Abstract
Physical activity (PA) is a key health promotion strategy for preventing non-communicable diseases such as obesity. However, certain populations, such as immigrants, may participate less and have lower levels of PA. The objective of this study was to co-design a PA program aimed at increasing PA participation among immigrant children in Canada. This program was developed in partnership with community members (caregivers and children), service providers, and community leaders. Using an experience-based co-design (EBCD) approach, participants identified key issues and challenges related to PA in their community and then co-designed programs and activities that addressed these concerns. Three co-design workshops were held to explore barriers and facilitators to PA and a healthy lifestyle. In small groups, 49 participants led the design of seasonal community programs, including swimming, soccer, gardening, and tennis. Through the workshops, a tailored program was developed in collaboration with the community to address barriers and facilitators to PA for immigrant families. By actively involving relevant community members in the design and development process, the co-design workshops aimed to create a PA program that is more likely to be effective, accepted, and sustainable in promoting PA and a healthy lifestyle for immigrant children and families.
Keywords
Background
Non-communicable diseases such as obesity have reached epidemic proportions in Canada, with almost two-thirds of adults and one-third of children, aged 5 to 11 years, identifying as overweight and/or obese (Public Health Agency of Canada, n.d.). Immigrants in Canada, defined as persons who have settled permanently in another country by choice, experience a different pattern of overweight/obesity than the Canadian-born population. There is evidence that risk of obesity increases with time spent in Canada shown by higher zBMI scores associated with length of time in the country (Canadian Council for Refugees, n.d.; Wahi et al., 2014). The healthy immigrant effect (HIE) suggests that immigrants arrive in a host country with a favorable state of health, however over time their health declines and converges to that of the native-born population (Sanou et al., 2014). This may in part explain these population-level trends.
The growth in Canada’s diverse population necessitates that strategies to mitigate the impacts of non-communicable diseases be tailored to consider the needs of communities. Immigrants represent a large component of Canada’s population growth with almost one in four people considered an immigrant or permanent resident (Immigration, Refugees and Citizenship Canada, n.d.-a). As Canada expects to gradually welcome approximately 1.5 million immigrants between 2024 to 2026, policymakers must ensure that health policies and interventions are inclusive and address the diverse needs of this growing population (Immigration, Refugees and Citizenship Canada, n.d.-b).
Physical activity (PA), defined more broadly than exercise, is bodily movement that can be achieved in various ways (e.g., daily tasks, exercise, sport, recreation, Gagliardi et al., 2022). PA is a key health promotion strategy that can be used to address the rising prevalence of childhood obesity, however among immigrant communities in Canada, both adults and children new to Canada have been shown to have lower participation in PA compared with Canadian-born adults and children (Kukaswadia et al., 2014). Determinants of PA participation among immigrants include but are not limited to lack of time, health status, motivation, family support, seasonality, neighborhood support, and social support (Gagliardi et al., 2022). Programs that are co-designed by participants help to overcome barriers because they can consider the cultural, social, and environmental factors that influence the health behaviors of immigrant families (Bird et al., 2021). Co-design has been defined as the “meaningful involvement of end-users in research” (Slattery et al., 2020, para 1). The methods of co-design play a significant role in developing interventions for children and families as it centers the design and development of the intervention around the active participation of its potential users (Malloy et al., 2022). By involving voices marginalized by systemic barriers in the design process, their perspectives, experiences, and needs are considered, resulting in interventions that are more relevant, acceptable, and effective.
This study was embedded within the “Strengthening Community Roots: Anchoring Newcomers in Wellness and Sustainability” (SCORE!) academic-community research partnership focused on co-designing and evaluating programs to promote PA among immigrant children and families in Hamilton, Ontario (Wahi et al., 2023). This study aimed to co-design a culturally informed, community-based PA program that promotes a healthy lifestyle to reduce the risk of non-communicable diseases among immigrant families in the Riverdale neighborhood of Hamilton, Ontario.
Method
This study uses an experienced-based co-design (EBCD) approach, which is a community-based participatory informed design. It involves equitable collaboration of contributors in an emergent, flexible, and iterative approach. EBCD is suitable for multiphase projects and intervention design (Fylan et al., 2021). In this process, community collaborators share and reflect on their experiences to identify priorities for improvement and strategies for change (Donetto et al., 2015).
Study Setting and Population
This project focused on immigrant families in the Riverdale neighborhood in the city of Hamilton. Our study participants were the Riverdale community (children and families), community partners (e.g., Community Action Program for Children, YMCA, the Immigrant Working Center, and Dominic Agostino Community Center), and organizational leaders (e.g., Hamilton Wentworth District School Board (HWDSB) and Mohawk College). We invited those who reside in or work with residents of the Riverdale community. To include representation from the community and service users, speaking English was not a requirement to participate in the workshops and methods were used to have multi-lingual workshops as needed. Figure 1 illustrates SCORE! co-design contributors. Purposive sampling was employed to ensure a representative sample from within the community. Participants were recruited from the established SCORE! Community Advisory-Action Board (CAB), from community events, community partners, and word of mouth. This study was approved by the Hamilton Integrated Research Ethics Board (#15472).
SCORE! Co-Design Contributors
SCORE! Co-design workshops started with an orientation of the activity, including a discussion around goals and a description of activities. Touchpoints are defined as the experiences that occur along an individual’s pathway to services (Fylan et al., 2021). The identification and analysis of touchpoints is an integral part of the co-design process as it highlights the specific areas in need of service (Donetto et al., 2015). An initial list of touchpoints was developed from previous SCORE! activities including literature reviews, school-based engagement activities, a photovoice study, SCORE! CAB, and a pre-workshop questionnaire (Donetto et al., 2015; Kandasamy et al., 2024; Wahi et al., 2023). An animated video conveying the key touchpoints gathered was created by SCORE! team and shared with participants at each workshop. After watching the video, participants were presented a list that summarized different touchpoints (e.g., cost, proximity, awareness of programs) and prompted to share their thoughts and feedback. After the group discussed and modified the list of touchpoints, participants were then asked to put a red sticker beside touchpoints that they perceived as a barrier to PA and a blue sticker beside touchpoints that they perceived as facilitators. Following this exercise, participants were arranged into mixed, small groups with community members, community partners and organization leads, and collaborated to design activities that would improve community experiences in PA with the discussed barriers and facilitators considered.
The SCORE! co-design workshops were iterative, meaning they incorporated information learned from one workshop into the subsequent workshops, to ensure participants were designing interventions with the most up-to-date information. Each workshop was centered around understanding the perceived barriers and facilitators to PA in Riverdale from different groups and members within the community. The workshops conducted were not exhaustive but aimed to include marginalized voices within the community. Co-design workshops occurred in local settings feasible and convenient to participants, including the community center and local children’s center. A socio-ecological model (SEM) guided the categorization of the barriers and facilitators to PA and a healthy lifestyle for immigrant families identified in the workshops. The SEM framework was selected because it could account for the varying factors that influence decision-making around health behaviors (Subramaniam et al., 2022). Barriers and facilitators were placed in one of the following five categories: interpersonal, intrapersonal, environmental, organizational, and public policy.
Results
A total of three co-design workshops were facilitated by the SCORE! research team. During the co-design workshops, a total of 49 participants, 65% of participants of whom were female, actively engaged in the design and development of interventions aimed at promoting healthy active living (HAL) for immigrant children and families in Riverdale. Across all workshops, 80% of participants were community members, and half of the participants (51%) spoke a primary language other than English (refer to Table 1 for full demographic details).
Participant Demographics
Includes one community partner who participated in two workshops (workshops #1 and #2).
In the first SCORE! co-design workshop, participants came together to discuss their perspectives on PA in Riverdale. Through discussions, we identified barriers and facilitators and had participants design activities that could mitigate these issues and improve participation in PA. Table 2 illustrates key SCORE! design elements identified by participants. Participating community partners identified that some families within the community are marginalized from community events and updates because the primary language of communication is often English, with which they are less comfortable. To respond to this information and alleviate the language barrier that would be a barrier to participation, the SCORE! team hosted a co-design workshop in Arabic to include community members who prefer to communicate in this language. In the second co-design workshop, SCORE! collaborated with a community service agency to host an Arabic co-design workshop where 23 community members came together to discuss their perspectives on PA in Riverdale. Based on the prioritization of barriers and facilitators from community members in Riverdale, the greatest areas of concern for participants were the creation of indoor spaces and an open gym, the need to improve outdoor play areas that are currently available (noting that they are currently not maintained and too small), establishing bike routes and areas for children to safely ride their bikes, and improving the safety of play areas. In the third workshop, children and youth from the Riverdale community came together to discuss their perspectives on PA in their community. In small groups, 13 children and youth designed activity ideas for children and families during the summer and winter. Participants raised discussions regarding the intersectionality of socioeconomic status, disability, and being an immigrant and how this may further marginalize children and families in accessing programs and services that promote participation in PA.
Key SCORE! Design Elements
Barriers to PA in the community include the cost of programs, limited parental availability due to work commitments or child care needs, lack of transportation, poorly maintained spaces and the unfamiliarity of spaces and activities. Participants identified proximity of activities, communications that increase awareness of programs, feeling welcomed in programs and community spaces and culturally sensitive and inclusive programming as facilitators to participating in PA in Riverdale. From the list of barriers and facilitators, subsequent group discussions elaborated on how the barriers and facilitators could be managed to create a program conducive to the realities and circumstances of immigrant families in Riverdale. Through the iterative workshops, the list of barriers and facilitators was developed into core design elements for a PA program within the Riverdale community. See Table 3 and 4.
Descriptions of Barriers to Healthy Active Lifestyle
Descriptions of Facilitators to Healthy Active Lifestyle
Intrapersonal Barriers
Lack of Knowledge
Families felt that they did not know how to get involved, or where to go to participate in activities, and described an unfamiliarity in spaces that resulted in discomfort.
Environmental Barriers—Situational Factors
Limited Capacity
Parents described their limited availability during the week as a major factor influencing their and their children’s participation in physical activities. Due to working multiple jobs, taking care of young children, and/or going back to school to obtain credentials to work in their field, immigrant families described having to attend to competing priorities as a barrier. In addition, some families do not have personal transportation to travel to activities outside of the community which can further limit the opportunity to participate.
Poor and extreme weather conditions (i.e., rain, snow) also significantly deterred families from leaving their homes to participate in physical activities.
Organizational Barriers
Lack of Maintenance
Parents and children described flooding and poor maintenance of local soccer fields and playgrounds as a barrier to play. Maintenance issues such as no lighting around fields or playgrounds were an additional safety concern for families that deterred them from sending their children to play outside.
Interpersonal Facilitators
Feeling Welcomed
Participants described feeling welcomed in community spaces as a facilitator to participating in PA. This was later described as having positive connections and relationships with the coaches or staff facilitating activities and other attendees.
Environmental Facilitators
Situational Factors
Proximity of activities
Programs and activities offered at or within a short walking distance from the community center were most preferred by families. Families appreciated the proximity to home because they would send their children to walk to the activities with an older sibling or neighbor which allowed the parent(s) to attend to other priorities.
Bike paths and areas for children
Parents expressed the desire specifically for designated areas for children to know how to learn and how to ride their bikes comfortably.
Cultural Factors
Language
Parents described how having written communications shared in their language allowed them to understand when there was an opportunity to participate in activities. Parents also noted that having program staff speak the same language as they did make them feel more comfortable in the space.
Organizational Facilitators
Lower cost of programs
Some families described that lowering the cost of enrollment fees for organized programming would allow them to send their children to participate in more PA.
Provision of child care
Parents noted that having child care available during adult programming made it feasible for parents, especially mothers, to participate in activities.
Clear communication
Participants expressed how clear and explicit communications about the locations and time of activities were helpful in recognizing and remembering when an opportunity for PA was available in the community.
Increased variety
Families described the desire for diverse activity options and opportunities to build new skills through activities such as bike riding, tennis, and skating.
At the end of the three co-design workshops, more than 125 summer and winter activity ideas were generated by the participation of community members, community partners and organization leaders. Participants considered the barriers and facilitators within the community to suggest physical activities acceptable to the values and preferences of immigrant families in Riverdale.
The activities suggested in the workshops were not unique or novel to typical community programming, noting how everyday physical activities such as soccer, basketball, and swimming were among the main physical activities of interest, (refer to Table 5). As community partners and organizational leaders participated in discussions, it became clear that many of the suggested physical activities were offered in some capacity through existing community services. Discussions with participants in the workshops clarified that the main barrier to adopting and maintaining a healthy lifestyle was not a misalignment with the types of activities offered in the community but the manner of facilitation and accessibility to these PAs. Immigrant families in this community desired more direct communication about the activities offered in the community and the explicit next steps required to enroll in ways that were familiar. Families also expressed a desire for greater variety in overall programming, which included the types of activities offered, as well as the times they were available, specifically requesting more evening and weekend programming. In addition to this, families expressed the desire for more women’s only programming and spaces for all members to partake in physical activities. Workshop discussion with immigrant families emphasized the importance of affordability and physical, cultural, temporal, and social accessibility. While affordability is important, proximity also plays a significant role in accessibility with families noting programs located within a short walking distance as the most convenient and desirable. This preference aligns with the realities faced by immigrant families who often manage multiple responsibilities such as caring for children, continuing education, and working varying hours. In this context, activities within a close and safe enough distance for children to access with an older sibling or neighbor emerged as particularly accessible and practical for families with working schedules.
Key Physical Activities of Interest by Age Group
Discussion
This study offers valuable insights into the specific needs and challenges faced by a community of immigrant families with young children regarding access to recreation and opportunities for PA. It serves as a foundation for creating relevant interventions that address identified needs. In each workshop, participants discussed their values and preferences to develop a list of key priorities considered in the creation and pilot testing of interventions. Throughout these series of co-design workshops, we engaged parents, caregivers, children, service providers, and community leaders to tackle major challenges and unlock opportunities for PA among children in the community. The complexities faced by immigrant families, which includes language barriers, cultural differences, limited access to resources, and unfamiliarity with the local environment, make it challenging for them to adopt or maintain a healthy lifestyle. These issues could be addressed with co-created programs (Pandey et al., 2022). The data gathered from the co-design workshops were vital in informing the intervention pilot testing phase of the SCORE! project. The co-design process significantly influenced the development and implementation of the intervention pilot testing, ensuring that interventions were tailored to the community’s needs and preferences.
The co-design process helped to identify the most pressing issues related to PA in the Riverdale community, such as affordability, accessibility and variety of activities and subsequently generate realistic solutions to these problems. Other studies have described similar methods. A study by Huisken et al. (2021) sought to evaluate the acceptability and feasibility of a health promotion program from the perspective of immigrant and refugee caregiver participants attending the program with their children. That academic team sought to include findings from participants in future refinements to the program. The impact of the Healthy Together (HT) program extended beyond promoting and improving healthy eating and PA among immigrant and refugee families. It also enhanced knowledge of community resources, strengthened social connections and, in some cases, improved English literacy (Huisken et al., 2021). By involving community members in the design process alongside community partners and organization leads, our study ensured that the specific barriers and facilitators to PA were identified for those who participate in activities and services and the barriers and facilitators that may be encountered by those who facilitate activities and programs in the community. This approach supports the “exchange of knowledge and resources, enhancing the empowerment of migrant communities and simultaneously resulting in increased responsiveness from health and social organizations” (Dias et al., 2021, para 35). With the participation of community partners and organization leads who held positions in community social and health services, the parameters to feasible solutions were better understood, and realistic interventions that could be supported with community resources were generated. The advantages of this diverse collaborative group are supported by the Ophelia process, an approach used in the context of co-design health literacy interventions with migrant communities, demonstrating that the active involvement of relevant contributors throughout all phases of the co-design project allows for culturally tailored, multi-sectoral interventions which reinforce the potential for high-impact generation and systems reform (Dias et al., 2021).
The co-design process facilitated the selection and refinement of intervention strategies. Participants were able to provide input on the feasibility and acceptability of different intervention approaches, allowing for the identification of strategies that were most likely to be effective in the Canadian context. This collaborative approach ensured that the interventions were culturally appropriate and aligned with the community’s values and preferences which is necessary for sustainability. Given the diverse and multi-lingual needs of the Riverdale community, the SCORE! co-design workshops aimed to encourage participation from community members by conducting multi-lingual co-design workshops. In the workshops, interpreters were present to support translation as different language needs were identified. By providing interpretation when needed, the SCORE! team aimed to circumvent linguistic, emotional, and ideation barriers that may have been encountered if the workshops were only conducted in English with no language support (Bridgeable, n.d.). This process is intended to encourage participants to communicate and express their opinions in the language most comfortable to them. As there was limited literature on the use of conducting multi-lingual co-design workshops in immigrant communities, future research is needed to fill this gap and inform practices on the best way to support these needs.
Implications for Practice
These findings can help inform the design of health-related services for newcomer populations. Health promotion interventions may be tailored to the needs of a population by providing culturally relevant health education, offering multilingual services, and collaborating with community organizations, which can lead to building trust and reducing health disparities among marginalized communities. Similar to the findings in this study, language barriers and a fear of being misunderstood also negatively affect the delivery of care and patient satisfaction (Al Shamsi et al., 2020). With these findings, we can design culturally informed and responsive health promotion interventions that prioritize linguistic accessibility and community engagement while considering the unique barriers to PA experienced by immigrant populations. Through these interventions, communities can seek services with greater ease.
Implications for Research
The co-design approach in this study illustrates the potential for diverse, multi-sectoral collaboration in co-creating health interventions for immigrant communities. The collaborative, systemic, and iterative nature of this approach to knowledge generation results in culturally relevant and actionable interventions that are supported by local community services and organizations, ultimately fostering sustainability. The findings from these workshops highlight the significance of community engagement in the intervention design process and can assist researchers in crafting an optimal pathway to develop evidence-based practices that align with the lived experiences of the populations affected by the intervention.
Strengths and Limitations
Despite the strengths of this study, such as community engagement and the inclusion of marginalized voices, challenges were also encountered. Recruitment was not fully representative of the Riverdale community, thereby limiting the extent to which tailored solutions may address all members of the community. Some groups and voices, such as individuals with disabilities and families with children who have disabilities, were absent from the co-design workshops. This feedback will contribute to efforts to focus specifically on PA opportunities for immigrant families with children with disabilities, aiming to continuously refine programming that reflect the values and preferences of the community, thereby enhancing inclusivity and accessibility for all community members.
Conclusion
Through the SCORE! co-design workshops, a community’s voice was amplified by actively participating in the development of interventions that address their unique challenges and needs, and gaining agency in shaping their own health outcomes. Continued research and implementation of co-design methodologies are necessary to determine the effectiveness and scalability of co-designed interventions for promoting participation in PA among immigrant children and families.
Footnotes
Authors’ Note:
The SCORE! team gratefully acknowledges the contributions and efforts of the community members, families, community partners and local organization leaders in Riverdale whose efforts were integral to the success of this research, This work was funded by the Public Health Agency of Canada in the form of a grant to SSA [2223-HQ-000007], and by the Juravinski Research Institute in the form of an award and McMaster Children’s Hospital & McMaster University Department of Pediatrics to GW. SSA received funding for a post-doctoral fellow from Novartis and GW a received graduate student funding from the Faculty of Health Sciences (McMaster University). SSA is supported by a Tier 1 Canada Research Chair in Ethnicity and CVD and Heart, Stroke Foundation Chair in Population Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
