Sense of place and mental wellness of visible minority immigrants in Hamilton, Ontario: revelations from key informants.

Agyekum, Boadi ; Newbold, K. Bruce

Abstract

This paper explores key informants' revelations on immigrants' sense of place and mental wellness in Hamilton, Ontario, directed toward processes and programs that challenge belongingness and integration. Grounded in key informant interviews, our analysis underscores the importance of understanding immigrants' sense of community, belonging embedded in socioeconomic conditions, and implications on mental wellness. It is proposed that settlement service providers and other stakeholders adopt a broad and multifaceted approach that recognizes the importance of addressing immigrants' conditions in a holistic manner. This could be achieved by focusing on policies that affect all determinants of health (including mental health) through the integration of public policies into a comprehensive package of health improvement and promotion strategies, and should be incorporated into policies of health and health-related institutions for implementation.

Resume

Ce papier explore les indicateurs importants des revelations sur le sens du lieu et de la sante mentale a Hamilton, en Ontario, orientes vers des processus et des programmes qui remettent en question l'appartenance et l'integration. Fondee sur des entrevues avec indicateurs specifiques, notre analyse met en exergue l'importance de comprendre le sens de la communaute chez les immigrants, leur appartenance renforcee a des conditions socio-economiques, et leur implication dans la sante mentale. On propose ainsi que les pourvoyeurs des services d'etablissement et d'autres parties prenantes adoptent une approche plus globale et multiforme, qui reconnaisse l'importance d'aborder les conditions des immigrants de maniere holistique. Ceei pourrait etre fait en mettant l'accent sur les politiques qui affectent tous les determinants de la sante (y compris la sante mental), a travers l'integration des politiques publiques dans le dispositif global de l'amelioration de la sante et des promotions strategiques, et qui devraient etre incorporees dans les politiques de la sante ainsi que dans les institutions reliees a la sante pour leur realisation.

INTRODUCTION

Like many developed nations, immigrants represent a significant proportion of the total population (approximately 20.6%) of Canada (Statistics Canada 2011). Immigrants go through rigorous health screening to ensure that they are healthy before they are admitted, with immigrants having a relative health advantage over the general population, a common phenomenon known as the 'healthy immigrant effect' (i.e., Ali 2002; McDonald and Kennedy 2004; Newbold and Danforth 2003). However, the health of immigrants has been observed to deteriorate within a few years of arriving in Canada, with the decline in immigrants' physical and mental health said to be the result of pre-migration, migration and post-migration stressors associated with acculturation, barriers to health care, and/or changing diets (Pumariega et al. 2005; Dean and Wilson 2010), suggesting that there are factors within the host society that negatively affect the health of immigrants (McDonald and Kennedy 2004; Newbold 2005; Ali 2002; Ng et al. 2005).

Most research on immigrants' health has focused on post-migration factors of health, presumably due to a lack of data on pre-migration and migration experiences of immigrants. While Canadian scholars have given considerable attention to immigrants' physical and mental health in the context of an increasing number of immigrants from non-traditional source countries and by examining themes such as the 'healthy immigrant effect' and acculturative stress (Newbold 2005; Ng and Omariba 2010; Khanlou 2009), it is only recently that researchers have begun to explore the relationship between sense of place (often referred to as sense of belonging, sense of community, community belonging, and/or place attachment) and its implication on mental wellness amongst immigrants (Williams and Kitchen 2012; Kitchen et al. 2012). Research in these areas have shown that immigrants who rated their sense of place as 'positive' were more likely to say that their physical/mental health was excellent/very good (Williams and Kitchen 2012; Kitchen et al. 2012; Wilson et al. 2004). A recent study in Hamilton, Ontario found that immigrants in general were more likely to rate their sense of place lower than their Canadian-born counterparts (Gallina and Williams 2014). Their study disagrees with a past study in Hamilton on the evaluation of sense of place between immigrants and Canadian-born individuals, which did not show any clear pattern (Williams et al. 2010; Williams and Kitchen 2012), suggesting that greater attention is needed to nurture immigrants' connection with their new home. To be sure, some of the implications of these trends for immigrants' health are commonly alluded to but rarely examined with empirical evidence from the perspective of immigrant resettlement workers and other stakeholders. This study builds on previous studies in Hamilton by identifying resettlement stressors that impede on health, and the personal and social resources that promote a sense of community belonging amongst immigrants to help harness the rich experiences and expertise that immigrants bring to Canada.

The aim of this paper is to develop new insights regarding concepts of sense of place and mental wellness in health geography, highlighting the personal and social resources that promote a sense of community belonging. This exploratory study is not meant to identify causal relationships between sense of place and mental wellness, but rather, to shed light on the services and programs that are likely to promote immigrants' (including refugees) sense of place or community belonging, which is a prerequisite for positive mental wellness.

LITERATURE REVIEW: SENSE OF PLACE AND MENTAL WELLNESS

Sense of place is a multidimensional and contemporary concept (Lengen and Kistemann 2012) that encapsulates geographical place, social community or environment and is embedded with psychoanalytic meaning (Williams and Kitchen 2012). It is sometimes also referred to as sense of belonging (Kitchen et al. 2012; Hagerty and Williams 1999; Ma 2003; Choenarom et al. 2005; Bailey and McLaren 2005), sense of community (Bathum and Baumann 2007), community belonging (Ross 2001), and place attachment (Hidalgo and Hernandez 2001). The literature that follows will use these terminologies interchangeably.

The Dictionary of Human Geography (2009) defines sense of place as "the attitudes and feelings that individuals and groups hold vis-a-vis the geographical areas in which they live. It further commonly suggests intimate, personal and emotional relationships between self and place" (Wylie 2009, 676). Earlier on, Agnew (1987) and Altman and Low (1992) argued that sense of place emanates from places that develop from emotions related to experience and are composed not only of physical elements, but also of activity, meaning and place attachment. These places are locations (Cresswell 2004) and zones of experiences and meanings (Wilson et al. 2004), which influence how we think, the course of our life, our consciousness, our social structures, and our health and wellbeing (Lengen and Kistemann 2012). Place is therefore defined as any locality or space that has become imbued with meaning by human experience in it (Tuan 1977).

In recent decades, place has come to be understood to mean different things to different populations. For instance, Williams (1999) noted that people have certain places that they interact in and invest with meanings including peace, relaxation, rejuvenation, restoration and/or some form of physical, mental and/or spiritual healing. Furthermore, Williams (1999) posits that environments that have a strong sense of place can promote the maintenance of health and wellness. Contributing to the link between place and health, Williams noted that a positive sense of place can also create therapeutic landscapes in other locations, most obviously the home, which "without exception is considered to be the 'place' of greatest personal significance in one's life--the central reference point of human existence" (Williams 2002, 145). These environments that promote individuals' and groups' sense of place have also been observed to influence people's physical and mental wellness (Kitchen et al. 2012; Bathum and Baumann 2007) at the individual, intermediate and systemic levels (Ng and Omariba 2010; Khanlou 2009; Wu and Schimmele 2005).

Amongst immigrants, it may be that a positive sense of place encourages mental wellness. Understanding immigrant mental wellness is fundamental to Canada's immigration policy as it relates to general measures of population health. It also adds to our understanding of the costs and benefits of Canada's immigration policy. According to the World Health Organization (WHO 2007), there is no health without mental health. Mental health therefore refers to a broad array of activities directly or indirectly related to the mental wellbeing component included in the World Health Organization's (WHO) definition of health: "A state of complete physical, mental and social wellbeing and not merely the absence of disease." It is the foundation for wellbeing of individuals, families and communities (WHO 2001). The WHO defines mental health as " ... a state of wellbeing in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community" (WHO 2007, 1).

Mental health, like physical health, is determined by a number of social, psychological and biological factors known as the determinants of mental health. The WHO's Ottawa Charter for Health Promotion determined that the fundamental conditions and resources for health, including mental health, include peace, shelter, education, food, income, a stable ecosystem, sustainable resources, social justice and equity (WHO 1986). The determinants of mental health are often discussed in terms of risk factors and protective factors. Risk factors increase the probability that a particular individual or group of people will develop a mental disorder; they can also worsen the burden of an existing disorder. Protective factors moderate the impact of stress and reduce the likelihood of mental health problems (Commonwealth Department of Health and Aged Care (CDHAC 2000)). Indeed, one protective factor often discussed is the self-selection process where it is the physically and financially sound individuals who have the ability to withstand the rigours that migration entails (Ng et al. 2005; McDonald and Kennedy 2004). On the other hand, the decline in immigrant physical and mental health with increasing years in Canada is said to be the result of pre-migration, migration and post-migration stressors (Pumariega et al. 2005; Dean and Wilson 2010), with the latter suggesting that there is something within the host society that negatively affects the health of immigrants (McDonald and Kennedy 2004; Newbold 2005; Ali 2002; Ng et al. 2005).

Research that has focused on pre-migration stressors often recognizes that immigration itself can be a lengthy and stressful process that can lead to increased risk for emotional disorders in newer immigrants (Pumariega et al. 2005; Stafford et al. 2010). The pre-migration stressors according to Pumariega et al. (2005) include previous traumatic exposure such as terrorism, torture, war, famine and natural disaster; detention in refugee camps for extended periods; illegal immigration, and loss of extended family and kinship networks (Pumariega et al. 2005; Kirmayer et al. 2011; Beiser 2009). The migration stressors are often discussed around exposure to harsh living conditions (e.g., refugee camps), exposure to violence, disruption of family and community networks as well as uncertainty about the outcome of migration (Kamperman et al. 2007; Lindert et al. 2009; Kirmayer et al. 2011). Lastly, research that has focused on characteristics of the host society that influence mental and physical health of immigrants discusses the lack of access to health care, difficulties in language and language learning, concerns about family members left behind and the possibility of reunification, and the acculturation process as the main determinants of immigrant health (McDonald and Kennedy 2004; Newbold 2005; Dean and Wilson 2010; Stafford et al. 2010; Kirmayer et al. 2011). Following these studies on immigrant mental health, a study by the Centre for Research on Inner City Health (2012) in Toronto found that fewer immigrants received treatment for depression despite similar levels of depression symptoms among immigrants and Canadian-born participants. The study also found that recent immigrants were half as likely to have taken prescription medication for a mental health problem, and non-recent immigrants (those arriving more than 10 years ago) were about 30% less likely compared to Canadian-born participants. In addition, recent immigrants were half as likely to have consulted with a psychiatrist or psychologist.

Considering the nature of this study, the major focus of the literature is on post-migration conditions that influence immigrants' health in general and mental health in particular. Strong evidence shows that some immigrants have a higher incidence of psychotic disorders after migration (Cantor-Grace 2007; Coid et al. 2008; Morgan et al. 2008). Some researchers (McDonald and Kennedy 2004; Newbold 2005; Ng et al. 2005) hypothesize that the decline of health status of immigrants is due to barriers to the use of health services, including gender roles, trust of western medicine, preferential use of traditional health care providers, education and income, language or cultural differences, and a lack of information about and experience with their new health care system. These barriers are seen to worsen immigrants' health status because of relative under-utilization of preventive health services and under-diagnosis and treatment of health problems. An alternative explanation given by McDonald and Kennedy (2004) posits that improved access to and use of health services over time reveals existing but undiagnosed conditions, hence a worsening of health.

Other studies have discussed conditions that influence immigrants' health and mental health under three main factors, namely: individual, intermediate and system influences. For example, studies have identified individual factors that affect mental health as being female, low income, lower education, having children under six years old, marital status (separated/divorced, widowed, never married compared to married/cohabitation) to be significantly related with depression (Wu and Schimmele 2005; Khanlou and Crawford 2006; Guruge and Collins 2008; Mawani 2008). At the intermediate level, family and social support networks (Canadian Association for Community Living 2005) have been identified as a protective factor against depression (Wu and Schimmele 2005). Immigrants often leave behind family and friends who provide emotional, informational and cognitive supports that are important in maintaining health. These supports are difficult to access in a new society. Coupled with loneliness and isolation, the lack of support structures contribute to stress and mental health problems (Beiser 2005; Canadian Task Force on Mental Health Issues 1988). It is increasingly noted that in smaller communities, developing social support networks across social sectors and ethnocultural groups can be useful in a way that provides a sense of belonging and support to newcomers (Reitmanova and Gustafson 2009; Khanlou et al. 2008). In particular, Khanlou et al. (2008) note that underemployment and unemployment is one of the most significant stressors for mental health that has been identified by immigrants.

Historically immigrants have been treated as a secondary labour force or "reserve army" (Hakim 1982) and therefore find it difficult to gain relatively better jobs or full employment (Canadian Task Force on Mental Health Issues 1988; Gastaldo et al. 2005). This experience is often linked to discrimination relating to language, skin colour and undervaluing of foreign credentials (Dean and Wilson 2009). Unemployment is a very stressful experience and is linked with low self-esteem, isolation and family conflicts that can subsequently lead to mental health problems. Continual unemployment may lead to poverty, which is linked with poorer nutrition and lower housing standards, fewer educational opportunities and access to quality health care. Again, an unemployed person may adopt unhealthy coping skills, including smoking, alcohol or drug abuse, which may jeopardize health. Early research has shown that unemployment is associated with poor marital adjustment and communication, separation and divorce as well as physical violence among couples (Dew et al. 1991). Aside from the above factors, it is noted that the transition from a familiar climate and diet add stress to the difficulties that newcomers face in a new environment (Ahmad et al. 2004).

The review has identified a list of community resources and services, including employment, housing, food, education and language, social support and quality health care. These resources, which are necessary for mental health needs, are also noted to be important for promoting immigrants' sense of place (community belonging). Resettlement after migration is strongly affected by the policies, practices and opportunities of the resettlement society and other organizations, including ethnocultural community organizations and religious institutions, which support immigrants in the process of integration (Pumariega et al. 2005; Beiser 2009; Kirmayer et al. 2011). This process is designed to help immigrants take control of their lives and improve their mental health.

THE STUDY AREA

Hamilton is a medium-sized city in Ontario about 75 kilometres southwest of Toronto, and it is comprised of six communities: Ancaster, Stoney Creek, Dundas, Flamborough, Glanbrook, and Hamilton. With a population of 519,949 in 2011, the City of Hamilton is ranked 5th largest in the province of Ontario and 10th in Canada (Statistic Canada 2011), with almost 25% of its residents born outside of Canada and 12.3% as visible minorities (City of Hamilton 2005-2010). A comparatively large proportion (approximately 30%) of the foreign-born entered as refugees. In terms of religion, about 344,625 people are Christians, and 19,025 identified as Muslims. Hamilton has been labelled as the 'Steeltown' of Canada. However, the City has undergone major economic changes and is now recognized for its health care and education sectors (Barber 2004; Freeman 2001; Russ 2007), with several large hospitals, clinics, laboratories as well as educational institutions, including McMaster University and Mohawk College. The City had an unemployment rate of 6.0% in July 2013, which was below that of the province of Ontario (7.3%) (Statistics Canada 2013).

Hamilton is a diverse city, home to successful newcomers and immigrants. It provides newcomers a wide variety of living accommodation, including single family homes, high- and low-rise apartments and townhouses (City of Hamilton 20052010). Physically divided by the Niagara escarpment which runs east-west through the city, poverty is most severe in the lower city, and particularly in the downtown core as compared to the western communities of Ancaster and Dundas. While the downtown core has been the traditional entry point for newcomers, large numbers of immigrants have also settled in suburban communities such as Stoney Creek or newer suburbs of Hamilton, including its 'mountain neighbourhoods.

A look at the 2013 health profile of Canada reveals interesting and intriguing facts about the position of Hamilton with respect to the health of its residents. For example, 64.6% and 77.3% of residents in Hamilton reported very good or excellent perceived health and mental health, respectively. In comparison, somewhat smaller proportions were observed at the provincial level (61% and 74.3%). Residents of Hamilton also reported a lower level of perceived life stress (22.5%) than the province of Ontario (24%). Approximately 93.2% of residents in Hamilton identified themselves as satisfied or very satisfied with their life satisfaction compared to 91.5% for Ontario. Finally, 69.8% of the residents of Hamilton rated their sense of community belonging as positive compared to 67.5% of the province of Ontario (Statistics Canada 2013). As noted by Williams et al. (2010) and Williams and Kitchen (2012), sense of place differs among residents with respect to where they live. For example, they found that residents of the Southwest Mountain are upper middle class and rate their sense of place as positive, whereas those living in the Central and Lower City are comparatively older, lower-income people who tend to rate their sense of place more negatively.

STUDY DESIGN

This exploratory study is one of the first attempts to explore key informants' (service providers) views on the personal and social resources that influence sense of place and how those resources might shape mental wellness of visible minorities in Hamilton. Purposive sampling was used to recruit participants for the key informant interviews. In recruiting participants, organizations including churches, mosques, associations, and Hamilton city organizations in charge of immigration and resettlement services were contacted. With a total of 11 organizations contacted, approximately 81% expressed interest in the study. Organizations that could not directly participate helped in distributing invitations to their workers/service providers through e-mail. In total, nine in-depth interviews were conducted with key informants, including three religious leaders (with all of their congregation members being visible minorities), two local group leaders, one health practitioner and three participants from members of the Hamilton Immigration Partnership Council (HIPC). HIPC includes representatives from the immigrant service provider sector (i.e., health), businesses, unions, government and community-based organizations along with other groups, and aims to create a welcoming community for new immigrants. We recruited a relatively small number of key informants due to the limited number of immigrant resettlement service providers in Hamilton, Ontario. Because of the limited number of participants, we make no claims about the representativeness or the generalizability of our findings. However, we are confident that our data is credible and trustworthy, as Guest et al. (2006) observed that saturation occurs with meta-themes emerging as early as six interviews. Participants were between 29 and 56 years of age; four females and five males; seven married, one widowed and one single; all had completed post-secondary school. In terms of country of origin, the study sample was quite heterogeneous with participants coming from Africa, Asia, South America and Europe. It is important to note that all key informants were visible minorities themselves who have lived in Hamilton between 11 and 28 years.

The aim of the analysis was not to directly measure the relationship between sense of place/community belongingness and mental wellness but rather, to infer from the perspectives of service providers and religious organizations how visible minorities' sense of place is nurtured in their everyday activities and the perceived impacts on their mental wellness. Some of the areas explored in the interviews included employment, housing, language training and interpretation, immigration and health. Key informant interviews took place between June 2014 and September 2014. After individual consent was obtained, community service providers and religious leaders participated in individual open-ended interviews in English. All key informant interviews were recorded, except two who requested that the interview not be recorded. In this case, notes were taken verbatim. The interviews lasted between approximately 60 and 90 minutes and were conducted at locations preferred by the participants, including offices, shops, church/mosque premises and homes.

All interviews were transcribed verbatim. Codes were developed after several readings of the transcripts and the selection of categories followed. Selection of categories was reviewed and refined with the help of two colleagues who are knowledgeable in qualitative research. The first analysis was coding the data and categorizing it into sub-headings. The next level involved analyzing codes and rereading the transcripts to develop pattern codes. This level was to uncover the process of enhancing the capacity of individuals and communities to take control over their lives and improve their wellbeing. In order to maintain confidentiality, different key informants are identified in the following by their major association (i.e., religious leader, service provider, health provider, etc.), with a number to distinguish between different respondents in each group.

FINDINGS

There are a number of similarities with regards to the key informants' revelations on sense of place and how that might shape mental wellness amongst visible minorities. Our findings revealed eight factors that influence sense of place amongst immigrants in Hamilton: discrimination, education, religion, housing, employment, language, gender and social support network. These factors reinforce the importance of housing, employment and language that we have seen elsewhere in the literature (Williams and Kitchen 2012; Kitchen et al. 2012; Ross 2001). Key informant service providers claim discrimination compromises health and inhibits access to healthcare services. There is a growing research suggesting the effect of discrimination experienced by visible minorities through various mechanisms (e.g., psychosocial stressors, economic deprivation, social exclusion, etc.) (Edge and Newbold 2013; Harris et al. 2006; Taylor and Turner 2002; Nazroo 2003). In a Statistic Canada's longitudinal survey of Immigrants to Canada, which asked respondents whether they have experienced discrimination, DeMaio and Kemp (2010) observed a significant association between discrimination and declines in health. Many of these observations confirmed the "healthy immigrant effect" highlighted elsewhere in the literature.

Of specific importance to this study is the role of education and how religion as a 'home' and as a social support network is tied to employment, housing and health. Educational outcomes amongst the children of immigrants provide a longer-term assessment of the effectiveness of a country's immigration policy. Again, it provides an evaluation of whether immigrant parents' desire for and improvement in their quality of life and that of their offspring has been successful and accomplished. However, key informants revealed the presence of improper placement within the educational system. For example, some youth from refugee camps that have never been to school, are placed in school based on their age rather than the ability to understand what is required of them. This, along with acculturative stress experienced by the parents, challenges the process of belonging to a community with its associated effect on mental wellness. In his own words:

The other area is the portion of, like, we have a lot of youth from refugee camps (visible minorities) that have never been in school. And what happens is that when they come here and, you know what, you're 15 years old so you have to be in grade 9. So how is someone that has never been in a school setting going to be in grade 9. And again we see that on a daily basis where they are sitting down. They give them a paper and say do this, they don't know how to read in their own language, let alone they are going to read here in Canada (Service provider participant #1).

Traditionally, religion has been a unifying force for developing a sense of community for immigrants, and provides a way of balancing their identity with that of the host country's identity. The construction of religious centres as a 'home' for believers helps to promote a sense of belonging and cohesiveness. Indeed, it has been suggested that it is the social aspect of religion, rather than faith or spirituality that leads to life satisfaction (Lima and Putnam 2010). The religious leaders in the study demonstrated the various ways through which religion is tied to housing, employment and other social services needed to promote members' belongingness and wellbeing.

With respect to housing, where new arrivals live was also identified as having a large impact on their wellbeing and functioning:

Most visible minority newcomers live in the downtown core because that's where the rent is cheaper and it's more affordable. Unfortunately, the living conditions are not the greatest; it's atrocious and some of the places you wouldn't even think of living in (Health practitioner participant).

So a lot of visible minorities that come to the country, sometimes they turn to be very disadvantaged economically, and socioeconomic disadvantage limits where they can live and oftentimes they would confine to a specific government housing and really limits their upward mobility and their interaction with other people, it limits the opportunities, it really limits what they can do (Religious leader participant #2).

As noted by Murdie (2003), appropriate housing establishes conditions for access to other formal and informal supports and networks and thus speeds the integration of immigrants into the host societies. Thus, the lack of appropriate housing as identified by the informants is likely to inhibit visible minorities' sense of belonging, which is vital to general and mental wellness. To help in this respect, all religious groups indicated ways through which they help new members to settle before they find government assisted housing or are able to find their own accommodation:

When we receive newcomers we offer them the 1st, 2nd and 3rd month rents and help them look for something, get them connected with other resources in the community (Religious group leader #2).

In terms of employment, key informants stressed how visible minorities are excluded, directly or indirectly, from job opportunities and key information networks. According to a study by Block and Galabuzi (2011), data show that while racialized Canadians have slightly higher levels of labour market participation, they continue to experience higher levels of unemployment and earn less income. Thus, racial discrimination denies the visible minorities from reaching their full career potential. This issue has compelled some organizations, including religious bodies, to help remedy the unemployment situation. As one religious leader put it:

We do have programs, we are working on a database on employment so that means if somebody comes across employment or job opportunity positions they would enter that in the system and that would be basically opened for anybody who is basically looking. This is intended to help achieve equality in the workplace so that no person will be denied employment opportunities based on one's physical traits (Religious group leader #1).

I noticed that most men don't want to take part in house chores even if their wives are working full time outside the home. They still expect them to come home from work, cook and perform all other household chores; it was only a week ago that 1 received a phone call around 2:00 o'clock in the morning that one of my members was attempting to commit suicide. We got there as early as possible. So as ... (Religious name withheld), we highlighted sayings from the prophetic from the traditions and the importance of staying both physically and mentally fit (Religious group leader #1).

Social support and networks are vital to the functioning of religious groups. Most of the religious leaders indicated that members see themselves as a family where they can communicate and interact freely, share, and ask for anything they need. Given the emphasis that most major religions place on human relationships, love and compassion, members' sense of community is nurtured and wellness promoted;

But when it comes to other supplements like food and clothing we help them to stand on their feet. Other areas are bereavements, naming and wedding ceremonies, all other things that members could help (Religious group leader #2).

At the end of the year, we have a banquet, so we all come together and we give some gifts to the people and we have music and enjoy. And then we go to a picnic, we play all kinds of games (Religious group leader #3).

Religious key informants identified the need to promote religion in various communities given that religious organizations provide spaces and other services through which a sense of place is nurtured amongst immigrants. Again, it has been observed that places where people have a sense of belonging are also noted for their therapeutic conditions (Williams 1999), including mental health. One religious leader shares his opinion on this:

We discuss the importance of health and one of the best things to do as a [Name withheld] is to highlight sayings from the prophetic traditions from the scholars who discuss the importance of health. The discussion they had about 400 years ago is about the importance of staying fit, healthy, in shape, walking, physically active, all of these things are important (Religious leader participant #1).

When it comes to the benefit of having a sense of place in a community, all participants shared similar experiences. They expressed that belonging to a community is an important need for residents in general, and for immigrants in particular. They think it is even greater for immigrants because there is a sense of separation from home, from family and friends, from where one is used to living, as most immigrants left their places of origin to start a new life in Canada. Therefore, when immigrants feel that they do not belong, feelings of isolation, separation, social exclusion and increased anxiety are common:

If you come to a place and you have no family member, no friend to talk to and explain things for you, it hurts. It can lead to sickness because you don't know where and when to go. It brings about anxiety, etc., so I think what bothers many immigrants is anxiety, distress and such like (Service provider participant #1).

Participants thought that improving language skills is an important motivation to make sure that immigrants get outside of their comfort zone, get involved in community activities, and learn some of the values within the community through programs at clubs or youth centres or through sports clubs. Together, they work to improve immigrants' career success, expand their networks and consequently promote a sense of community belonging:

When visible minorities come in, they're faced with a lot of challenges. When I came here I didn't speak the same word of English, and I was not used to the study system; it was very very difficult, but having a community that offers certain assistance and certain levels of transition programs, and transition processes. For example, having an English language class teacher who speaks your language can really help; having an introduction about the school system by somebody who has gone through the same experience, comes from the same place, which can really make it easy (Service provider participant #2).

Access to social support networks was identified as a prospect in every single key informant interview. All service providers, associational groups, and religious leaders who work with immigrants and newcomers develop programs that would help immigrants connect to others for resources, information, ideas, skills, knowledge as well as other forms of social and human capital. They are of the opinion that immigrants who come to the city, regardless of their status, hold some resources that may be useful to others in the city. Likewise, members of the city also possess resources that are beneficial for newcomers. Thus, it is through active social networking that these reciprocal tendencies can be achieved, which help to promote sense of community belonging amongst individuals and groups, with positive implications on mental wellness:

I think some of the factors that helped me personally were being part of an organization. I was part of this organization (Name withheld) before I started working with them and afterwards, since then, I'm not saying just this organization but just being part of an organization from the beginning in this country, this community, and learning some of the values within the community helped. I think that friends, families, how well they are connected themselves within the community makes a big difference (Service provider participant #3).

A feeling of belongingness in a community where you live is a two-way street, according to participants. Even though the city works to create an inclusive and welcoming environment, immigrants are also responsible for making themselves feel welcome:

There is a saying that you can take the horse to a river side but you cannot force it to drink, as one participant noted. Sometimes I find that it's the immigrants also who isolate themselves and say things like.... Oh these guys, these people ... and it doesn't help them because they don't allow themselves to integrate into the community, they want to do things ... as if they are transferring their countries of origin to Canada, it doesn't work. It has to be give and take. So I think from the part of immigrants they should also allow themselves to integrate into the community, learn the processes that make this place the way it is (Local group leader participant #1).

The combination of the stress of trying to make ends meet and the frustration of not being able to speak proficiently and interact freely negatively impact the health of immigrants in general. Studies on visible minority immigrants emphasize how prejudicial and discriminatory treatment within the media, school, labour market and other settings impedes their sense of belonging (Caxaj and Berman 2010; Khanlou et al. 2008) which forms an important part of their health, mental health and positive esteem (Beiser and Hou 2006). Participants indicated a varied number of ways that not belonging to a community or not feeling a part of a community impact their physical and mental wellness:

Very frequently, it's when people, when they don't feel part of the community that they are living in, whether Hamilton community or a Canadian society at large or ethnic group that they are part of, whatever you may have, it highly takes a toll mentally and we know there is impact on mental health like depression and anxiety, that kind of stuff. Oftentimes it also manifest in physical ways so, hmmm, people end up with chronic illness, they become socially isolated and medically declined (Health practitioner participant).

They feel that they are not just outsiders looking inside and that they are part of the community, nobody questions them. For instance if they are looking for a doctor and they can, just like anybody else within the community, go through the process of getting a doctor, it makes them feel well; it makes them feel a part of it if they take the child to school and nobody said because you're this so take your child there it makes them feel that we all belong (Local group leader participant #2).

Key informants advocate for expanded access to language interpretation services as a means to address the language needs of immigrants whose day-to-day language is not English or French. In terms of health, one initiative within the city is the establishment of the Refuge clinic in 2011 by a group of physicians to address the health gaps that many refugees and immigrants face. The clinic offers primary health care, pediatrics, nutrition specialists, cardiology and a host of other services. An evaluation assessment by refugees and immigrants who access the clinic revealed that the centre is welcoming and easy for people to navigate compared to other clinics and health centres in the city. Indeed, a welcoming environment throughout the literature has been observed to promote individuals' and groups' sense of belonging and its association on both physical and mental wellness. As one practitioner illustrates,

The clinic facilitates language interpretation, people see this place as safe, welcoming, and you are not the 'other' so there is that sense of belonging I think. It is really important, that is other people who look like them, who talk like them, and I think it is important and I think we need to look at diversity and work place (Health practitioner participant).

DISCUSSION AND CONCLUSION

This paper underscores the importance of promoting sense of place amongst visible minorities by attending to the broader structural constraints associated with the well-being of immigrants. These key informant revelations reaffirm other literature demonstrating the importance of place on mental wellness for individuals and groups alike (Williams and Kitchen 2012; Kitchen et al. 2012; Wilson et al. 2004). Our analysis of the key informant interviews emphasizes the challenges to belongingness and integration, and consequently physical and mental wellness when conditions necessary for immigrants' inclusion are ignored or poorly promoted in our communities.

Past research in Hamilton has shown that higher socioeconomic status neighbourhoods have a higher evaluation of sense of place and associated mental health. Given that visible minorities reside in poor housing conditions as revealed in this study, it was hypothesized that they are more likely to suffer from health and mental health-related issues. Adverse outcomes associated with discrimination include poor physical health (e.g., cardiovascular, respiratory), mental health (e.g., anxiety, depression) and risky lifestyle behaviours (e.g., smoking and drinking) (Williams et al. 2003).

The findings revealed that visible minorities face many challenges that affect the process of integration. Some of the areas explored include employment, housing, education, health, language interpretation and training, and the role of religion. These factors are perceived to be important in determining the success of visible minorities' integration and general wellbeing in their host communities.

Visible minorities are more likely to perceive work-related discrimination than their Canadian-born counterparts according to key informants. This is not surprising, given that visible minorities are known to experience greater disadvantage than non-visible minority immigrants in almost all spheres of life, including housing (Murdie 2003), employment (Mensah 2010), education (Dei 2005), and health and mental health (Ali 2002; Newbold 2005).

The findings offer additional insight into the determinants of health and mental wellness as the calls for culturally appropriate care have been increasing (Oxman-Martinez et al. 2001; Carillo et al. 1999; Betancourt et al. 2003). The aim is to enable health and social service providers to reflect on their own and others' cultural beliefs, behaviours and communication strategies to enable practical skills that facilitate quality, non-discriminatory care (Magoon 2005; Reitmanova and Gustafson 2009; Guilfoyle et al. 2008). In Hamilton, Ontario specifically, a strategy employed is the setting up of the Refuge clinic in 2011 to address refugees' health needs by bringing in professionals that share their clients' languages and ethnic backgrounds. This initiative was intended to bridge the health needs gap between visible minority new immigrants and the Canadian population, which is likely to promote visible minorities' sense of belonging and associated wellbeing. Thus, this initiative is in line with the calls for specific programs and strategies to address specific immigrant needs in immigrant receiving communities. It is reasoned that medium to large cities tend to employ 'one-size-fits-all' programs to address immigrants' needs due to cost constraints (Frideres 2006) that may hinder the supply of immigrant services and further place attachment.

It is interesting to note that religious organizations were identified as contributing to the promotion of sense of place and mental wellness of immigrant visible minorities. While it was mainly discussed by religious leaders, it does highlight religion as a potential for promoting sense of place, particularly when it is tied to employment, housing, health and social support network. Religion helps to empower the individual through connecting individuals to the community, and a greater force that might in turn give psychological stability (Oman and Thoresen 2003). Thus, the restorative effects of religion on emotional, cognitive and physical functioning are well illustrated and acknowledged (Giaquinto et al. 2007; Lima and Putnam 2010; Koenig et al. 2012).

The study limitations need to be mentioned. First, this study had a small sample of key informants due to the limited number of immigrant settlement service providers in Hamilton. Notwithstanding this limitation, the paper contributes to an improved understanding of the factors that promote immigrants' sense of place and mental wellbeing in medium-sized cities with limited ethno-specific facilities. A second limitation involves the scope of this study, which encompasses all immigrant visible minorities regardless of immigration status (e.g., refugee groups). It is possible that different immigrant groups may have different experiences of sense of place that could be studied by exploring more homogeneous groups of immigrants, given that other research has shown that immigrant experiences and perceptions often vary across immigrant subgroups (Beiser 2005; Ng et al. 2005; Dean and Wilson 2010). Therefore, there is a need to examine the experiences of different immigrant groups.

Third, this study did not directly measure the relationship between visible minorities' sense of place and mental wellness. Rather, it explored key service providers' experiences and perceptions of immigrant visible minorities' sense of community belonging and how that might shape their mental wellness. Thus, examining sense of place and mental wellness of specific immigrant groups is important, and we seek to examine this in future studies.

Despite these limitations, the findings of this study are important. While we recognize that our study did not identify causal pathways between sense of place and mental wellness, it does provide insight on those significant factors that promote immigrant visible minorities' sense of community belonging and how they may shape their mental wellbeing. Our study has demonstrated the importance of key factors (e.g., the role of religion) that may be overlooked when considering sense of place and mental wellness.

In conclusion, we emphasize the need for policies and programs that reflect the broader social determinants of health as articulated in the Ottawa Chapter for Health Promotion (World Health Organization 1986). The social determinants literature has shown that the most important pathways of human health status are not necessarily medical care inputs and health behaviours. Instead, they are the social and economic conditions of individuals and populations that promote belongingness and health (Mikkonen and Raphael 2010). In recognition of the fact that health is a complex phenomenon, it is recommended that a broad and multifaceted approach that recognizes the importance of addressing health in a holistic manner be adopted. This could be achieved by focusing on policies that affect all determinants of health (including mental health) through the integration of public policies into a comprehensive package of health improvement and promotion strategies; and should be incorporated into policies of health and health-related institutions for implementation. A focus on intersectoral approaches that would enhance sense of community belonging amongst immigrants (e.g., social services, language training and interpretation) and across groups categorized by race/ethnicity, gender, and place, and their association with health outcomes, are recommended. Accordingly, this would uncover the extent to which socio-economic conditions influence sense of community belonging, physical and mental health of different populations and provide a lens through which we could improve and reduce health inequalities.

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ACKNOWLEDGEMENT

The authors are very grateful to the Hamilton Immigration Partnership Council for onward distribution of information about this project to various settlement service providers in the city. We also thank the key informants who shared their knowledge and expertise as participants in this project.

BOADI AGYEKUM is a PhD Candidate at McMaster University, Department of Geography. He is interested in immigrants' resettlement and integration processes. His current project focuses on African immigrant community belonging and mental health.

K. BRUCE NEWBOLD is Professor of Geography at McMaster University. He is currently the director of the School of Geography and Earth Sciences, McMaster University. His research focuses on internal migration in Canada and the United States, immigration and health.

TABLE 1. Key Informant Study Interview Guide

1. Can you tell me a bit about your own background?

2. What do we mean by place attachment?

3. What factors do you think contribute to immigrant's attachment to
place/neighbourhood?

4. Is sense of place important for immigrants? Why? Can you give
specific examples if a positive sense of place might improve mental
or physical health?

5. Should sense of place be promoted? Why?

6. What things do you think the city should do to promote immigrants'
sense of place (feeling that they are "Hamiltonian")?

7. Does your organization (i.e., religious group) promote sense of
place? How does it do this? Do you think it does a good job?

8. What other ways could sense of place be promoted?