Abstract
Children’s healthy active living (HAL)—encompassing nutrition, physical activity, and sleep—is shaped by complex socio-ecological factors spanning individual, familial, environmental, and societal levels. For newcomer families, migration introduces additional challenges that can deprioritize health-promoting behaviors amid competing settlement demands. This article presents insights for researchers and practitioners from the Strengthening Community Roots: Anchoring Newcomers in Wellness and Sustainability (SCORE!) research program, which co-designed a child-focused HAL intervention with immigrant families in Hamilton, Ontario, Canada. Grounded in a socio-ecological framework, SCORE! employed a participatory, community-engaged approach to address structural inequities and foster culturally responsive health promotion. The tripartite methodology included: (A) synthesis of evidence on nature-based HAL interventions; (B) multi-level community engagement through trust-building, photovoice, co-design workshops, surveys, environmental mapping, and policy dialogues; and (C) implementation and evaluation of co-designed interventions aimed at enhancing children’s self-efficacy for physical activity. By positioning families as co-creators rather than passive recipients, the project mobilized local knowledge and fostered community ownership. This work contributes to the growing field of knowledge mobilization in health promotion research and offers practical lessons for designing sustainable, community-driven HAL initiatives in diverse urban settings.
Keywords
Background and Context
Children’s healthy active living behaviors—including nutrition, physical activity, and sleep—are shaped by a web of interrelated factors (known as the socio-ecological framework) that operate across multiple levels: individual and family routines, behavioral settings, built environments, and prevailing social norms (Sallis et al., 2015). When this delicate balance is disrupted, it can lead to increased risk of obesity and other chronic conditions during childhood and into early adulthood. Recognizing this complexity, the 2022 American Academy of Pediatrics Practice Guidelines emphasize that obesity risk is deeply embedded within socio-ecological and environmental contexts. Practitioners caution against disaggregating outcomes by race, ethnicity, age, or gender without accounting for the structural inequities—economic, political, cultural, and environmental—that underlie these differences (Hampl et al., 2023). However, when appropriately contextualized, disaggregation can reveal meaningful structural disparities that require targeted action.
These challenges are further compounded during periods of migration, when newcomer families often face competing priorities such as housing, employment, and language acquisition/advancement. In such contexts, health-promoting behaviors may be deprioritized, not due to lack of interest, but because the settlement trajectory itself is not designed to support optimal health. This emphasizes the need for interventions that are not only evidence-based but also culturally responsive and contextually grounded. Integrating nature-based approaches into health promotion strategies offers promising avenues to reconnect families with environments that support physical activity, mental well-being, and community belonging. This is of particular importance as Canada has welcomed a surge of immigrants, refugees, and international students over the recent years (Statistics Canada, 2022).
Theoretical Framework
Despite growing awareness of these complexities, traditional prevention strategies have largely focused on individual behaviors—diet, sleep, and exercise—without adequately addressing the broader socio-ecological landscape. These approaches have proven insufficient in achieving sustainable health outcomes, particularly among equity-denied populations. In contrast, a socio-ecological framework provides a more holistic lens, recognizing the dynamic interplay between individuals, families, communities, societal structures, and broader global environments (Golden & Earp, 2012; Richard et al., 2011; Willows et al., 2012).
Guided by this framework, the SCORE! research program was developed to co-design, implement, and evaluate Healthy Active Living (HAL) interventions that enhance physical activity among immigrant families with children (Wahi et al., 2023). Central to this approach is a flexible co-design methodology that acknowledges participants as experts, co-creators, and beneficiaries (Sanchez de la Guia et al., 2017). By engaging families and communities in the design and delivery of interventions, SCORE! offers a novel and inclusive pathway to operationalize the socio-ecological framework in real-world settings.
Our Approach
This vision was operationalized through a tripartite phased approach:
The initial community of focus was the Riverdale neighborhood, located in Hamilton, Ontario, Canada. Half of the residents (50%) identify as visible minorities, with 25% of families immigrating to Canada in the last 20 years and 26% living in low-income households, as defined by Statistics Canada. The neighborhood includes communities of South Asian, Southeast Asian, and Middle Eastern heritage, with Punjabi and Arabic as the most commonly spoken languages.
Results
During phase A, we conducted a scoping review examining how nature-based interventions are designed and implemented in community settings to promote healthy active living among children in newcomer families (Bhopa et al., 2025). We reviewed 4,010 articles, ultimately including 50 studies, to identify the major theories, frameworks, and strategies used to develop these interventions. Findings highlight several key themes such as how communities integrate nature into health-promoting programs, how families engage with these initiatives, and the existing gaps in accessibility and program design that limit participation. The synthesis of included studies emphasize the critical role of community engagement, culturally responsive program design, and consideration of structural barriers faced by newcomer families. Strengthening and tailoring nature-based healthy active living programs is essential to improving the well-being of children in these communities.
In Phase B, the first qualitative study (Kandasamy et al., 2024) explored how residents in a newcomer-dense community experience and access local greenspaces, with the goal of understanding factors that support or hinder engagement in nature-based activities. Using photovoice methodology, researchers collaborated with 39 participants—ranging in age from 11 to 70 and living in Canada for a median of just over 3 years—through focus groups, photowalks, and photo-elicitation interviews to document community perspectives. Our analysis revealed four central themes shaping greenspace engagement:
To ensure the findings informed local decision-making, we organized an in-person exhibition and guided tour, where community members and investigators collaboratively presented the themes as a narrative accompanied by discussion prompts for policymakers.
The second qualitative study (Ross et al., 2025) used an experience-based co-design (EBCD) approach where researchers partnered with caregivers, children, service providers, and community leaders to identify barriers and facilitators to PA within immigrant communities. Across three co-design workshops, 49 participants collaboratively explored challenges to healthy lifestyles and generated solutions tailored to their needs.
Through small-group discussions, participants designed seasonal PA programs—including swimming, soccer, gardening, and tennis—that reflected community preferences and addressed locally identified issues. The resulting program was intentionally shaped to be culturally relevant, accessible, and supportive of immigrant families’ unique circumstances. By engaging community members directly in the design process, we co-produced a PA program positioned to be more effective, acceptable, and sustainable in promoting active living among immigrant children and their families.
Throughout Phase C, we engaged co-investigators and community partners in knowledge exchange meetings (both in-person and online) to compile the results from the previous phases to propose and implement a multi-component program (Manuscript in progress). Specifically, the design phases (A and B) led to the cultivation of elements that span the key socio-ecological components (Golden & Earp, 2012) including individual, family, community and socio-cultural environments, built environment, and social and policies.
Components of the intervention that crystallized through the formative work include the following:
Implications for Practice
Through various activities to understand the local ecosystem, challenges, and opportunities for promoting healthy lifestyles (described in Wahi et al., 2023), we identified three key lessons for researchers and practitioners working on co-designed health promotion studies.
Invest in Flexible, Community-Centered Research Methodologies
As researchers committed to shifting entrenched power dynamics, it is essential to meaningfully center beneficiaries as experts—especially in the co-creation of research questions. This reorientation demands that we see our role not as extractors of data, but as facilitators of learning from those whose insights are grounded in lived and living experiences. This is significant because traditional research paradigms often privilege academic “ease, comfort, and familiarity” over community relevance, reinforcing hierarchies that minimize the voices we aim to amplify. To counter this, we must embrace and celebrate methodologies that generate diverse, expressive forms of data—such as narratives, videos, and photographs—data sources that reflect the richness of community perspectives.
This shift requires internal adaptation: activating a deeper sense of meaning-making by collaborating with new investigators who bring cultural, experiential, and methodological expertise. Rather than expecting communities to conform to conventional tools like surveys and scales, we must adapt our practices to honor community ways of knowing. Trust-building becomes central to this process. “Moving at the pace of trust” is a commitment to cultivating authentic, reciprocal relationships with community members, leaders, and anchor organizations.
Two methodologies embedded within SCORE! that exemplify this ethos are (a)
Photovoice, for instance, invites participants to engage in a “photography mission,” capturing elements of their environment that reflect personal and collective experiences. In our study on greenspace access, community members took hundreds of photographs, shared stories over evening meals, and co-created the meaning underlying the images alongside the research team (a formalized content analysis was employed). This process not only surfaced critical insights but also created space for advocacy. The study culminated in a public exhibition and guided tour, where policymakers heard directly from community members about their lived realities and aspirations for change. This approach exemplifies how research can become a platform for empowerment, storytelling, and systemic transformation. For more details, see Kandasamy et al. (2024) and watch the photovoice exhibition summary video here: https://www.youtube.com/watch?v=5ndTzbeKMtU.
The gallery walks, conducted in collaboration with the local school, engaged students in a dynamic exploration of physical activity across the four seasons. A series of open-ended questions—focused on activities they currently participate in, aspire to try, and find challenging (including reasons why)—were displayed on flip-chart paper. Students rotated through stations in small and large facilitated groups, contributing their responses, ideas, and reflections. This participatory approach exemplifies versatile methodologies that prioritize voice, agency, and inclusivity. By enabling participants to articulate their experiences in their own words, such methods foster deeper engagement and authenticity. Moreover, these expressive formats support the design of tailored, context-sensitive interventions that individuals are more likely to relate to, adopt, and sustain over time. A summary of all gallery walk findings can be found in the SCORE! Summary video here: https://www.youtube.com/watch?v=cQdUbpW8Ym8.
Sustain Effective Internal and External Communication With Invested Partners
To maintain strong, timely communication within the internal research team, we held weekly team huddles where we reviewed new challenges, collaborated on decisions, and ensured awareness across sub-teams of their progress. This also provided space to reflect on the current week and respond with timeliness. Second, the operational manager continued to play a role in connecting with and providing information on project progress to donors. Different donors may have different requests regarding information provision (e.g., annual report vs. monthly updates, etc.), which makes it vital to understand the specifics of these needs in advance and provide requested updates. Having a dedicated staff member responsible for stewarding donor relationships is essential for long-term funding. Third, as part of this project, we established and fostered a Community Advisory-Action Board (CAAB) reflective of beneficiary families and community-based organizational leaders. Serving as an avenue for two-way communication and strategic guidance, the CAAB met regularly in-person over the course of the 2-year study design period to provide the leadership team with feedback, identify gaps, amplify successes, champion new frontiers, advocate for change, and empower others to get involved (and remain involved long-term). (A description and evaluation of the CAAB is under review elsewhere: Bhopa et al., 2025). To successfully recruit participants, we worked collaboratively with local organizations to identify, contact, and on-board diverse voices. Once on-boarded, active participation among members was optimized by hosting two parallel sessions: one for adults and one for children. Child care, honoraria, and language support were provided at all meetings.
Embed Knowledge Mobilization and Advocacy Into Co-Design
We augmented communications with the broader community by producing weekly social media content on the intersecting topics of HAL, lay reports describing community events, and simple digital stories (videos) that summarize study findings (of sub-projects and synthesized across sub-projects). These materials were developed immediately after key milestones and promoted widely. All of these public-facing documents are displayed on our website and specific examples of reports and videos can be found here: https://drive.google.com/drive/folders/1qsW-8sjc3y5ZRzUpkWRKi6e89ToH687H?usp=sharing.
In addition, we learned that deeper community engagement can pave vital avenues for advocacy. For example, through the photovoice study, we learned of the barriers to greenspace access experienced by many families (as an example, inadequate waste disposal infrastructure was one of the contributing factors to lack of engagement with outdoor spaces in the neighborhood). As a venue to showcase these perspectives to policy and decision-makers, we held a guided exhibition walk alongside community members. Over many conversations, this advocacy materialized to tangible change: the installation of an additional garbage bin in the local park. This small but meaningful outcome illustrates how community narratives can catalyze policy action by transforming the mundane into a conversation for change.
Conclusion
Through these lessons, we demonstrate that the SCORE! research program seeks to elevate the value of community-engaged, co-designed approaches in health promotion research. By applying a socio-ecological framework and participatory methods, the program has generated rich, contextual data and mobilized knowledge in equitable, practical ways. This work demonstrates the importance of trust-based partnerships and inclusive methodologies in transforming health promotion into community-led models of inquiry and impact.
Footnotes
Authors’ Note:
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: 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 received funding from the Joyce Family Foundation. 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.
Ethical Considerations and Informed Consent
Please note this article includes reflections from sub-projects involving human research participants. All projects referenced in this piece obtained ethics approval from the Hamilton Integrated Research Ethics Board (HIREB) at McMaster University (HIREB approvals: 14272, 18371, 17739, 15604, and 15028).
