Abstract

In this study, the district Narowal, Punjab authorities were polled on a wide range of health inequality-related topics. These included their understanding of the need to address these inequities, the advantages and disadvantages of doing so, and the various approaches they took to the subject. The three focus groups had 47 members, including representatives from the environmental, public safety, and education sectors. As a result, the conversations were recorded on camera, transcribed, and assessed. People's opinions on health disparities varied, according to the survey. This study also found a number of barriers to community health group cooperation and health equity. An effective communication plan should inform the public about the difficulties disadvantaged groups experience and the efforts being made by local governments to address health disparities. In order for successful collaborative initiatives, local public health organizations must take the initiative in identifying and resolving the underlying causes of health inequalities.

Key Words:

Communication, Public Safety, Community Health, Health Disparities

Introduction

From birth till old age, a person's environment has a significant impact on their health (Freumuth et al., 2001). This extends from the time they are born until they reach old age. This holds true in every single country on the planet. The World Health Organization and Healthy People 2030 both agree that these are significant issues that need to be addressed in order to improve public health (Al Zabadi, et al., 2021). Social determinants of health are a common name for these factors. The phrase "health disparities" is used to characterize the health inequalities associated with socioeconomic status. Social determinants of health are the primary factors that impact health inequalities (Mahoney, et al., 2020). 

The phrase "health inequalities" is defined by Star-field and Birn (2007) as the existence of systematic and potentially reversible differences in health across demographically, economically, socially, or geographically classified populations or groups (Ferdous, et al., 2020). One or more aspects of health may exhibit these differences. The term "health disparities" refers to inequalities in health outcomes that are affected by individual characteristics such as age, gender, and heredity. This definition accurately describes the concept of health disparities. These factors are positioned within a hierarchical framework that includes lifestyle factors, social and community factors, proximal social determinants of health (such as living and working conditions), and distal social determinants of health (such as socioeconomic, cultural, and environmental factors) (Dahlgren and Whitehead, 1991). 

When public health issues arise, they tend to make existing disparities in health conditions worse. Those with less financial means and who live in harmful conditions, such as overcrowded housing, are more likely to become ill during a pandemic, according to the research of O'Sullivan and Bourgoin (2020). During the outbreak, something was either found or noticed. Additionally, the research found that certain socioeconomic characteristics, including language, culture, age, ethnicity, and job status, are linked to a greater probability of encountering adverse health consequences during a pandemic. According to new research, this is also true for the present COVID-19 pandemic. An increase in deaths, hospitalizations, and infection rates as well as a decrease in preventative measures among socially vulnerable people have all occurred during the COVID-19 pandemic. Therefore, it is essential to evaluate vulnerability in a variety of ways, not just in terms of increased risk of infection-related complications or death. Because of their disproportionate vulnerability to negative health effects, socially excluded populations must have the social hierarchy of risk recognized. Finding and understanding the causes of these health inequalities is critical for successfully addressing them.

In their study, Baker and colleagues discovered that disadvantaged groups had a greater likelihood of having inferior health outcomes owing to the restricted access they have to programs that may potentially improve their well-being.

It is necessary to implement a multidisciplinary approach in order to achieve health equality (Anonymous, 2009; CSDH, 2008; Smedley, 2006). This strategy should include communities as well as government entities at the local, state, and national levels.

 Local governments have the capacity to make changes to the distribution of socioeconomic factors that are considered to be health determinants in their respective regions. Within the boundaries of the state of Connecticut, the main duty for the provision of a diverse array of social services is with the local governments. Services such as education, housing (particularly for populations with low incomes), police and fire services, traffic safety, and social services for the elderly and young people are included in this category of services. When it comes to the management of parks and recreational facilities, local governments are also accountable for this responsibility. Planning and zoning rules, licensing, the construction and maintenance of transportation networks, and capital expenditures are some of the ways in which they may promote economic growth and environmental health (Federal Bureau, 2020).

Although local government agencies and health departments frequently collaborate on various health issues (Lovelace, 2020), they face several challenges when trying to establish successful partnerships to address health disparities in their respective regions. Cohen, Iton, Davis, and Rodriguez (2009) argue that a primary issue that needs attention is the lack of comprehension among the general public and government officials about the socioeconomic factors that influence health equity. There is a lack of clarity on the specific responsibilities and functions of local, state, and federal governments, as well as community groups, in addressing complex issues that cut across many sectors. Furthermore, the delineation of leadership responsibilities remains unclear, particularly in relation to public health agents and sectors that possess the capacity to impact determinants of health equity (Cohen et al., 2019). Local governments, especially health departments, seldom have insufficient funding, and agencies typically struggle to coordinate due to financial and jurisdictional limitations (Hofrichter, 2020). An effective communication strategy for addressing these hurdles should have the following elements: establishing efficient communication channels, resolving conflicts related to jurisdiction, and clearly defining common aims and objectives (Cohen et al., 2020 p. 8). There is a lack of published information on the attitudes of local government agents toward health equity and their readiness to engage with public health specialists. Furthermore, the protocols followed by local public health departments have not undergone thorough investigation so far. Conducting research on these matters will contribute to the growing body of knowledge in this sector (Lovelace; Plough, 2005).

 It is crucial to raise awareness about these disparities among local government officials in Pakistan and encourage their cooperation to find solutions. However, no research has been conducted to explore communication strategies that may effectively achieve this objective.

Objectives

The objective of this research is to assess the efficacy of strategic communication principles in fostering collaboration between public health officials and representatives from different departments, including those involved in local economic development, land use and housing, public safety, education, and the environment. The aim is to address health inequities.

The objectives of this research study are to: 

1. Find out how much is known about health inequalities.

2. Explore the importance of fixing health inequalities.

3. Assess the advantages and disadvantages of raising awareness of injustices to influential opinion leaders and stakeholders in Connecticut.

4. Create recommendations for a communication strategy that will be implemented by local public health authorities in collaboration with influential district opinion leaders and stakeholders. 

 Officials in other states seeking to address the determinants of health inequalities may find the information provided in this article useful for guidance.

Literature Review

Collaborators pool their knowledge and work together to better understand a phenomenon and find ways to use what we know for the benefit of the community at large. Community-Based Participatory Research stands out when compared to other community involvement strategies that have effectively addressed health inequities.

Hofrichter (2019) states that the majority of proponents of communication approaches to tackle health inequalities have mostly focused on raising awareness among the general public about these issues. Furthermore, it is worth noting that the bulk of health equality programs that have been documented have mostly focused on improving community capacity.

 This is because it has three crucial components. Among these components are the following: involving community members from the start to finish of the research process (including the dissemination of findings), helping community members and academic partners with the dissemination of information, and finding a balance between research and study execution. 

In their investigation of the difficulties associated with achieving a truly balanced researcher-community relationship, Wallerstein and Duran (2021) focused on issues such as power, privilege, engagement, community approbation, racial and ethnic discrimination, and the role that research plays in the process of social development. As a means of finding this compromise, Wallerstein and Duran conducted an analysis of the prospects, limitations, and realities associated with this research technique.

This last facet is a significant obstacle in the field of public health, and it pertains to the question of how the changes in research paradigm influence the policies and practices that are implemented to eliminate inequity. In addition, (Bloss, 2019) conducted research on the constraints and challenges that are encountered by intervention and implementation science. They reasoned that community-based participatory research is essential for broadening the scope of translational intervention and implementation sciences, which is important when it comes to influencing policies and practices that attempt to erase disparities.

Ferdous et al., (2020) in their research stated that the phrase "community engagement" encompasses a range of strategies that aim to involve local communities in local efforts to enhance their health and wellness and decrease health inequalities, according to the website of the National Institute for Health and Clinical Excellence in the UK. A needs assessment, community development, planning, design, development, delivery, and evaluation are all part of this process.

Methods

Participants

Three focus groups were conducted with a selection of elected district officials/heads involved in economic development. Officials from the departments of education (n=15), public safety (n=10), and municipal (n=10) are selected.  In addition to varied positions and disciplines, participants were selected to represent the entire community. We used the lists provided by the district's Council of Municipalities to figure out who they were.

Data Collection

The average duration of a focus group was forty minutes. 

In the course of the talks that lasted for one hour, audio recordings were made, and meticulous notes were collected during the whole session. The transcription of each and every recording was done word for word.

There were four questions that were asked throughout the focus group process: 

1. Do you belong to a community where there are health disparities?

2. Is it possible for you to provide examples of situations in which a policy or rule that was enacted by your department had a disproportionately skewed influence on the health of one group in comparison to another?

3. What would be the most effective way to convince the town's officials that they need to work together across departments to eradicate health disparities?

4. Who would be the most suitable person to initiate and coordinate this communication effort? 

Data Analysis

For the purpose of conducting the analysis of the data, the following approach was used (Brown, 1999). The first step consisted of doing an analysis of the replies to each topic to look for any similarities. Following that, we determined the most significant themes, which enabled us to group together concerns that were connected to one another and assign them to broad groups. In order to ensure that we did not overlook any significant issues, we went over the transcripts many times. During the second phase, both writers were required to look through their extensive notes and choose subjects. This step was pretty comparable to the previous phase. In the third stage, we brought together the data from the two stages that came before it and presented the themes that were identified the most often and felt the most strongly to the participants.

Results Perceived Health Inequities

The following themes emerged from the replies of the participants to questions dealing with the existence of health inequalities in their communities and the possible influence that their policies and initiatives may have on these disparities. Urban environments are characterized by the presence of inequities or imbalances. In urban areas, there is a larger proportion of multi-family rental housing, housing that is not up to standard, adverse environmental health conditions, a restricted supply of nutritious meals, and low incomes. These are all indicators of health disparities. In each of the three focus groups that have been conducted, this problem has been brought up repeatedly. The following is how one of the participants characterized these patterns of development:  “individuals who live in the central portions of the city and have lower wages as a result of the lower housing expenses and rental rates in such areas. Lead paint and other things containing asbestos will be kept in the basements of those older buildings, which will contribute to the additional pollution in the air and the increased traffic in the neighborhood, respectively.” Health complications such as "lead paint hazards and elevated blood lead levels, obesity, diabetes, and asthma" are likely to arise from these conditions.

According to the contributions made by the participants, filthy circumstances are the root cause of a variety of adverse health consequences. One of these problems is that there are not enough alternatives for consuming healthful meals in the immediate area. In response to a question regarding the high prevalence of diabetes and hypertension in a particular neighborhood, one of the respondents stated, "There is no healthy type of outlet for nutrition, so they have to deal with immediate availability of fried food and food high in fat intake, and this inevitably has an effect upon their health." Not only is the concentration of social services in urban areas a positive development, but it also has the ability to bring about difficulties that were not expected. When clients fail to reach the criteria that these firms have established, one of the attendees expressed their unhappiness by saying, "It's a shame that these are in my community."

There was a widespread belief that those with low incomes would be disproportionately affected by rural regions and small towns. These are some of the downsides that were noted by one of the participants, among others:

 At this time, 64.5 percent of our preschoolers are enrolled. We are experiencing a severe lack of mental health services, medical facilities, and supplies in our community. Because there is essentially no public transit, taxis, or sidewalks in this area, it is very challenging for those who are economically disadvantaged to use these modes of transportation. In the event that you come across problems associated with homelessness.

Participants in the study made the statement that "income and status in the economic stepladder is a main component to disparity." This statement was made by a significant number of people. Your ability to make a decision about where you want to call home is increased when you have adequate financial resources. If you had the ability to pick where you live, you may choose a location that is cleaner and healthier; nevertheless, if you are poor and have no other options, you will have to make do with what you can afford. Due to the fact that having money grants access to a wide variety of services, having money is of utmost significance. 

Awareness of Incorporating Health Inequity Concerns Education

For the purpose of addressing health disparities, school administrators have highlighted the need to provide funds within their school budgets, claiming a "humanitarian perspective." On the other hand, there are some people who have expressed skepticism about the extent to which public schools can help eliminate health disparities. Additionally, they questioned the level of responsibility that public schools ought to have in terms of resolving health imbalances. If, on the other hand, a child's health prevented them from receiving an education, they were prepared to fulfill this need. To clarify this responsibility, one of the participants provided an explanation. "It is incumbent upon us to guarantee that those children are catered for since we have a duty towards them. As per the reports from several school authorities, their institutions' budgets include allocations for the provision of social work and mental health services. In addition, they presented details on many projects that they believe are successful in tackling health inequalities. These initiatives include "school-based health care centers," "family resource centers and after-school supports," and "support for special education."

Public Safety

Authorities responsible for public safety have emphasized the inherent connection between their job and public health. According to their statement, their ultimate objective is to create a thriving community, and they acknowledge that addressing health and other concerns is an important aspect of police. They see themselves as "equalizers" in addressing health disparities since they are legally obligated to intervene if a person poses harm to themselves or others. The need for them to do so ensures the feasibility of this. Consequently, they are associated with cases of protective custody including drug misuse, mental illness, suicidal thoughts, and domestic violence. They are required by other laws to be involved in the enforcement of housing limits, zoning rules, and health inspections. 

In contrast, instances necessitating protective custody were seen as "inefficient" and just "treating the symptom" due to the system's design, which mandates dealing with the same persons again. Consuming alcohol hampers an individual's capacity to do tasks effectively, resulting in the need for hospitalization. Not only are they detained temporarily before being released, but no supplementary services are offered to them. In the next week or two, we shall encounter their presence once again. Furthermore, a number of the individuals interviewed said that medical calls significantly deplete their finances. One participant said that they often prevent the final vehicle from going to medical because there are no firefighters available. This tendency is progressively worse with each successive year. Another individual said, "A single-engine company is consistently implicated in traffic congestion." The daily average frequency of their visits to this specific region is six. This is a residential community designed specifically for senior citizens.

Municipal

People who are concerned about the conservation of the environment and the growth of the economy have similar perspectives about the depressing status of health equality. The local authorities are not taking into consideration how to safeguard the health of all inhabitants, according to a participant in the debate who took part in the conversation. When they are working toward achieving a budget balance, they discuss a variety of things, including financing for schools, funding police, funding for fire, and funding for emergency medical services. As a result of the fact that the primary objective of economic development professionals is to "get development that provides jobs in their towns," they do not often consider health equality concerns to be a direct obstacle. Participants, on the other hand, are of the opinion that their efforts would "ultimately lead to health," despite the fact that they are quick to explain that health and health equality are not their main goals.

Conclusion

It should be the primary objective of any

communication plan that aims to eliminate health inequalities in municipalities to enhance knowledge of the causal linkages that exist between the health of vulnerable groups and the policies and programs that are executed by local governments. The majority of respondents favored it when the CEO and local health directors took the initiative to eliminate health disparities in their respective areas. The capacity of local health departments (LHDs) to exhibit leadership, financial stability, and jurisdictional authority; present strong evidence of health disparities and the causes of those disparities; and define the role that public health plays in the community are all essential to the success of joint programs. 

Recommendations

The strategy for communication is strongly dependent on the use of a number of different channels of communication. At the beginning of the data-collecting process, it is recommended to have direct conversations with state and local health authorities on the significance of health equality advocacy as a crucial role. The next phase, which is to speak at meetings of relevant professional groups (those involved with education, public safety, land-use/housing, environmental management, and economic development), is to discuss health equality and the roles of public health. This will be done after these officials have agreed to participate. These discussions will take place at the conferences of the appropriate professional organizations to which they are invited.

 For instance, if you are giving a presentation to someone who is responsible for public safety, you should explain how choices about public safety affect the health of the community. The aforementioned is but one illustration of how presentations may be tailored to meet the requirements of various audiences.

After these activities have been finished, it will be the duty of government employees who are in charge of public health to offer ongoing education. In order to enhance awareness, interest, and fundamental comprehension of the matter, it would be beneficial to spread instructional materials on the incidence and severity of health inequalities, both online and in printed form, as well as a monthly town or district bulletin. This would be effective among key stakeholders and strategic partners.  The emphasis may turn to the motivating phase of the communication strategy after the informational phase of the communication strategy has been completed and stakeholders and strategic partners have obtained adequate knowledge with which to make informed decisions. Building ties with important stakeholders and strategic allies should be our primary focus throughout this stage of the process. In accordance with what was said before, the chief executive officer will be the one to commence the partnership process. Government authorities in charge of public health would take on leadership responsibilities after all of the strategic partners had begun holding regular meetings.

References

• Zabadi, H. A., Yaseen, N., Alhroub, T., & Haj-Yahya, M. (2021). Assessment of quarantine understanding and adherence to lockdown measures during the COVID-19 pandemic in Palestine: Community experience and Evidence for action. Frontiers in

•  Cohen, L., Davis, R., Lee, V., & Valdovinos, E. (2020). Transforming elements of public health practice: Preliminary considerations. In R. Hofrichter (Ed.), Tackling health inequities through public health practice: A handbook for action (pp. 59-75). Washington, DC:

• Dalgren and Whitehead (1991). A review of collaborative partnerships as a strategy for improving community health. Annual Review of Public Health, 21, 369-402.

• Federal Bureau. (2020). Closing the gap in a generation: Health equity through action on the social determinants of health. Final report of the Commission on Social Determinants of Health. Geneva: World Health Organization.

• Hofrichter, R. (2020). Rural community health in Connecticut: Challenges and opportunities. New Haven, CT: Connecticut State Office of Rural Health.

• Lovelace; Plough, (2020). Secular changes in mortality disparities in New York City: A reexamination. Journal of Urban Health, 86(5), 729-744

• Mahoney, D., Obure, R., Billingsley, K., Inks, M., Umurutasate, E., & Baer, R. D. (2020). Evaluating Understandings of State and Federal Pandemic Policies: The Situation of Refugees from the Congo Wars in Tampa, Florida. Human Organization<

• Ferdous, M. Z., Islam, M. S., Sikder, M. T., Mosaddek, A. S. M., Zegarra-Valdivia, J. A., & Gozal, D. (2020). Knowledge, attitude, and practice regarding COVID-19 outbreak in Bangladesh: An online-based cross-sectional study. PloS One,

• Ferdous, M. Z., Islam, M. S., Sikder, M. T., Mosaddek, A. S. M., Zegarra-Valdivia, J. A., & Gozal, D. (2020). Knowledge, attitude, and practice regarding COVID-19 outbreak in Bangladesh: An online-based cross-sectional study. PloS One,

•  O'Sullivan, M., & Bourgoin, J. (2020). Addressing social determinants of health through community-based participatory research: The East Side Village Health Worker Partnership. Health Education and Behavior, 29(3), 326-341.

• Plough, A. (2005). Promoting social justice through public health policies, programs, and services. In Oxford University Press eBooks (pp. 418–432).

  Starfield, B., & Birn, A. (2007). The role of health insurance in explaining immigrant versus non-immigrant disparities in access to health care: Comparing the United States to Canada. Social Science and Medicine, 69(10), 1452-1459.