Optimizing Health Literacy and Community Engagement in Relation to Active Living with Edmonton’s Newcomer Young People and their Families Gina Higginbottom (1) , Solina Richter (1) ,Helen Vallianatos (2) , Sophie Yohani (3) Rashmi Joshee (4) , Munira Lalji (5) , Ann Mah (5) , Eileen Omosa (1) Faculty of Nursing (1) , Department of Anthropology (2) , Department of Educational Psychology (3) , University of Alberta; Public Health Agency of Canada (4) ; Edmonton Public Schools (5) Funding Source: Alberta Centre for Child, Family and Community Research REFERENCES EMPOWERMENT Community identifies issues, solutions, and actions-system supports COLLABORATE Community shares decision-making; system defines limitations BASIC / FUNCTIONAL LITERACY INVOLVE System involves stakeholders in planning and policy processes CRITICAL LITERACY CONSULT Community receives information and announcements COMMUNICATIVE INTERACTIVE LITERACY INFORM Community identifies issues, solutions and actions-system supports  Population growth in Canada over the past 100 years has resulted from immigration with successive governments having utilized immigration as a population expansion policy. 1  Recent policy documents continue to espouse a pro-immigration and non-discriminatory stance; however some immigrant communities, such as those who hold refugee status, experience greater ill-health than the general population. 2,3  The role of immigrant status in health literacy is supported by observational evidence from community nurses working in schools with high newcomer populations that suggests that many youth and their parents may not have sufficient health literacy. 4,5  Health literacy “the achievement of a level of knowledge, personal skills and confidence to take action to improve personal skills and confidence to take action to improve personal and community health by changing lifestyle and living conditions. Thus, health literacy means more than being able to read pamphlets and make appointments. By improving people’s access to health information, and their capacity to use it effectively, health literacy is critical to empowerment” (p.2074-75). 6 Our overall aims were: 1. To obtain an in-depth understanding of health literacy and active living amongst young immigrant and refugees as well as of factors that promote the engagement of newcomer young people and their families 2. To develop and evaluate the impact of interventions within EPSB and/or community settings to promote healthy eating and active living in immigrant and refugee children This research was guided by principles of community engagement (Figure 1). 7 1. Smick, E. (2006). Canada’s Immigration Policy. New York: Council on Foreign Relations. 2. Hyman, I. (2007) Immigration and Health: Reviewing the Evidence of the Healthy Immigrant Effect in Canada. CERIS Working Paper No. 55. Toronto: Joint Centre of Excellence for Research on Immigration and Settlement. Retrieved from http://ceris.metropolis.net/Virtual%20Library/WKPP%20Li st/WKPP2007/CWP55.pdf 3. Newbold, K.B. (2005). Self-rated health within the Canadian immigrant population: risk and the healthy immigrant effect. Social Science and Medicine, 60, 1359- 1370. 4. Beiser, M. (2005) The health of immigrants and refugees in Canada. Canadian Journal of Public Health, 96(Supp 2), S30-S44. 5. Beiser, M. (2006) Longitudinal research to promote effective refugee resettlement. Transcultural Psychiatry, 43, 56-71. 6. Nutbeam, D. (2008). The evolving concept of health literacy. Social Sciences & Medicine, 67, 2072 – 2078. 7. Vancouver Costal health. Community Engagement Framework, http://www.vch.ca/media/CE%20Booklet%202009.pdf 8. Yin, R. (1994). Cases study research design and methods (2 nd Edition). Thousand Oaks. CA, Sage. 9. Roper, J., & Shapira, J. (2000). Ethnography in Nursing Research: MNR Methods in Nursing Research. London: SAGE 10. Highley, B. L., & Ferentz, T. C. (1989). The camera in nursing research and practice. In C. L. Gillis et al. (Eds.), Toward a science of family nursing. California: Addison- Wesley Publishing Company. 11. Schwatz, D. (1989). Qualitative Sociology, 12(2), 119- 153. 12. Wang, C., Yuan, Y.L., & Feng, M.L. (1996). Journal of Contemporary Health, 4, 47-4 Figure 1. Adapted cycle of community engagement 7 as relates to health literacy BACKGROUND DESIGN, METHODOLOGY & METHODS  Mixed methodological approach with case study design 8 employing a participatory approach and photo-voice.  Utilizing focus group and individual interviews for understanding multivariate issues and multiple means of data collection.  Participatory approach includes families’ active role in decision making and development of the interventions.  We employed a mixed methodological approach using a case study design with multiple sources of evidence including: Systematic literature review Focus group interviews (FGI) Photo-assisted FGI Semi-structured qualitative interviews A health-related quality of life visual analogue tool  Qualitative data were managed using Atlas.ti software (ATLAS.TI Scientific Development, Germany) and analyzed using Roper and Shapira’s analytical framework for ethnographic data. 9 PHOTOVOICE & PHOTO-ASSISTED INTERVIEWS  The process of photography often leads to uncovering misconceptions and arriving at more reality-based understandings of phenomena. 10 “In order to benefit social research, the use of photographic methods must be grounded in the interactive context in which photographs acquire meaning". 11  Photovoice is “the process by which people identify, represent, and enhance their community through specific photographic technique.” 12 Effective in participatory research with youth (promotes empowerment) and ethnically diverse groups.  After photographic documentation representing the community members’ perspectives, small or large group discussions offer reflection in a safe environment. Dual process of engaging communities on a topic of concern & providing valuable information about their current life.  Photovoice was used to engage the youth on the topic of healthy eating and active living by (1) recording and reflecting the community’s strengths and concerns, (2) promoting critical dialogue and knowledge about personal and community practices through small group discussions of photographs, and (3) as a dissemination tool with community members, partner agencies, and policy makers. FINDINGS Young People’s Perspectives from FGI #1 and #2 Challenges to engagement P1: Yeah, I can, like I can play [basketball], but because like I live, it’s far, and when we went to play like it’s here in school, so it’s far. Like I live in west so it’s hard for me to go. FGI #1 P5: [Back home] You don’t have to go for a job when you’re young so you make many friends; you can have like 15 friends. I: Yeah. Yeah, so here people start working a lot younger and they’re really busy? P5: Yeah. You can’t see them all the time. FGI #2 Knowledge of health & food P3: My dad like kind of whenever he buys something he buys something like healthier than like unhealthy. Like granola bars...because a granola bar, if it has nuts in it, it can like because nuts help you feel more full for a longer period of time than like sugar or, yeah. Bread, it burns a little slower but it gives you more energy. FGI #2 P5: They have calcium. I: Alright. How did you learn that these cookies had calcium in them and were good for you? P5: I read. When I buy something I read like at the back. I: Okay. So what other foods could you eat that have calcium in them? Do you know? P5: Milk. I: Uh-huh. P5: Cereals, the kind of cookies because they can put milk inside, calcium, and there’s egg has calcium. FGI #2 Sources of knowledge I: So from your Health classes you learn a lot about maintaining safety and safe bodies. Oh, you read it? From pamphlets and posters? P7: I also learned some safeties at home and those are keep away from the stove and the heat. I: So who teaches you at home? P7: My mother and my father. FGI #2 Social isolation P8: You feel healthy. You meet some other people. I: Okay. P8: And it makes you feel different. It makes you feel like you’re not alone. FGI #2 PHASE 3 D ATA COLLECTION  The team collected data in the spring of 2010 with youth of Dickensfield High School and the Africa Centre attending program activities of the Edmonton Public School board. After EPSB program expiration, we were very pleased to connect with the Action for Healthy Communities Society, and during the summer of 2010 the team completed its data collection in 4 high school sites where Action for Healthy Communities was implementing four-week leadership programs: Victoria High School, Queen Alexandra High School, Jasper Place High School and J. Percy Page High School.  This phase included (i) an initial stage when youth participated in workshops creating collages on healthy living and then and initial FGI (FGI #1) with subsequent training on the photovoice methods, and (ii) a post-program FGI (FGI #2) which incorporated their photos captured during the programming and their leisure time.  38 youth representing 22 ethnocultural groups participated in the photo-assisted focus groups  21 parents participated in semi-structured interviews Parent’s Perspectives Language barriers She is navigating the system by herself, everything. Her major problem of participating in active and healthy living is communication, it’s the language barrier. She thinks the services are there but she cannot understand them. Even when she goes to the Settlement Services, they still have to look for an interpreter for her and she doesn’t have one (QE95 Notes - Somali) Factors preventing healthy diet She gets some baby bonus but she has to pay all the utilities. Plus she has to pay every month $100.00 for the air ticket for when she came here ... $140.00 for the utilities. T: And $100.00 for Koran school. T: She has a tutor for Igra., I: Oh so the money they are getting is too little to cover everything, even to cover Somali food. Because they are expensive (D23 - Somali) Sources of information And he says they have been given information about finding and been told that they need to find a family doctor. But to date when they called that number they have not been able to be - they have not been given information to enable them to get a family doctor (QE110 - Burundian) They have Internet but they never try to find active living online from Internet. Yeah, because she said most of the information on the Internet for this are English so it’s not very good for her. And she had her own computer and Internet access but usually she use for communicate with friends and family members in China (VH88 - Chinese) CONCLUSIONS Immigrants and refugee families experience barriers that prevent participation in mainstream recreational activities due to i) financial and time constraints, ii) lack of transportation, iii) cultural differences in what is perceived as recreation and experience with different sports activities, iv) climate, and v) experiences of discrimination/racism in public recreational facilities.