Youth 4 Health Final Report by Cense

Youth4Health: A Youth Engagement Initiative for Newcomers to Canada and The Navigation of the Health System Final Report A partnership between: The Youth Voices Research Group & The People, Health Equity and Innovation Group Dalla Lana School of Public Health University of Toronto Toronto, ON Canada May 2011

Youth4Health: Final Project Report 1 – Executive Summary Youth4Health is a community-based research project that seeks to empower newcomer youth to become “health navigators”. Youth from recent immigrant families often serve as bridges between their households and their wider communities. Now, with the availability of powerful information and communication technologies, such as mobile phones, search engines and web-based social networks, there are unprecedented opportunities for youth to network in support of their families while connecting with other youth playing the same role. The cornerstone of the Youth4Health project is training in Youth Health Navigation, developed with our core partners FindHelp/211. Youth Health Navigation training aims to equip young people with the knowledge, skills, and resources they need in order to support their friends and families in navigating the Ontario health care and health promotion systems. Youth4Health worked with young newcomers in several diverse communities across Ontario, training them in health system awareness, with an emphasis on the social determinants of health, the roles and responsibilities of a health navigator, health promotion concepts, and awareness of available resources and tools that support health navigation. This training was built around the ‘Identify, Sensitize, Connect’ model of Health Navigation developed by our team, and described in more detail in Section 4 below. The Youth4Health training in Youth Health Navigation was delivered to 101 youth in three communities: St. James Town Toronto, Kitchener-Waterloo Ontario and London Ontario. Armed with this newfound knowledge, our highly trained Youth Health Navigators (YHNs) were then engaged in an eight-to-ten week program for further reflection, knowledge development and application of their skills. These reflection and action programs were focused around four complex health and social issues identified by newcomers as important to their lives: 1) food security and health equity; 2) mental health promotion and addiction; 3) wellness promotion for caner survivors and 4) university campus wellness. To address these topic areas YHNs were divided into five groups, which were co-facilitated by our team members along with our project partners the Centre for Addiction and Mental Health, the YMCA of Cambridge and KitchenerWaterloo, Waterloo Collegiate Institute, the Electronic Living Laboratory for Interdisciplinary Cancer Survivorship Research (ELLICSR), Green Thumbs Growing Kids, Conestoga College and Mind Your Mind. Following these in-depth training and reflection/action programs, YHNs were then empowered to take their newfound knowledge back to their peers and communities through a train the trainer approach. YHNs developed and delivered capacity-building workshops to a total of 349 young people and adults in settings like high school assemblies, community centers and student clubs. Train the trainer sessions focused on demonstrating the “Identify, Sensitize, Connect” model and engaging participants in roleplays and participatory exercises to build their capacity and skills around Youth Health Navigation. An interactive toolkit of resources to support Youth Health Navigation was also developed, to support the train the trainer sessions, and to build capacity in Youth

Health Navigation through social networks. The Navigate This! toolkit includes educational elements developed in partnership between youth and adults, including “The Basics” video on Youth Health Navigation, “The Navigators” interactive mental health trivia game, a Food Security video and game, a Youth Health Navigation field guide, and a YHN curriculum for teachers and educators. Throughout the project Youth4Health has relied upon the use of new technologies for social networking and information provision, along with citizen journalism approaches to health literacy and media production, through the use of educational video production and photo and video blogging. In particular, iPhones were used to support YHNs as they learned, reflected, acted and disseminated their knowledge. Popular social networking tools like Facebook, Twitter and YouTube were also extensively utilized to generate a project following. A dedicated project website, www.youth4health.ca, was created to capture the overall experience, allowing YHNs to share and support one another as they created the knowledge and identity of Youth Health Navigation. The content from youth4health.ca was then used to inform the development of the final Navigate This! toolkit, which is hosted by the youth social action network TakingITGlobal.org, and can be found at www.navigatethis.org. Over 10,000 people were reached through these social networks. Most notably, we received 8,400 unique visitors to our project websites, with a peak interaction time of 30 minutes and average page views of 5.8 pages/visit, indicating extensive engagement with the resources. The YHN model has proven to be extremely powerful as a way of engaging young people in leadership for community health, and meeting the needs of newcomers and others who have trouble navigating the health care systems. Youth participants were strongly committed to their role as navigators and found many empowering opportunities for applying their skills. A formal evaluation of the project found that the YHNs skills in relation to knowledge and self-efficacy increased significantly throughout the project. Youth4Health offers an ideal platform for the development of additional, cost-effective strategies aimed at reaching out to multicultural communities in Ontario. As a key recommendation for moving forward, a selected group of highly dynamic, innovative, and motivated YHNs could be supported in the creation of a social enterprise that would offer navigation and cultural interpretation services to both agencies and communities. YHNs would add a ‘proactive’, community-based, outreaching component to the often ‘reactive’ service model that many agencies, including information and referral services like 211, are currently based on. This social enterprise model would represent a way of supporting multicultural communities in Ontario and an opportunity for the human and professional development of young newcomers who are often at risk of becoming marginalized.

2 – Youth Health Navigation Training In partnership with FindHelp/211 Ontario, and in consultation with a number of key informants including leading public health doctors, professors, and researchers, Youth4Health developed a comprehensive Youth Health Navigation training curriculum. The training aimed to equip youth with the knowledge, skills, and resources needed in order to support their friends and families in navigating the health care and health promotion systems in Ontario. Core concepts and competencies were identified and explored in relation to the role of the youth health navigator to: “Assist others by empowering under-served populations to identify and better access quality health services. [Health Navigators] do this by creating connections within the community and helping people become more aware of the health related challenges they face and the opportunities for change.” Health Navigation Fieldguide

Capacity Build Figure 2.1: Health Navigation Model The ‘Identify, Sensitize, and Connect’ (ISC) model of health navigation formed the crux of the Youth4Health trainings. 1. IDENTIFY health challenges and opportunities for addressing health concerns, by establishing awareness and knowledge of particular issues, resources and services. 2. SENSITIZE by understanding and addressing difficulties related to stigma, fear, insecurity and lack of familiarity with the issues, resources and services that are available. 3. CONNECT by facilitating access to relevant health and social services, as well as empowering community members to identify and access resources on their own. By practicing the ISC model, Youth Health Navigators could build capacity in underserved populations by not only demonstrating how to identify, sensitize and connect, but also teaching others how to do so.

Macro and Micro Level Navigation Training Health navigation training was implemented in two phases. Phase One consisted of an in-depth “Macro” Navigation Training developed in collaboration with Findhelp/211 Ontario. This training was delivered to 101 youth participants throughout November 2010. Trainings were on average 3 hours in length, and consisted of three main components: 1. Canadian Health Care System: Understanding and effectively communicating how human services operate. 2. Health Promotion: Exploring concepts like the social determinants of health and health equity; Understanding the roles and responsibilities of a health navigator, including issues around safety, limits, and boundaries. 3. ‘Identify, Sensitize, and Connect’ Model of Health Navigation: Developing the capacity to identify health issues, being aware and sensitive to people’s culture and needs, and connecting others to appropriate health resources, services and tools. Table 2.1: Macro-Navigation Trainings Location/Agency # of Participants U4Change 17 Mind Your Mind ELLICSR Waterloo Collegiate Institute Total

13 17 54 101

Phase Two consisted of a series of “Micro” Navigation Activities delivered through a train the trainer approach by youth who had completed the “Macro” Navigation training and the subsequent 8-to-10 week of Youth4Health programmatic activities. Micro navigation trainings were conducted between February and March 2011, and were hosted for other youth and newcomer audiences within local schools, community centers, with partner organizations and institutions, and at the University of Toronto. Micro trainings mirrored the structure of the macro navigation trainings, however, were condensed into a 1 to 2 hour time frame. Micro trainings consisted of several core components:  Introduction: Navigators introduced themselves and the project  Training Videos: Video describing the ISC model and heath promotion concepts were screened  Activities: Navigators facilitated activities to demonstrate health navigation concepts including role plays or community mapping exercises  Conclusion: Resources, including the NavigateThis toolkit, were shared and discussed, and questions addressed

Table 2.2: Micro-Navigation Trainings Location/Agency

# of Participants

Athletic Centre Staff and Physical Activity Ambassadors Orphan Sponsorship program @ U of T Waterloo Collegiate Institute Assembly Scarborough Youth Resource Centre, Tropicana Youth Services U4Change East Metro Youth Services Marc Garneau Collegiate Toronto Public Health Youth Action Alliance

10 8 154 23

Total

15 16 93 30 349

3 â&#x20AC;&#x201C; Youth4Health Programmatic Activities 3.1 Food Security and Health Equity Food sits at the nexus between nutrition, culture, social wellbeing and human performance, and is both vital for human live and a medium to bring diverse groups together. In order to address issues of food security and health equity, the Youth4Health project engaged 11 youth with connections to the St. James Town community of Toronto, a highly diverse area comprised of a high proportion of newcomer and multicultural groups. Green Thumbs Growing Kids and the Wellesley Institute served as community partners for this phase of the project. Green Thumbs Growing Kids is an urban community gardening organization in St. James Town and this partnership enabled 8 youth participating in the project to also engage in hands-on gardening work. The Wellesley Institute is an urban health community based research organization. Three youth that were employed with the Wellesley Institute over the summer also participated in the food security project activities. Phase 1: Research and Gardening In this phase, youth participants explored the issues of food security and health equity through channels that included photo and video-based story telling, the writing of instructional how-to articles, and by blogging. These stories and writings were shared on the project website youth4health.ca. In addition to identifying issues through the above channel, 8 of the 11 participants also explored food security and developed hands-on gardening skills by facilitating community programming with partner organization Green Thumbs Growing Kids. Phase 2: Community Engagement In this phase, the 11 youth participants along with Youth Voices Research Group staff planned and delivered a community event to share their stories and writings with the broader St. James Town community on August 25th 2010. Activities ranged from sharing content the youth developed over the summer to accessing feedback from community members on the topics of food security and health equity. Table 3.1 Food Security Activities Activity Description iPhone Navigation A workshop was conducted by mobile service providers building capacity for the use of iPhones for Youth Health Navigation. Navigators also used iPhones to document their experience with food security through photo, video and blogging, which were uploaded to the youth4health website. Photovoice A photography technique for community engagement, empowering participants to take photos and engage in critical analysis on the issues they represent. Consciousness Throughout the 6-week project, various educational activities Raising Activities were facilitated to raise awareness about the issues of food security and health equity. Some activities included a group debate themed around the social determinants and inspired by a news article, two videos on food production and an interactive activity on the food system. Community Facilitation of gardening programs with children and adult Gardening community members, during school hours an evening drop-in.

3.2 Mental Health Promotion Mental health and addiction were identified early on in the project as key areas of concern for newcomer populations, in particular in relation to stigma and lack of awareness around mental health issues and resources. To address issues of mental health promotion, the Youth4Health project conducted activities with the following partners: Centre for Addition and Mental Health (CAMH). By means of partnerships with (CAMH), 14 newcomer youth from the St. James Town community of Toronto were trained as Mental Health Navigators. These youth met twice weekly to explore the concepts of Youth Health Navigation in relation to mental health and their community. Programming began in November 2010 and ended at the end of January 2011, however additional micro-training events occurred throughout February. YMCA Kitchener-Waterloo and Waterloo Collegiate Institute. A partnership with YMCA Cross Cultural and Immigrant Services in Kitchener-Waterloo and Waterloo Collegiate Institute (WCI) has led to the development of Youth4Health programming with 54 newcomer youth in the Waterloo area. These 50-plus students from three local Waterloo high schools met every Monday after school to explore Youth Health Navigation with a focus on mental health. In total, 12 weeks of programming occurred from November 2010 to February 2011. Mind Your Mind. Working in partnership with mindyourmind.ca, a community-based organization focused on youth mental health issues, a two-weekend intensive workshop was held in London, Ontario between November 12th and 28th, 2010. The workshop was conducted with 13 young newcomers ages 15 to 29 from Southern Ontario. These Youth Health Navigators designed web-based health promotion tools and interactive resources to be used by other young newcomers to Ontario for the purposes of health navigation training and education. Table 3.2 Mental Health Promotion Activities Activity Description Guest Speakers

Role-Playing Exercises Photovoice Site Visits Design Charette

Speakers from CAMH discussed concepts of mental health, specific topics such as addiction, mental illnesses and stigma. Included youth who have lived experience with mental health. Other broader topics were discussed such as “stress, race and culture” and “the psycho-social construction of hip hop”. YHNs were given role-play scenarios and asked to act out scenes based on stereotypes surrounding mental illness. A photography technique for community engagement, empowering participants to take photos and engage in critical analysis on the issues they represent. Visits to mental health services, including the emergency room at CAMH and the Gerstein Centre. Conducted with the Mind Your Mind group, this was an activity that involved learning, critical reflection and then intense design and development in order to create materials addressing stigma around mental health. Results were incorporated into the NavigateThis! toolkit, discussed in Part 5 of this report.

3.3 Wellness Promotion for Cancer Survivors The concept of Health Navigation, which the Youth4Health project is based upon, grew out of the field of cancer care and survivorship. Health Navigation is highly relevant to experiences in cancer care given the complex web of services and experiences that cancer patients must negotiate. In partnership with the Electronic Living Laboratory for Interdisciplinary Cancer Survivorship Research (ELLICSR), Youth4Health explored the ways in which Youth Health Navigators can support cancer patients. 7 Youth Health Navigators worked with ELLICSR to provide support to cancer patients at the Princess Margaret Hospital. In addition to the YHN training these youth received training in â&#x20AC;&#x153;Healing Beyond the Bodyâ&#x20AC;?, a Princess Margaret Hospital program that trains volunteers in information navigation and emotional support in the area of cancer survivorship. The ELLICSR YHNs were then empowered to provide direct support to cancer patients at PMH. Table 3.3 Cancer Survivorship Activities Activity Description Patient Education Network Environmental Scan Healing Beyond the Body and Roving Navigation

Blogging and Citizen Journalism

Orientation to the various resources available to cancer patients through Princess Margaret Hospital and ELLICSR YHNs conducted an environmental scan on approaches to patient engagement YHNs received training and then engaged in one to one interaction with cancer patients at Princess Margaret Hospital. YHNs were available on shifts throughout the hospital, and approached and/or were approached by patients to serve as supports and help them navigate the PMH experience and resources. YHN ongoing blogging and online journalism about their experiences on the project, posted to the youth4health website.

3.4. Campus Wellness In addition to the specific health issues of food security, mental health and cancer, a general approach to campus wellness was also identified as an important project pillar. This emerged through the Youth Voices Research Groups location within the University of Toronto, as well as our partnership with Conestoga College. The model of Youth Health Navigation has much to offer efforts to promote campus wellness, given the challenge in navigating the resource system on large diverse campuses. University of Toronto Campus Wellness 10 Youth Health Navigators (YHN) were recruited, all undergraduate university students from the University of Toronto, based on their previous experiences and accomplishments, both professionally and academically. The campus health navigators worked to identify key health issues in relation to to campus wellness for students, and developed an interactive map of health resources in and around campus.

Conestoga College Campus Wellness To create a supportive environment for newcomer students on campus, Conestoga College created the Students4Health project. The mission of the project is to build the capacity of immigrant students and their families to take charge of their health and mental well-being. To achieve this goal Conestoga recruited 3 student peer support leaders to serve as mentors who have gone through the immigrant experience. These peer support leaders facilitate group sessions where immigrant students can share success stories and raise issues for discussion. The group has also created the students4health website (www.conestogac.on.ca/students4health), which provides links to resources on campus and in the community, as well as an ‘Ask S4H’ function which allows students to get direct support from mentors. Table 3.4 Campus Wellness Activities Activity Description Issue Identification Community Mapping iPhone Navigation University of Toronto campus health map Conestoga College Students4Life website

Identification of key issues facing young people on campus. Issues identified include alcohol and drug consumption, sexual health, mental health, and food. Mapping of resources available to students on campus, including formal resources such as health and athletic centres, as well as “tips” for healthy and affordable food, social hubs, cultural activities and accessibility services. Utilizing iPhones to identify and document resources and services. Creation of an interactive map using the community mapping and iPhone data, pinpointing specific services on the University of Toronto campus in the areas of sexual health, mental health, food, general services and physical activity. A website dedicated to assisting students who are immigrants and their families to find support at Conestoga College and in the community. Students can connect with one another, identify important concerns, and find solutions.

4 – Youth4Health Social Media Strategy The Youth4Health social media strategy was developed as a guiding framework to facilitate online engagement of health navigators and their broader community, including their families and friends. The strategy was also developed to be malleable and adaptive to the rapidly evolving, complex, and emergent nature of the online social landscape. Social media platforms most popular and familiar to navigators such as Facebook and YouTube were utilized for the project in an effort to reach them online ‘where they were already at’. Although young people generally do not have a strong presence on Twitter, this platform was introduced to youth navigators as a novel way of blogging ‘on the spot’ and getting their message out rapidly, similar to text messaging – a ubiquitous activity amongst today’s youth. Various online tools were also used to facilitate engagement through social media platforms including CoTweet, Tweetie, iPhone Apps (e.g., Facebook, Twitter, etc.), and URL shorteners (e.g., bit.ly). The strategy aimed to engage with multiple agents (individuals and organizations) and embed social media generated content and communications into other online and offline project activities. Social media engagement was used in multiple ways:

1. Project Activities: Using social media platforms to inform the digital community of Youth4Health events, activities, products and tools.

2. Storytelling and Promotions: Using social media to craft and convey a narrative around the Youth4Health project through the use of project themes as well as a social marketing strategy to promote the NavigateThis Toolkit through an art and writing Youth Contest. A Twitter contest countdown and themed days on Twitter (e.g. “Artistic Monday”) also helped to consistently generate buzz. These are some examples of how social media was used to build-up an online story and link activities together for message delivery, content generation and building support within the Youth4Health community. 3. Communities of Practice: Social media provided the project with a means of organizing and supporting its activities. Communities within popular social networks including YouTube, Flickr, Facebook, and Twitter were fostered over the duration of the project.

Figure 4.1 Content flow through social media channels

Statistics: Online Engagement Statistics for all social media platforms and websites were monitored using evaluation tools including Google Analytics or internal metrics provided by the platform itself (e.g., Facebook Insights, Twitter statistics, etc.). Statistics below are reported for online interactions during the project period, June 1, 2010 â&#x20AC;&#x201C; March 30, 2011. WEBSITES Table: Statistics from Youth4Health project websites Metric Youth4Health.ca NavigateThis.org YouthVoices.ca

Total

Pageviews*

28,336

Absolute Unique 1,681 Visitors**

2,177

24,932

55,445

883

5,836

8,400

*Pageviews indicates the total number of pageviews for your site when applied over the selected dimension **Absolute Unique Visitors indicates how many people came to the website Average Time and Pageviews The average time users spent on the Youth4Health.ca website was 6:31min between November 1, 2010 and March 30, 2011, with a peak visitation time of 31:23min, midprogram. These statistics illustrate that users were interacting extensively with the website, in prolonged exchanges that likely indicate meaningful interaction. As well the average pageviews were 5.8 pages/visit, indicating that users were viewing and absorbing numerous types and levels of content.

FLICKR Table: Views on Youth4Health Flickr Stream Metric Total Number of Uploads

120

Total Views

1,021

TWITTER Table: Statistics from Twitter accounts Metric Youth4Health Youth Voices (@youth4health) Research Group (@yvresearch) Tweets 1,098 818

Food4Health (@Food4Health)

Following

Followers

266

330

341

Listed

698

YOUTUBE Table: Views on Project YouTube Channels Metric YouthVoicesResearch

Youth4Health

Channel Views

908

454

Total Upload Views

10,103*

1,980

*Total upload views for YouthVoicesResearch channel between June 1, 2010 to March 30, 2011. Total upload views ever is 15,162. FACEBOOK Table: Statistics from Facebook Fan Pages Metric Youth4Health Number of Likes

333

Youth Voices Research Group 64

Total

Post Views*

59,948

4,386

64,334

Post Feedback**

607

656

397

*Post Views The number of times people (Fans and non-Fans) have viewed a News Feed story posted by your Page. This data corresponds to 06/01/2010 - 03/28/2011. **Post Feedback The number of likes and comments made on News Feed stories posted by your Page. This data corresponds to 06/01/2010 - 03/28/2011.

5 – NavigateThis! Health Navigation Toolkit The culminating output on the Youth4Health project is the NavigateThis! Toolkit. This toolkit was developed using the learning and outputs from the various project activities described above. The toolkit is housed at NavigateThis.org and is powered by Taking IT Global (www.tigweb.org), an organization that facilitates global education, social entrepreneurship, and civic engagement for youth worldwide. The components of the toolkit offer users a self-directed journey through concepts and resources related to Youth Heath Navigation. The site was designed for young people, particularly newcomer youth, interested in learning more about the concept of Health Navigation and seeking health promotion resources. Tools available on NavigateThis.org have a special focus on issues related to mental health, campus wellness, and food security. Web-based Education Tools NavigateThis.org visually maps out three main Health Navigation modules that contain web-based education tools that aim to teach and measure core Health Navigation competencies. In completing all three modules, users earn their Taking IT Global “NavigateThis!” badge on their personal profile page. These tools are further detailed in Table 5.1. Table 5.1 Web-based education tools available on NavigateThis.org Tool Resource Partners Involved in Description Type Tool Development ‘The Basics’ Video and FindHelp/211 ‘The Basics’ is a video outlining the Video & flash-based Ontario core concepts of the ISC model of Game matching card health navigation. Users play a followgame up matching card game to test their knowledge on core health navigation concepts described in the video. ‘The Flash-based mindyourmind.ca ‘The Navigators’ is a mental health and Navigators’ trivia game health navigation trivia game created Trivia Game by youth for youth. Food Security Video and East Metro Youth ‘Food Security and Health Navigation’ Video & flash-based Services Food is a short documentary highlighting Game matching card Share Meal food issues affecting Ontarians game Exchange The Stop through a series of interviews with individuals and organizations working in the area of food security. Users play a follow-up matching card game to test their knowledge on core health navigation and food security concepts described in the video.

Viewable/Downloadable Resources The second series of tools in the Y4H toolkit, viewable and downloadable health navigation resources, serve as online reference guides and assets for users interested in health navigation. These tools are listed items in a “Legend” on NavigateThis.org, and

aim to complement and help users navigate through the main modules. These tools are further detailed in Table 5.2. Table 5.2 Health Navigation Tools available through NavigateThis.org Tool Resource Type Partners involved in Description Tool Development Campus Map URL link to Hart Hart House, UofT Interactive map of health House website services at St. George Campus, University of Toronto Field Guide Downloadable FindHelp/211 Ontario A comprehensive guide on PDF health navigation for youth Curriculum Downloadable FindHelp/211 Ontario A guide for educators on health PDF navigation with classroom activities What? Pop up interactive mindyourmind.ca Interactive art piece Interactive challenging mental health stigma with positive mental health messaging in multiple languages Health Equity Pop up Vimeo N/A Video on the social Hero! video determinants of health Youth4Health URL link to Taking IT Global Social tools to connect to the Blog project page online Taking IT Global community interested in health navigation Resource List List of resources N/A Health Navigation resources and services Social Network Social tools, including a blog reel, photo gallery, and discussion boards, are available through the NavigateThis.org project page (http://projects.tigweb.org/youth4health). These networking tools have enabled for the creation of an online space for a community of young people interested in learning about, practicing and discussing health navigation.

6 – Key Project Findings and Recommendations 6.1 Youth4Health Navigator Evaluation Quantitative Project Outcomes A survey was administered to macro-navigator participants at three time points during the youth navigator training program: prior to the first navigator training session (T1), following the first training session (T2) and following the final training session (T3). The objective of the survey was to evaluate knowledge and confidence gained from the Youth Health Navigation training program. Table 6.1 Participant Characteristics Participant Characteristics

(n = 26) N

Age, mean ± SD 26 Years Sex Male 10 Female 16 School Enrollment 23 Years lived in Canada 26 ± SD Citizenship Status Immigrant 1 Landed Immigrant 2 Canadian Citizen 23 Continent of Birth North America 8 North Africa & Middle 5 East Asia South Asia 7 East Asia 5 Caribbean 1 Language Spoken at home English 9 Other 17

Value 20.0± 2.7

38.5 61.5 88.5 15.0± 4.4

3.8 7.7 88.5 30.8 19.2 26.9 19.2 3.8

34.6 65.4

6.2 YHN Knowledge and Self-Efficacy Development Knowledge Knowledge constructs significantly increased over the course of the training program. At baseline, participants reported knowing little about the Canadian health system, social determinants of health and informational and referral services. In contrast, students reported a higher baseline understanding of using online resources. After the first training session, participants reported significantly greater knowledge in all areas of the training program. After the final training session, knowledge constructs also grew but non-significantly. Self-Efficacy Self-efficacy (e.g. confidence) to be a community navigator followed a similar trend to knowledge constructs and significantly increased over the course of the training program. Participants reported high confidence at baseline. This confidence increased significantly after the first (88%) and final training session (92%). Qualitative Project Outcomes Focus groups were conducted with all macro-navigators to examine their experiences with the project, and explore personal and community impacts. Full academic analysis is still under way, but below are a few of the high level findings. Overview of the Project Experience Overall, participants considered Youth4Health to be a highly worthwhile experience. Participants felt valued and well-supported and expressed high regard for the project team. Many felt that the project had been intellectually and socially stimulating, and had fostered personal growth and professional opportunity and aspiration. The project had also engendered a greater understanding of the social determinants of health and had motivated many to approach daily life with a greater sense of mindfulness about the needs and circumstances of others. Moreover, Youth4Health also impacted some participantsâ&#x20AC;&#x2122; thinking about their future career choices and had led others to approach their chosen discipline with an enhanced sense of the human side of healthcare and health promotion. Many participants found the experience to be transformational and believed it would continue to impact their lives for many years to come. Impact of the Program on Participants Most participants felt that they had experienced considerable personal growth including a broadening of social perspectives, improved communication skills and greater personal confidence as a result of being in the program. There was also a widely-shared feeling that the program had enhanced their professional prospects by providing relevant practical experience and training related to health, and by allowing them to explore aspects of health promotion they had not previously considered. The sense of camaraderie within the groups was extremely strong and the personal relationships forged through the course of the project were clearly highly valued and likely to continue. Impact of the Program on the Wider Community With the exception of the ELLICSR group, (who had direct contact with patients), and groups who had made formal presentations at schools, at the time of interview, the impact of the program on the wider community was largely limited to informal sharing of information with family members, classmates, teachers and friends. While these

interactions are integral to the role and should not be undervalued, there was a discernible sense of frustration, amongst some participants, that the project had not allowed for more direct and more structured interaction with the wider community. This said, some of the most highly motivated participants were making plans to continue activity beyond the end of the project, for example, by forming campus-based groups and by approaching community centres in newcomer neighbourhoods. Social Media Component (blogging) Not unexpectedly, some participants were enthusiastic about this component while others found writing to be a chore or struggled to find topics to blog about. Participants who enjoyed the blogging described it, most often, as a space for deeper reflection, and as a forum to give and receive support within their group. Two concerns about the blogging component were also raised. First, several participants felt that the inflexible format had limited their engagement with the medium because the aesthetic dimension was important to them and they were unable to alter the appearance of their work. Second, there was widespread disappointment at the fact that the blog was not fully accessible to people outside the project since this severely limited opportunities for wider community engagement and impact. 6.3 Key Project Findings Youth Health Navigation The YHN model has proven to be extremely powerful as a way of engaging young people in leadership for community health, and meeting the needs of newcomers and others who have trouble navigating the health care systems. Youth participants were strongly committed to their role as navigators and found many empowering opportunities for applying their skills. Some quotes from our navigators: “When my friend was stressed out for her exam because she has a lower average she was worried that she might fail and have to take the course again. When I knew the problem, I talked to her and calmed her down. And I gave her information about the YMCA because they have a helper to help you with any kind of subject that you have in school and they help you prepare for their quiz, test and exam.” “I've never learned so much about mental illness, and health resources, as much as I've had while working for this project; As a Youth Health Navigator I can help newcomers who are struggling to find a suitable resource. It’s a rewarding experience.” “After Youth4Health, I see myself as a navigator still. I believe that the things I learned during this project isn't just limited to this short 8 weeks but throughout the rest of my life. Being a navigator isn't just a job, but a role that one can play as a student, friend, stranger etc. Helping others is what we should do and a trait that we should practice on throughout our lives.” Community Partnerships Community partnerships were critical to the successful completion of the project. Working from the strengths, credibility and visibility of partners in the local community enabled for a sustainable model of youth engagement. Overall the partnerships were

very successful, however certain aspects of planning could have been strengthen by increased communication at the planning stages of this project. Some youth identified that the programming between both partners was too disparate and disconnected. In order to maximize the opportunities to share resources, practices, and ideas a similar project in the future might benefit from integrating programming between two or more partners as one unified program. Mentorship Youth looked up to various mentors on the project, from YVRG personnel to community partners, who were clearly key motivators and important sources of knowledge and support. Community Action YHNs reported their experiences in the community/with hands on action to be some of the most meaningful throughout the program. Site visits, interactions with cancer patients, presentations to peers, etc. were consistently identified as highlights. This demonstrates the critical importance of having ‘real life’ experiences to contextualize the learning done in a ‘class room’ setting. Sometimes the lack of direct action was a challenge, as the project timeline did not allow for many formal opportunities for young people to apply navigation skills, but instead focused more on training and train the trainer approaches. Moving forward it would be useful to establish such opportunities. Social Determinants of Health The focus on social determinants of health and looking at health holistically and as a continuum was an important learning experience for the YHNs, and also allowed to address critical issues such as stigma, inequity, etc. In-depth Critical Reflection YHNs benefitted from activities to stimulate issue-based discussions, readily share information, and the ability for youth participants to share their completed products with other members of the team thereby sparking thought-provoking dialogue about the complex issues of food security, mental health and cancer survivorship. Participatory Research Overall, the opportunities to meet and create research products together were described by many youth at the completion of the project to be a positive experience. In this vein, while facilitators sought to create opportunities for youth participants to complete their research products (e.g.: take videos/ photos) on their own time outside of group meetings, several research participants preferred times when work was completed in a group environment for the opportunities to build discussion and create a team identity. Power of Visual Methods The Photovoice process used to analyze photos and videos offered a frame for the Youth Health Navigators to develop narratives to critically reflect on the issues under investigation. Social Media Equipping Youth Health Navigators with the skills and technology to create media based projects was essential to the project. The availability of iPhones and laptops facilitated blogging, photos and videos, and accessing social media for reflection and dialogue.

While social media functioned as a great asset to the project there were some challenges. It is interesting to note the finding that macro-navigators felt limited by the fact that the others were not permitted to join in the project blogging. Only macronavigators were permitted to blog, others could view the blog but could not post their own blogs or comments. This was due to concerns over online safety, given the sensitive topics under discussion, in particular mental health. The decision was made to limit the blogging to macro-navigator participants, as the project team was not equipped to deal with any disclosures of mental health concerns that might arise from strangers with whom we were not able to follow-up. This duty of care issue is one that must be taken into consideration when developing any long-term social media strategies of this nature. The balance between engaging with wider networks, while maintaining duty of care is a sensitive one. Online Engagement Use of an online social network (youth4health.ca) enabled youth health navigators to document their ideas, experiences and reflections before, during and following their programmatic activities. This network allowed for ongoing engagement, deepening of youth dialogue around issues of health navigation, and encouraged conversation, relationship building, and sharing amongst users involved in different Youth4Health projects from across Ontario. Furthermore, the use of multiple online social platforms including Twitter, Facebook, YouTube and Flickr for project outreach and dissemination purposes were found to strengthen communications and relationships between Youth4Health and its partners, supporters, and staff, and foster new and exclusive digital relationships with users and groups that would not have otherwise interacted with Youth4Health. Safety At the beginning of the project, YVRG and the Youth Health Navigators agreed to adhere to a set of guiding principles or ground rules to ensure all participants had a safe, fun and valuable experience. A key rule was the need to limit navigation to family and friends, due to the myriad of concerns that could arise if navigators were to approach strangers. This was an important boundary to articulate. As well, within the Y4H website, given that some students and youth were expressing sensitive content online, it was necessary for the Y4H team to establish a protocol for responding to youth concerns posed online and for reporting these instances internally. Incentives Participation in this project was an employment opportunity. This may have assisted in motivating the Youth Health Navigators to regularly complete their tasks. Context The application of health navigation must be considered within a local context. In addition, to sharing information in a linguistic way that is appropriate for this group, it is important to consider how the barriers that newcomer youth face relating to health and otherwise might impact how they apply their health navigation skills. In other words, cultural and local contexts should be considered when providing training to youth on health navigation.

School Context The Waterloo program was unique in that it involves all high school students who are meeting within the school environment. Going forward it will be interesting to consider how the practice of health navigation might be facilitated by young people within the social and geographic context of a high school.

7. Recommendations and Next Steps Formal Opportunities for Applying Navigation Skills The timeline and focus of the Youth4Health project has been on developing and a conducting training program on Youth Health Navigation. Through the projects 8-week programming YHNs were also able to explore and apply these skills. However youth participants were also eager for more formal opportunities to apply their skills. Having a space where YHNs are recognized and able to formally practice navigation would be a powerful way to move forward with this programming. Institutionalizing Navigation Following from the recommendation above, it would be very powerful to link navigation as a role within a specific institution or site. Potentials for this include the “roving navigators” program currently being discussed by Princess Margaret Hospital, as well as the idea of a navigator-related job or placement within a community and/or health setting. Focus on Social Determinants of Health The emphasis in this project on the social determinants of health was a particularly effective way of approaching issues around accessing and navigating complex health services. By looking at social determinants like food security and mental health stigma a broader understanding can be achieved of the nature of the challenges around health navigation. Future health navigation programs should consider this approach. Use of Mobile and Social Media The broad net of social media used on this project was a strong asset. The use of iPhones to document and explore resources was particularly effective. One participant likened the use of the iPhone to the idea of having “GPS in your head”. Mobile technologies like smart phones and portable computers can act as significant supports for information and navigation. Coupled with the use of social media, these technologies allowed for a great deal of knowledge development, reflection and dialogue/outreach. Entrepreneurial Opportunities Youth4Health offers an ideal platform for the development of additional, cost-effective strategies aimed at reaching out to multicultural communities in Ontario. A selected group of highly dynamic, innovative, and motivated YHNs could be supported in the creation of a social enterprise that would offer navigation and cultural interpretation services to both agencies and communities. YHNs would add a ‘proactive’, communitybased, outreaching component to the often ‘reactive’ service model that many agencies, including information and referral services like 211 Toronto, are currently based on. This social enterprise model would represent, at the same time, a way of supporting multicultural communities in Ontario and an opportunity for the human and professional development of young newcomers who are often at risk of becoming marginalized.