of ‘what works’. Most focus on multiple method selection processes often driven by resource-poor contexts.
Sustainability: the contribution of evaluation and training to recruitment
Evaluation – planning and measures of success
A key component of sustainability is effective programme evaluation. There was a wide variation in the degree of evaluation found. Twenty-seven of the 28 interviewees engaged in some kind of ‘process’ (assessing implementation) evaluation. Of these, 5 had also either been or were about to be evaluated by independent researchers. It was clear that the vast majority of evaluations focused on evaluating participation with none methodically collecting exposure, delivery or context data. All programme evaluations noted numbers of participants, a measure of primary importance.
"We do count up how many people we get on a walk. I wouldn’t say there was competition exactly [between walk leaders], but if you get 30+ the leader gets a certain smugness!"
"Respondent 10, (Agency B)"
In the case of health walk programmes run under the Agency B umbrella, evaluations were usually based on data obtained from the Outdoor Health Questionnaire (OHQ) which walkers complete on their first visit. Questions about method of recruitment, health status, background as a walker, and weekly engagement in moderate levels of physical activity, are collated at local level by coordinators and at national level by Agency B. No respondent reported interrogating the OHQ data to relate numbers of participants to their health or physical activity status, and therefore whether or not they were representatively capturing the ‘sedentary’ target populations they sought to recruit. Thus, despite respondents’ awareness of the target population, the focus of most evaluation seemed to be descriptive rather than diagnostic in terms of prospective recruitment direction. As shown by Figure , respondents believed the most effective recruitment method to be ‘word of mouth’, often quoting their OHQ data as evidence, but no programme evaluated recruitment methods used and their relative success in achieving a representative sample population.
"We do have a database and record how many participants there have been to the programme, but we don’t necessarily relate that to whether we’ve just delivered a load of leaflets or whatever."
"Respondent 13, (Agency B)"
Other than one respondent (whose programme measured Body Mass Index ‘before and after’ no programme evaluated outcomes (treatment effectiveness) systematically, although anecdotal evidence was widely offered. Across all programmes, it was the number of participants and the level of recruitment, i.e. process evaluation data, which was used and accepted as evidence of effectiveness instead.
"We feed into Agency B’s database now…what I’m able to use if for now is the number of new walkers. I can certainly track every single walker now to see how regularly they are walking. We have a Service Level Agreement…I have to report the number of walker attendances. The expectation is that that will have increased."
"Respondent 16, (Agency B)"
Training – knowing how to recruit
The Agency A Membership Recruitment and Publicity Handbook [37
] lists ideas for recruitment, but local groups are advised to consider using a whole range of methods in a ‘belt and braces’ approach. Word of mouth is encouraged as a successful method, but is phrased as ‘recommendation to a friend’, a suggestion likely to succeed only insofar as recruiting those from similar backgrounds. Agency B and Agency C now embrace health-related social marketing, defined as
"‘the systematic application of marketing, alongside other concepts and techniques, to achieve specific behavioural goals, to improve health and reduce health inequalities’.
In thinking carefully about the barriers to walking for particular groups [39
], the skill of the publicity officer in Case Study A, who came from a marketing background, was in matching the nature of the group to the motivations of the 20s to 30s audience.
"We unashamedly did a Valentine’s feature this year, because it is like a dating club, our group."
"Respondent 5, Case study A (Agency A)"
In a contrast to all other programmes, fliers and posters were not adopted by Case Study A as recruitment tools, although word-of-mouth between friends was still cited as important. Innovative recruitment practices included the use of new social communication media – the group used the internet exclusively to communicate (and recruit) via their website, Time Out, Facebook and Twitter – including ‘piggybacking’ walking onto existing events e.g. ‘Films on Foot’, walking to well-known film locations as part of a city film festival. Such strategies thus tapped into the cultural norms and behaviours of young urban populations, presenting walking as ‘cool’ and therefore appealing.
Under social marketing principles, recruiters of health walks should emphasise social rather than health benefits, a strategy thought to be more persuasive. Indeed one interviewee alluded to these potential ‘negative’ perceptions of promoting ‘health’.
"I don’t advertise it as a health walk any more. All my promotion says, ‘get out, make friends, have fun,’…just telling them the walk will do them some physical good won’t necessarily motivate them…the social aspect is much more motivating."
"Respondent 13, (Agency B)"
Indeed this social aspect of walking programme sustainability was emphasised by many respondents, particularly in relation to combating social isolation [40
], believing that participants are retained on programmes by the interactions they have with volunteers and fellow walkers.
"…participants pick up that enthusiasm from the volunteers…Most of the time people are going on the walks because they want a chat…[volunteers] listening to the stories if someone’s been poorly or something’s happened to someone in their family."
"Respondent 20, (Agency B)"
Such ‘easy’ retention, perhaps amongst programmes attended by long-standing walkers, may not be the experience of those trying to recruit in more challenging settings. Three research case studies, working with ‘hard to recruit’ groups, richly demonstrated that recruiters working with groups that don’t already
walk need to understand what will persuade
them to walk. However, the interview data show that most recruitment decisions are taken by programme coordinators ‘on the ground’, often piecemeal, none of whom have received any formal recruitment or marketing training in effectively reaching the target population. Therefore, whilst it is clear that some walking organisations have embraced the need to market persuasively to the inactive [41
] and now offer social marketing training courses [40
], the data here show gaps in the effective delivery of that training which might help to facilitate sustainable walking programmes for targeted groups.
To summarise this finding, sustainability seems dependent on how many rather than which participants are recruited to walking programmes. Recruiters know from experience how to retain participants who are already committed to walking programmes, but do not receive standard training to help them recruit the correct participant representation at the outset.