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Article

A Mixed Methods Synthesis Investigating the Personal and Ecological Resources Promoting Mental Health and Resilience in Youth Exposed to Intimate Partner Violence

by
Margherita Cameranesi
1,* and
Caroline C. Piotrowski
2
1
Department of Psychology, Saint Mary’s University, Halifax, Nova Scotia, NS B3H 3C3, Canada
2
Department of Community Health Sciences, University of Manitoba, Winnipeg, MB R3T 2N2, Canada
*
Author to whom correspondence should be addressed.
Youth 2024, 4(4), 1610-1627; https://doi.org/10.3390/youth4040103
Submission received: 16 July 2024 / Revised: 7 November 2024 / Accepted: 8 November 2024 / Published: 15 November 2024
(This article belongs to the Special Issue Promoting Resilience, Wellbeing, and Mental Health of Young People)
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Abstract

Resilience research is concerned with studying the complex interplay of personal and ecological resources that promote positive adaptation following adversity in different populations. Although much research has investigated adjustment in young persons exposed to intimate partner violence (IPV), most of this research has taken a deficit approach by focusing on the negative cascades of effects that exposure to IPV has on the functioning of this group. In this paper, we discuss a mixed methods integration of two independent strength-based or resilience-focused studies involving Canadian youth exposed to IPV. Study 1 is a qualitative constructive grounded theory study that aimed to identify the coping strategies that youth exposed to IPV use to effectively cope with the traumatic experience of growing up in an IPV-affected family. This study included 13 youths with a history of IPV exposure who completed individual in-depth interviews, the drawing of ecomaps, and photovoice projects. Study 2 is a quantitative population-based study that aimed to identify profiles of adjustment in a cohort of 3886 youth who had previously experienced IPV exposure, as well as the specific risk and promotive factors that significantly predicted membership in the identified adjustment profiles. Both studies independently identified personal and ecological resources that were instrumental in supporting the resilience of study participants. By comparing and contrasting the two sets of findings, the present mixed methods integration provides further evidence on the complex interactions of mechanisms that promote positive adaptation in youth exposed to IPV, which aligns with a multisystemic understanding of resilience in this population. We provided recommendations for practice and policy based on the integrated findings.

1. Introduction

Recent collective traumatic events, including the COVID-19 pandemic, climate change, economic instability, and war have contributed to a significant increase in mental health problems among North American youth [1,2]. In Canada specifically, mental health problems impact youth ages 10–24 years the most, with more than 10% of young Canadians consulting mental health professionals and about 25% seeking informal support for mental health problems each year [3,4,5]. Depression, anxiety, suicidality, perceived stress, sleep problems, and addictions are among the most common mental health issues experienced by Canadian youth, with intentional injury or self-harm being a leading cause of death for Canadians ages 15–24 years [5,6].
The consequences of mental health problems in youth are far-reaching, affecting youth’s well-being in virtually all domains of functioning, including the emotional, social, educational, and behavioral domains. Compared to same-age peers without mental health problems, youth with mental health problems are at significantly higher risk of experiencing stigma, discrimination, and premature death by suicide [7,8]. Mental health problems during the youth years are also associated with poor academic performance, social problems, and risk-taking behaviors, including substance abuse [9,10,11]. Additionally, early mental health challenges tend to persist into adulthood, leading to an increased risk of adult mental health disorders, poor psychosocial functioning, and poor physical health [12,13].
In an effort to prevent mental health problems in youth, researchers, healthcare providers, and policymakers have become interested in identifying modifiable risk factors to address in prevention initiatives targeting youth and families [14]. One well-known factor consistently associated with poor mental health in youth is exposure to violence in the home or intimate partner violence (IPV) exposure. IPV refers to any physically or emotionally abusive behavior occurring between current or former intimate partners, such as physical aggression or assault, sexual assault, harassment, coercion, psychological or emotional abuse, and controlling behaviors [15]. IPV frequently occurs in families with youth and can also include threats of harm or actual harm toward them, often as an attempt to control a current or former partner. Exposure to IPV occurs when youth live in families impacted by IPV; they may witness, hear, be involved in, or be aware of the abuse occurring in their homes [16].
Although youth exposed to IPV are at an increased risk of experiencing a wide range of negative developmental outcomes, including poor mental health [17,18], some specific individual and ecological factors and processes are known to protect youth’s mental health from the negative effects of exposure to IPV [19]. These influences, known as promotive and protective factors and processes (PPFPs), are either directly associated with positive outcomes in youth exposed to IPV (promotive) or moderate the negative effects of IPV exposure on youth mental health (protective) [20]. Specifically, promotive factors include personal qualities, such as emotional self-regulation, and ecological resources, such as effective parenting, that are directly associated with positive outcomes in populations exposed to risk; they predict positive adaptation regardless of risk level. In contrast, protective factors are personal qualities and ecological resources that moderate the negative effects of risk in predicting negative outcomes; they mitigate or buffer the effects of risk exposure. In this sense, for instance, when youth are exposed to risks within the home (e.g., parental mental health problems), a supportive peer group can help mitigate the negative effects of this exposure and promote healthier, more positive outcomes in youth. In other words, supportive friends can provide protection, making it less likely that family adversity will lead to harmful consequences. PPFPs are seen as contributing to positive developmental outcomes in youth exposed to early IPV or to their resilience [21,22]). Understanding the PPFPs that positively influence the mental health of youth exposed to IPV by promoting their resilience is essential for developing effective prevention and intervention initiatives that leverage the individual qualities and ecological resources these youth need to recover from the stress they experience at home and grow into well-adjusted adults. The present mixed methods integration examined PPFPs in youth exposed to IPV, with the overarching goal of generating clinically relevant knowledge valuable for informing prevention and intervention strategies targeting at-risk youth and families. Given that many mechanisms leading to resilient developmental outcomes in youth exposed to IPV are still largely unknown, this mixed methods synthesis represents a novel contribution to the resilience literature.

1.1. Theoretical Framework: Multisystemic Resilience

Resilience science is concerned with studying the dynamic and complex interplay of mechanisms that account for positive adaptation of different groups following their exposure to atypical adversity or chronic stress [23,24]. Resilience research, then, requires operational definitions of three major components [21,25]: (1) risk or adversity exposure (what are the stressors?); (2) desired outcomes for evaluating successful adaptation (how is the person doing?); and (3) PPFPs (what accounts for successful adaptation in the context of these stressors?). There is growing interest in youth resilience as a multisystemic capacity—i.e., one that is distributed across multiple systems, including the intrapersonal microsystem, interpersonal mesosystem, and institutional macrosystem [25,26]. Multisystemic resilience, therefore, refers to positive adaptation following adversity exposure that occurs by mobilizing resources from and interacting with these multiple systems [22]. Through a multisystemic resilience lens, PPFPs represent the personal strengths (i.e., biology and psychology) and ecological resources (i.e., family, school, neighborhood, community, culture, social policy, and belief systems) that work synergistically to help youth build and maintain their capacity to successfully cope with exposure to atypical adversity. In the two independent but interrelated research studies discussed here, a multisystemic resilience model was used as a framework to guide the two investigations.

1.2. Multisystemic Resilience in Youth Exposed to IPV

Only recently have scholars started to investigate the mechanisms associated with differing degrees of resilience identified in youth exposed to IPV [19]. The limited research on resilience in youth exposed to IPV has identified some assets and resources that seem to play the role of PPFPs, as they are consistently associated with positive adaptation and healthy development in this population. These factors include positive maternal mental health, close mother–child relationships characterized by warmth and understanding, positive caregiver parenting practices, advantaged socioeconomic circumstances, and exposure to shorter and less severe IPV [27,28]. These associations have been found across different sample types (e.g., community and shelter samples) as well as across different ethno-cultural backgrounds and developmental stages.
Despite the advances that research on youth exposed to IPV has undertaken in the last three decades, there are still several questions regarding the specific PPFPs that may be leveraged to promote positive adaptation in youth following exposure to IPV. The two studies included in this mixed methods synthesis aimed to fill some of these important gaps in the literature and to advance resilience research by integrating quantitative (QUAN) and qualitative (QUAL) evidence from two studies on the PPFPs and positive coping strategies of youth exposed to IPV. The goal of the two individual studies was to inform prevention and intervention initiatives, as well as policies that target families at high risk of experiencing multiple adverse life circumstances.

2. The Present Mixed Methods Synthesis

In this mixed methods synthesis, we integrated QUAL evidence generated through a grounded theory study with QUAN evidence produced via a population-based study to reach a better understanding of the PPFPs linked to positive mental health in youth exposed to IPV. The results of the grounded theory study and population-based study were integrated using a one-phase mixed methods convergent parallel design (QUAL + QUAN) [29]. This mixed methods study involved the nearly simultaneous and independent collection and analysis of QUAL and QUAN data on resilience in young persons exposed to IPV, followed by the integration of the two complementary sets of data with the purpose of enhancing our understanding of the research problem. Figure 1 shows a visual model of the mixed methods study design.
The overall objective of this integration was to reach a more robust and complete understanding of resilience processes in youth exposed to IPV and the specific PPFPs that influence their mental health. The main question was as follows: What new understanding of resilience processes in youth exposed to IPV emerged from the complementary integration of the QUAL evidence collected in the grounded theory study and the QUAN evidence collected in the population-based study? Specifically, in what ways does the convergence or divergence of the two strands of evidence help identify individual and ecological factors that promote resilience processes in youth exposed to IPV? The two independent but related research strands are described next.

2.1. Qualitative Strand

The QUAL strand of this mixed methods synthesis involved a grounded theory study that drew concepts from the constructivist grounded theory method to investigate and comprehensively summarize the strategies that youth ages 9–17 years used to cope following exposure to IPV [30].

2.2. Quantitative Strand

In the QUAN strand of this mixed methods synthesis, which involved a population-based study, de-identified population-based health and non-health data on a cohort of youth ages 6–11 years exposed to IPV were used to identify profiles of adjustment in the study cohort, as well as the specific risk and protective factors that significantly predicted membership in differing adjustment profiles (including a “resilient profile”) [31].

3. Methods

3.1. Mixed Methods Design and Procedures (QUAL + QUAN)

The evidence gathered in the context of the two individual studies was integrated using a convergent parallel mixed methods design [29]. This design is a one-phase mixed methods research design in which QUAL and QUAN data are collected in parallel and independently, analyzed separately, and then merged only during the interpretation phase. We implemented this design to obtain different but complementary data on resilience in youth exposed to IPV by bringing together the strengths of the grounded theory study (e.g., in-depth analysis of personal accounts, subjectivity, investigation of areas relevant to study participants) with those of the population-based study (e.g., large sample size, generalizability of results to similar populations, objectivity) in order to provide a richer, multi-faceted and more comprehensive understanding of resilience processes in this young population.
The convergent parallel design was well suited to address the main research objective because it involved the triangulation of QUAL and QUAN methods by directly comparing and contrasting the personal stories of a small group of selected individuals with the results of large-scale statistical analysis for validating purposes [32]. Equal priority and emphasis were placed on both QUAL and QUAN strands, which were conducted concurrently and independently to develop a parallel-databases variant of convergent parallel design (QUAL + QUAN) [29]. The two strands were brought together only during the last steps of research, the interpretation phase.
In implementing this convergent parallel design, four procedural steps were followed (see Figure 1 for details) [29]. During step 1, QUAL and QUAN data about the PPFPs that promote mental health in youth exposed to IPV were concurrently but separately collected—that is, one dataset did not depend on the results of the other. However, to the extent possible given the available administrative datasets in Manitoba, the findings of the grounded theory study informed the selection of the variables included in the population-based study. Specifically, given that the most relevant PPFPs that emerged from the accounts of the youth included in the QUAL study involved maternal mental health and family well-being, in the QUAN study, we included variables representing indicators of these constructs, such as maternal mood disorders, anxiety disorders, or post-traumatic PTSD and family contact with the child welfare system. In step 2, the two sets of data were analyzed separately and independently from each other using specific QUAL and QUAN analytic procedures. Once the two sets of initial results were available, these two separate sets of information were integrated by directly comparing and contrasting them at the point of interface in step 3. Finally, in the last step, step 4, the extent to which and in what ways the two sets of results converged, diverged, or complemented each other to create a more complete understanding of the PPFPs that promote mental health in youth exposed to IPV was examined.

3.2. Qualitative Design and Procedures

3.2.1. Research Design

A multi-method exploratory study informed by constructivist grounded theory [33] was conducted to develop a model that reflected our understanding of the subjective and contextual experiences of youth participants.

3.2.2. Study Participants

Primary informants were 13 youth who had experienced IPV exposure after birth. They ranged in age from 9 to 17 years (M = 13.5; SD = 2.8). At the time of data collection, all were residing in a mid-sized city in central Canada. Most of the youth identified as female (n = 9), and the majority (n = 10) reported growing up in a single-parent family. All youth under the age of 16 were enrolled in school (n = 8), while five over the age of 16 years were not. All youth self-identified as having either an Indigenous or Hispanic ethnocultural background, and they were either born in Canada or moved to Canada as infants.

3.2.3. Data Collection Procedures

Families were recruited through purposive (non-random) sampling from community agencies that offer a variety of programs and services to low-income families who are at risk of experiencing differing adverse life circumstances, such as incarceration, unemployment, homelessness, community violence, and IPV. Inclusion criteria for participating in the study included (a) reporting any type of IPV in a past relationship, (b) having at least one child between the ages of 9 and 17 years willing to participate in the study, and (c) being able to speak English fluently. A total of 13 families were enrolled in the study; these include 13 ethnic minority youth aged 9–17 years (M = 13.5; SD = 2.8). A multi-method QUAL approach to data collection was implemented by performing research activities with these 13. Three primary methods were used to collect data on the PPFPs characterizing study participants, including in-depth trauma-informed interviewing with a focus on strengths, resources, and successful coping strategies; drawing of ecomaps or graphic portrayals of social relationships and networks between study participants and the people, places, and activities meaningful to them [34]; and photovoice projects [35], which involved taking pictures that represented participants’ preferred ways of coping with adversity and discussing the pictures with an investigator. All youth participated in the in-depth interviews and drawing ecomaps, which lasted approximately 60 min, while only four youth completed a photovoice project, and their photovoice interviews lasted around 30 min. Memo-writing was used throughout the research process to help the researchers take a reflexive stance by examining and clarifying how our past life experiences, worldviews, and assumptions affected the way we conducted this investigation [36].

3.2.4. Data Analysis

Transcribed interviews, ecomaps, photos, and interviewer fieldnotes, including memos and reflexive notes, were analyzed thematically using a constant comparative method and the software NVivo 12® [33]. As recommended by Charmaz, data collection and data analysis occurred simultaneously and in an iterative fashion, and the analytic process unfolded in three steps, including initial coding, focused selective coding, and theoretical coding. First, we used gerunds as in-vivo codes to name or label short segments of meaningful text within each transcript (i.e., initial coding); whenever possible, participants’ words were used [33]. Next, we identified the most significant and relevant codes to begin sorting, synthesizing, integrating, and organizing the large amounts of data (i.e., focused selective coding). The focused coding summary of each participant was compared between participants as each new interview was completed, and these data were added to the overall coding. In the last step of this constant comparative process, the most meaningful concepts both within and across participants, including categories and themes, were organized into a resilience model that reflected the subjective and contextual experiences of the youth included in the study (for a detailed description of these three analytic steps, see Cameranesi and colleagues [30]).

3.3. Quantitative Design and Procedures

3.3.1. Study Design

Using a retrospective cohort study design, population-based data on all residents of the Province of Manitoba over a 12-year period (January of 2006–December of 2017) were used to create a cohort of youth who were exposed to IPV within their homes and to identify relevant health and sociodemographic variables.

3.3.2. Data Sources

Data were extracted from multiple administrative databases that were available in the Manitoba Population Research Data Repository, which is housed and maintained by the Manitoba Centre for Health Policy (MCHP). De-identified data were linked across health, social, and justice datasets using an encrypted, scrambled version of each person’s Personal Health Identification Number (PHIN). The use of these unique identifiers enabled individuals to be tracked across the specified datasets and over the study period while ensuring their anonymity. For a comprehensive list of the specific health, social, and justice databases accessed for this study, see Cameranesi and colleagues [31].

3.3.3. Study Population

The target population included youth between the ages of 6 and 11 at the end of the study period (calendar year 2017). Information on prenatal and postnatal IPV exposure over the first 10 years of the study period (2006–2016) was extracted from multiple datasets and used to create a cohort of children who experienced IPV exposure (see Cameranesi and colleagues for details) [31]. Youth who were not exposed to IPV were excluded from this investigation. When there were two or more youth from a family within the required age range, only one youth per family was randomly selected to prevent violating the assumption of independence of observations during data analysis. Outcome indicators from the last five years of the study period (2013–2017) were used to identify profiles of adjustment in the study cohort.

3.3.4. Study Cohort

The study cohort included 3886 youth ages 6 to 11 years who were living in Manitoba, had Manitoba Health coverage for the required years, and had been exposed to prenatal or postnatal IPV between January of 2006 and December of 2016. The study cohort was evenly divided by biological sex at birth, including 1975 boys (50.8%) and 1911 girls (49.2%). The mean age of youth was 8.65 years (SD = 1.68). Information concerning the ethnocultural background of youth was not available from their administrative records.

3.3.5. Study Measures

Several standardized measures developed by the MCHP were used to assess child, mother, and family characteristics. A comprehensive list and description of these measures is presented in Table 1 and Table 2. Given that for most children it was not possible to identify their biological father in the administrative datasets, fathers were excluded from this investigation.

3.3.6. Statistical Analyses

Latent Class Analysis [37,38] was used to address the study objectives and identify distinct subgroups of children in the study cohort that showed particular profiles of adjustment. First, we identified different profiles (classes) of adjustment in the study cohort by fitting a baseline model to the data. To identify this optimal baseline model, we fit a sequence of models with two classes, three classes, and so on. The information used for model selection included the log-likelihood (LL), likelihood-ratio G2 statistic [37], Akaike’s Information Criterion (AIC) [39], Bayesian Information Criterion (BIC) [40], consistent AIC (CAIC) [41], and model entropy. Model interpretability was also considered by analyzing prevalences and item response probabilities of the estimated classes [37]. Next, multiple-group LCA was conducted with biological sex as the grouping variable to test for measurement invariance across sex or whether the profiles identified in the baseline model have the same meaning for boys and girls. To test whether measurement was invariant across sex, this model was run with all parameters freely estimated and again with item response probabilities constrained equal across groups. Covariates (i.e., sociodemographic and maternal health indicators) were then incorporated in the LCA model as potential predictors of profile membership; latent class membership probabilities were predicted by covariates through a logistic link.

3.4. Ethical Considerations

Both studies were approved by an institutional Research Ethics Board (REB) and all data providers. Before starting QUAL data collection, all mothers provided informed consent on behalf of their children and all youth provided their assent.

4. Mixed Methods Synthesis Findings

The purpose of the present mixed methods study was to integrate and synthesize the QUAL findings of the grounded theory study with the QUAN results of the population-based study and interpretation of the merged evidence. Table 3 presents a comparison of the QUAL and QUAN results. The QUAL findings were organized into a resilience model categorizing the coping strategies described by youth participants in individual-level, family-level, and community-level strategies; these are listed in the left column of Table 3. The population-based study identified four distinct adjustment profiles in youth exposed to IPV, which differed for boys and girls. These included a resilient profile in which youth showed no adjustment problems, as well as three profiles showing different combinations of externalizing problems and physical health problems. Positive maternal mental and physical health were predictors of resilient profile membership in both boys and girls, alongside other ecological factors at the family and larger societal levels (these are listed in the right column of Table 3). Detailed results of the two individual studies are presented elsewhere [30,31].
To compare the findings across the two studies, the QUAN predictors of resilience that emerged through LCA were conceptually linked to the resilient processes identified through the QUAL analysis. The QUAL findings were inductively generated and rooted in the narrative and pictorial data collected from the youth who participated in the grounded theory study; see the left column of Table 3. In the right column of Table 3, we indicated whether each QUAL finding was confirmed or disconfirmed by the QUAN profiles of adjustment and significant predictors of profile membership in the study cohort.
As shown in Table 3, the evidence provided by the QUAL study has more breadth as a greater number of domains of participants’ social ecologies were investigated. Therefore, findings from the QUAL study were somewhat more comprehensive than the evidence provided by the population-based study. However, only 13 children and adolescents participated in the grounded theory study, while the evidence provided by the population-based study represented a much larger sample of 3886 youth. Therefore, the results of the population-based study can be generalized to similar populations, while the same does not apply to the evidence provided by the grounded theory study.
The main positive coping strategy that emerged from the QUAL study was the presence of an available, caring, and sensitive mother with whom participants could establish a close and supportive relationship. This finding converged with the QUAN finding that more positive maternal mental and physical health significantly predicted profile membership labelled as resilient for both boys and girls in the population-based study. Membership in this profile was characterized by fewer, if any, mental health diagnoses or physical health problems. Specifically, the population-based study results indicated that fewer annual ambulatory physician visits and prescription medications for mothers, as well as the absence of asthma, diabetes, mood and anxiety disorders, and PTSD diagnoses for mothers, significantly predicted resilient profile membership for the study cohort of youth exposed to IPV.
The youth in the QUAL study also discussed how experiencing low levels of exposure to adversity helped them successfully cope with the challenges they were facing in their home. This protective mechanism converged with the QUAN finding that the absence of contact with the child welfare system was a significant predictor of membership in the adjustment profile labelled as resilient in youth exposed to IPV. In fact, it is plausible that the children in the population-based study whose families had no contact with the child welfare system or Child and Family Services (CFS) during the study period were experiencing lower levels of adversity, as compared to the children who were growing up in families who had one or more contacts with the child welfare system during the same period. This argument is based on the definition of involvement with the child welfare system, which included (i) children in families receiving services from the child welfare system, whose health or emotional well-being was thought to be endangered, but who remained in the families that received the child welfare services, either requested by the families or upon recommendation by the child welfare system, and intended to serve as aid in the resolution of family issues; or (ii) children in care of the child welfare system who were removed from their family of origin and placed in the care of another adult(s) (not a parent or guardian) due to concerns about the proper provision of care in the family of origin [42].
Given this definition, there may have been a variety of situations where a family was unable or unprepared to provide care for child(ren), including maltreatment (abuse or neglect), illness, death, conflict in their family, disability, or emotional problems. It may be reasonable to expect that children whose families experienced involvement with the child welfare system were experiencing higher levels of adversity than children whose families were never in contact with the child welfare system. Therefore, a parallel can be drawn between the population-based study result that no contact with the child welfare system significantly predicted resilient profile membership in the study cohort and the QUAL finding that lower levels of exposure to adversity significantly helped participants cope more successfully with the adverse home environment they experienced.
Many youths in the grounded theory study also mentioned the availability of a positive father, stepfather, or father figure as an essential factor that helped them to successfully cope with the multiple adversities they experienced in their lives, including growing up in an IPV-affected home. This finding converged with results from the population-based study in which we found that being part of a dual-parent family significantly independently predicted membership in the resilient profiles of adjustment in the study cohort. We believe that this protective effect of dual-parent family status may be due to the availability of an additional adult in the family, likely a male (e.g., father, stepfather, or father figure) who can act as a positive role model for the youth. Additionally, given that being part of a dual-parent family may also provide greater access to resources (e.g., more supervision, more emotional support, and greater economic resources), this QUAN result also converged with the QUAL finding that the availability of adequate resources both within the family and in the community was essential to facilitate positive coping in youth participants. The resources that these youth identified as facilitating their effective coping included the availability of multiple caregivers, adequate economic resources for their families, and safe and positive spaces in their schools and communities.
In the population-based study, the socioeconomic factor index—Version 2 (SEFI-2)—was used as an indicator of family socioeconomic status [42]. In the SEFI-2, an overall score is calculated based on the postal code where the family reside using (a) the average household income; (b) the percent of single-parent households in that residential area; (c) the unemployment rate in that residential area; and (d) the high school education rate in that residential area. Given the findings of the grounded theory study indicating that living in mid-to-high socioeconomic circumstances considerably helped children and adolescents to cope positively with adversity, this factor was expected to significantly predict resilient profile membership in the population-based study. Instead, lower family socioeconomic status significantly predicted resilient profile membership, as compared to the other adjustment profiles. This was a surprising and apparently counterintuitive finding, given that lower socioeconomic status as assessed by the SEFI-2 typically indicates residence in neighborhoods with fewer community services and resources and a higher likelihood of exposure to other adverse experiences (e.g., additional exposure to community violence and bullying). Therefore, in this instance, the finding from the grounded theory study seemed to diverge from or directly contradict the finding from the population-based study.
Child and mother ages were also found to be significant independent predictors of membership in resilient profiles for youth exposed to IPV in the QUAN study. However, this result was not reflected in the findings of the QUAL study. In fact, none of the youth included in the QUAL study mentioned their age or their mothers’ age as factors that affected their ability to successfully cope with adversity. While this lack of congruence does not mean that age was not a factor in the lives of the participants, it was not as salient or significant for them as other factors they discussed.

5. Discussion

The findings of our mixed methods synthesis revealed some overarching conclusions concerning the most relevant PPFPs that help youth exposed to IPV to successfully cope with adversity. The main convergent finding between the two studies supported other work in the literature that stresses the key role that mothers play in protecting their children’s positive adjustment and promoting their resilience [27,43]. For the youth who participated in the QUAL study, the presence of an available, caring, and sensitive mother with whom they could establish a close and supportive relationship was the main resource they relied upon when experiencing significant adversity. Similarly, in the QUAN study, positive maternal mental and physical health were significant predictors of membership in resilient profiles. Abundant research has shown that both mental and physical health problems may substantially impact women’s ability to perform their role of mothers in a sensitive and attentive way, especially for women who have experienced IPV and who are at an increased risk for developing mild-to-severe PTSD and depressive symptoms in combination with other mental and physical health problems [44,45,46]. The convergence found by the integration of the QUAL and QUAN findings confirmed the importance of having a more positive mother–child relationship for youth who are experiencing an adverse home environment.
For youth who are experiencing adversity in the form of IPV exposure, the absence of additional adverse childhood experiences (ACEs), especially in the form of mother mental or physical health problems, may be a significant protective factor with resilience-promoting effects. In fact, experiencing low levels of adversity was mentioned by many of the youth in the QUAL study as a factor that significantly helped them to successfully cope with IPV exposure. Mental and physical health problems in both youth and mothers may develop independently from their experiences of IPV and may contribute to increasing the level of adversity perceived by these families, leading to more negative outcomes, as supported by this mixed methods synthesis. This finding is supported by extensive research showing the existence of a dose–response relationship between ACEs and later adjustment. Several studies have shown that exposure to a greater number of ACEs is predictive of more negative adjustment, with the likelihood of experiencing adjustment problems increasing with any one additional ACE experienced by youth [43].
The pivotal role that mothers play in promoting positive adjustment and resilience in youth exposed to IPV has important implications for clinical practice with this population. To be truly effective, prevention programs directed to families experiencing adverse life events, such as IPV, should include and emphasize strengthening the mother–child relationship and promoting positive parenting behaviors in mothers [47]. For example, two intervention programs originally created in the United States, the Moms’ Empowerment Program (MEP) for women who have experienced IPV and the Kid’s Club (KC) program for youth exposed to IPV, were found to be effective in several contexts (e.g., Michigan, Texas, Australia, Alaska, Sweden) [48,49]. These interventions could also leverage the strengths of women survivors of IPV by involving them as facilitators and positive role models for other women showing that recovery and healthy romantic relationships are possible.
Whenever possible, fathers, stepfathers, and father figures should also be included in these interventions as they emerged from the stories of the youth include in the grounded theory study as key role models that significantly shaped their development. The limited evidence on the father–child relationship in families impacted by male-perpetrated IPV indicates that youth in these families experience ambivalence towards these men due to a combination of positive and negative feelings that they often struggle to combine into an integrated experience [50]. There is also evidence that exposure to multiple abusive father figures is associated with more negative developmental outcomes for youth exposed to IPV [51], while youth contact with a nonviolent male role model (e.g., father, stepfather, or father figure) may have a buffering effect on behavioral problems for these youth [52]. The findings of this mixed methods synthesis should, therefore, be interpreted cautiously because growing up in a dual-parent family may act as PPFP for youth exposed to IPV only if the additional adult in the family is a positive, nonviolent role model for them.
Additionally, parenting support to mothers who are facing IPV should be provided to help them maintain a positive parenting style despite the stress they may be experiencing. Recent research examining predictors of well-being in over 2000 mothers aged 21+ found that interventions that strengthen the dimensions of personal emotional support involving feeling unconditional love and acceptance, finding reliable comfort when in distress, and experiencing authenticity in relationships and satisfaction with friendships could be highly beneficial for mothers struggling with parenting difficulties [53]. These results suggest that the emotional support that mothers receive from their surrounding environments is far more important for their well-being than how they feel about the experience of parenting itself. With appropriate corroborating evidence, these four dimensions of emotional support may be usefully targeted in the formulation of future interventions aiming to promote the resilience and well-being of mothers who are struggling to provide effective parenting to their children while experiencing significant adversity. It would be also helpful to investigate whether improving the emotional support mothers receive from others affects their perception of their parenting so that interventions that strengthen mothers’ emotional support also improve their feelings about parenting (i.e., “Because I receive unconditional love from others, I am more satisfied with my parenting”).
Intervention programs directed to IPV-affected families should also address the mental and physical health problems that family members may have developed due to IPV or concurrently with the IPV experiences. In the present QUAN study, youth and mothers in the IPV-affected families were more likely to experience a wider variety of mental and physical health problems than non IPV-affected families. Additionally, the QUAN findings highlighted that the absence of a diagnosis of asthma in mothers was the strongest predictor of membership in the resilience profile for both boys and girls who were exposed to IPV. This finding provided partial support for the vast literature linking IPV to adverse health outcomes, particularly those involving the autoimmune system, in both adults and children involved [54].
The apparently counterintuitive finding that higher socioeconomic circumstances did not predict membership in the resilience profile following IPV exposure corroborates previous research showing that the stressors and relative isolation experienced by youth living in marginalized families who move into more advantaged areas are associated with poorer adjustment in comparison to youth who do not go through the upwardly moving process [55]. It is plausible to hypothesize that this may apply to our sample of Canadian youth exposed to IPV. Additionally, it is noteworthy that even the youth who participated in the QUAL study who were living in economically disadvantaged neighborhoods mentioned the availability of community services and resources as a factor that significantly promoted their positive adjustment to adversity. Therefore, these youth may fare better when social support and resources are available in the neighborhood where they are living, regardless of the socioeconomic characteristics of that neighborhood. This hypothesis is consistent with longitudinal research on youth involved with the justice system in the United States showing that when neighborhood support is available to meet the emotional and belonging needs of young people, this may help to offset risks conferred by the family environment [56]. If interpreted in this fashion, these two apparently contradictory findings point towards the same resilience mechanism, that is, youth exposed to adversity fair best when adequate support and resources are provided to them in culturally and contextually meaningful ways in their neighborhood of residence. For instance, interventions that effectively promote the mental health and well-being of Indigenous youth in Canada take a culturally and contextually sensitive approach, also known as the “two-eyed way of seeing” approach [57], whereby contributions of Indigenous and Western “ways of knowing” (worldviews) work alongside one another with respect and balance. Interventions that take this approach include wholistic Indigenous healing factors that simultaneously address the emotional, mental, physical, and spiritual domains by strengthening culturally meaningful PPFPs, such as connection to nature, cultural pride, interconnectedness, land-based learning, and wisdom from the Elders, alongside Western PPFPs, such as emotional regulations, mindfulness, building healthy relationships, and developing an integrated identity [58,59]. Such programs respect youth’s cultural background and acknowledge the intergenerational traumas their families have experienced and the impact these traumas have on their development.
Similarly, the findings from the “Moving to Opportunity” program evaluation in the United States support this counterintuitive finding of the mixed methods synthesis. In this program evaluation, differential impacts involving both negative and positive outcomes were found in youth in families randomly assigned from disadvantage housing into more favorable circumstances [60]. For visible minority families, the ethnic composition of socioeconomically disadvantaged neighborhoods may offer a greater sense of belonging and social support than they may experience in more advantaged neighborhoods that are not as diverse or welcoming [61]. Therefore, the results of the two independent studies integrated here seem to be consistent with research showing that the beneficial effects of living in more socioeconomically advantaged neighborhoods that are not ethnically diverse may not apply for ethnic minority youth who transition into those neighborhoods and that the stresses associated with upward social mobility negatively affect the adjustment of the youth who move [62]. While information about the ethnocultural background of the study cohort included in the population-based study is not available, considering the current Manitoban population and the evidence showing that Indigenous and ethnic minority women are more likely to experience IPV than Caucasian women [63], it can be hypothesized that approximately 30% of the families in the study cohort (N = 1165) were likely Indigenous or belonged to a visible ethnic minority group. For these families, living in a socioeconomically disadvantaged neighborhood may provide a greater sense of belonging and social support than if they made a disruptive transition to less ethnoculturally diverse and potentially unwelcoming economically advantaged neighborhoods. Clearly, further research is needed that addresses this hypothesis directly, including the nature and timing of the transition and how it is associated with resilience in youth exposed to IPV.
While our finding that youth exposed to IPV reported that they fared best when adequate support and resources are provided in their neighborhood of residence requires replication, it has bearing on the design of public policies and community-based initiatives that engage and support marginalized young people in a contextually and culturally sensitive way. For example, the Bear Clan Patrol [64] is a community-based and volunteer-led initiative that emerged in the Canadian city of Winnipeg in 1992 because of the ongoing community violence and substance-related problems experienced by families located in inner city neighborhoods that are predominantly populated by Indigenous communities. To help create a safer environment, Indigenous community members came together and organized a patrol system to monitor and discourage crime and substance use in the neighborhoods and to provide an early response to these situations when they occur. Specifically, the Patrol aims to maintain harmony within the Indigenous communities by providing a visible presence on the streets through rides, escorts, and referrals; safety, conflict resolution, mobile witnessing, and crime prevention; and early responses to dangerous situations. This is one example of a grassroots community-based initiative that has contributed to building social capital in underserved communities.

Limitations and Future Directions

Due to the characteristics of the two individual studies synthesized here, many of the specific coping strategies discussed by the youth who participated in the grounded theory study as promoting their resilience were not quantitatively addressed using population-based data in the QUAN study. Additionally, the administrative data used in the population-based study did not include measures of positive adaptation, such as emotional regulation or gratitude, which may have strengthened the results of the study. These limitations should be addressed in future mixed methods research.
The two studies integrated here included youth of different ages—9–17 years in the QUAL study and 6–11 years in the QUAN study—which may have affected the convergence or divergence between findings. Given that PPFPs can vary significantly across different age groups and between sexes [65,66], this variation in age between the two independent studies may represent a limitation of this work that impacts the mixed methods findings. However, given the substantial convergence of the QUAN findings and QUAL results, we believe that including two different age groups that span the entire adolescence period (6–17 years) represents also a strength of this synthesis. The issue of whether or not certain PPFPs are relevant throughout the teenage years should be further investigated in future research. Including youth of multiple age groups in more complex mixed methods sequential or hybrid studies may represent an effective strategy to investigate resilience in young persons exposed to IPV from a developmental perspective as it is well recognized that certain PPFPs are more salient in specific developmental stages rather than others [67].
In the QUAN study included in this mixed methods synthesis, we used the variable “dual-parent family status” (Yes/No) as an indicator of the presence of an additional role model, likely a male (e.g., father, stepfather, or father figure), in the family with whom the youth included in the study cohort had a relationship. However, the QUAN data we used did not directly evaluate the presence and quality of this relationship. So, although the convergence of QUAN and QUAL data on this PPFP provides evidence in support of our hypothesis, we did not directly test this hypothesis. Given the substantial lack of research on the father–child relationship in families impacted by IPV, it would represent a valuable contribution to our understanding of PPFPs in youth exposed to IPV if future research investigated this issue in a more nuanced fashion by collecting data on not only the presence of a father–child relationship but also its quality and subjective value for youth exposed to IPV.
Future mixed methods studies should also use QUAL and QUAN research methods to collect subjective and objective information about the sociocultural ecologies of the same study participants [68] to help identify the PPFPs that characterize them. The two-phase mixed methods explanatory sequential design may be better suited to address this research goal [29].
The present mixed methods synthesis was also limited as it did not address PPFPs factors associated with participants’ ethnocultural backgrounds as it is well documented that ethnocultural PPFPs significantly predict resilience and well-being in visible minority youth [69,70]. For instance, ethnic identity is one culturally and developmentally relevant factor that buffers the negative impacts of discrimination on well-being and self-esteem [71,72]. Research on risk and resilience in ethnic minority youth has shown that ethnic identity affirmation (i.e., positive feelings about one’s ethnicity) is protective against the negative effects of discrimination. This evidence suggests that ethnic identity affirmation may be a key cultural factor to include in prevention and intervention efforts aimed to reduce the negative effects of discrimination on later adjustment. Future research should investigate these mechanisms in ethnic minority youth exposed to IPV.
Future research should also address whether there are significant differences in the factors and processes associated with resilience in gender diverse youth of different ages. Recognizing and identifying gender and age-salient factors associated with resilience in youth exposed to IPV is an important first step in the formulation and implementation of public policies and intervention programs aimed at promoting mental health and resilience in these youth. By incorporating a gender and age sensitive approach into the development of intervention programs, it is more likely to design initiatives that help youth acquire gender and developmentally salient protective skills that are associated with resilience [73].
Given the evidence provided by the population-based study concerning the role that disadvantaged socioeconomic circumstances may play as a significant facilitator of resilience in certain young persons exposed to IPV, future research should further investigate this issue by addressing a variety of socioeconomic status indicators separately, including maternal education, family level income, neighborhood characteristics including social capital, and extended family involvement and resources; this would be especially important in ethnic minority families.
Considering the stories of the children and adolescents included in the grounded theory study, one specific question arises: Are we, as a society, providing resources and support to marginalized youth in a contextually and culturally sensitive way and in a way that is relevant to their experiences? Future mixed methods research should address this important question.

Author Contributions

Conceptualization, M.C.; methodology, M.C.; software, M.C.; validation, M.C. and C.C.P.; formal analysis, M.C.; investigation, M.C. and C.C.P.; data curation, M.C.; writing—original draft preparation, M.C.; writing—review and editing, M.C. and C.C.P.; supervision, C.C.P.; project administration, M.C.; funding acquisition, M.C. All authors have read and agreed to the published version of the manuscript.

Funding

This research was funded by the University of Manitoba and Research Manitoba.

Institutional Review Board Statement

The qualitative study was conducted in accordance with the Declaration of Helsinki, and approved by the Research Ethics Board of the University of Manitoba (REB File #HS21780 (H2018:183) on 21 June 2018). The quantitative study involving de-identified administrative data was approved by the University of Manitoba REB (REB File #HS23139 (H2019:332) on 9 August 2019) as well as by the Health Information Privacy Committee of Manitoba (HIPC No. 2019/2020–30) on 12 February 2020 and all data providers, including the Department of Education, Department of Families, Department of Justice, Vital Statistics, and Winnipeg Regional Health Authority (WRHA).

Informed Consent Statement

Informed consent was obtained from all youth involved in the qualitative study. Informed consent for use of de-identified administrative data is not required as per local legislation of the Health Information Privacy Committee.

Data Availability Statement

The data used in the qualitative study are available on request from the corresponding author due to privacy and confidentiality reasons.

Conflicts of Interest

The authors declare no conflict of interest.

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Figure 1. Visual model of the mixed methods synthesis (QUAL + QUAN).
Figure 1. Visual model of the mixed methods synthesis (QUAL + QUAN).
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Table 1. List and description of the family well-being variables used in the population-based study.
Table 1. List and description of the family well-being variables used in the population-based study.
Family VariablesDescription
IPV exposureChildren’s prenatal and postnatal IPV exposure. Children were included in the IPV cohort if in any of these records there was evidence of a history of IPV exposure. No information about length or severity of IPV exposure was available in the databases.
Family typeSingle- or dual-parent family status was determined based on the presence of a living spouse or common-law partner.
Contact with the child welfare system Number of contacts that each family had with the child welfare system or Child and Family Services (CFS) for any reasons after the birth of the child included in the study.
Family socioeconomic statusThe socioeconomic factor index—Version 2 (SEFI-2)—was used as a measure of household socioeconomic status. The SEFI reflects social determinants of health and is used as a proxy measure of socioeconomic status. The SEFI-2 is calculated at the geographic level of the dissemination area using (1) the average household income, (2) the percent of single-parent households, (3) the unemployment rate, and (4) the high school education rate, and it is then assigned to residents based on their postal codes.
Table 2. List and description of the child and maternal well-being variables used in the population-based study.
Table 2. List and description of the child and maternal well-being variables used in the population-based study.
Child and Maternal VariablesDescription
Age Children’s age in years in 2017
Mother’s age at the birth of the child included in this study
Biological sex (male, female) Children’s biological sex
Externalizing disorders (yes, no) Child diagnosis of attention-deficit/hyperactivity disorder (ADHD), conduct disorder, or substance use disorder in 2017
Internalizing disorders (yes, no) Child diagnosis of mood disorder (e.g., depression, mania, or bipolar disorder), anxiety disorder (e.g., anxiety state, phobia, or obsessive-compulsive disorder, or post-traumatic stress disorder (PTSD) in 2017
Maternal diagnosis of mood disorder, anxiety disorder, or PTSD in 2017
Chronic physical health conditions (yes, no)Child diagnosis of asthma or diabetes in 2017
Maternal diagnosis of asthma or diabetes in 2017
Ambulatory physician visits (no visits, average visits, or above average visits)Number of physician visits that children required in the calendar year 2017, including all contacts with General Practitioners or Family Practitioners and specialists occurring in offices, walk-in clinics, home visits, personal care home or nursing home visits, and visits to outpatient departments
Number of physician visits that mothers required in the calendar year 2017
Prescription medications Number of any class of prescription medications prescribed to children in the calendar year 2017
Number of any class of prescription medications prescribed to mothers in the calendar year 2017
Over-the-counter medications purchased without a prescription were not included
Inpatient hospital episodes and inpatient hospital episode length of stayNumber of all inpatient hospital episodes and inpatient hospital length of stay (LOS) in days experienced by children in 2017
Number of inpatient hospital episodes and inpatient hospital length of stay (LOS) in days experienced by mothers in 2017
Birth hospitalizations were excluded because nearly all children are born in hospital
Table 3. Comparison of the qualitative findings of the grounded theory study with the quantitative results of the population-based study.
Table 3. Comparison of the qualitative findings of the grounded theory study with the quantitative results of the population-based study.
PPFPs in Youth Exposed to IPV
N = 13		Significant Predictors of Resilience in Youth Exposed to IPV
N = 3886
Individual-level coping strategies:
  • Effective coping mechanisms
  • Actively seeking change
  • Being future oriented
Not assessed
Family-level coping strategies:
  • Close and supportive family relationships
  • Available and sensitive caregivers
  • Positive role models
  • Actively reaching for family connections
  • Enjoying the company of pets
  • Seeing parents thorough a positive lens
  • Questioning unhealthy family beliefs and dynamics
Positive maternal mental and physical health
Community-level coping strategies:
  • Healthy school environment
  • Supportive teachers
  • Connecting positively to school
  • Close and supportive peer relationships
  • Positive role models
  • Accessing community services and resources
Not assessed
Factors promoting resilience across levels of social ecologies:
  • Low levels of exposure to adversity
  • Adequate and accessible resources
  • Multiple caregivers
  • Mid-to-high socioeconomic standing
  • Neighborhood safety
  • Accessible community services and resources
  • Actively seeking human connections
  • Performing fulfilling activities
  • Worrying about others’ well-being
Positive maternal mental and physical health
Absence of contact with the child welfare system
Dual-parent family status
Lower family socioeconomic status
N/AChild and mother age
Note: Convergent findings are reported in italics.
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Cameranesi, M.; Piotrowski, C.C. A Mixed Methods Synthesis Investigating the Personal and Ecological Resources Promoting Mental Health and Resilience in Youth Exposed to Intimate Partner Violence. Youth 2024, 4, 1610-1627. https://doi.org/10.3390/youth4040103

AMA Style

Cameranesi M, Piotrowski CC. A Mixed Methods Synthesis Investigating the Personal and Ecological Resources Promoting Mental Health and Resilience in Youth Exposed to Intimate Partner Violence. Youth. 2024; 4(4):1610-1627. https://doi.org/10.3390/youth4040103

Chicago/Turabian Style

Cameranesi, Margherita, and Caroline C. Piotrowski. 2024. "A Mixed Methods Synthesis Investigating the Personal and Ecological Resources Promoting Mental Health and Resilience in Youth Exposed to Intimate Partner Violence" Youth 4, no. 4: 1610-1627. https://doi.org/10.3390/youth4040103

APA Style

Cameranesi, M., & Piotrowski, C. C. (2024). A Mixed Methods Synthesis Investigating the Personal and Ecological Resources Promoting Mental Health and Resilience in Youth Exposed to Intimate Partner Violence. Youth, 4(4), 1610-1627. https://doi.org/10.3390/youth4040103

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