Transcultural Psychiatry 2014, Vol. 51(6) 790–805 !

The Author(s) 2014

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Article

Research ethics in global mental health:

Advancing culturally responsive mental
health research
Mónica Ruiz-Casares
McGill University and Centre de Santé et de Services Sociaux de la Montagne

Abstract
Global mental health research is needed to inform effective and efficient services and
policy interventions within and between countries. Ethical reflection should accompany
all GMHR and human resource capacity endeavors to ensure high standards of respect
for participants and communities and to raise public debate leading to changes in
policies and regulations. The views and circumstances of ethno-cultural and disadvan-
taged communities in the Majority and Minority world need to be considered to
enhance scientific merit, public awareness, and social justice. The same applies to
people with vulnerabilities yet who are simultaneously capable, such as children and
youth. The ethical principles of respect for persons or autonomy, beneficence/non-
maleficence, justice, and relationality require careful contextualization for research
involving human beings. Building on the work of Fisher and colleagues (2002), this article
highlights some strategies to stimulate the ethical conduct of global mental health
research and to guide decision-making for culturally responsible research, such as
developing culturally sensitive informed consent and disclosure policies and procedures;
paying special attention to socioeconomic, cultural, and environmental risks and bene-
fits; and ensuring meaningful community and individual participation. Research and
capacity-building partnerships, political will, and access to resources are needed to
stimulate global mental health research and consolidate ethical practice.

Keywords
children, consent, global mental health, research ethics, youth

Corresponding author:
Mónica Ruiz-Casares, Santé Mentale Jeunesse, CSSS de la Montagne, 7085 Hutchison, Office 204.2.14,
Montreal, QC, H3N 1Y9, Canada.
Email: monica.ruizcasares@mcgill.ca
Ruiz-Casares 791

Focusing on issues that affect mental health transnationally, global mental health
research (GMHR) aims to contribute to improving mental health outcomes and
achieving equity in mental health for all people worldwide (Koplan et al., 2009;
Patel & Prince, 2010). Factors affecting mental health cover a broad range of issues
and settings—from the conditions of care of persons with mental disorders in low-
and middle-income countries (LMICs) and underserved subgroups in high-income
countries (e.g., undocumented migrants and asylum seekers) to the mental health
consequences of armed conflict, natural disasters, migration and acculturation, and
global policies (e.g., on environment or trade). Despite increased attention to
mental health issues internationally in the last decade, there is still a meager evi-
dence base. More GMHR is needed to inform systemic and policy changes, pre-
vention and treatment interventions, and human resource capacity and public
awareness efforts (Collins et al., 2011).
Arguments continue on the issues of universal and relative human rights duties
and moral values and the Western bias in this debate (Donnelly, 2007, 2008, 2013;
Goodhart, 2008). Still, widespread ratification of the Universal Declaration of
Human Rights (General Assembly, 1948) has advanced the recognition of
human dignity and a common set of values, such as solidarity and equity, which
provide a foundation for the study of global issues (Benatar, Daar, & Singer, 2003).
Strong condemnation of double ethical standards between resource-rich and -poor
countries continues to be voiced on similar grounds (Kottow, 2002). Besides codes
of conduct of professional societies, several research codes of ethics have emerged
in the last 70 years and continue to be revised to provide guidelines for human
experimentation. The Nuremberg Code (1947), the Belmont Report (1979), the
Council for International Organizations of Medical Sciences (CIOMS, 2002), the
Declaration of Helsinki (WMA, 2008), and, in Canada, the Tri-Council Policy
Statement (CIHR, NSERC, & SSHRC, 2010), are among the most relevant. The
Belmont Report, issued in 1978 by the National Commission for the Protection of
Human Subjects of Biomedical and Behavioral Research in the United States,
identified three fundamental ethical principles for using humans in research and
provided a framework for future regulations on this matter. The three basic prin-
ciples are the respect of persons or autonomy, beneficence/non-maleficence, and
justice or fairness.
The extent to which these rules of scientific and ethical conduct, including the
Belmont principles, are transcultural, however, has been questioned (DuBois,
2005a; Fisher et al., 2002). In fact, the National Commission (1979) clearly
stated that the fundamental principles they identified as “particularly relevant to
the ethics of research involving human subjects” were selected “among those gen-
erally accepted in our cultural tradition” (p. 4). While the principles of autonomy,
beneficence, non-maleficence, and fairness seem broadly applicable to research
involving human subjects in other settings, their understanding and applications
require careful consideration of socioeconomic, cultural, and environmental con-
texts. Thus, for example, DuBois’s (2005a; 2008) contextualization of the principle
of autonomy warns researchers against requesting signatures wherever such a
792 Transcultural Psychiatry 51(6)

practice generates mistrust, and highlights the differential emphasis across societies
of autonomy/relationality and certain people’s disempowerment to make autono-
mous choices (e.g., due to low education, gender, or diagnostic discrimination).
Similarly, a context-sensitive application of the principle of beneficence/non-
maleficence requires that researchers assess, for example, how the study may
burden participants, and how research findings may stigmatize the study popula-
tion. Then, the principle of justice may target vulnerable groups for convenience or
fail to distribute research benefits and burdens fairly. DuBois’s addition of the
principle of relationality that situates individuals in their social contexts aims to
facilitate balancing the needs and rights of the individual and those of the com-
munity in the tradition of communitarism (Dresden, McElmurry, & McCreary,
2003). Overall, DuBois encourages researchers to ask in order to clarify the mean-
ing of wellbeing, hierarchy of needs, and risks acceptable to the group (beneficence/
non-maleficence), as well as existing relations that need to be respected (relation-
ality), and other crucial information needed to ensure respect of these core ethical
principles. The application of these principles to the conduct of global mental
health research requires special attention to the processes for obtaining informed
consent, conducting risk–benefit assessment, and engaging research participants
and communities to ensure equity and regard for existing relations that need to
be respected. This article is organized around these three dimensions that facilitate
the ethical conduct of global mental health research. The paper ends with an indi-
cation of some strategies to develop and stimulate mental health research globally.

Culturally responsible informed consent and disclosure

policies and procedures
Informed consent and assessment of decision-making capacity
Informed, reasoned, voluntary consent (IC) is a key ethical requirement for the
conduct of research involving humans. IC with vulnerable individuals and/or in
resource-poor settings has gained increased attention in medical research during
the last decades (Verástegui, 2006). Culturally responsible IC procedures for mental
health research require that researchers carefully consider participants’ (and their
guardians, if applicable) understanding of research, collective responsibility,
authority, and individual autonomy (e.g., in adult–child relations), as well as any
cultural, linguistic, and economic circumstances that may influence people’s inter-
est and ability to participate (Benatar, 2002; Macklin, 2001; Molyneux, Peshu, &
Marsh, 2004; Sánchez, Salazar, Tijero, & Dı́az, 2001). A systematic review of IC
procedures in non-Western societies documented the usefulness of involving peers
as well as local community and/or cultural leaders in the presentation of study
information (Mystakidou, Panagiotou, Katsaragakis, Tsilika, & Parpa, 2009).
Their input can also assist in determining fair and non-coercive compensation.
Time to ponder the information provided and to discuss it with partners or rela-
tives was important for women participating in medical trials in Santiago,
Ruiz-Casares 793

Chile (Sánchez et al., 2001). Furthermore, cultural traditions and community struc-
tures, such as Aboriginal populations, may require that community elders, grand-
parents or other relatives are involved in decision making, to gain access to
community members, most notably children (Alberta Mental Health Board, 2006).
To ensure adequate understanding of the consent information, IC instruments
must take into account the developmental level, language preference and profi-
ciency, and communication style utilized in each particular community, privileging
the use of professional/trained interpreters whenever translation is necessary
(Fisher et al., 2002). For instance, the use of a locally-appropriate pictorial flipchart
developed through participatory community research methods resulted in a good
understanding of the conditions of the study among female participants in
Mwanza, Tanzania (Vallely et al., 2010). Careful consideration of how terminology
varies across cultural groups may even lead to avoiding terms such as “mental
health” to avoid misunderstanding and stigma: for example, if “going to a psych-
ologist suggests there is something wrong with you” (Alberta Mental Health
Board, 2006, p. 5). Similarly, future empirical research on the cultural context of
informed consent should consider the effect of local beliefs about disease etiology
and treatment and previous experiences with medical or behavioral research
(Marshall, 2006).
In determining whether the individual has the mental abilities required to make
the decision to participate in research, researchers should be mindful that criteria
for determining a person’s ability to give informed consent reflect social structures,
dynamics, and perceptions of capacity (EMHR, 2005c). For example, in the con-
text of mental health research, concerns about the participation of trauma sur-
vivors (McClain, Laughon, Steeves, & Parker, 2007), people with dementia (Cubit,
2010; Slaughter, Cole, Jennings, & Reimer, 2007), and other potentially vulnerable
groups have been raised (Keogh & Daly, 2009; Macklin, 2001). However, capacity
to consent and capacity to participate do not always go hand in hand. For instance,
children and adolescents are also considered a population requiring special protec-
tion, yet their meaningful involvement in research is increasingly acknowledged
(Lind, Anderson, & Oberle, 2003). In order to facilitate participation, researchers
should make reasonable accommodations, avoid unfairly targeting people to be
screened for decision-making capacity, and acquire the necessary skills to establish
true rapport with participants and be sensitive to their needs (EMHR, 2005a).
Trust and relationships play an important role in people’s agreement or refusal
to participate as well as in the quality of their involvement (Molyneux, Peshu, &
Marsh, 2005; Ruiz-Casares, 2011a). Knowledge of context is important in nego-
tiating spaces for participants, as some communities may not automatically seek
the agreement of children or adults unable to consent. Community meetings and
other “awareness-raising activities” may prove useful to sensitize local stake-
holders, as done in preparation for a mental health study among people living
with severe mental illness in rural Kenya (Lund et al., 2013).
The way to document informed consent is also context dependent, as signed
consent is mostly a Western concept, and in many settings, signed documents may
794 Transcultural Psychiatry 51(6)

raise suspicion and even put participants in danger (e.g., in repressive political
regimes or undocumented migrants fearing deportation). Moreover, in societies
with oral traditions, “the power and validity of words and deeds outweighs that
of a written contract” (Brunger & Weijer, 2002, p. 386). On occasion, participants
will benefit from not keeping any “proof” of participation. For example, a group of
homeless girls I interviewed in Caprivi, Namibia, requested not to receive any
document or material compensation, as they feared aggression from their “neigh-
bors” if they found out of their participation in the study.

Privacy and confidentiality in context

Privacy violations, embarrassment, and harm to reputation are among the primary
risks of social science research on mental health (EMHR, 2005d). The protection of
the privacy of participants and communities is often required by law and profes-
sional codes of conduct. Research team members, including translators and inter-
preters, are called to abide to the highest standards of confidentiality. This includes
carefully managing all nominal information by collecting data anonymously when-
ever possible, using codes instead of personal identifiers, and securely storing,
accessing, and disposing of nominal information. Special precautions are needed
to protect confidentiality in small or close-knit communities (e.g., small ethnic
populations) or institutions (e.g., schools or detention facilities) where participa-
tion in a study may lead to public disclosure of mental health conditions and the
stigma locally associated with these conditions (Fisher et al., 2002).
Local understandings of privacy may conflict with those enshrined in existing
regulations and that originate mostly in Western industrialized countries.
Nonetheless, the creation of safe spaces for disclosure seems necessary across all
settings. For example, although I could have been able to obtain much of the
information on family history and social relations by asking relatives and neigh-
bors of the child-headed households I was working with in Northern Namibia, it
was only in the context of privacy and promise of confidentiality that suicidal ideas
were shared—often for the first time! This required that interviews were conducted
out of earshot yet within sight of the community (Ruiz-Casares, 2011a). Fisher and
colleagues (2002) advocate for building “culturally valid criteria for disclosing con-
fidential information” (p. 1033) as well as culturally valid referral/protection sys-
tems. Confidentiality and disclosure policies should be clearly explained during IC
procedures.

Contextualized assessment of risk, harm, and benefit

All research should minimize risks and maximize potential benefits for individuals,
communities, and society at large. Systematic consideration of sociocultural and
environmental factors is needed to develop an accurate assessment of risks
and benefits, including necessary measures for equitable selection of participants,
and to enhance the scientific quality of research. Scientific quality and careful
Ruiz-Casares 795

assessment of risks and benefits are needed to determine whether a study is justified
(Ruiz-Casares, 2013). Indeed, GMHR challenges researchers to “wed sound scien-
tific practices with meaningful ethical protections for participants” (Zeanah, Fox,
& Nelson, 2012).

Scientific merit as precondition to the conduct of research

Several factors impinge directly on the scientific value of a study without which no
benefits can be expected. Factors identified by Fisher and colleagues (2002) in the
context of mental health studies involving ethnic minority children and youth can
apply to other participants or settings. Together with understanding the social and
political conditions of participants’ lives, these include:

a. Careful, explicit consideration of the social and political factors influencing the
definitions of race, ethnicity, and culture and the impact of discrimination on
mental health outcomes. The former is essential to “ensure the scientific validity
of the research question” (p. 1026); the latter, to ensure a correct interpretation
of results. In programmatic research, this is particularly important in order to
promote treatments that address the social realities of vulnerable
subpopulations.
b. Attention to within-group differences and individual variability. When design-
ing studies and interpreting findings researchers should avoid both extremes,
i.e., “ignoring cultural differences and stereotyping” (EMHR, 2005a, 2005b).
Overgeneralizations or grouping participants under broad labels may hide indi-
vidual and within-group variations (e.g., due to immigration history, accultur-
ation, ethnic self-identification, socioeconomic status, or religion). Similarly,
those conducting global mental health research with children must bear in
mind the “different cultures of childhood and adulthood” and “the heteroge-
neous nature of childhood itself” (Kirk, 2007).
c. Ensuring cultural validity of assessment measures. Researchers should priori-
tize the use of “instruments that have been standardized on members of the
participant’s racial, ethnic, or cultural group” or, if necessary, rigorously trans-
lated versions of such instruments. If not available, they should carefully assess
their cultural validity and measurement equivalence for each population stu-
died (Fisher et al., 2002, p. 1026).

Role of sociocultural and environmental contexts in mental health

outcomes and access to services
Accumulating evidence links racism, discrimination, poverty, immigration status,
and other social factors to negative developmental and mental health outcomes and
unequal access to healthcare (Murali & Oyebode, 2004; Paradies, 2006; Rousseau
& Drapeau, 2004). However, comparative research designs utilizing as standards
796 Transcultural Psychiatry 51(6)

the developmental patterns of ethnic majority groups may lead to misinterpretation

of differences in mental health outcomes between these and minority groups (i.e.,
considering these differences as deficits in strengths and developmental capacities
among the latter). Similarly, social, cultural, or religious values and traditions may
interfere with the participation of certain groups: for example, women being inter-
viewed by men or strangers (Crosby & Grodin, 2002) and the paucity of culturally
appropriate standards and diagnostic criteria may interfere with a fair selection of
treatment and control groups in clinical trials. In consequence, adopting study
designs that take into account assets and resilience as well as the cultural and
contextual factors that may influence responsiveness to treatment and/or research
participation are recommended (Fisher et al., 2002). Close collaboration with a
“culturally competent advocate” from the community where the research will take
place throughout the design and implementation of the study (Crosby & Grodin,
2002) and cultural feasibility studies in preparation for clinical trials (Coreil et al.,
1998) are among the ways proposed to ensure adequate consideration of ethical
and social issues in the design of cross-cultural studies. Furthermore, some scholars
advocate for the inclusion of “the religious, spiritual, and/or traditional principles
that characterize a local population” into international ethical guidelines for the
conduct of GMHR (Nolan, Whetten, & Koenig, 2011).

Personal integrity, self-reflection, and ethical, legal, and cultural training

for all research team members
Ethical conduct of research ultimately depends upon the personal integrity and
training of researcher(s) themselves. Thus, the National Health & Medical
Research Council requires that researchers working with Aboriginal communities
in Australia honor integrity and respect as guiding values when they engage with
local people and structures; in their words, researchers demonstrate integrity “in a
commitment to the search for knowledge, recognised principles of research conduct
and in the honest and ethical conduct of research and dissemination and commu-
nication of results” (NHMRC, 2003, p. 17). Confronted with unanticipated ethical
dilemmas during fieldwork, researchers are often tested in their personal integrity,
professional knowledge, and interpersonal skills. Thus, Murphy and Dingwall
(2007) advocate for the development of “professional models of regulation which
emphasise education, training and mutual accountability” to their peers (p. 2223).
In order to advance unbiased research and to increase understanding of the core
ethical, legal, and human rights issues, all research team members should acquire a
good understanding of both the culture in which the study will take place as well as
the applicable legal norms and ethics framework and procedures. They should also
become familiar with the resources available in the locations where the study will be
implemented, so that referrals can be made if necessary (Ruiz-Casares, 2013).
Training, coupled with ongoing self-questioning of their own assumptions and
exchange of perspectives among team members can facilitate methodological
adjustments to better respond to each participating culture (Fisher et al., 2002).
Ruiz-Casares 797

Meaningful participation of communities and individuals

Shared ownership and ongoing, respectful dialogue (on the ethical challenges of
mental health studies) among scientist, participants, and community stakeholders
may enhance the ethical and scientific quality of research (DuBois, 2005b) as well
as research governance (Larkin, de Casterlé, & Schotsmans, 2008). This exchange
may take many different forms. Participatory research approaches that include a
diverse group of community members as co-investigators in the design, imple-
mentation, and dissemination of research are recommended despite being more
time consuming. Valuable community input may also be obtained through par-
ticipation in focus group discussions and local panels. As Garrafa and Lorenzo
(2008) advocate, there is a need to open up “democratic spaces for social audi-
ting” of research endeavors (e.g., through the creation of national commissions
for clinical trials). For example, prior to conducting a large child protection
survey in Liberia, a local Advisory Committee was convened to regularly discuss
ethical (e.g., clarify locally-appropriate IC procedures, desired benefits, and risks
of concern) and methodological (e.g., focus group protocols and recruitment)
issues (Ruiz-Casares, 2011b). Collaborative partnerships may contribute to scien-
tific and ethical merit, as well as to identifying resources and building networks of
support so that assistance can be offered to research participants in need and to
facilitate dissemination of research findings. These partnerships, for example,
were particularly crucial to justify depression research other than screening
(Thombs et al., 2012) in contexts where mental health services were not readily
available (Ruiz-Casares, 2013).
Increasing community consultation and collaboration is particularly needed to
regain the trust of groups historically marginalized or mistreated by science (e.g.,
the African American community as a result of the Tuskegee study). The selec-
tion of stakeholders who may adequately represent the views and interests of the
population under study requires a good understanding of each community’s
social fabric. For example, in many communities political leaders or tribal coun-
cils may represent the particular culture and mental health concerns of individual
participants. Mabaraza (traditional East African community assemblies) in
Western Kenya, for instance, advocate for community consent and decision-
making about research (Vreeman et al., 2012). Special attention is needed to
ensure meaningful representation of the views and interests of marginalized/
vulnerable groups within communities (e.g., children and adolescents) as concerns
for their wellbeing may well lead to overprotection and gatekeeping out of mental
health research without equal recognition of their need for research and their
right to participation (Arnold et al., 1995; Graham & Fitzgerald, 2010; Powell,
Fitzgerald, Taylor, & Graham, 2012). Adult gatekeepers can also use their power
to censor young people (Masson, 2004). Similarly, true collaborative research
requires a well-balanced consideration and distribution of the needs, benefits,
and obligations of all scientists and institutions involved and not only of those
from resource-rich settings.
798 Transcultural Psychiatry 51(6)

Strategies to develop and stimulate mental health

research globally
Research partnerships and partnerships to strengthen capacity
for GMHR
In contrast with public and international health approaches, successful global
mental health solutions often require global cooperation. This reflects

a shift in philosophy and attitude that emphasizes the mutuality of real partnership, a
pooling of experience and knowledge, and a two-way flow between developed and
developing countries. Global health thus uses the resources, knowledge, and experi-
ence of diverse societies to address health challenges throughout the world. (Koplan
et al., 2009, pp. 1994–1995)

Some of the proposed models of collaboration aim to participate in research devel-

opment that will reinforce health policy and clinical services with solid evidence;
others aim to build mental health research capacity in low-resource settings. The
former may be done by means of training and supporting local researchers, and
promoting the utilization of research findings by decision-makers at all levels. The
latter may be done through long-term partnerships (e.g., between institutions in
high-, low-, and middle-income countries),1 structured programs, and monitored
training and mentorship of research staff at every career stage (Crump, Sugarman,
& the Working Group on Ethics Guidelines for Global Health Training, 2010;
Fricchione et al., 2012; Thornicroft, Cooper, Van Bortel, Kakuma, & Lund,
2012). The ethical issues associated with such research and service training initia-
tives need to be explicitly addressed through, for example, the development of
ethical guidelines and formal ethical guidance (Crump & Sugarman, 2008).
Mutual and reciprocal benefit as a goal for both sending and host institutions is
further emphasized by the Working Group on Ethics Guidelines for Global Health
Training (Crump et al., 2010). The core research content and skills to be taught to
all researchers (i.e., from both host and sending institutions) should include ethical
and human rights frameworks and procedures, applicable legal norms, critical
thinking/reading and research methods, cultural competency/local customs, and
the sociocultural, economic, and political context of research wherever research
will be conducted (Shah, Nodell, Montano, Behrens, & Zunt, 2010).
In addition to formal training, it is advisable to create safe spaces for reflection
and dialogue on the scientific and ethical principles relevant to mental health
research and the cultural, social, and other factors that may facilitate or hinder
the conditions under study. Strengthened mental health research capacity in
Minority settings (including low-resource settings within the Majority world) is
not only needed to advance medical science but may lead to increased attention
to understudied conditions (i.e., diseases afflicting Minority settings) and research
publication equity (Sumathipala, Siribaddana, & Patel, 2004).
Ruiz-Casares 799

Political will and access to resources

Political will and lack of appreciation of the importance of ethical conduct of
research and clinical practice are major constraints to the consolidation of ethical
practice. Anya and Raine (2008) talk about the need for a “cultural shift” because
“if clinicians and health-care workers do not believe ethical issues in clinical care
to be relevant or important to them, they are unlikely to change their practice
within the isolated context of a research study” (p. 1595). High-level commitments
are needed to establish and regulate standards for ethical practice, and to imple-
ment and monitor these standards.
Access to both resources for research and research findings is also essential to
advancing a GMHR agenda. In line with the principle of shared benefits and risks,
there is a need to make prestigious scientific publications and research infrastruc-
ture available to researchers in low-resource countries. Greater dialogue around
access to products under investigation and other forms of benefits is needed among
stakeholders (Lairumbi, Michael, Fitzpatrick, & English, 2011; Lairumbi, Parker,
Fitzpatrick, & English, 2012). Mentoring on writing for publication as well as lin-
guistic assistance for those with limited command of English or other major pub-
lishing languages may increase the amount and quality of manuscripts authored
by scientists from Minority world countries.

Conclusions
GMHR is a much-needed tool towards reducing disparities in mental health out-
comes and access to services. In order to develop locally appropriate strategies and
effective solutions across cultural settings and health systems, the views and cir-
cumstances of ethno-cultural and disadvantaged communities in the Majority and
Minority world need to be considered. Normative regulations in research that
reflect the socioeconomic and cultural contexts of each country also need
to be developed and enforced. Legal and procedural norms, however, cannot
replace ethical principles and reflection (DuBois, 2008). In fact, I have here advo-
cated for increased attention to personal integrity and ethics in the development
and instruction of GMHR. Training of researchers and stakeholders in research
ethics and the creation of spaces for ethical reflection and dialogue are needed
in both Minority and Majority world contexts.
A contextualized understanding of the fundamental ethical principles of
autonomy, beneficence, non-maleficence, and justice provides a framework for
the development of research projects, regulations, and training. This is particu-
larly relevant in GMHR, whereby the people and communities involved often
live in countries without clear legal and ethical frameworks and Minority coun-
try regulations may be inadequate in international research (DuBois, 2005a).
Guidelines for the conduct of culturally responsible GMHR include the devel-
opment and implementation of culturally sensitive informed consent and dis-
closure policies and procedures, special attention to context when assessing
800 Transcultural Psychiatry 51(6)

research risks and benefits, and meaningful community and individual partici-
pation (Fisher et al., 2002).
To stimulate the ethical conduct of GMHR, well-balanced collaborations, pol-
itical will, and additional resources are needed. Stronger research capacity
in resource-poor countries may expand the research agenda to include currently
understudied conditions and sub-populations as well as diverse phenomena
impinging on mental health and wellbeing globally (Benatar, 2002). Ultimately,
as Benatar et al. (2003) advocated for the field of global health ethics more broadly,
GMHR may offer an interdisciplinary space for human values such as those of soli-
darity, empathy, and civic responsibility to thrive (p. 138).

Funding
This research received no specific grant from any funding agency in the public, commercial,
or not-for-profit sectors.

Acknowledgments
Thank you to Cécile Rousseau and two anonymous reviewers for their comments on an
earlier version of this manuscript. An earlier version of this paper was presented at the
McGill Advanced Study Institute on Cultural Psychiatry held in Montreal in July 2012.

Note
1. This may include partnerships among clinicians and/or researchers and locally based
research groups and networks.

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Mónica Ruiz-Casares, PhD, is an Assistant Professor in the Division of Social and

Transcultural Psychiatry and the Centre for Research on Children and Families at
McGill University. She is also a Scientific Advisor at the Centre de Sante´ et des
Ruiz-Casares 805

Services Sociaux de la Montagne in Montreal, where she evaluates health and social
programs with ethno-culturally diverse families. Her published works focus on
children’s rights, protection, and wellbeing cross-culturally and on ethical and
methodological issues involved in research with children. She leads mixed-methods
studies related to child protection and wellbeing, mainly in contexts of parent–child
separation such as children home alone in Canada and children in alternative care
in Namibia, Laos, and Liberia.
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