Marginalized adolescents are disproportionately vulnerable to experiencing psychological distress due to trauma exposure but are less likely to access, engage in, and benefit from existing trauma focused evidence based interventions (EBIs). It is hypothesized that one reason for the disparities in EBI access, engagement, and effectiveness is that current trauma focused EBIs do not effectively account for the contextual conditions that contributed to the onset and maintenance of psychological problems following trauma exposure. Therefore, the goal of this dissertation was to utilize an approach informed by socio-ecological model of health to complete three studies to examine the effect of contextual factors on psychological treatment (1) access, (2) engagement, and (3) effectiveness among marginalized adolescents with trauma exposure. Study one utilized data from a large epidemiological dataset to examine the explanatory power of neighborhood level moderators of the relationship between psychological need and likelihood of adolescents accessing psychological services. I found that neighborhood level inequality negatively impacted adolescents’ ability to access care, even when accounting for psychological need and marginalized identity. Study two utilized a mixed methods approach to determine whether contextual barriers to psychological treatment impacted engagement in a small, randomized control trial for a trauma focused EBI. I found modest preliminary evidence that adolescents anticipated that contextual barriers would impact their ability to engage in care. Study three was a qualitative examination of whether content related to contextual stressors in individual therapy sessions impacted adolescent and provider perceptions of EBI effectiveness. I found that contextual stressors were related to psychological distress, difficulty with engaging in treatment, and decreased intervention acceptability. Results from the dissertation have the capacity to inform novel public health and clinical interventions to eliminate disparities and to improve existing EBIs.

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