Empowering community health professionals for effective air pollution information communication | BMC Public Health

Four FGDs were conducted for the study, with a total of 19 participants (Table 1).

The codes produced in the first two stages were sorted into sub-categories and larger categories in stages three and four (Categorisation and Compilation) of the content analysis. A coding table was then formed, where five main categories relevant to the research questions were identified, each encompassing diverse subcategories (Additional file 3).

The following section provides an overview of the current knowledge level and behaviour of the community professionals, contextualizing the findings of the study. We then describe in more detail the findings.

Air pollution knowledge

Almost all of the participants highlighted that their level of air pollution knowledge was overall low, stating they should “learn more about it” (A1) A highly recognized point across all FGDs, was that London had poor air quality, with D2 commenting that “London, air pollution is huge as compared to rural areas”. High pollution hotspots can be found within inner London boroughs, which have “major roads which run through it” (D3). This shows a general awareness of the situation on both at a larger geographical and local level. Despite this, air pollution was mentioned as something which was rarely thought about in daily life. “It’s not something we think on a regular basis we need to stop and think about it.” (A1). The comments show a certain form of desensitisation to air pollution in London.

C1: It’s a given that people who have lived in London for so long, they just don’t think about it.

The health impacts of air pollution were similarly mentioned across all FGDs, with emphasis on how it disproportionately impacts vulnerable populations such as those suffering from Chronic Obstructive Pulmonary Disease (COPD), asthma and other respiratory diseases. The link between air pollution and health was often quickly and clearly drawn by the community health professionals, though they mentioned being unclear of specific percentages and facts. There was a consensus that air pollution was detrimental to health and thus of concern to those providing health advice.

Despite knowledge of health impacts, the majority of the participants admitted that they rarely spoke to or advised their clients on air pollution due to barriers outlined in later sections.

Structural resources and support

This category, based on the “access to resources” and “assess to support” components of the SET, encompasses physical and social resources which influence community health professionals’ abilities to provide information and advice to the general community. Support includes other related sources that “maximize the efficiency of their role” [25].

Time constraints

HCPs mentioned that hectic schedules made air pollution less of a priority topic in clinics. There was inadequate time in their everyday job scopes to perform this task and look up resources to bridge their knowledge gaps. It was mentioned that small physical collateral such as “resources which can be handed out to clients, even when they don’t have time to talk to them about it” (B2), would thus be helpful.

Lack of supporting services

Lack of air pollution supporting services was mentioned by both SPLW FGDs, as part of their role was to signpost patients to related services for their health and social problems. The lack of air pollution support services made it difficult for them to integrate air pollution-related topics into their job scope.

A participant mentioned that “GPs have more information about the services that are available to patients” (D3), and how referrals to SPLWs from GPs could be accompanied with information on patient engagement with air pollution services. This shows the integrated care system in place and how different community health professionals can work with each other to achieve positive outcomes for the patients in their care. Currently, however, with a lack of known services which provide support for air pollution-related topics, SPLWs find it difficult to carry out their roles of signposting. The lack of services was not mentioned by HCPs or CHWW, possibly as there might be less emphasis on directing patients to relevant services in their role.

C1: I’m not sure what resources are already there in our local community, and some of the services that are available for residents at the moment, how can we have discussions with patients and signpost them to the right services?

Physical collaterals for engagement

All FGDs brought up the need for collaterals on air pollution, be it resources which give them information about air pollution, or resources which can be passed on to residents or patients themselves. All FGDs, with exception of the CHWWs, asked the facilitator for advice on where they might find air pollution resources, which allowed for a clear segue into the section where they were shown examples of resources. Following this, participants requested that the links be sent to them for further reference. Overall, this behaviour reflects an interest in air pollution resources, but a lack of exposure to them.

It was mentioned that the “vast amount of information could be intense for residents” (C1) searching for information, and simpler methods of communication would be preferable. A commonly mentioned example was physical leaflets which could be distributed to residents with which had advice on them and further resources they could explore if they were interested in the topic. Other suggestions included pollution notices detailing the level of pollution in the area (D3), “Pollution alerts which operate like weather alerts, so professionals are aware of when pollution is heavy and advice more necessary” (A1) and “traffic light systems in communities which show a visual representation of pollution levels to residents” (D1). These are examples of resources which could be provided to community health professionals and the wider community.

C1: We can start with a leaflet with simple guidelines, but there could be websites and things so if people wanted to look more into it, you know, data statistics, all of that.

Structural knowledge

This category, based on the “access to information” component of the structural empowerment theory [24], relates to factors influencing the knowledge and skills of community health professionals.

Lack of knowledge

Lack of air pollution knowledge is a theme mentioned in the previous section and is the largest barrier to advising among all the professions. B5, a GP in training, acknowledged that while most healthcare professionals might possess basic knowledge and awareness of air pollution, they lacked sufficient depth to provide specific advice to patients. This point is reinforced by the other healthcare professionals, who displayed hesitancy and fear in giving “poor advice” (B2), and the need for a “strong evidence base” in the advice they are prescribing to the patients. This lack of knowledge contributes to the lack of advice being given out.

With current levels of knowledge, health coaches and SPLWs felt unqualified to provide advice on or speak to their patients about air quality. Participants from all roles agreed that air pollution is something they currently do not intentionally bring up with their patients due to their own limited understanding of it. All of the participants agreed that the lack of knowledge was a product of the lack of training or resources to advise on air pollution. Air pollution was not covered in detail in the curriculums for SPLWs and CHWWs training and is not part of the formal curriculum in medical school (B5).

Advice to be distributed

Community health professionals did not only require knowledge in the form of “facts, but also advice to get the attention of residents” (A2). It was highlighted that there was not clear understanding about what advice should be given to residents. Table 2 shows some of the ‘only simple advice’, participants felt they could mention to residents.

Participants mentioned a diversity of advice that they could give, with heterogeneity across and within their occupations. This likely stems from the lack of structured instructions or knowledge on what advice can and should be given, resulting in a lack of consistency on what they see as protective actions. There is a lack of knowledge on what would be considered “good advice” (B2) which should be distributed.

All FGDs highlighted that advice should be tailored to the participants they are speaking to as there is a need to “think of who you were really communicating it with” (B2) since different populations require different advice. High-risk groups such as children, the elderly, and patients who suffer from COPD and asthma, for instance, would require different advice compared to the general population. B1, a paediatrician, mentioned it will be difficult to convince parents to discourage their children from playing outside. Moreover, HCPs raised the concern that indoor air pollution is equally harmful as outdoor air pollution. B5 reiterated that “telling patients to stay indoors is not the best thing. If the air quality in their own home is really poor”. They suggested a form of risk stratification and clearer information on what advice should be given to people of different risk groups at different times.

B2: It would have to be thinking of who you were really communicating it with. You know that they would be the people who really are at high risk.

B1 (In Response): Yes, it’s like risk-profiling, is it specific enough at the moment, is there a strong enough evidence base to say [the advice] is definitely beneficial.

With more information on air pollution and the services which are available for resident use in the local community, community leaders would feel more comfortable speaking about it to their patients.

Confidence as advisor

Even with sufficient knowledge, however, community health professionals could remain hesitant to advise due to a lack of psychological empowerment [26]. Thus, the next category touches on factors which influence the professional’s confidence in giving advice, relating to their personal perception of their skills and emotional capacity to do so.

Difficulty in approaching topic

Participants of all occupations found that they lacked the skills to bring up air pollution with their patients and a formal way of including air pollution in health-related conversations they were having with their patients. CHWWs mentioned that the focus of their conversations was not solely on health but on current problems pertaining to each individual, making air pollution even more challenging to bring up.

After being shown current air pollution resources, the HCPs took an interest in the advice suggested on DEFRA’s website, highlighting that it largely suggested staying indoors. They discussed the “lack of positive framing of advice” (B1), stating that they find it difficult in their capacity to tell patients to refrain from doing something.

Some participants did not know how to approach conversations due to the large, invisible problem that is air pollution, which elicited a sense of futility amongst them. This would be damaging to their confidence to advise on the topics, as they felt as individuals, that they lacked power to effect significant changes in the issues. A5 highlighted that air pollution in London is out of individual control. This view on air pollution can demotivate people to talk about it, as attempts seem futile without proper suggestions for actionable change.

Conflicting information

The existence of conflicting information makes community health professionals hesitant to provide advice, negatively impacting their self-assurance. This tension makes it difficult for them to be confident in the information they advise. The HCP FGD was the first to bring up existing tensions between the advice of staying indoors and the advice to go outside, which has other public health benefits. There should not be “more barrier for going outside, since there are negative health outcomes to NOT going outside” B1. The health coaches in the Focus group expressed concerns about sending conflicting messages after encouraging patients to go outside for physical exercise and mental wellness. SPLWs also touched on how the routines of going outside could be crucial to the mental health of the vulnerable population they work with, “going to the local shop is the one thing that they do in the day or the week” C1.

A5, however, highlighted that the suggestion to stay inside was for a short period, usually isolated days, and does not equate to asking patients to reduce physical activity. It could remain especially important for people who suffer from co-morbidities but are currently spending more time exercising outside, for instance, to be taken into consideration as they represent a type of intersectionality in this tension. They can be advised to safely continue their healthy habits while protecting themselves from air pollution during bad pollution episodes.

Given that these community advisors are not in constant contact with patients, this brings up an important point on how the advice should be given and how it needs to be emphasised that patients reduce activity in times of higher pollution, and not simply in general. Thus, recommendations to stay indoors perhaps lacked nuance and the advice given to different groups should be considered more deeply, as discussed later.

Resource and skill building

Skill building is key to building the confidence of the advisors. It was previously highlighted that participants did not have training and resources, but they were quick to say that proper training and a good resource bank would be the largest factor which enabled them to provide advice. Overall, participants came to a consensus that training, alongside a resource bank, would be a definite facilitator to more actions, with many of their recommendations being centred around their resource and training needs. Suggestions included getting experts on the topic to facilitate sessions.

Responsibility as advisors

This category relates to how the community health professional saw their responsibilities and duty to the residents in the community and their self-perception as a source of advice for the people they interact with. This relates to the possible meaning they attach to their job, an element of psychological empowerment.

Expectation to advise

As community health professionals, all FGDs brought up how it was part of their role to provide advice and to help residents. HCPs spoke of the “power and that responsibility” (B1) attached to the role, as patients take note of what they are saying, a point that the whole FGD agreed with.

For CHWWs and SPLWs, they mentioned that it was part of their role to provide advice and solve problems for the residents they come into contact with. While they are not able to provide clinical advice like HCPs can, they saw it as meaningful to be able to speak to their residents about it, to “educate residents and help them better take care of themselves”, a point mentioned in FGD 3 which the group agreed with.SPLWs saw providing air pollution advice as a way they can “work towards supporting our COPD patients” (D3) and expressed curiosity in approaching it to “empower residents to see what’s best for them” (D3). FGD 4 highlighted the need to engage with patients on this topic as well, to gain a better understanding of the support required. Overall, participants saw the inclusion of air pollution-related topics as relevant to their roles and saw a possibility in providing advice.

Trust and connection

HCPs in particular expressed awareness of the weight of their advice to their patients and identified as trusted sources. The concept of a ladder of trust was mentioned, where nurses and doctors were seen as the most trustworthy sources. While not explicitly mentioned by CHWW and SPLWs, their descriptions of their job scopes alluded to a high amount of interaction with the people they are working with. CHWWs often needing to conduct home visits and aid residents in a continual process of “problem-solving” (A1), and SPLWs “promoting self-care and independence” (C1).

Receptiveness to advice

While earlier categories centre around the empowerment of community health professionals, this theme focuses more on how advice is received by the community. It includes factors which either increase or lower the likelihood of the audience following advice from the community health professionals.

Personal risk level

The advice given by these community health professionals is “helpful to residents who want to listen” (A1), it thus remains important to be aware of these factors. Participants felt that patients were more likely to listen if they suffered from co-morbidities such as COPD and asthma, where pollution would clearly inhibit their quality of life. These patients likely are more conscious of pollution in the first place. A5 mentioned that they had patients who actively sought advice for air pollution due to their own interests. At the same time, other residents in what those might consider “low risk” groups are unlikely to listen to advice, a sentiment shared by both HCPs and SPLWs.

Hierarchy of needs

Audiences are less likely to listen and act on advice as they see air pollution as a non-priority in their lives. This was a point more strongly mentioned in FDGs involving CHWW and SPLWs rather than HCPs, possibly due to the more interdisciplinary, integrated nature of the role where the focus is not solely on healthcare. “Air pollution was not a priority for any of the patients they saw” (C4) and part of why they did not give advice was because patients were not asking for it. Other participants agree with this, stating that given the large plethora of issues they cover with patients, at times air pollution and its impacts could take the backseat. This is especially due to the desensitisation the patients feel towards air pollution, given that they’ve “lived in London for so long, they just don’t think about it” (C1).

CHWWs are in a unique position where they do not work on health problems alone, but often have to take into account the wider determinants of health. They expressed that at times it is difficult to even centre the conversations they have on health, with residents being more focused on what they perceive as time-sensitive issues, be it a leak in the house or other personal issues. This limits the receptiveness residents have to the advice, and sheds insight on possible reasons for disinterest in air pollution amongst residents. It also suggests difficulties CHWWs might have in broaching the topic given the diversity of issues they are to discuss.

Ability to engage in advice

It was also suggested that audiences are more likely to respond if the advice is easily accessible to them. FGD 3 found felt that residents would face issues trying to assess current resources given the vast quantity of resources which can be overwhelming, they suggested that small specific steps would be better received by their target group, making them more likely to follow the advice. Advice should also be more specific and “prescriptive than terms like reducing activity” (B5). It would be beneficial to include specific timeframes they should stay inside, or specific pollution bandings they should avoid going outside.

At the same time, the advice given must be feasible for the target groups. For instance, wearing a mask would likely be easy advice given the common usage during the COVID pandemic (C1), but telling a cyclist not to cycle because of air pollution might not go over as well (D2). HCPs also saw the need to provide alternatives when telling patients not to do something. For example, when they are told not to go outside due to air pollution, they should be offered alternatives such as online exercise classes (B2). Local level policies could support this by for instance opening community spaces on pollution-heavy days, so children have an alternative to spending time outside (B1). This would empower the population to follow the advice and increase adherence.

The concept of financial feasibility was mentioned on two occasions, once by a HCP and the other by a SPLW. In both instances, the purchasing of an air filter for the household was used as an example. They mentioned the purchasing of the filter as a good preventive action to take but acknowledged this was not financially feasible for all residents. This was a unique code as it introduced more dimensions to the issues at hand and reflected how other social determinants of health such as financial status could determine how residents acted on the advice given.

In summary, we identified current barriers to empowerment of community health professionals in the borough, and recommendations to overcome said barriers to achieving effective communication. SET and PET [24] were used as guiding frameworks, undercovering themes relevant to the local context (Fig. 1).

Application of Categories to Empowerment Models