Investing in Families: Building resilience to address mental health inequities
This blog post by Public Health Nurse Linh Nguyen (Toronto Public Health, pictured above) highlights an interdivisional resiliency project she presented at the 2019 Community Health Nurses of Canada (CHNC) Conference in Saint John, New Brunswick. Contributors to this post also include Patricia Stevens, health promotion specialist, and Nicolette Slovitt, child health and development manager at Toronto Public Health.
Promoting resilience in individuals and families contributes to healthier, happier relationships with ourselves and each other. People and communities who develop strategies to build resilience tend to experience less anxiety and depression, leading to improved overall physical and mental well-being.  Learning how to better cope with life's inevitable challenges may reduce the sense of helplessness often associated with adversity.
Childhood experiences, physical environments, social supports and coping skills impact a person's long-term mental health . This is an important consideration for public health and community partners working with families. According to a 2014 Ontario Child Health study,  approximately one in five children and youth in Ontario experience poor mental health. Given that 70% of mental health challenges start in childhood or adolescence, this is a critically important time in life to promote mental health strategies with families. 
Some families have the additional burden of living in poverty. In the city of Toronto, one in four children and one in five adults live in poverty. [5, p. 145-9]. As a social determinant of health, poverty shapes and challenges the way children are born, grow and experience daily life and has a direct impact on mental health and well-being across the life course. [3, 6]
Investing in Families: Mitigating the impacts of poverty and promoting positive mental health
Developing resilience is an important consideration for public health and community partners who work with families. In 2019, Toronto Public Health (TPH), Toronto Employment and Social Services (TESS) and Toronto Parks, Forestry and Recreation (TPFR) expanded a collaborative approach to provide services for families receiving financial assistance through Ontario Works, aptly named Investing in Families.
The overarching goal of Investing in Families is to reduce the impact of poverty and increase prosperity for families with children and youth.  Investing in Families looks to enhance the knowledge and skills of public health nurses related to resilience and ensure partner service providers have a similar understanding of the concept. Having all partners aware of resiliency strategies helps provide better support for families.
Developing staff capacity
Families who are part of the Investing in Families program are those that frequently experience adverse life circumstances that can make having positive mental health a challenge for both children and caregivers. In order to develop staff capacity to apply resiliency theory, which would allow them to provide better support to families, training was provided to ninety-five of Investing in Families partner staff from TPH, TESS and TPFR.
Realizing that the concept of resiliency may mitigate some of the risk factors associated with families living in poverty, Investing in Families applied for and received a one-time provincial grant to support mental health promotion initiatives for children and youth. Building on the Investing in Families approach, City of Toronto partners had an opportunity to learn more about resiliency theory and its application to practice.
Meeting with partners to discuss strategy
In order to enhance understanding of resilience, a two-day workshop for interdivisional partner staff was offered featuring Dr. Michael Ungar, a researcher and expert on nurturing and supporting resilience with culturally diverse families who live with structural inequities. Participants learned practical strategies to promote positive child development and gained a better understanding of how children, youth and families with complex needs can be supported by enhancing resilience. 
Ungar noted factors that build resilience in young people, which included:
- having a web of supports to promote healthy family relationships;
- building a sense of control and belonging; and
- feelings of safety.
For example, children who are provided with support and structure that allows them to feel safe are less likely to develop mental health problems.
As partners in this interdivisional program, public health has the opportunity to help families in mobilizing their web of supports to promote positive relationships. Coordinating services through partnerships across sectors helps make participation in recreation, camps and leadership programs more accessible for children and youth living in poverty. These activities help youth to develop a sense of purpose and build positive social connections.
Promoting resilience — supporting youth
Once the interdivisional partners had a common understanding of resilience theory, it was time to put their learning into practice. TESS, TPFR and TPH recruited youth to participate in focus groups to learn more about the strategies needed for the youth to feel safe and engage in public health programming.
In terms of logistics that would encourage their participation in programming, the youth identified several "must haves." These included having Wi-Fi, transportation and food available. In addition, most of the adolescents said they wanted to learn practical skills when they attend such a group. They also suggested learning more about leadership and how to adopt skills to enhance their own and each other's positive mental health.
As a direct result of their input, the Investing in Families team went on to organize a skills workshop promoting mental wellness and offered a food handlers certification program for the youth. Being certified to handle food provides valuable resume-building and employment skills.
Organizations who work with families want to support the building of resiliency and positive mental health within each family unit. Interdivisional, collaborative working relationships with partners such as those in the Investing in Families project are key to delivering seamless service to promote positive mental health among families living in poverty.
Mitigating the impact of poverty by providing concrete, practical strategies to learn how to better cope with life's challenges is an important step in supporting families to achieve better overall physical and mental health. Providing support during adolescence help youth learn to cope effectively, even if they are living in difficult life situations, such as growing up in poverty. It can also help them enter adulthood with tools to support their long-term positive mental health.
This project does not aim to eliminate poverty and building resilience to cope with the resulting circumstances is not enough. Public health must advocate and work with partners to address income inequity, inadequate housing and other socioeconomic roots that determine physical and mental health of individuals, families, communities and the population.
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6. Commission on Social Determinants of Health. Closing the gap in a generation: health equity through action on the social determinants of health. Final Report of the Commission on Social Determinants of Health [Internet]. Geneva (SW): World Health Organization; 2008 [cited 2019 Nov 11]. 236 p. Available from: https://www.who.int/social_determinants/thecommission/finalreport/en/
7. Browne G, Byrne C, Roberts J, Gafni A, Whittaker S. When the bough breaks: provider-initiated comprehensive care is more effective and less expensive for sole support parents on social assistance. Soc Sci Med. 2001 Dec;53(12):1697-1710.
8. Ungar M [Internet]. Halifax (NS): date unknown. “Diagnosing” resilience across cultures and contexts: seeing the positive in young people even when there are serious problems; date unknown [cited 2019 Nov 11];[about 1 screen]. Available from: http://www.michaelungar.com/about-michael/sample-presentations/