OPTIMIZING HEALTH LITERACY AND
COMMUNITY ENGAGEMENT IN RELATION TO
ACTIVE LIVING WITH EDMONTON‘S NEWCOMER
YOUNG PEOPLE AND THEIR FAMILIES
Executive Summary submitted to the Alberta Centre for Child,
Family and Community Research
February 28, 2012
Gina MA Higginbottom, Solina Richter, Sophie Yohani, Helen Vallianatos,
Rashmi Joshee, Munira Lajli, Ann Mah, Eileen Omosa
Acknowledgements: The authors would like to thank: the Alberta Centre for Child, Family and Community Research for
funding this project; Shirley Mogale and Dr Jayantha Dassanayake for their assistance with data collection; Dr Yun
Ghimn for assistance with data analysis; and Jennifer Pillay and assistance with the statistical analysis and editing this
executive summary and the final report and our anonymous external peer reviewer. They are also grateful for the
partnership with various organizations to enable the data collection, including the Action for Healthy Communities
Society of Edmonton (Programs Managers Suzana Dumo and Chris Ford and their teachers at Victoria High School
[Rute & Grace], Queen Elizabeth High School [Katie & Sam], Jasper Place [Lilian & Fern], and J. Percy Page High
School [Sujin]), and the sites where Edmonton Public Schools implemented their activities - Dickensfield High School
(Teacher Juliette McLean), and the Africa Centre (Executive Director Tesfaye Ayalew and Nathaniel Bimba). Finally, but
with much appreciation, the team thanks the newcomer youth and parents who participated in this study.
Published by the Faculty of Nursing, University of Alberta, 3rd Floor, Edmonton Clinic Health Academy, 11405 114th
Street, Edmonton, Alberta, Canada , 2012
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EXECUTIVE SUMMARY
Key Findings
1. 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, and iv) experiences of discrimination/racism in public
recreational facilities.
2. While many immigrant and refugee families take initiative to contact available organizations (e.g. ethnocultural
organizations) and obtain relevant information (e.g. using libraries), many are not able to easily access Canadian
health literacy information due to lack of awareness of resources (partly due to failure to obtain a family physician),
language barriers, and limited social and institutional networks.
3. Perceptions of what constitutes health literacy are culture specific and therefore immigrants and refugees typically
undergo an acculturation process towards understanding Canadian standards of health literacy. This process takes
time and individual family members may experience different levels of understanding of what constitutes health and
healthy living within the Canadian context.
Introduction
Population growth in Canada over the past 100 years has resulted from immigration as successive governments have
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. Though migrants are welcomed into the country, they may then find
themselves actively and passively excluded from opportunities to participate fully in Canadian society including the
opportunity to engage fully with dimensions of active living essential for health and well-being.
Health literacy implies “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” 2 (p.
2074-75). Low health literacy leads to a limitation in the individual‘s capacity to obtain, process and understand basic health
information and services needed to make healthy lifestyle decisions.3 It is also associated with poor socioeconomic
circumstances and an adverse effect on health.4
Different types of health literacy are described in the literature. Functional literacy refers to those literacy skills
needed to function in everyday situations; interactive literacy involves more advanced cognitive and literacy skills which a
person needs to actively participate in everyday activities; and critical literacy relates to the skills a person needs to exert
greater control over life events and situations.2 The development of interactive literacy leads to the development of new
knowledge, positive attitude and behaviour change that will contribute to improved health outcomes (critical literacy). Skills in
health literacy can be developed by formal education or more informal experiences like participating in daily living activities
with other members in a community and, as in the case with this study, a series of planned activities and community
engagement.5
Research Context
As newcomer youths’ main entry point into Canadian society, the Edmonton Public School (EPS) board identified the need to
actively address the needs of refugee and immigrant school children and their families. With the EPS priorities for 2009-2012
emphasizing literacy and promotion of health and well-being6, EPS felt well-situated to inform and deliver services aimed at
health promotion within its immigrant and refugee populations. After obtaining funding from the Public Health Agency of
Canada in 2008, a project was implemented to work with immigrant and refugee families to build health literacy. Cultural
brokers began to work with community organizations to engage the community through a variety of projects including
weekend and summer health programs in three school clusters, which balanced academics, active living and cultural
competency. It was through this programming that the research team planned to collect data on their identified research
questions. Unfortunately the funding for this program expired after data collection in two sites (one junior high school and one
community centre) and the research team then engaged the Action for Healthy Communities Society which was running
summer leadership programs for newcomers within four public school sites during the summer of 2010.
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The Research Questions
1) What factors and mechanisms support and promote or enhance health literacy for newcomer young people and
their families?
2) What are the factors that promote the engagement of newcomer young people and their families in school-based
dimensions of active living?
3) Does the development and evaluation of an intervention to promote healthy eating and active living in immigrant
and refugee children in three school clusters within Edmonton Public Schools impact upon the health and well-being
of immigrant and refugee children?
Objectives & Framework
(a) To identify the specific health literacy and active living needs of immigrant and refugee children and their families in
relation to health literacy in three school clusters within the Edmonton Public School district.
(b) To employ photovoice methods and interviews to elicit health literacy and community engagements mechanisms
used by the youth and their families.
(c) To evaluate the outcomes of the interventions/programming and identify factors at the individual, family, and
community levels that lead to improvements in health literacy and healthy living, and
(d) To make recommendations for future interventions and policy change.
Our research was informed by the following principles drawing upon the key tenets of health literacy and community
engagement framework.
Research Methods
We employed a mixed methodological approach using a case study design with multiple sources of evidence including:
(1)
(2)
(3)
(4)
(5)
Systematic literature review
Focus group interviews (FGI)
Photo-assisted FGI
Semi-structured qualitative interviews
A health-related quality of life visual analogue tool
The second and third were conducted with youth; the forth was completed with parents of the participating youth; and the last
was completed by youth and parents at two time points. Throughout the study, a participatory approach was employed
collaborating closely with various facilitators of the EPS, Action for Healthy Communities Society, and the Africa Centre. We
also actively engaged the young people in the research process through participation in the photovoice activities. Of note is
the fact that participants formed a linguistically diverse group arising from 22 ethno-cultural groups creating a need for
substantial use of interpreters during data collection.
Phase 1 - A systematic review was conducted of international quantitative and qualitative research related to active living
and the processes and mechanisms through which newcomer young people and their families become engaged (including
community development, cultural/social capital, basic health literacy, communicative health literacy and critical health
literacy). In summary of the findings, although there were methodological limitations in some studies, most demonstrated that
newcomers in Canada struggle with health literacy due to having limited ability with reading, speaking and understanding the
English language. This reduced functional literacy may be a major factor at the individual level leading to poor health literacy
outcomes. Available evidence provides limited understanding of factors or mechanisms enhancing health literacy for
newcomers in Canada. The review did not provide any significant insight to help inform our study because of the paucity of
literature in the Canadian context. It did though support the need for more empirical research such as this study to provide
more information on this topic.
Phase 2 – The self-perceived current health-related quality of life was measured from all participating youth and parents.
Using a visual analogue scale (an interval measurement with units 0 (worst health state imaginable) -100 (best health state
imaginable)) the youth and parents responded with average scores of 77 and 82 at the beginning of the study without any
statistically significant change after attending the activities described below for Phase 3. While there is no identifiable
reference in the literature for comparison to non-immigrant adolescents and adults in Canada, comparison to grade 5
students within Edmonton shows that the values are quite similar. There are potential limitations of these findings due to
language barriers and measuring limitations when not using a cross-culturally adapted tool.
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Phase 3 - This phase included (i) an initial stage when youth participated in workshops creating collages on healthy living, a
FGI, and then training on the photovoice methods, and (ii) a post-program FGI which incorporated their photos captured
during the programming and their leisure time. Photovoice is particularly useful for individuals who speak English as an
additional language. Subsequently, the parents of several youth consented to be interviewed individually and interviews were
completed with heavy dependence on interpreters. All FGI and individual interviews were digitally recorded and transcribed,
as necessary, by a professional transcriptionist with verification by the research team and the interpreters when applicable.
Data analysis was performed using a framework for ethnographic data and qualitative data analysis software (Atlas.ti). We
had originally intended to focus on Sudanese and Somali young people and families, however the change in our recruitment
and data collection strategies yielded a very diverse group of young people and parents embracing 22 ethnocultural groups
which created a highly complex research study in respect of translation and interpretation. Nevertheless we were successful
in capturing the perspectives of this diverse group.
Recommendations
1. Funding of services for professional translation in public health clinics with specific focus on educating for health
literacy. This would also be echoed in school environments where parental involvement appears to be critical in
order for health literacy and active living knowledge to be effectively communicated between the school and home
context. Efforts to reduce language and cultural barriers are essential for improving health literacy.
2. Education for city recreational facility staff and school personnel related to fairness and inclusivity. Our study
highlights the importance of teachers, particularly gym teachers, in fostering inclusive active living environments.
3. Increase points of access to recreational facilities, sports organizations, and primary care healthcare services in
immigrant settlement/support agencies, community centers, ethnocultural associations, and public institutions
(libraries, schools). Our study suggests that services should include both youth-focused and youth/family-centered
activities. Programming for these two areas will facilitate health literacy and active living in a manner that engages
the whole community.
4. Encourage schools to promote and offer alternative recreational activities to align with the capabilities and interests
of its newcomer populations. This will facilitate greater integration for newcomer youth and also allow the
recognition of different skills and aptitudes in sports and active living.
5. Increase funding for recreational programs and facilities located within neighborhoods where newcomers highly
reside. A critical finding in this study was the importance of community-based centres in facilitating health and
active living. As a complement to school-based programming, community centres provide a safe and secure
environment for newcomer youth and families to explore critical issues relating to health literacy and active living.
References
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Smick, E. (2006). Canada’s Immigration Policy. New York: Council on Foreign Relations.
Nutbeam, D. (2008). The evolving concept of health literacy. Social Sciences & Medicine, 67, 2072 – 2078.
Lee, S.D., Arozullah, A.M. Cho, Y.I., Crittenden, K. & Vicencio, D. (2009). Health Literacy, Social Support, and Health Status
among Older Adults. Educational Gerontology, 35, 191- 201.
DeWalt, D.A. and Hink, A. (2009) Health literacy and child health outcomes: a systematic review of the literature. Pediatrics,
124, S265-274.
Zanchetta, M. S. & Poureslami, I.M. (2006). Health literacy Within the reality of Immigrants‘ Culture and Language. Canadian
Journal of Public Health, 97(2) S26 – S 30.
Edmonton Public Schools. Three-Year Education Plan 2009-2012. Retrieved from
http://www.epsb.ca/datafiles/ThreeYearEducationPlan.pdf
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