Background: In South Africa and internationally, there is policy written and work done around empowering persons with disabilities to earn an income to become economically independent. Similarly, much has been written about the importance of social inclusion for persons with disabilities. However, very little is known about how persons with disabilities use education and training opportunities to advance their social capital in the South African context through being economically empowered. The ultimate goal of education is to obtain and maintain gainful employment but historically, work and disability were mutually exclusive (Howard, 2005). Ville (2005) suggests that while there are studies around the unemployment of persons with disabilities, few examine the experiences of these persons as players in their own lives. The focus of this qualitative study is to explore how persons with disabilities advance their social capital through participation in auxiliary (non-formal) education and training programmes that prepare them for employment, or as a pathway to economic inclusion or employment. This knowledge will inform training providers providing training to persons with disabilities at various levels, potential employers as well as persons with disabilities, on how skills development can include processes that would encourage both social and economic inclusion. Aim: The study aimed to critically examine the experiences of persons with disabilities who participated in the auxiliary programme to determine whether and to what extent it has strengthened and expanded their social capital to advance their opportunities for economic inclusion and/or employment. Objectives: The objectives of the study were to: • Explore how skills development programmes facilitate economic inclusion and/ or employment for persons with disabilities and why persons with disabilities engage in skills development opportunities; • Describe the profiles of persons with disabilities who undertake skills development opportunities, exploring how database information is and can be used to inform the transition to employment or economic inclusion for persons with disabilities; • Identify features of social capital evident in employers' perspectives on the employment of persons with disabilities. Methodology: An intrinsic exploratory case study design was used. Case study design provided contextual boundedness and situatedness to the research. Data was collected from databases developed and utilised by the QuadPara Association of South Africa that contained demographic and training information of participants. In-depth interviews with eight participants who had completed skills development training contributed to the understanding of the experiences of persons with disabilities in seeking employment or economic inclusion following skills development. Critical conversations with employers of persons with disabilities contributed to the understanding of the perspectives and attitudes held in the employment sector, when considering the employment of persons with disabilities. Other methods of data collection included document analysis, naturalistic researcher observations and reflections. The findings are presented as three separate papers. The first paper presents the voices of persons who have undertaken skills development training. This paper asserts that if training providers are able to recognize the determinants of social capital within their trainees, these determinants can be nurtured and developed alongside skills development in order to make their trainees more ‘employable', as well as to facilitate the transition into the labour force more smoothly. The second article argues that while it is necessary that alternative, suitable and sustainable training pathways are developed and recognized, these programmes need to build and present the prospective employee's social capital. This paper presents how information, which is used to facilitate the transition into employment can be better utilised. A database containing only demographic information is seemingly insufficient in the face of the number of barriers to employment that persons with disabilities have to overcome. The last article in this thesis speaks to the role of employers in the development of social capital. In order to further understand and promote the employment of persons with disabilities, efforts have to be made to increase social capital in all of the factors that influence the role of being a worker. To this end, individuals need to acknowledge and expand their own social capital, training providers need to support the expansion of networks and social capital through their engagements with trainees, and employers are required to look beyond the disability so that employment goals are shared and re-enforced. Conclusion: This study has uncovered that current practices related to the employment of persons with disabilities works in a very colonial, top-down fashion and seem to have been uncritically exported/imported from the Global North. This study has highlighted the absence of the African concept of “Ubuntu” - like interaction, which emphasises the self as part of others. In order to use social capital for mutual benefit, the employment of persons with disabilities must look different and have different considerations. A decolonial framework, which places less emphasis on practices used in the global North, will improve employment practices for persons with disabilities, as employers will be forced to look beyond the disability and relevant legislation only.

Background Childhood trauma (CT) has been associated with development of substance use disorders (SUDs) and severe mental illness (SMI) in community cohorts. There is a paucity of data on correlates of CT in dually diagnosed clinical populations in South Africa. We investigated the association among mono-substance use, polysubstance use and CT. Additionally, we explored demographic and clinical correlates of CT. Study aims We investigated associations between CT and SUD in patients with SMI. Setting Participants included patients aged 18–59 years with psychotic disorders attending specialist psychiatric hospital. Methods A cross-sectional study was conducted and the structured clinical interview for DSM-IV, (SCID – I) to determine SUD and SMI, and the childhood trauma questionnaire (CTQ) to measure CT were administered. Results Of the 74 patients, the mean age was 29 years (SD = 8.6) and 64% were male; 64% had schizophrenia-spectrum diagnoses, 23% had BMD-I and 14% had SIPD. Of the patients, 41% were taking no drugs, 22% were mono-drug users and 38% were poly-drug users. There was no significant difference between substance use groups in terms of age or level of education. However, those with no SUDs were significantly more likely to be female, whereas those with mono- or-poly-substance use were significantly more likely to be male. Patients with poly-SUD were significantly less likely to have been married and significantly more likely to have had a diagnosis of SIPD. There were no significant differences in CTQ scores by SUD groups. In this sample of patients with SMI, we found no significant association between CT and SUDs. Conclusion More research is needed into the effects CT has on dual diagnoses to inform treatment approaches to explore traumatic experiences.

Intimate partner violence (IPV) constitutes a major global health problem, affecting one in three women worldwide at some point during their life. IPV is particularly high in low and middle income countries (LMICs) and is associated with a wide range of adverse maternal and child health outcomes. Despite evidence that exposure to IPV affects child development and growth at birth and in infancy, there are limitations to our existing knowledge. First, few studies have considered the impact of maternal emotional IPV separately on child outcomes investigated, focusing primarily on physical and/or sexual IPV. Second, much of the existing data derives from high income countries, rather than from LMIC settings, where the majority of the world's child population lives and where many children are exposed to disproportionately high levels of poverty and violence-related risk factors. Third, there is limited information from well characterized longitudinal studies in these settings and a lack of investigation of associations in very young children, despite the fact that children under 2 years may be particularly at risk for long-term health sequelae relating to IPV exposure. Lastly, few studies have formally investigated potential mediators, inclusive of both behavioral and biological mechanisms underlying associations between IPV and food security and early-life child growth or development. In high-risk settings such as South Africa it is critical to gain improved understanding of pathways by which violence affects child health. This may be especially important given that LMIC contexts often have fewer programs in place to address IPV, and that associated mental health issues and risk factors may be different than in higher income countries. This thesis aimed to investigate IPV in a South African birth cohort, the Drakenstein Child Health Cohort, to understand better the patterns of IPV amongst pregnant and postpartum women, the impact antenatal and postnatal IPV exposure may have on their child's growth and development, and the pathways by which IPV may impact child health sequelae. Chapter 1 reviews the relevant literature, discusses key gaps and presents thesis aims and structure. Chapter 2 comprises a methods chapter which provides an overview of the study population, measures and ethical considerations. Chapter 3 (Paper 1) presents longitudinal profiles of maternal IPV exposure by sub-type from pregnancy through 24 months post-partum and associations between maternal childhood maltreatment and longitudinal frequency and severity of IPV. Chapter 4 (Paper 2) investigates the association between maternal childhood trauma as well as IPV and food insecurity among pregnant women, and examines whether maternal depression mediates these relationships. Chapter 5 (Paper 3) investigates associations between IPV sub-types and growth at birth and 12 months. Further, multiple psychosocial (substance use, depression) and clinical factors (number of hospitalizations) are tested to determine whether any of these may be mediators in the relationship between IPV and child growth. Chapter 6 (Paper 4) investigates emotional, physical and sexual IPV and their relationship with child development at 24 months of age, and whether depression or maternal alcohol dependence mediates these relationships. Chapter 7 presents a summary of findings across results chapters and includes recommendations for future policy and research. Key findings in this population show that: i) a high proportion of mothers are exposed to chronic IPV during and after pregnancy and that maternal childhood abuse or neglect is associated with higher frequency and severity of IPV exposure; ii) maternal IPV and childhood trauma are each associated with food insecurity during pregnancy and that depression partially explains these relationships; iii) emotional and physical IPV are associated with reduced fetal growth and reduced growth through infancy, and maternal substance use (alcohol or tobacco) partially explains these relationships; iv) both emotional and physical IPV are associated with poorer child development at 2 years, and neither maternal current depression nor alcohol dependence explain these relationships. Overall, the findings highlight that emotional IPV in addition to physical IPV is a key risk factor for child growth and development, and identify potential pathways underlying explored relationships. Maternal depression and substance use emerged as partial explanatory variables for nutritional outcomes, specifically food insecurity during pregnancy and growth outcomes at birth and through infancy. The high prevalence of IPV and its negative impact on child health, together comprise a major public health problem, causing significant hardship and representing a significant burden for families, economies and health systems. Findings presented in this thesis suggest that comprehensive and intersectoral programs are needed to 5 address IPV and associated adverse child health outcomes, inclusive of efforts to address maternal mental health and substance use. Further, it is also vital to ensure emotional IPV is included in training and intervention efforts. Clinical implications and areas for future research are discussed.

Introduction: Cognitive impairment is the most significant predictor of long-term outcomes in psychotic disorders, and neuropsychological assessment is therefore recommended in first-episode psychosis patients. However, the literature on neuropsychological assessment for first-episode psychosis patients in low resource settings is limited, the clinical utility of such assessments are unclear, and lengthy assessments may not be practicable in these contexts. This thesis therefore investigated 1) which brief neuropsychological assessment measures researched in patients with psychotic disorders from low and middle-income countries are appropriate for cognitive screening, 2) the differences in prevalence and profile of cognitive impairment between first-episode psychosis patients and healthy peers in one low resource setting, 3) the association of clinical variables with impairment in different cognitive domains in first-episode psychosis patients from one low resource setting, and 4) the validity of the NeuroScreen (a collection of brief neuropsychological test delivered via smartphone) for neuropsychological assessment in first-episode psychosis patients in this setting (as determined by comparison with a gold standard evaluation). Methods: First, a systematic review of articles in which brief neuropsychological assessments were researched in patients with psychotic disorders from low and middle-income countries was performed. The 2014 Working Group on Screening and Assessment (WGSA) guidelines were used as a benchmark of the appropriateness for cognitive screening for the neuropsychological assessment measures employed. Second, first-episode psychosis patients and matched healthy peers were recruited into an observational study at the National mental referral hospital in Uganda. Clinical variables were collated (including sociodemographic characteristics, dietary history, previous childhood trauma and illness severity), and after the resolution of psychotic symptoms, a neuropsychological assessment was performed using the gold standard MATRICS consensus cognitive battery. Student t-tests and chi-square tests were used to determine differences in the prevalence and profile of cognitive impairment in patients with psychosis and healthy peers. Multiple linear regression analyses were used to determined associations between clinical variables and cognitive domains while controlling for potential confounders. Finally, Pearson's rank correlation coefficients and receiver operating curves were computed to examine the validity of the NeuroScreen against the MATRICS consensus cognitive battery. Results: In the 29 articles reviewed, none of the neuropsychological measures researched in patients with psychotic disorders of low and middle-income countries was appropriate for cognitive screening according to the Working Group on Screening and Assessment (WGSA) guidelines. Neuropsychological assessment with the MATRICS consensus cognitive battery found the burden of cognitive impairment in first-episode psychosis patients six times that of healthy peers. The largest cognitive impairment burden was in the visual learning and memory domain. Increased age was associated with impairment in the domains of the speed of processing (p= 0.001). . Cassava rich diets had a negative association with cognitive impairment in the visual learning and memory domain (p=0.04). There were no significant associations between sex, history of childhood trauma or illness severity with any of the seven cognitive domains. A composite score from five cognitive domains of the NeuroScreen had a moderate accuracy of 0.79 compared to the MATRICS consensus cognitive battery. Conclusion: There is need for further research on appropriate measures for neuropsychological assessment in low resource settings. As demonstrated here, the use of such assessments may reveal modifiable risk factors for such impairment; appropriate nutrition may be a particularly important intervention for individuals with psychotic disorders in poorly resourced settings. The NeuroScreen may be useful for neuropsychological assessment of patients with psychotic disorders in low resource settings but needs modification to improve its accuracy.

Background: The frontal lobe of the human brain is integral in regulating behaviour. Behavioural disturbances such as apathy, disinhibition, and dysexecutive function are well-known consequences of frontal lobe pathology, leading to significant impairment. Heavy episodic drinking (HED) and HIV are common conditions that impair the frontal lobe, with disinhibition frequently being seen in people with HED, apathy in HIV positive patients and both HIV and HED leading to executive dysfunction. There is a paucity of research on the interplay between HIV and HED and how this impacts behaviour associated with frontal lobe dysfunction. The Frontal Systems Behaviour Scale (FrSBe) is a questionnaire designed to measure problematic behaviour associated with frontal systems impairment. It has been used in a range of clinical populations. It consists of a total score and three subscale scores, namely apathy (Scale A), disinhibition (Scale D) and executive dysfunction (Scale E). This tool is easy to administer and has the potential to provide clinically useful information that could guide management of patients with these conditions. Aim: As a first step to knowing more about the complex interplay between HIV and HED and its effects on frontal lobe function, the aim of this study was to determine the relationship between HIV status, HED and frontal-systems behavioural dysfunction (impulsivity, apathy, and executive dysfunction) as measured by the FrSBe. Methods: Participants for this quantitative, cross-sectional, and analytical study were recruited from the Nolungile Clinic in Khayelitsha, Cape Town. They were grouped according to their HIV- and HED status. Relevant demographic and clinical data were obtained. Participants completed the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) questionnaires and the FrSBe self-report measure that was translated into isiXhosa. Both measures were scored and the FrSBe raw scores were converted to T-scores. Results: A total of the 99 participants met the inclusion criteria, of which 25 were in the HED only group, 22 in the HIV+ only group, 26 in the dual group, and 26 were in the control group. The mean age (SD) of the sample was 37.92 (8.8) years. There was a statistical difference between groups for the total drinking score on the SAMISS (p = 65), were present on the FrSBe Total Score in 29 of the participants. On the apathy subscale score, 36 participants had clinically significant (T-score >= 65) deficits, 14 had deficits on the disinhibition subscale, and 34 had on the executive dysfunction subscale. There were no statistically significant differences in the proportion of participants with clinically significant deficits between groups for any FrSBe scores. Conclusions: This study shows that people with HED have more dysfunctional behaviour associated with frontal system impairment and are more disinhibited. HIV status does not appear to influence frontal system behaviour. These finding needs to be interpreted with caution as the study FrSBe was administered in isiXhosa, in which it has not been validated, and no normative data was available for the study population. Future studies validating the FrSBe in a South African context and deriving normative data for South African populations would be a first step into developing the FrSBe into a clinically useful tool. This could, in turn, potentially lead to improved care and treatment in these conditions by identifying specific impairments and problematic behaviours as targets for intervention.

Background Mental disorders including substance use disorders are a leading cause of disease burden, contributing 16% of the global burden of disease in young people aged 10 to 19 years. Substance use in adolescents and young people cannot be viewed outside of the family system. The family may influence the development of substance use problems in young people and the family system is an important part of recovery. The burden of substance use on family members is, however, often overlooked with emphasis being placed on the need to involve families in treatment of individuals using substances but little said about care for the family members themselves. There is need for a better understanding of the experiences of family members affected by substance use in young people and their own perceptions of the family's role in influencing adolescents' substance use. This study aimed to explore the experiences of families who have dealt with adolescent psychoactive substance use and their perceptions on how families can influence the development or avoidance of substance use in young people. Methods This was an exploratory qualitative study eliciting the experiences of nineteen family members dealing with substance use in young people aged less than 24 years purposively sampled from families of young people being managed for substance-related conditions at a tertiary mental health unit in Harare, Zimbabwe. Potential participants were identified using admission and outpatient registers and invited to take part in the study. In-depth interviews were conducted in Shona or English using a semi-structured interview guide exploring the experiences of family members dealing with substance use in a young person as well as their perceptions on the role of the family in development of substance use. The interviews were voice recorded, transcribed verbatim and the data were analysed in NVivo 12 using the framework approach. Ethical approval was granted from the University of Cape Town, Faculty of Health Sciences Human Research Ethics Committee and the Medical Research Council of Zimbabwe and the Institutional Ethics Review Boards for Harare Central Hospital. Results Five themes emerged from the data namely: Perceived causes of substance use in young people; Discovery of the substance use; Impact of the substance use; Family coping strategies and Family suggested interventions. Substance use by a young person affected family life, affecting family members and siblings emotionally, causing conflict in the family and burdening the family finances. Family members struggled with physical health problems; emotional distress, fear; helplessness; hopelessness; guilty, stigma and isolation, social and occupational consequences as a result of substance use by a young person in the family. Families also described various ways in which they attempted to cope with the challenges with spirituality highlighted as a key coping strategy. Participants suggested the family can be a mitigating factor against substance use in young people through having a better understanding about substance use, improved communication; providing an emotionally supportive home environment; creating healthier value systems in the family; actively supervising and monitoring of young people; encouraging young people to engage in meaningful work; facilitating admission for medical rehabilitation when needed as well as providing spiritual support. Conclusion There is a substantial but hidden burden of substance use on families and caregivers. This study illustrates the need for health services to provide better support for affected families, improving access to care and support for family members of young people using substances at risky levels. Further research is needed to explore how existing frameworks for structured support may be adapted for and implemented in the local setting. Substance use, particularly in young people, remains a family condition and the family needs to be not only included in treatment of young people but to be cared for themselves as well.

Introduction Information on the relationship between cigarette use and recovery from substance use disorders (SUDs) is contradictory and limited to studies conducted in high-income countries characterised by a predominance of injection drug use. In South Africa, a low-and-middleincome country where drugs are mainly smoked, there is an absence of research examining the relationship between smoking and SUD treatment outcomes. This study seeks to bridge this gap by exploring service users' perceptions of smoking and how cigarette use affects their recovery from SUDs. Methods This exploratory study employed a qualitative research design. Twenty participants were recruited from six Matrix Outpatient SUD treatment programmes in the greater Cape Town region for in-depth interviews. A semi-structured interview guide structured the interviews. Interviews were audio-recorded before being transcribed verbatim. Qualitative data were analysed using the framework approach. Results Three main findings emerged from the data. First, powerful socio-cultural and contextual factors seem to underpin participants early initiation and maintenance of cigarette use. Participants identified socio-cultural processes that strongly influenced their perceptions of smoking and the social and emotional functions it served, which contributed to continued cigarette use. Second, participants described the intertwining of cigarettes and other substances, with shared modes of administration and mixing of substances - they thought this made it very challenging to maintain recovery from substances while continuing to smoke tobacco. Third, although service users perceive benefits to tobacco cessation for health and recovery from SUDs, most participants using tobacco expressed ambivalence about quitting and seem to lack confidence in their ability to stop smoking and maintain their abstinence from other substances. Conclusion The current study suggests that SUD service users view cigarette use as potentially detrimental to their SUD treatment and recovery. As such, this study provides support, from a service user perspective, for (i) the introduction of interventions to prevent tobacco initiation among young people as part of SUD prevention and (ii) the integration of tobacco cessation interventions into SUD treatment programming to improve the likelihood of successful treatment outcomes for people who smoke tobacco. More specifically, findings highlight the potential value of a client-centred approach in screening service users for tobacco use as they enter SUD treatment, educating them about the potential impacts of continued smoking on SUD recovery, and integrating evidence-based smoking cessation programmes into SUD treatment.

Background Mental and substance use disorders cause significant disability worldwide. In spite of the availability of evidence-based treatment, non-adherence rates remain high in people with severe mental illness. Mental health services are however under-resourced, especially in low- and middle-income countries. Interventions that employ task shifting, the delegation of health care delivery tasks to less specialized health workers, have the potential to address this resource shortage. Community health workers, while an established and important delivery agent for task shifting in many forms of chronic illness, including mental illness, have lacked access to standardized structured training in mental health. Together with novel approaches such as mobile health, task-shifting interventions have the potential to improve adherence and clinical outcomes for MHSU, thus reducing the burden on stretched mental health resources. While the evidence for the effectiveness of task shifting interventions is growing, it is unclear whether the combination of a task shifting intervention with mobile health would be acceptable and feasible in low resource settings. It is also unclear to what extent a structured mental health training programme would result in improved knowledge, confidence and attitudes amongst community health workers. Methods First, I conducted an appraisal of current evidence for interventions delivered by non-specialist workers for mental illness in Sub-Saharan Africa. The aim was to characterize the types of such interventions that have been carried out in Sub-Saharan Africa, to ascertain extent of use of non-specialist workers; the outcomes explored; any acceptability and feasibility findings; as well as any efficacy outcomes. Second, I developed and piloted two task shifting interventions geared at improving care for severe mental illness in Cape Town, and evaluated their acceptability, feasibility and preliminary effectiveness. Systematic review: For the systematic review, eligible studies published prior to 21 June 2017 were identified by searching the Cochrane library, PsychInfo, and Medline databases; as well as the World Health Organization International Clinical Trials and Pan African Clinical Trials Registries. The bibliographies of study reports for all eligible trials were scanned for additional studies. Included trials were those of interventions a) delivered by non-specialist health workers for b) adult populations (18-65 years) with c) psychiatric disorders diagnosed in line with ICD or DSM classification systems in d) Sub-Saharan Africa. No restriction was placed on the nature of the psychiatric disorder. Pilot randomized controlled trial: A pilot randomized controlled trial was conducted, in which 77 participants with severe mental illness were recruited from Valkenberg psychiatric hospital in Cape Town, with 42 randomized to receive the intervention and 37 to receive treatment as usual. In the intervention arm, a treatment-partner selected by the participating MHSU underwent a psychoeducation and treatment-partner contracting session. The intervention pair then received two text message reminders of clinic visit appointments monthly. The primary outcomes were acceptability and feasibility of the intervention, measured through qualitative interview and process evaluation at 3 months post-discharge. Secondary outcomes for efficacy were 1) adherence to the first clinic visit; 2) any readmission in the 9 months following discharge; 3) quality of life; 4) symptomatic relief; and 5) medication adherence. These efficacy measures were conducted at baseline and again at 3-month study review. Between-group comparisons were done using an intention to-treat ANOVA analysis for efficacy outcomes. Community Health Worker Training Intervention: My second task shifting intervention was a quasi-experiment evaluating whether structured mental health training would improve the knowledge and skill of community health workers while improving their confidence and attitudes towards mental illness. A training programme was developed in partnership with the Western Cape Department of Health, and piloted with 58 community health workers who had not previously received mental health training. Mental health knowledge and skill were measured though the use of case vignettes and the Mental Health Knowledge Schedule (MAKS). Confidence was measured using the Mental Health Nursing Clinical Confidence Scale (MHNCCS), while attitudes were measured using the Community Attitudes towards the Mental Ill Scale (CAMI). Measures were conducted at baseline, at the end of the training, and again 3 months after the end of training for the knowledge and skill measures. Daily evaluation questionnaires were used to establish acceptability, and a training evaluation questionnaire was used to obtain further acceptability data, as well as to establish feasibility of the training intervention. T-tests and regression models were used to test changes in questionnaire scores before and after each intervention, adjusting for baseline scores. Quantitative data were entered and analysed using STATA 10.0 for the pilot randomized controlled trial and the R statistical programme for the CHW intervention, while qualitative data were managed and analysed using NVIVO 8, a qualitative analysis programme for all analyses, for which a grounded theory approach was used, followed by thematic analysis. Ethics and registration: Ethical approval was obtained from the University of Cape Town Human Research Ethics Committee, Faculty of Health Sciences for the treatment partner and mobile health intervention (HREC REF: 511/2011) and for the community health worker training intervention (HREC 913/2015). Both interventions were registered on the Pan African Clinical Trials Registry (PACTR201610001830190 and PACTR201610001834198 respectively). Finally, Health Impact Assessment Unit clearance was obtained from the Western Cape Department of Health for both trials (RP168/2011 and WC_2016RP59_635 respectively). The systematic review was registered on the International prospective register of systematic reviews (PROPSERO) (CRD42017065190)). Results Systematic Review: Due to heterogeneous methods and treatment outcomes, a meta-analysis was not possible. A narrative synthesis is thus presented. Fifteen trials of interventions delivered by non-specialist workers (5087 participants) were identified. In each of the trials, the intervention was acceptable and feasible, with preliminary efficacy findings favouring the interventions. Pilot randomized controlled trial: The treatment partner and text message intervention components were acceptable. While the treatment partner and psychoeducation components were feasible, the text message component was not, as a consequence of several socioeconomic and individual factors. While efficacy outcomes favoured the intervention, they did not reach statistical significance due to the small sample size. Community Health Worker Training Intervention: Mental health knowledge improved as demonstrated by improved diagnostic accuracy on case vignette response. Sixty-three percent of participants demonstrated improved accuracy in making a diagnosis, with a roughly two-fold increase in performance in these individuals. There was a significant increase in the average scores on the Mental HeAlth Knowledge Schedule pre- to post training (t = -4.523, df = 55, p < 0.001, N=56). This improvement was sustained at 3 months after the end of training assessment scores (t = -5.0, df = 53, p < 0.001, N = 54). There was a significant increase in the average Confidence scores pre-intervention (mean SD): 45.25 (9.97) to post-intervention 61.75 (7.42), t-test: t = -8.749, df = 54, p < 0.001, N=58). Attitude scores (n=45) indicated no change in authoritarian attitudes [mean (SD): Pre 27.87 (2.97); Post 26.38 (4.1), t = 2.720, p-value = 0.995], while benevolence [mean (SD): Pre 37.67 (4.46); Post 38.82 (3.79), t = -1.818, p-value = 0.038] and social restrictiveness [mean (SD): Pre 24.73 (4.28); Post 22.4 (5.3), t = -2.960, p-value = 0.002] attitudes showed improvement pre- and post-training, as did tolerance to rehabilitation of the mentally ill in the community (t = 2.176, p-value = 0.018). Participants responded well to training, appraising it as acceptable and appropriate to their work. They expressed a need for a longer training programme with further training on substance use and geriatric disorders. Stakeholder participation was consistent and contributed to the feasibility of the intervention. Conclusions A review of task shifting interventions by non-specialist health workers indicates that these have yielded positive outcomes for mental health service users in published trials. Such interventions have the potential for reducing the mental health treatment gap in low and middle income countries in a cost-efficient way. Further work is however required to develop specific treatment approaches for particular disorders, and to assess the outcomes of such interventions, including cost-efficiency measures. The measures of outcome used in this field remains somewhat disparate; the development of a common research agenda may assist in developing and replicating further investigations and generalising findings. A treatment-partner intervention is acceptable and feasible in a low- and middle-income setting such as ours. Careful work is, however, needed to ensure that any additional components of such an intervention, such as mobile health, are tailored to the local context. Appropriately powered studies are needed to assess efficacy. Structured training in mental health is acceptable and feasible in our setting. The training intervention led to an improvement in knowledge and skill amongst community health workers while improving confidence and attitudes. Participation of policy stakeholders was key in ensuring the success of the intervention. There is a need for interventions evaluating the outcomes of community health worker training to provide more detailed descriptions of their training interventions. More focus must be placed on measuring service and end-user outcomes to improve the rigor and quality of such investigations, with well-powered randomized controlled trials being best placed to answer questions regarding efficacy and cost-effectiveness. In summary, my systematic review, and my pilot task-shifting interventions in the South African context indicate that task shifting interventions such as these are acceptable and feasible, offering a promising solution to addressing the under-resourcing of mental health care. However, interventions should ideally be tailored to the specific communities they target, taking into account specific individual, community, technological, and sociodemographic factors. Future training interventions should provide more detailed descriptions of programme components and focus on measuring patient outcomes, while all task shifting interventions may benefit from incorporating an evaluation of cost effectiveness. Task shifting presents a viable and accessible opportunity for creative innovation and as we work towards achieving mental health for all.

Over the past decade, calls to address the increasing burden of mental, neurological and substance-use (MNS) disorders and to include mental health care as an essential component of universal health coverage (UHC) have attracted mounting interest from governments. With the inclusion of mental health in the 2015 Sustainable Development Goals (SDGs) there is now a global policy commitment to invest in mental health as a health, humanitarian and development priority. Low and middle-income countries (LMICs) such as South Africa, contemplating mental health system scale-up embedded into wider SDG- and UHC-related health-sector transformations, must address a number of key mental health financing policy considerations for attaining population-based improvements in mental health. Despite ongoing transformations in the South African health sector, there has been an implicit neglect of the integration of mental health services into general health service development. This has been driven in part by a lack of locally-derived evidence in several areas, including: the economic basis for investing in mental health, the current resourcing of the mental health system, opportunities for improved efficiency and equity, and how reforms may be structured and paid for in light of the country's ongoing efforts to implement a National Health Insurance (NHI) scheme. This thesis therefore attempts to address these gaps and aims to generate new knowledge on the economic costs, impacts and financing strategies for mental health in South Africa. This aim is achieved by fulfilling the following research objectives: 1. To examine the impact of social, national and community-based health insurance on health care utilization for MNS disorders in low- and middle-income countries. 2. To examine the policy context, strategic needs, barriers and opportunities for sustainable financing for mental health in South Africa. 3. To quantify public health system expenditure on mental health services, by service level and province, and to document and evaluate the resources and constraints of the mental health system in South Africa. 4. To examine the household economic costs and levels of financial risk protection associated with depression symptoms in South Africa. In the first part, the systematic review reports on the impact of social, national and community based health insurance on health care utilization for MNS disorders in LMICs, published until October 2018. As a secondary goal, the systematic review identifies whether there are any specific lessons that can be learnt from existing approaches to integrate mental health care into financing reforms towards universal health coverage. In the second part, a qualitative examination of the policy context, strategic needs, barriers and opportunities for sustainable financing for mental health in South Africa was conducted through a situational analysis that was complimented with a synthesis of key stakeholder consultations. The findings provide recommendations for how scaled-up mental health services can best be paid for in a way that is feasible, fair and appropriate within the fiscal constraints and structures of the country. In the third part, the thesis then empirically quantified public health system expenditure on mental health services, by service-level and province for the 2016/17 financial year, and documented and evaluated the resources and constraints of existing mental health investments in South Africa through a national survey; achieving one of the highest sample sizes of any costing study conducted for mental health in LMICs. In the fourth and final part, a household survey study was conducted to determine the level of financial protection for persons living with depression symptoms in the Dr. Kenneth Kaunda health district of South Africa, which is serving as a pilot site for the NHI. The household economic factors associated with increased depression symptom severity on a continuum are reported; and demonstrate that financial risk protection efforts are needed across this continuum. The thesis concludes by synthesizing findings towards an improved understanding of the key lessons that can be learned from other LMICs toward sustainable financing for mental health; the economic burden of inadequate mental health care to households in South Africa; and the efficiency of existing mental health investments and inequities in resourcing and access. Through this lens, and borrowing from the experiences of other LMICs, recommendations for key priorities for health service and financing reforms towards the scaled-up delivery of mental health services in South Africa are generated. The thesis is presented as papers embedded in a narrative that includes an introduction and synthesis discussion. Four papers (3 published and 1 under review) form the basis of the results chapters.

Includes bibliographical references. / In the last decade, multiple diffusion tensor imaging (DTI) studies have revealed changes in the microstructure of white matter in bipolar disorder. The results are poorly replicated and inconsistent, however, with some authors suggesting a predominance of alterations in fronto-limbic white matter. Preliminary reading of the literature suggests that white matter changes as revealed by DTI may be more widespread throughout the brain. Two extant reviews have each been limited by including all affective disorders or by a methodology which ignores tracts and discards potentially meaningful data. This background in the review includes a detailed exposition of the main DTI techniques and shortcomings. The review aims to determine whether certain white matter tracts are affected preferentially in the brain, as opposed to more diffuse white matter involvement. It also aims to determine if there is an anterior-posterior gradient of abnormalities. This review systematically collates data relating to tract involvement as demonstrated by DTI, as well as data regarding anterior-posterior distribution of abnormalities. Medline and EMBASE databases are searched systematically to select original papers comparing a bipolar group with healthy controls, using DTI, in adults, and reporting at least fractional anisotropy (FA). Subject, scan and analysis characteristics are extracted. Details of affected tracts are collated, as is the y-axis (anterior/posterior) of the most affected ('peak') voxels.