Neighbourhoods and Health Research Interest Group

Alexis Kane Speer (Centre for Urban Health Initiatives, University of Toronto)
Blair Wheaton (Department of Sociology, University of Toronto)
Brent Berry (Department of Sociology, University of Toronto)
Cyndy Baskin (Social Work, Ryerson University)
Dennis Magill (Department of Sociology, University of Toronto)
Dianne Patychuk (Planning and Policy, Toronto Public Health)
Gala Arh (Ontario Tobacco Research Unit, University of Toronto)
Jame Dunn (Centre for Research on Inner City Health, St. Michael's Hospital, Geography, University of Toronto)
John Spence (Physical Education and Health, University of Alberta)
Kathi Wilcon (Department of Georgraphys, University of Toronto Mississauga)
Nadia Minian (Ontario Tobacco Research Unit, University of Toronto)
Nancy Ross (Geography, McGill University)
Nick Holt (Physical Education and Health, University of Alberta)
Pat O'Campo (Centre for Research on Inner City Health, St. Michael's Hospital, Public Health, University of Toronto)
Patricia Manuel (School of Planning, Dalhousie University)
Paul Hamel (Health Studies Program, University of Toronto)
Rick Glazier (Centre for Research on Inner City Health, St. Michael's Hospital, Public Health, University of Toronto)
Yogendra Shakya (Access Alliance Multicultural Health and Community Services)

Project Descriptions

1. Space for Healthy Communities: An Exploration of the Social Pathways between Public Space and Health

Principal Investigator(s):  
Alexis Kane Speer (Centre for Urban Health Initiatives, University of Toronto) and Dr. James Dunn (Centre for Research on Inner City Health, St. Michael’s Hospital)

This thesis investigates the relationship between access to public gathering spaces and self-reported health with indicators of community life (sense of community, collective efficacy, etc.) as the intervening variables. This study was undertaken to investigate the relationship between the access to public space and self-rated health status, specifically those aspects of public space which foster place attachment and may address urban health concerns in multicultural communities.

A survey of randomly-selected households was conducted across four low-income Toronto neighbourhoods, which were selected to represent diverse built environment types and different distances from the central business district. A sample of 785 people participated in the study, representing a 77.8% response rate. Although the survey focused on a broad range of health-related issues, the current study highlights variables related to social support, social capital, sense of community, community gathering/green spaces, recreational facilities and self-rated health status.

The investigation is framed by the production of healthy public space model proposed by this thesis, which draws on the work of Lefebvre, Jacobs and Sandercock to conceptualize the pathways between the lived experience of space and health as between the absolute and the abstract dimensions of space. The lived dimension of space impacts an individual’s likelihood of establishing place attachment. The model also emphasizes that there are many different ways to experience the same space. The analysis consisted of non-parametric tests of significance and results overall supported elements of the conceptual model presented in this thesis and suggest that there is a relationship between public space, place attachment and health.

The findings suggest that indicators of both physical and mental space are related to lived space (as an outcome). The results support the hypothesis that there is a relationship between the lived dimension of space and health, and its most important impacts seem to be on mental health as an outcome. Mental health appears to be the outcome most affected by indicators of place attachment. Several of the aforementioned relationships were found more commonly in the densest of the four neighbourhoods. Variations were found between foreign- and Canadian-born, which suggests that each subgroup values different elements of public space. Nearly one quarter of participants indicated that public space concerns were among their top neighbourhood priorities, which suggests that residents are aware that neighbourhood public spaces play a role in the local social environment.

Space for Health Communities Project Report

Space for Healthy Communities Project Update

International Conference on Urban Health Project Poster

2. Toronto Neighbourhood Effects on Mental Health Project

Principal Investigator(s):
Dr. Blair Wheaton (Dept. of Sociology, University of Toronto) and Dr. Patricia O’Campo (Centre for Research on Inner City Health, St. Michael’s Hospital)

Project Co-Applicants:
Dr. Brent Berry (Dept. of Sociology, University of Toronto), Dr. James Dunn (Centre for Research on Inner City Health, St. Michael’s Hospital), Dr. Richard Glazier (Centre for Research on Inner City Health, St. Michael’s Hospital), and Dr. Rosane Nisenbaum (Centre for Research on Inner City Health, St. Michael’s Hospital)

CUHI is pleased to congratulate Blair Wheaton from the Department of Sociology at the University of Toronto and Pat O'Campo from the Centre for Research on Inner City Health on their successful grant applications to conduct a large-scale study into the neighbourhoods effects on health in the Toronto region.  The Co-PI's and a number of the co-applicants received seed grant funding from CUHI in the development phase of this project.  CUHI continues to support this project with resources for its implementation. 

3. “Building Community Health Mapping Tools to Investigate and Reduce Racialized Health Disparities within and across Neighbourhoods in Toronto”

Principal Investigator(s):  
Dianne Patychuk & Yogendra Shakya (Access Alliance Multicultural Health and Community Services)

Lead Community and/or Policy Partners:
Access Alliance Multicultural Health and Community Services, Black Creek CHC, The Four Villages CHC, Regent Park CHC, Women’s Health in Women’s Hands CHC and the Association of Ontario Health Centres.

Description:
The key goal of this proposed pilot project is to build capacity of community health centres (CHCs) and their community partners in developing and utilizing community mapping tools for evidence-based service planning and advocacy work geared at reducing racialzed health disparities. In particular, the project will innovate and evaluate three types of community mapping tools:

1. simple, user defined maps generated by and selected by CHCs for service planning (client and service data plus census/ custom census data to be mapped in ArcGIS or comparable platform);
2. multi-criteria map-based decision tools (based on CommonGIS software) with indicators selected by participants on determinants of health for racialized groups
3. qualitative community mapping/audit methods (to be mapped in google maps and other mapping prototypes and incorporated into neighborhood profiles) for mapping qualitative knowledge produced by CHC communities through community-based research, community audits, community tours etc.

Project Poster

See CUHI's Spring 2009 Newsletter for more information on this project.

4. Toronto Intensive Research on Neighbourhoods & Health Initiative (Toronto-IRONhI)

Principal Investigator(s):
Dr. James Dunn (Centre for Research on Inner City Health, St. Michael’s Hospital)

A Joint Initiative of:
The Centre for Urban Health Initiatives (CUHI), University of Toronto, and The Centre for Research on Inner City Health (CRICH), St. Michael’s Hospital

A great deal of recent health research has studied the role neighbourhoods play in shaping health outcomes. There is now evidence that over and above an individual’s socio-economic position, their residential neighbourhood's physical, built, social, economic, service-based and cultural attributes exert an influence on their health status.

Toronto-IRONhI seeks to describe and understand how “health opportunity structures” differ between neighbourhoods and how they may contribute to health outcomes. Its primary objective is to improve understanding of the pathways and mechanisms linking neighbourhoods and health and to inform policy and community action about how neighbourhood-based interventions could address health disparities.

Toronto-IRONhI has selected six Toronto neighbourhoods to house comparative case studies of the pathways linking the social, economic, built and service attributes of neighbourhoods to health.  Neighbourhoods have been selected for their contrasts – some lower-income neighbourhoods, some upper-income, some inner-city, some suburban, some under-served, some better-served. The six neighbourhoods are:

• Parkdale South
• Banbury-Don Mills
• St. Jamestown
• North Riverdale
• Eglinton East
• Weston-Mt. Dennis

Two of the neighbourhoods are City and United Way Priority Neighbourhoods and two already have established research partners.  Toronto IRONhI will create research capacity and foster genuine multi-sectoral, interdisciplinary health research on neighbourhoods between academic researchers, policy makers and community stakeholders.

Research by Toronto IRONhI Users:
Some possible substantive areas of research that would benefit from the opportunity Toronto-IRONhI would provide include:

• Neighbourhoods and healthy early child development: child development forms the basis for health, and for health disparities, throughout the life course and is thought to be influenced by neighbourhood factors such as opportunities for socialization, availability of quality daycare, safety, clean air and soil, opportunities for indoor and outdoor play activities, and parenting support. The precise pathways linking these factors to relevant outcomes, however, are not well understood;
  
  
• Adult mental health & addictions: even mental health problems that do not reach the threshold of clinical significance create a substantial burden of disability and suffering. Mental health and addictions are commonly studied in extensive neighbourhoods and health studies but such methods have seldom been combined with intensive research to gain a fundamental understanding of mechanisms, pathways and avenues for intervention;
  
  
• Availability and use of resources and services that affect health: these include neighbourhood environments and resources such as recreation centres, parks, grocery stores, fruit and vegetable markets, bike paths; unhealthy influences such as fast food outlets and cigarette vendors; and social and health care services. These factors can influence a wide variety of health outcomes, but to date most research has simply counted the number of such influences, rather than understanding the process by which people access and use resources and, in turn, how this process shapes health;
  
  
• Ethnicity, immigration, concentrated poverty, neighbourhoods and health: over ½ of Toronto residents were born outside of Canada and this trend is going to continue. The health effects of concentrated poverty and ethnic segregation are poorly understood in the Canadian context. Although a large literature exists on racial segregation in the U.S., it is likely inappropriate to the Canadian context.

a. Systematic Observation of Neighbourhood Disorder in IRONhI neighbourhoods:
In this project, we collected standardized measures of social and physical disorder on 176 randomly selected block faces across all 6 IRONhI neighbourhoods (four low income neighbourhoods – Eglington East, South Parkdale, Weston and St. Jamestown – and two middle or high income – North Riverdale and Banbury-Don Mills. This technique is called Systematic Structured Observations (SSO) such measures have previously been used as predictors of a wide range of population health and child development outcomes, primarily in the U.S. Our purpose was to investigate the appropriateness of these measures in a Canadian context, to describe differences in social and physical disorder between IRONhI neighbourhoods and to determine the utility of these measure for future research in Toronto and other Canadian cities. While three ‘factors’ were able to be generated using the quantitative data (physical decay and disorder, neighborhood social accessibility, and recreational opportunities), only the first reflected the findings of other investigators. Coupled with the qualitative findings which related to raters’ experiences of conducting the neighborhood observations, the study raised important questions regarding the theoretical premises (such as social disorder) underlying much neighborhoods-and-health research. This study is the first to employ a qualitative component to SSO. This study demonstrates that U.S.-generated constructs are not readily adaptable to a Canadian context, and suggests other constructs that may be more appropriate to the Toronto setting. A final report will be complete in May 2008. This IRONhI component was supported by the CIHR Strategic Training Program in Health Research at the Centre for Research on Inner City Health (CRICH) and the Centre for Urban Health Initiatives (CUHI) at the University of Toronto.

b. Concept Mapping of Residents’ Experiences of Neighbourhood Determinants of Mental Health & Well-Being:
This project, like the previous one, was undertaken by the trainees (doctoral students and post-doctoral fellows) in the CRICH Strategic Training Program. We conducted concept mapping sessions in 5 of the 6 IRONhI neighbourhoods (all but Banbury-Don Mills) to determine residents’ perceptions and experiences of the neighbourhood factors most important for mental health and well-being. In concept mapping, specific data gathering activities are completed by each participant (brainstorming, sorting rating, diagramming) to fully represent each individual’s viewpoint while also incorporating group consensus. Qualitative and quantitative methods are used by creating a visual display of how the participants and the group as a whole conceptualize a particular topic. During the group, participants were asked to generate a list of items that described the “characteristics of your neighbourhood that can affect mental well being in a good or bad way.” Once all brainstorming was completed a list of all items was created. This list was edited to eliminate duplicates and consolidated like items. This final master list was used in the sorting and rating activities. Five sorting and rating group sessions, one in each study neighbourhood, of about 2- 4 hours in duration were held.  For the sorting task, participants were asked to place the 75 items from the master list into piles that “made sense to them” and label the piles accordingly. Specifically, participants grouped similar items together according to their own perspectives. After completing the sorting, each participant was asked to complete two rating sheets. The 75 items were placed on a sheet and were rated according to two areas of mental well-being. The data collection and analysis for this project is now complete and a draft manuscript will be available in May, 2008.

c. Rapid Small-Area Health Needs Assessment (Neighbourhood Health Survey): With funding from the Ministry of Health and Long-Term Care, we were able to conduct a survey in the four lower-income IRONhI neighbourhoods to determine baseline health status of those neighbourhoods as well as priority health and neighbourhood issues for residents. A 20-30 minute interview was prepared with the assistance of the Advisory Committee.

The project developed, pilot tested and evaluated a rapid assessment tool for small-area health needs. The tool (questionnaire) being studied has the potential equip LHINs and community-based health care providers and other decision-makers, providers and community groups in Ontario to use evidence to understand local health needs, to generate solutions that are appropriate to local conditions and to act on significant disparities in health and health care access between local communities within their jurisdictions.

The focus of the questionnaire is a rapid assessment of the general and mental health status of neighbourhood residents aged 18 and above, including resident-identified neighbourhood health priorities and specific health needs. Questions are primarily closed-ended – to produce comparable data describing health status and its determinants – but also include open-ended questions identifying neighbourhood health priorities and possibilities for targeted or participatory interventions.  The target length of the interview was 30 minutes, and the questionnaire is being conducted in person.

In September 2007 we began surveying randomly selected households in the four IRONhI neighbourhoods using the same block faces that were assessed using the measure of social and physical disorder (in project a, above). Prior to commencing the surveys, we sent leaflets to over 10,000 households to give advance notice of the study. In the following week, interviewers began knocking on doors to invite people to participate in the study. Our target was 300 interviews in each of the 4 neighbourhoods for a total of 1,200 interviews, however it has been much more difficult to recruit participants than we anticipated. As a result, we were only able to recruit 800 participants after 6 months of surveying, about four months longer than we anticipated.

Data analysis has consisted primarily of simple descriptive statistics, including means, medians, rates, and standard deviations for individual variables. Simple tests of association and significant differences between predictor variables and outcomes are being calculated, to test for example, the relationships between socio-economic factors such as age, gender, education and health status, as well as the association between risk factors and health status. Our report to the MOHLTC is in progress and should be available in June 2008). This project has been supported by a grant from the MOHLTC and by in-kind contributions from the Centre for Urban Health Initiatives (CUHI) at the University of Toronto.

• IRONhI Update: Since its proposal in the spring of 2006, IRONhI has completed three core neighbourhood projects: systematic social disorder observations, concept mapping of mental health and well-being and a neighbourhood health survey. It has supported the research of two University of Toronto Department of Geography graduate students which focused on issues of residential food production and the role of public space in the well-being of urban residents. IRONhI has provided research experiences for over fifty undergraduate students in various capacities. Furthermore, CUHI is currently supervising four University of Toronto Health Studies students who are using the data from IRONhI’s core projects for independent study projects. At least one of these student projects will focus on disseminating IRONhI results to community agencies and service providers in the studied neighbourhoods, providing valuable information on residents’ perceptions of health service delivery, self-rated health and their health priorities. Finally, a report based on findings from the neighbourhood health survey is being prepared for the Ontario Ministry of Health and Long- Term Care. Two presentations on IRONhI projects were given at this year’s International Conference on Urban Health in Vancouver.

5. The Role of the "Third Place" in Community Health & Well-being

Principal Investigator(s):  
Dr. Patricia Manuel (School of Planning, Dalhousie University)

Lead Community and/or Policy Partners:
Captain Williams Spry Community Centre Board; Chebucto West Community Health Board

Description:
“Third Places” are informal meeting places in neighbourhoods outside of home (first place) or work (second place): they may be coffee shops, parks, trails, streets, sidewalks, or the local post office.  Third places give residents opportunities to socialize, to learn about new ideas, to receive support from others, and to play, among other things.  They also help to define what makes a community unique. In general, third places are becoming scarcer and less accessible.

We suspect that third places play an important but poorly understood role in the health and well being of residents.  For example, the friendly conversation and play in third places lets people express themselves emotionally and physically, and helps to establish the social networks that build social capital.

To date, third places in Canadian neighbourhoods and their role in community health have not been explored in depth.  This study in the community of Spryfield, Nova Scotia, will examine third places and how residents use them. The study will also develop a method for a larger project to understand the role of third places in the health of residents, how policy may support including them in neighbourhoods, and the potential of using third places as community health indicators.

*Co-Funded by the Wellesley Institute

Project Summary Report

PowerPoint Presentation

6. Mapping the Attributes of the Church & Wellesley Neighbourhoods which Influence Tobacco Use Among Lesbian, Bi-Sexual, Transgender People

Principal Investigator(s):  
Dr. Gala Arh & Nadia Minian (Ontario Tobacco Research Unit, University of Toronto)

Lead Community and/or Policy Partners:
Ontario Tobacco Research Unit, University of Toronto

Description:
In Ontario, approximately 16 000 tobacco related deaths occur annually (OTRU, 2005). These deaths are preventable. While little is know about tobacco use among lesbian, bisexual, gay, transgender (LBGT) populations and the effects of tobacco control on these communities (Healthy People 2010, 2001), American studies have found higher rates of smoking in LBGT communities (Goebel, 1994; Skinner, 1994; Penkower, Dew, Kingsley, 1991; Arday, 1993). Using social network analysis, our proposed research project will explore the attributes of the urban Toronto Church and Wellesley neighbourhood which influence tobacco use among LBGT people.

In our study, we will map the attributes of the Church and Wellesley neighbourhood that facilitate tobacco use. We will ask the following questions: How is the social, economic and environmental attributes of the neighbourhood and its history facilitating smoking? What are the consequences? What is the effect of tobacco control, programs and services on LBGT individuals and our neighbourhood? The outcome of this research will describe interconnected factors influencing the health and wellbeing of LBGT communities thus, determining gaps in cessation, protection and prevention strategies for LBGT communities.  Understanding these relationships will support the development of tobacco control initiatives for LBGT individuals thereby improving the health of LBGT communities.

*Co-Funded by the Wellesley Institute

7. Examining Determinants of Health Among Immigrant Populations in the Dixie-Bloor Neighbourhood

Principal Investigator(s):  
Dr. Kathi Wilson (Department of Geography, University of Toronto Mississauga)

Lead Community and/or Policy Partners:
Dixie-Bloor Neighbourhood Centre

Description:
The proposed research is an exploratory study interested in examining those determinants of health that are most relevant to immigrant populations at the neighbourhood level. Working in collaboration with the Dixie Bloor Neighbourhood Centre (DBNC), serving a community in the City of Mississauga, this study will explore what factors immigrants perceive as being important for health in the local community. Individual interviews will be conducted with approximately 30 residents in the neighbourhood with the aide of the community partner. Results of the research will assist DBNC in future program planning and will help develop a larger research proposal to focused on the role of neighbourhoods in promoting or inhibiting health among immigrant populations.

*Co-Funded by the Wellesley Institute

8. Unlocking context: Operationalizing "Neighbourhood" in Urban Health Research

Principal Investigator(s):
Drs. Kathi Wilson, Sarah Wakefield, and Ferenc Csillag (Department of Geography, University of Toronto)

Description:
A large amount of urban health research and policy focuses on the role of neighbourhoods. This reflects a growing interest in understanding the role that our local neighbourhoods play in shaping health. However, the growth of research in this area has not been accompanied by critical reflection on the theories and methods used to study the connections between neighbourhood and health. This research development initiative will help us understand and measure neighbourhoods better. In this project, we will review existing studies and speak with key researchers in the field, to determine how "neighbourhood" is being defined and measured in current research, and what the strengths adn weaknesses are of current approaches. We will identify the best approaches and techniques that are being used, and consider whether these can be readily applied to the Canadian context.  This research will be one of the first studies in Canada to examine in detail the best practices for defining and identifying neighbourhood characteristics that are meaningful for health.  The findings of the research will advance neighbourhood and health research at local, national and international levels. 

9. Children’s Perceptions and Understanding of Physical Activity in Their Neighbourhood

Principal Investigator(s):
Dr. Nicholas L. Holt (Faculty of Physical Education and Recreation, University of Alberta) and Dr. John C. Spence (Faculty of Physical Education and Recreation, University of Alberta) 

Lead Community and/or Policy Partners:
Alberta Centre for Active Living and Capital Health Authority

Description:
Fewer than half of Canadian youth aged 5 to 17 are sufficiently active for optimal growth and development (Craig et al., 2001). Childhood inactivity represents a major public health concern, and there is an urgent need to increase children’s physical activity levels. In response to this situation, this study will examine connections between urban and suburban school children’s perceptions of their local environment and their understanding of physical activity. Using a novel research approach, children will be asked to create ‘concept maps’ about what they think about physical activity. They will then be asked to draw ‘mental maps’ of their local neighbourhood, focusing on the places in their neighbourhood where they can be physically active. These data will help provide children with a voice influencing possible changes in the provision of physical activity resources.

View the PDF of "Neighborhood and developmental differences in children’s perceptions of opportunities for play and physical activity".

10. Concept Mapping Neighbourhood Effects on Mental Health and Establishing the Validity of Collecting Data on Residential History  

Principal Investigator(s):
Dr. Patricia O’Campo (Centre for Research on Inner City Health, St. Micheal’s Hospital) 

Lead Community and/or Policy Partner:
South East Toronto Project (SETo)

Description:
Ample evidence documents disparities in mental health and well-being based upon socio-economic position. Emerging research suggests that context, and residential neighbourhood in particular, can influence the mental health of persons. Yet, the dearth of strong conceptual information describing how neighbourhoods might influence the mental health, including whether men and women or high and low income residents are equally affected, supports the use of qualitative methods as a good starting point to generating testable hypotheses for this area of inquiry. Therefore, we will employ concept mapping to obtain information from those with ‘lived experiences’ about which neighbourhood factors are important for mental health as well as how those neighbourhoods characteristics influence the mental health of residents. As a second activity in this project, we will validate methods for collecting information on residential history as accurate information on residential history will advance the research agenda on neighbourhood effects on health.

11. Using Observational Data to Study Neighbourhood Effects on Health: Evidence from Pilot Studies in Toronto and Baltimore 

Principal Investigator(s):
Dr. Blair Wheaton (Dept of Sociology, University of Toronto) and Dr. Patricia O’Campo (Centre for Research on Inner City Health, St. Micheal’s Hospital) 

Lead Community and/or Policy Partner:
South East Toronto Project (SETo)

Description:
This proposal focuses on the utility of observational measures of neighbourhoods, focusing especially on neighbourhood resources, climate, and disorganization, as part of a set of pilot studies intended to establish the feasibility of a multi-method Toronto Area Survey of neighbourhoods and health. We propose analysis of two existing data sources, each of which contains observational measures, to assess links to general health status and mental health indicators. The 1990-1991 Toronto Study of Mental Health and Stress is a longitudinal study of 1206 adults 18-55 in the Toronto urban area, and includes both depression and anxiety scales and DSM-III-R lifetime and “current” diagnoses, as well as neighbourhood observation by interviewers. The Baltimore Schools Study is a study of 400 children and their families in Baltimore, including systematic neighbourhood observation surrounding each child’s residence. The primary goal is to assess the importance of observationally derived measures of neighbourhood as predictors of overall health status and mental health, over and above widely used Census-derived neighbourhood measures. In addition, we will assess inter-rater reliability within neighbourhoods.

12. Using Secondary Data to Understand Area-Level and Individual-Level Factors in Depression  

Principal Investigator(s):
Dr. Richard Glazier (Centre for Research on Inner City Health, St. Micheal’s Hospital) and Dr. Blair Wheaton (Dept of Sociology, University of Toronto) 

Lead Community and/or Policy Partner:
South East Toronto Project (SETo)

Description:
The overall goal of this study was to determine whether there was random variation in depression across Toronto neighbourhoods. Several definitions of neighbourhood were employed for the City of Toronto in an effort to describe the variability in depression across these ‘neighbourhoods’.

The study used two cycles of the Canadian Community Health Survey (2000-2001 and 2003-2004, respectively).  Individual were allocated to neighbourhoods through postal code information. The final sample consisted of 4,669 people living in 494 census tracts, 140 neighbourhoods, and 41 local health planning areas in the city of Toronto. Variation in area rates of depression was described using descriptive statistics. Multilevel modelling was used to explore random variation in depression.

The prevalence of depression in Toronto was 6.92%, 5.06% for men and 8.73% for women. Census tract and neighbourhood were the most statistically meaningful definition of area (based on what criteria?). The mean proportion depressed across census tracts and neighbourhoods was 7.31% and 7.06% respectively. Multilevel analysis did not show statistically significant random effects.

There do not appear to be ‘neighbourhood’ random variation in depression in Toronto using currently available data. Depression is a low-prevalent outcome which presents a challenge in quantifying area effects. In areas that are sufficiently small to display differences in depression, it is difficult to obtain stable estimates of depression due to low numbers of respondents per area. Heterogeneity in depression may be masked with larger definitions of area.