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Canadian Public Health Association

Wellesley Institute's St. James Town initiative; Toronto, Ontario

Working with the community to improve immigrant health

St. James Town

St. James Town is a large neighborhood in the northeast corner of downtown Toronto. Standing on Rose Avenue, you can turn a full circle and see nothing but tall, aging apartment complexes separated by parking lots and small patches of grass. The neighborhood consists of 19 high-rise buildings crowded into less than a third of a kilometre of land. Officially, the neighborhood contains about 15,000 residents. Unofficially, residents estimate that over 25,000 people live here. It is one of the poorest, most diverse and densely populated parts of Canada. Many new immigrants settle in St. James Town due to the low rent and convenient location. On any given day, you can hear over 50 languages spoken in the area.

The "healthy immigrant effect"

Like many similar neighborhoods, St. James Town suffers from the "healthy immigrant effect." Overall, newcomers have better health than the Canadian average. Several explanations exist for this including the use of health screening through the immigration process, healthy behaviours of immigrants before migration, as well as the tendency of healthier and wealthier people to immigrate. But as time wears on, usually in about 5-10 years, the health of immigrants deteriorates to the point where it is much worse than the average.

The Wellesley Institute in Toronto examined this phenomenon by looking at how social determinants of health (SDH) affect the long-term health and well-being of St. James Town residents. "We're really trying to drive better understanding of social determinants into policy and community change," says Bob Gardner, director of policy at the Wellesley Institute. "We look at social determinants of health as not just single factors like income or immigration, but rather as many social factors that interact with each other, that are connected and have an impact on a community by how are why they are connected. We want to understand how these connections then play out in particular communities."

Concept mapping helped determine priorities and action

St. James TownThe research component of the project took five years to complete and involved both St. James Town residents (immigrants and non-immigrants) and local social services. Innovative interviewing techniques were used to tell the story of St. James Town and the social determinants of health including Photovoice, a method of participatory qualitative research, wherein researchers gave residents disposable cameras to take pictures of the things that were significant to them and that they felt impacted their health and the health of their community. This method directly engages residents in defining existing problems and helping to develop solutions. Through their photos and stories, residents identified issues such as social isolation, precarious employment, food safety, limited access to green space and recreation, poor garbage collection, and compromised safety as issues facing their communities.

A unique facet of this project was combining Photovoice and an innovative analytical method called concept mapping. The photographs were brought to community focus groups and sorted into "concept maps," which show all the elements in relation to one another. In concept mapping participants sort the photos into groups by subject and then rate them in two areas: relative importance and potential for action. This not only provided a concrete categorization of problems facing residents, it attached priority status to each issue. The next step was to place similar ideas in close proximity and different ideas further apart. Patterns emerged to describe how each concept was related, which helped to organize them further to determine priority and action.

Keeping people engaged

As is the case with many studies, the research team struggled to keep participants engaged and to accommodate language, schedules and personal circumstances. "The whole point was to involve community residents, but people were often doing two jobs or had precarious and inflexible jobs, so they're worn out at the end of the day," says Gardner.

Click to see a larger map
Click to see a larger map St. James

Language barriers were another issue. While conducting research in Tamil, Mandarin or English was crucial, there are many more languages spoken in St. James Town. The one common research barrier that wasn't an issue for their study was transportation. "People are so densely packed there, they can wander over to the community hall or it's pretty easy to go interview them in their buildings. It's not like a suburb where you have to provide transportation," says Gardner. The Wellesley Institute made an effort to make it convenient to participate in the study. Child-care services were provided, interpreters were brought in, and a small honorarium was given when possible.

Gardner says that it was important to the Wellesley Institute to keep the community involved at every step of the study. The Wellesley Institute team took time to build trusting relationships in the community and shared their findings along the way. "Anytime we did a report, we would have a big community forum and we'd often have it in St. James Town. We'd display the photos and community members would speak to what was found and what they felt about doing the research," he says. "We essentially involved the community at every stage from defining the key questions, to doing the research, to interpreting the findings, and then to trying to get some action on the findings."

The project led to increased local interest in health equity, immigrant health and health barriers in disadvantaged populations. Wellesley staff developed various policy briefs to supplement the research and worked with community residents and organizations to get these conclusions and implications to decision makers. Some action has been taken to improve quality of life based on the research findings; for example, garbage collection activities have improved.

The Wellesley Institute's website describes the importance of initiatives like the St. James Town Project: "Policy-makers and program planners can use this knowledge to help inform policy changes and new services for immigrants in low-income neighbourhoods, and the community can use this knowledge in thinking about actions they can take to make their neighborhood a better place for themselves, and their families, to live in."