Background Globally, there is increasing emphasis on the importance of understanding the ways in which social inequality and injustice impact individual and community mental health. Set in the states of Uttar Pradesh and Uttarakhand, India, this thesis examines the complex relationships between individuals, communities and the social environment in relation to mental health. North India is characterised by stark gender and socio-economic inequalities and social exclusion for people with psycho-social disability (PPSD) and mental health services in these study areas were essentially absent. Community mental health competency means people are collectively able to participate in efforts to promote, prevent, treat and advocate for mental health. This thesis reflexively examines the presence and absence of community mental health competence in the upper Ganges region. Methods A mixed methods approach allowed for a multi-level examination of community mental health competence, and generated four sub-studies. In-depth interviews with thirteen PPSD and eighteen caregivers in Bijnor and Saharanpur (Uttar Pradesh state) were carried out in 2013 providing data for qualitative analysis. These data were analysed using qualitative content analysis to examine experiences of exclusion and inclusion of PPSD in sub-study I, and thematic analysis to examine the gendered experiences of caregivers in sub-study II. A community based sample of 960 people in Dehradun district (Uttarakhand) were surveyed in 2014 to examine the prevalence, treatment gap and social determinants of depression in substudy III, and the attitudes and preferred social distance from people with depression and psychosis were investigated in sub-study IV. Multi-variate regression analysis in both studies was conducted with Stata software Version 13.1. Results Within the domain of knowledge, relatively low community mental health literacy, a diverse range of explanatory models of mental health, and creative and persistent efforts in helpseeking were the themes identified. Within the domain of safe social spaces, social exclusion was harsh and prevalent for PPSD, with contrasting sub-domains of belonging, social support, social participation and ahimsa (non-violence). Women were disadvantaged more than men in most spheres of caregiving. Social determinants of depression with an adjusted odds ratio of more than 2.0 included being a member of the most oppressed caste or tribal group, having taken a recent loan, and not completing primary schooling. The prevalence of depression was 6.0% in the community sample, and there was a 100% treatment gap for counselling, and a 96% treatment gap for anti-depressant therapy, even though 79% of those with depression had visited a primary care provider in the previous three months. Social determinants of health and access to care are proposed as additional domains of community mental health competency. The prevailing gender regime that values males and disadvantages women influenced every domain of community mental health competency, particularly increasing caregiver burden, social exclusion and experiences of physical violence for women.  Conclusions In this thesis I have refined and strengthened a conceptual framework that portrays community mental health competence as a tree, where foundational roots of social determinants of mental health support four branches depicting access to care, knowledge, safe social spaces and partnerships for action. This tree model proposes that all five domains must operate in unison to support action for community mental health involving: development of community knowledge; promoting social inclusion, gender equality and participation; addressing upstream health determinants; and increasing access to mental health care.

Culture is critical to delivering effective mental health care, necessitating tailored approaches aligned with the respective cultural contexts. The rise of globalization and transcultural psychiatry highlights the importance of integrating culture comprehensively into mental health and psychosocial interventions within humanitarian contexts. Existing research underscores the significance of culture in mental health. However, a prevailing influence of Western perspectives on mental health is evident globally, leading to the widespread implementation of Euro-American viewpoints in humanitarian fieldwork. This approach negatively impacts individuals affected by crisis by sidelining culturally grounded understandings of illness. While several studies examine the impact of culture on mental health care, there is limited research on how humanitarian organizations perceive and incorporate culture in training materials. This study aims to examine how the Red Cross Red Crescent Movement conceptualizes and integrates culture within its mental health and psychosocial support (MHPSS) intervention. I collected data from nineteen Red Cross guidebooks to conduct a thematic analysis and extract insights into the organization’s approach. I found nine themes: understanding culture through self, culture as behaviour, culture as meanings, community-based approach, assessment, planning and implementation, training, monitoring and evaluation, and universality of mental illness. My findings indicate that the Red Cross conceptualizes culture holistically, and by doing so, they aim to produce culturally relevant care. While the Red Cross emphasizes cultural relativism in its MHPSS responses, encouraging cultural competency, it also tends towards universalism when discussing mental health, reflecting the nuanced nature of MHPSS interventions. This tension highlights the complex relationship between these two perspectives in creating the Movement’s MHPSS responses and speaks to broader challenges in delivering mental health and psychosocial care in humanitarian fields. Further avenues for research lie in exploring strategies to reconcile relativist and universalist frameworks, aiming to produce seamless MHPSSs. / Thesis / Master of Arts (MA) / Effective mental health care respects and incorporates the cultural beliefs and practices of the individuals receiving it. However, according to the literature, there is a pattern amongst international aid agencies of applying Westernized mental health ideas globally. In this study, I investigate how the Red Cross Red Crescent Movement understands and incorporates local culture in its mental health and psychosocial supports (MHPSS). The study reveals that the Movement recognizes culture holistically. The Movement closely works with communities, aiming to ensure that the support matches local ways of understanding well-being and distress. However, the Movement tends to apply a more universal understanding regarding specific mental disorders. This discrepancy highlights issues within the humanitarian field at large. My findings suggest that while the Red Cross does well to integrate cultural understandings of psychosocial distress, there is a need for better collaboration between universal and local perspectives in MHPSS.

With yearly rates ranking clearly above world average in Europe, suicide constitutes a substantial public health problem. Because of that, prevention has become a major concern for German mental health institutions. A requirement for successful prevention strategies is to address all key factors that contribute to suicidality. It is highly relevant in this respect that suicidal behaviour itself exhibits a social gradient: drawing on the relevant literature, low socioeconomic status (SES) and a high extent of social isolation (SI) are related to increased suicide risks (Lorant et al. 2005; Li et al. 2011; Qin et al. 2003; Agerbo et al. 2007). The purpose of this study was therefore to add to these findings and to further investigate associations of SES and SI with suicide in order to define starting points for public health interventions. It was consequently hypothesized that lower individual levels of SES and higher individual levels of SI are correlated with increased suicide rates. SI potentially compromises the perception of social support in stressful live events associated with low SES (Cohen et al. 2006; Kumari et al. 2010). Since such life events correlate with suicidal behavior (Beautrais et al. 1997; Cohen et al. 2019), the effects of low SES were further hypothesized to be aggravated in individuals with high SI levels (SES x SI interaction). In order to test the hypotheses, all 149.033 suicide deaths between 1997 and 2010 (T = 14 years) were extracted from the official German death record as coded by ICD categories E950 - E959 for 1997 and X60 - X84 for the years from 1998 onwards, respectively. Information on SES and SI was gained by merging the dataset with Germany’s main household survey, i.e. the Microcensus. In accordance with the existing literature, established indexes on occupational status (ISEI, Ganzeboom & Treiman 1996) and educational achievements (CASMIN, König et al. 1988) were applied as well as items on income, minor employment, unemployment, the number of received public transfers and the reception of social bene fits due to unemployment (ALG I/II) in order to capture SES. SI was proxied with variables measuring single marital status, living in a one-person-household and relocations throughout the year before the survey was conducted. Due to German data protection regulations that do not permit the analysis of death record data based on individual level information, suicide deaths were examined as aggregated rates at the level of N = 390 administrative districts. In order to deal with two problems associated with this kind of statistical analysis, Prentice and Sheppard’s model for aggregate data (1995) was applied accounting for potential estimation biases due to differences in baseline suicide rates between districts and between time periods. The model specification further corrected for spatial effect correlations. An important limitation to this procedure is that the estimates represent a blend of effects at the individual and district levels. However, an adequate solution is only available through the application of individual level data. The statistical analysis turned out the following results: The positive effect on suicide rates of unemployment and the negative effect of income as two out of seven SES proxies and the positive effect of living in a one-person-household as one out of three SI proxies validate the proposed hypotheses on the relations of SES and SI with suicide rates. Confirming the hypothesis on SI mediating SES effects, the model revealed positive effects on suicide rates of income decreases in single individuals. Likewise, we observed positive effects on district suicide rates for decreasing levels of CASMIN in district population shares who had relocated throughout the past year. In contradiction to the theoretical claims, however, increases in CASMIN scores were found to result in positive effects on suicide rates just as a history of relocation prior to suicide was related to decreasing suicide rates. Furthermore, decreases in income were found to result in negative effects on suicide rates in the district population of persons living in a one-person-household. The results indicating associations of SES and SI with increases in district suicide rates represent appropriate starting points for the definition of suicide prevention strategies. Thus, particularly the unemployed, individuals with low incomes, persons living in one-person-households and relocated individuals with lower educational levels should be targeted by public health interventions. Moreover, the observations of the present study clearly demonstrate the significance of longitudinal individual level data for public health policies. Respective research incorporating such data would permit a better understanding of the causal mechanisms resulting in suicidality and help to further investigate the robustness of the shown results. By this means, prevention strategies could be better adapted to the specfic needs of the individuals under concern. Regarding the findings contradicting the theoretical claims, it needs to be mentioned that associations of low SES and high SI levels with increases in suicide risks can not be ruled out at the individual level. Rather, the observed inconsistent effects might be attributable to differences in district compositions than to differences in characteristics of the respective subjects. Also a statistical separation of compositional effects from effects of individual traits would be made possible by including individual level data in future work.:Abbrevations II Tables II 1 Introduction 1 1.1 Suicide - A Global Health Burden 1 1.2 Risk Factors and Etiology of Suicide 1 1.3 Suicide Prevention 2 1.4 Social Disparities in Suicide 2 1.4.1 Socioeconomic Status 2 1.4.2 Social Isolation 3 1.4.3 Health Inequalities and Health Inequities 4 1.4.4 Causation and Selection 5 1.4.5 Individual Life Courses 7 1.5 Stress and Diathesis 8 1.5.1 Critical Life Events 9 1.6 Neurobiological Correlates of Suicidality 9 1.6.1 Neurobiological Correlates of SES and SI 10 1.7 SES, SI and Social Support 11 1.8 Aims of the Thesis 11 1.9 Methods 12 2 Original Publication 14 Summary 23 References 26 Supplementary Materials - Further Statistical Tests & Models 41 Structural Breaks in Suicide Numbers 41 Age- and Gender-Adjustment of District Suicide Rates 42 Alternate Model Specifications Anlagen i Erklärung über die eigenständige Abfassung der Arbeit i Spezifizierung des eigenen wissenschaftlichen Beitrags iii Danksagung iii

PURPOSE: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has not yet been systematically evaluated in the Caribbean context, particularly with Hispanic youth exposed to multiple disasters. The objective of this project was twofold: 1) to train mental health providers in Puerto Rico in TF-CBT as part of a clinical implementation project within the largest managed behavioral health organization (MBHO) on the island, and 2) to conduct a program evaluation to determine the feasibility of implementation and the effectiveness of the treatment. METHOD: Fifteen psychologists were trained in TF-CBT. These psychologists then provided TF-CBT to 56 children and adolescents, ages 5-18, in community-based mental health clinics and one primary care clinic with a co-located psychologist in Puerto Rico. The mean number of traumatic events reported by youth referred for TF-CBT was 4.11. RESULTS: Thirty-six out of 56 children enrolled in the project (64.3%) successfully completed all components of TF-CBT. Results demonstrated large effect sizes for reduction in youth-reported posttraumatic stress symptoms (PTSS) (Cohen's d = 1.32), depressive symptoms (Cohen's d = 1.32), and anxiety symptoms (Cohen's d = 1.18). CONCLUSIONS: These results suggest that it was feasible to train providers in TF-CBT, that providers were able to deliver TF-CBT in community-based settings both in person and via telehealth (due to the COVID-19 pandemic), and that TF-CBT was an effective treatment option to address trauma-related concerns for youth in Puerto Rico in a post-disaster context. This project is an important first step in the dissemination and implementation of evidence-based trauma-focused treatment for Hispanic youth and disaster-affected youth in the Caribbean.

Children and adolescents in low- and middle-income countries (LMIC) suffer heightened vulnerability for the development of mental health conditions which is exacerbated due to enduring socioemotional, economic, and biological risk factors. The constellation of co-occurring adverse childhood experiences (ACEs; e.g. poverty, maltreatment, household dysfunction, exposure to violence) confer heightened vulnerability for the development of mental health disorders that may persist into adulthood. Although the mechanisms for transmission from one generation to the next has not yet been fully elucidated, contemporary evidence has converged primarily on maternal mental health as a key mediator between childhood exposure to ACEs, and the subsequent mental health of her children. Access to mental health assessment or treatment resources in Kenya are limited or non-existent. Due to the heightened risk for intergenerational transmission of mental health problems across generations, with support from the World Health Organization and key stakeholders in Kenya, the development of task-sharing approaches to address the unmet psychological needs of children and mothers has been advocated for. Task-sharing involves the rational redistribution of mental health care tasks from higher cadres of mental health professionals to non-specialized community health care workers in order to increase the capacity for, and access to, mental health services across Kenya. This dissertation seeks to explore: 1) the development of a partnership between the Africa Mental Health Research and Training Foundation and McMaster University to explore the use of task-sharing in the development of a technology-supported assessment for common mental disorders in children and adolescents; 2) the validity and reliability of the newly developed International Mobile Assessment for Children and Teens (IMPACT) administered by non-specialized community health workers when compared to a gold-standard assessment, the MINI-KID, when administered by trained psychology graduate students, and finally; 3) the association between maternal exposure ACEs and the subsequent mental health of her children, mediated by maternal mental health. The first study outlines the process of the development of the IMPACT using a novel blending of emic-etic approaches, and the practical evaluation of the IMPACT by ten local community health workers. Results from this study demonstrated the demand for, and utility of, the IMPACT and outlined the practical considerations of conducting field work of this nature. The second study examined the diagnostic agreement (e.g. validity) of mental health conditions in Kenyan school children (n=189) between the IMPACT and the MINI-KID. The results of this study demonstrated relatively high agreement between the diagnosis of common mental disorders in children between the IMPACT and the MINI-KID. The third study explores the relationship between ACEs (Y-VACS) of mothers (n=149) and the socioemotional wellbeing of her children (e.g. internalizing and externalizing problems; CBCL), mediated by maternal mental health (CBCL). The results of this study demonstrate the association between maternal ACEs and child internalizing and externalizing behaviours, mediated by maternal mental health and moderated by maternal education. Collectively, the results of these dissertation studies support the use of task-sharing approaches for the assessment of common mental disorders in children and adolescents, by non-specialized community health workers and that the transmission of mental health problems between generations is associated with a multitude of complex and inter-related factors (e.g. maternal ACEs and maternal mental health), exacerbated by chronic and co-occurring adversity. Additionally, the results of these studies demonstrated the need for further research that prioritizes the equitable accessibility interventions that target the mental health related-sequelae experienced by maternal-child dyads exposed to chronic and enduring adversity in LMIC. / Dissertation / Doctor of Philosophy (PhD) / Children who grow up in circumstances of chronic poverty and adversity suffer heightened risk for mental health problems as they grow up. This is especially true of children who live in low- and middle-income countries, where children are more likely to experience chronic and co-occurring forms of adversity. Access to mental health services in these contexts are limited or non-existent, conferring heightened vulnerability for mental health problems that may persist across the lifespan. The risk for mental health problems can be transmitted across generations. Although it is not fully understood how mental health problems can be transmitted from a mother to a child, one commonly studied mechanism is the role of maternal adversity and maternal mental health. Because the barriers to mental health care are abundant, the needs of children and mothers with mental health problems are frequently left unmet. The World Health Organization proposes a task-sharing solution, whereby less specialized community health care workers are trained to provide services to improve access to assessment and treatment in low income countries. Using data collected in rural Kenya, this dissertation seeks to explore: 1) the development of a partnership between the Africa Mental Health Research and Training Foundation and McMaster University with the aim of working together to create mental health assessment for children, using a task-sharing approach, 2) to compare the results of the novel mental health assessment to a gold-standard, and 3) to evaluate maternal adversity, maternal mental health, and the transmission of mental health problems between mothers and children in Kenya. Collectively, the results of this dissertation demonstrate that utilizing a task-sharing model for the development of a mental health assessment for use by community health workers is a valid method for assessing and diagnosing mental health problems in children, and that the transmission of mental health problems across generations is associated complex factors (e.g. maternal exposure to adversity and maternal mental health) as a result of exposure to chronic and enduring adversity in LMIC.