Implementation of the World Health Organization's QualityRights initiative in Ghana: an overview.

BACKGROUND: Globally, human rights violations experienced by persons with psychosocial, intellectual or cognitive disabilities continue to be a concern. The World Health Organization's (WHO) QualityRights initiative presents practical remedies to address these abuses. This paper presents an overview of the implementation of the initiative in Ghana. AIMS: The main objective of the QualityRights initiative in Ghana was to train and change attitudes among a wide range of stakeholders to promote recovery and respect for human rights for people with psychosocial, intellectual and cognitive disabilities. METHOD: Reports of in-person and online training, minutes of meetings and correspondence among stakeholders of the QualityRights initiative in Ghana, including activities of international collaborators, were analysed to shed light on the implementation of the project in Ghana. RESULTS: In-person and online e-training on mental health were conducted. At the time of writing, 40 443 people had registered for the training, 25 416 had started the training and 20 865 people had completed the training and obtained a certificate. The team conducted 27 in-person training sessions with 910 people. The successful implementation of the project is underpinned by a committed partnership among stakeholders, strong leadership from the coordinating agency, the acceptance of the initiative and the outcome. A few challenges, both in implementation and acceptance, are discussed. CONCLUSIONS: The exposure of the WHO QualityRights initiative to a substantial number of key stakeholders involved in mental healthcare in Ghana is critical to reducing human rights abuses for people with psychosocial, intellectual and cognitive disabilities.

Social determinants of anxiety and mood disorders in a nationally-representative sample - Results from the Saudi National Mental Health Survey (SNMHS).

INTRODUCTION: Social determinants of health (SDH) influence and modify the risk for mental health disorders. To our knowledge, no study has explored SDH in the context of mental health in Saudi Arabia (SA) using population-based data. This study investigated the association between several SDH and anxiety and mood disorders in SA. METHODS: We utilized data from the nationally-representative Saudi National Mental Health Survey (SNMHS) conducted in 2014 to 2016. This study examined associations between personal-level, socioeconomic, physical health, and family environment characteristics and anxiety and mood disorders. Participants were classified as having anxiety-only disorders, mood-only disorders, or comorbidity of both disorders. Multinomial logistic regression models were employed to examine the associations between SDH and anxiety and/or mood disorders, comparing them to participants who had not experienced these disorders. RESULTS: A total of 4,004 participants were included in this analysis; the lifetime prevalence of disorders was: anxiety only (18%), mood only (3.8%), and comorbidity of both (5.3%). Regression models indicated that females, young adults (26-35 years), individuals with a higher level of education, and those who were separated or widowed had higher odds of experiencing anxiety and/or mood disorders. Furthermore, there was a significant and direct association between having physical chronic conditions and all three categories of anxiety and mood disorders. Experiencing Adverse Childhood Events (ACEs) was also associated with a significant risk of developing anxiety and/or mood disorders, with the highest risk associated with physical or sexual abuse, followed by violence and neglect. CONCLUSION: This study underscores the correlation between several personal-level, socioeconomic, and environmental SDH and anxiety and mood disorders in SA. These findings provide a foundation for future analyses examining the intricate interplay between upstream and downstream SDH in SA. Such research can enhance local scientific knowledge, aid in planning for social services, and inform policy decisions and treatment strategies.

A quantitative analysis of human rights-related attitude changes towards people with mental health conditions and psychosocial, intellectual, or cognitive disabilities following completion of the WHO QualityRights e-training in Ghana.

BACKGROUND: Despite growing recognition of essential human rights, people with mental health conditions and psychosocial, intellectual, or cognitive disabilities' rights are known to be frequently violated in mental healthcare worldwide, with common use of coercive practices and limited recognition of people's right to exercise their legal capacity and make decisions for themselves on treatment and other issues affecting them. To tackle this issue, Ghana adopted the WHO QualityRights Initiative in 2019. This aims to introduce a right-based, person-centred recovery approach within the mental health care system, protecting and promoting the rights of people with mental health conditions, psychosocial, cognitive, and intellectual disabilities in the healthcare context and community. METHODS: E-training (capacity-building) was provided in Ghana across a broad array of stakeholder groups including healthcare professionals, carers, and people with lived experience. The training covered legal capacity, coercion, community inclusion, recovery approach, service environment, and the negative attitudes commonly held by stakeholder groups; it was completed by 17,000 people in Ghana as of December 2021. We assessed the impact of the e-training on attitudes through comparing trainees' pre- and post-questionnaire responses on 17 items, each measured on a 5-point Likert scale (strongly disagree to strongly agree), such that higher scores indicated negative attitudes towards persons with mental health conditions and psychosocial disabilities as rights holders. Analyses were conducted on two main groups: matched pairs (417 pairs of baseline and follow-up questionnaire responses matched to a high degree of certainty), and the unmatched group (4299 individual completed questionnaire responses). RESULTS: We assessed the impact of the WHO QualityRights e-training on attitudes: training resulted in highly significant attitude changes towards alignment with human rights, with scores changing by approximately 40% between baseline and follow-up. In particular, attitude changes were seen in items representing treatment choice, legal capacity, and coercion. This change was not affected by age, gender, or background experience. CONCLUSIONS: The QualityRights e-training programme is effective in changing people's (especially healthcare professionals') attitudes towards people with mental health conditions and psychosocial, intellectual, or cognitive disabilities: this is a step towards mental healthcare being more with human rights-based worldwide.

Health equity for persons with disabilities: a global scoping review on barriers and interventions in healthcare services.

BACKGROUND: Persons with disabilities experience health inequities in terms of increased mortality, morbidity, and limitations in functioning when compared to the rest of the population. Many of the poor health outcomes experienced by persons with disabilities cannot be explained by the underlying health condition or impairment, but are health inequities driven by unfair societal and health system factors. A synthesis of the global evidence is needed to identify the factors that hinder equitable access to healthcare services for persons with disabilities, and the interventions to remove these barriers and promote disability inclusion. METHODS: We conducted a scoping review following the methodological framework proposed by Arksey and O'Malley, Int J Soc Res Methodol 8:19-32. We searched two scholarly databases, namely MEDLINE (Ovid) and Web of Science, the websites of Organizations of Persons with Disabilities and governments, and reviewed evidence shared during WHO-led consultations on the topic of health equity for persons with disabilities. We included articles published after 2011 with no restriction to geographical location, the type of underlying impairments or healthcare services. A charting form was developed and used to extract the relevant information for each included article. RESULTS: Of 11,884 articles identified in the search, we included 182 articles in this review. The majority of sources originated from high-income countries. Barriers were identified worldwide across different levels of the health system (such as healthcare costs, untrained healthcare workforces, issues of inclusive and coordinated services delivery), and through wider contributing factors of health inequities that expand beyond the health system (such as societal stigma or health literacy). However, the interventions to promote equitable access to healthcare services for persons with disabilities were not readily mapped onto those needs, their sources of funding and projected sustainability were often unclear, and few offered targeted approaches to address issues faced by marginalized groups of persons with disabilities with intersectional identities. CONCLUSION: Persons with disabilities continue to face considerable barriers when accessing healthcare services, which negatively affects their chances of achieving their highest attainable standard of health. It is encouraging to note the increasing evidence on interventions targeting equitable access to healthcare services, but they remain too few and sparce to meet the populations' needs. Profound systemic changes and action-oriented strategies are warranted to promote health equity for persons with disabilities, and advance global health priorities.

Attitudes towards persons with mental health conditions and psychosocial disabilities as rights holders in Ghana: a World Health Organization study.

BACKGROUND: There are currently major efforts underway in Ghana to address stigma and discrimination, and promote the human rights of those with mental health conditions, within mental health services and the community, working with the World Health Organization's QualityRights initiative. The present study aims to investigate attitudes towards people with lived experience of mental health conditions and psychosocial disabilities as rights holders. METHODS: Stakeholders within the Ghanaian mental health system and community, including health professionals, policy makers, and persons with lived experience, completed the QualityRights pre-training questionnaire. The items examined attitudes towards coercion, legal capacity, service environment, and community inclusion. Additional analyses explored how far participant factors may link to attitudes. RESULTS: Overall, attitudes towards the rights of persons with lived experience were not well aligned with a human rights approach to mental health. Most people supported the use of coercive practices and often thought that health practitioners and family members were in the best position to make treatment decisions. Health/mental health professionals were less likely to endorse coercive measures compared to other groups. CONCLUSION: This was the first in-depth study assessing attitudes towards persons with lived experience as rights holders in Ghana, and frequently attitudes did not comply with human rights standards, demonstrating a need for training initiatives to combat stigma and discrimination and promote human rights.

The Impact of the COVID-19 Pandemic on the Mental Health of Healthcare Workers in Italy: Analyzing the Role of Individual and Workplace-Level Factors in the Reopening Phase After Lockdown.

Introduction: Italy is one of the high-income countries hit hardest by Covid-19. During the first months of the pandemic, Italian healthcare workers were praised by media and the public for their efforts to face the emergency, although with limited knowledge and resources. However, healthcare workers soon had to face new challenges at a time when the national health system was working hard to recover. This study focuses on this difficult period to assess the impact of the COVID-19 pandemic on the mental health of Italian healthcare workers. Materials and Methods: Healthcare workers from all Italian regions [n = 5,502] completed an online questionnaire during the reopening phase after the first wave lockdown. We assessed a set of individual-level factors (e.g., stigma and violence against HCWs) and a set of workplace-level factors (e.g., trust in the workplace capacity to handle COVID-19) that were especially relevant in this context. The primary outcomes assessed were score ≥15 on the Patient Health Questionnaire-9 and score ≥4 on the General Health Questionnaire-12, indicators of clinically significant depressive symptoms and psychological distress, respectively. Logistic regression analyses were performed on depressive symptoms and psychological distress for each individual- and workplace-level factor adjusting for gender, age, and profession. Results: Clinically significant depressive symptoms were observed in 7.5% and psychological distress in 37.9% of HCWs. 30.5% of healthcare workers reported having felt stigmatized or discriminated, while 5.7% reported having experienced violence. Feeling stigmatized or discriminated and experiencing violence due to being a healthcare worker were strongly associated with clinically significant depressive symptoms [OR 2.98, 95%CI 2.36-3.77 and OR 4.72 95%CI 3.41-6.54] and psychological distress [OR 2.30, 95%CI 2.01-2.64 and OR 2.85 95%CI 2.16-3.75]. Numerous workplace-level factors, e.g., trust in the workplace capacity to handle COVID-19 [OR 2.43, 95%CI 1.92-3.07] and close contact with a co-worker who died of COVID-19 [OR 2.05, 95%CI 1.56-2.70] were also associated with clinically significant depressive symptoms. Similar results were found for psychological distress. Conclusions: Our study emphasizes the need to address discrimination and violence against healthcare professionals and improve healthcare work environments to strengthen the national health system's capacity to manage future emergencies.

Global mental health research and practice: a decolonial approach.

The global health movement is having a paradigm crisis-a period characterised by a questioning of one's values, goals, and sense of identity. Despite important advances in population health worldwide, global health and global mental health often produce and reproduce power imbalances and patterns of oppression and exploitation that perpetuate the current modern world system (ie, Eurocentric, capitalist, and patriarchal) and its entangled global hierarchies (eg, gender, economic, epistemic, and linguistic). A consensus is emerging to decolonise global mental health, but it is not clear how to move from rhetoric to action. In this Personal View, we aim to share our experiences and the practices developed in the context of the COVID-19 health care workers (HEROES) Study. To do so, we present our HEROES decolonial team approach, which comprises three underlying principles: epistemic justice, pragmatic solidarity, and sovereign acts. We have developed decolonial team practices such as co-creating communication spaces to foster horizontal and equitable dialogue, locating and managing the study database in Chile, and ensuring local teams' rights and access to the data without barriers.

COVID-19 Pandemic Factors and Depressive Symptoms Among Primary Care Workers in São Paulo, Brazil, October and November 2020.

Objectives. To investigate associations between COVID-19-related factors and depressive symptoms among primary care workers (PCWs) in São Paulo, Brazil, and to compare the prevalence of probable depression among PCWs before and during the pandemic. Methods. In a random sample of primary care clinics, we examined 6 pandemic-related factors among 828 PCWs. We used multivariate Poisson regression with robust variance to estimate prevalence ratios for probable depression. We assessed the prevalence of probable depression in PCWs before and during the pandemic in 2 comparable studies. Results. Adjusted prevalence ratios were substantial for insufficient personal protective equipment; experiences of discrimination, violence, or harassment; and lack of family support. Comparisons between PCWs before and during the pandemic showed that the prevalence of probable depression among physicians, nurses, and nursing assistants was higher during the pandemic and that the prevalence among community health workers was higher before the pandemic. Conclusions. Our findings indicate domains that may be crucial to mitigating depression among PCWs but that, with the exception of personal protective equipment, have not previously been examined in this population. It is crucial that governments and communities address discriminatory behaviors against PCWs, promote their well-being at work, and foster family support. (Am J Public Health. 2022;112(5):786-794. https://doi.org/10.2105/AJPH.2022.306723).

A nationwide evaluation study of the quality of care and respect of human rights in mental health facilities in Ghana: results from the World Health Organization QualityRights initiative.

BACKGROUND: In 2012, Ghana ratified the United Nations Convention on the Rights of Persons with Disabilities and enacted a Mental Health Act to improve the quality of mental health care and stop human rights violations against people with mental health conditions. In line with these objectives, Ghanaian stakeholders collected data on the quality of mental health services and respect for human rights in psychiatric facilities to identify challenges and gather useful information for the development of plans aimed to improve the quality of the services offered. This study aimed to assess psychiatric facilities from different Ghanaian regions and provide evidence on the quality of care and respect of human rights in mental health services. METHODS: Assessments were conducted by independent visiting committees that collected data through observation, review of documentation, and interviews with service users, staff, and carers, and provided scores using the World Health Organization QualityRights Toolkit methodology. RESULTS: This study revealed significant key challenges in the implementation of the United Nations Convention on the Rights of Persons with Disabilities principles in Ghanaian psychiatric services. The rights to an adequate standard of living and enjoyment of the highest attainable standard of health were not fully promoted. Only initial steps had been taken to guarantee the right to exercise legal capacity and the right to personal liberty and security. Significant gaps in the promotion of the right to live independently and be included in the community were identified. CONCLUSIONS: This study identifies shortcomings and critical areas that the Ghanaian government and facilities need to target for implementing a human rights-based approach in mental health and improve the quality of mental health care throughout the country.

The impact of the COVID-19 pandemic on the mental health of healthcare workers: study protocol for the COVID-19 HEalth caRe wOrkErS (HEROES) study.

BACKGROUND: Preliminary country-specific reports suggest that the COVID-19 pandemic has a negative impact on the mental health of the healthcare workforce. In this paper, we summarize the protocol of the COVID-19 HEalth caRe wOrkErS (HEROES) study, an ongoing, global initiative, aimed to describe and track longitudinal trajectories of mental health symptoms and disorders among health care workers at different phases of the pandemic across a wide range of countries in Latin America, Europe, Africa, Middle-East, and Asia. METHODS: Participants from various settings, including primary care clinics, hospitals, nursing homes, and mental health facilities, are being enrolled. In 26 countries, we are using a similar study design with harmonized measures to capture data on COVID-19 related exposures and variables of interest during two years of follow-up. Exposures include potential stressors related to working in healthcare during the COVID-19 pandemic, as well as sociodemographic and clinical factors. Primary outcomes of interest include mental health variables such as psychological distress, depressive symptoms, and posttraumatic stress disorders. Other domains of interest include potentially mediating or moderating influences such as workplace conditions, trust in the government, and the country's income level. RESULTS: As of August 2021, ~ 34,000 health workers have been recruited. A general characterization of the recruited samples by sociodemographic and workplace variables is presented. Most participating countries have identified several health facilities where they can identify denominators and attain acceptable response rates. Of the 26 countries, 22 are collecting data and 2 plan to start shortly. CONCLUSIONS: This is one of the most extensive global studies on the mental health of healthcare workers during the COVID-19 pandemic, including a variety of countries with diverse economic realities and different levels of severity of pandemic and management. Moreover, unlike most previous studies, we included workers (clinical and non-clinical staff) in a wide range of settings.

Quality of care and respect of human rights in mental health services in four West African countries: collaboration between the mental health leadership and advocacy programme and the World Health Organization QualityRights initiative.

BACKGROUND: Although recent reports suggest that service users in West African psychiatric facilities are exposed to poor quality of care and human rights violations, evidence is lacking on the extent and profile of specific deficits in the services provided to persons with mental health conditions. AIMS: To evaluate the quality of care and respect of human rights in psychiatric facilities in four West African countries, The Gambia, Ghana, Liberia and Sierra Leone, using the World Health Organization QualityRights Toolkit. METHOD: Trained research workers collected information through observation, review of records and interviews with service users, caregivers and staff. Independent panels of assessors used the information to assign scores to the criteria, standards and themes of the QualityRights Toolkit. RESULTS: The study revealed significant gaps in these facilities. The rights to an adequate standard of living and to enjoyment of the highest attainable standard of health were poorly promoted. Adherence to the right to exercise legal capacity and the right to personal liberty and security was almost absent. Severe shortcomings in the promotion of the right to live independently and be included in the community were reported. CONCLUSIONS: Inadequate appreciation of service users' rights, lack of basic approaches to protect them and the non-promotion of rights-based services in these facilities are major problems that need to be addressed. Although it recognises the resource constraints and need for more human and financial resources, the study also identifies critical areas and challenges that require significant changes at the facility level.

Prevalence of Mood Disorders and Associated Factors at the Time of the COVID-19 Pandemic: Potocol for a Community Survey in La Manouba Governorate, Tunisia.

Aims: The present survey aims to assess the overall mood disorder prevalence and identify associated socio-demographic and clinical factors in a Tunisian community sample, with special attention to the COVID-19 pandemic. Background: Mood disorders are one of the leading causes of all non-fatal burdens of disease, with depression being at the top of the list. The COVID-19 pandemic may have increased the prevalence of mood disorders, especially in Low and Middle-income countries (LMICs) and in vulnerable populations. Objective: 1/ Assess point and lifetime prevalence of depressive and bipolar disorders as well as subthreshold bipolarity in a representative population sample of La Manouba governorate and assess treatment patterns for these disorders; 2/Study socio-demographic and clinical correlates of mood disorders 3/ Assess the association between mood disorders and quality of life 4/ Study the impact of the COVID-pandemic on the prevalence of mood disorders 5/ Assess coping mechanisms to the COVID-pandemic and whether these mechanisms moderate the appearance of mood disorders or symptoms since the beginning of the pandemic. Methods: This is a household cross-sectional observational survey to be conducted in La Manouba Governorate in a sample of 4540 randomly selected individuals aged ≥ 15 years. Data collection will be carried out by trained interviewers with clinical experience, through face-to-face interviews and the use of the computer assisted personal interviewing approach (CAPI). The following assessment tools are administered. Results: Structured clinical Interview for DSM IV-TR (Mood disorder section and Screening questions on Anxiety), Mood Disorder Questionnaire (MDQ), Suicide Behaviors Questionnaire-Revised (SBQ), 12-item Short Form Survey (SF-12), the Brief-COPE, and a questionnaire about a headache. In addition, socio-demographic and clinical data will be collected. Conclusion: This will be one of the very few household surveys in a general population sample to assess mental health problems and COVID-19-related variables since the beginning of the pandemic. Through this research, we aim to obtain an epidemiological profile of mood disorders in Tunisia and an estimation of the impact of the COVID-19 pandemic on their prevalence. Results should contribute to improving mental health care in Tunisia.

The Burden of Agoraphobia in Worsening Quality of Life in a Community Survey in Italy.

OBJECTIVE: Current nosology redefined agoraphobia as an autonomous diagnosis distinct from panic disorder. We investigated the lifetime prevalence of agoraphobia, its association with other mental disorders, and its impact on the health-related quality of life (HR-QoL). METHODS: Community survey in 2,338 randomly selected adult subjects. Participants were interviewed with the Advanced Neuropsychiatric Tools and Assessment Schedule (ANTAS), administered by clinicians. The diagnoses were based on the ICD-10 criteria. The Short-Form Health Survey (SF-12) was used to quantify HR-QoL. RESULTS: In the sample, 35 subjects met the criteria for agoraphobia (1.5%), with greater prevalence among women (2.0%) than men (0.9%): odds ratio (OR) 2.23; 95% CI: 1.0-5-2. Agoraphobia was more often seen among those with (n=26; 1.1%) than without (n=9; 0.4%) panic disorder: OR=8.3; 2.9-24.4. Co-morbidity with other mental disorders was substantial. The mean score of SF-12 in people with agoraphobia was 35.2±7.8, with similar levels of HR-QoL in people with (35.3±7.9) or without (34.8±7.3) panic disorder: ANOVA: F(1;33)=0.0; p=1.00. CONCLUSION: One out of seventy people may suffer from agoraphobia in their lifetime. The attributable burden in terms of HR-QoL is substantial and comparable to the one observed for chronic mental disorders such as major depression, post-traumatic stress disorder, or obsessive-compulsive disorder.

General Practitioners' Experiences During the First Phase of the COVID-19 Pandemic in Italy: A Critical Incident Technique Study.

Since February 2020, when coronavirus disease began to spread in Italy, general practitioners (GPs) were called to manage a growing number of health situations. The challenges experienced by Italian GPs remained unrevealed. This study aimed at exploring Italian GPs' care experiences and practices associated with critical incidents during the first wave of the pandemic. A qualitative study design involving the critical incident technique through an online survey was applied. Sociodemographic data and open-ended responses were collected. While participants' characteristics were analyzed through descriptive statistics, qualitative data were thematically analyzed employing the framework method. 149 GPs responded to the survey and 99 participants completed the survey (dropout rate = 33%). Eight themes emerged indicating factors related to the organization of the healthcare system and factors related to the clinical management of patients, that were perceived as impacting on the GPs' care provision. The analysis revealed difficulties in communicating with other local services. This, together with the lack of coordination among services, was reported as a major challenge. Primary care was perceived as having been undervalued and criticalities in the organization of GP courses, led in a bureaucratic fashion, posed at risk some trainees to be infected. The digital technologies adopted for remote patient consultations were seen as useful tools for daily practice helping the GPs to stay emotionally connected with their patients. Besides, the improvement in the GP-patient relationship in terms of solidarity between patients and doctors and compliance to rules, had a positive impact. Moreover, many respondents addressed the importance of professional collaboration and teamwork, in terms of both support in practical issues (to find PPE, diagnostics and guidelines) and emotional support. At the same time, the lack of resources (e.g., PPE, swabs) and of specific guidelines and protocols impacted on the care provision. Our findings suggest that GPs in Italy are at risk of being left behind within the epidemic management. Communication and coordination among services are essential and should be substantially improved, and primary care research should be initiated to collect the context-specific evidence necessary to enhance the system's preparedness to public health emergencies and the quality of primary care services.

The lifetime prevalence and impact of generalized anxiety disorders in an epidemiologic Italian National Survey carried out by clinicians by means of semi-structured interviews.

BACKGROUND: Generalized anxiety disorder (GAD) is one of the most reported diagnoses in psychiatry, but there is some discrepancy between the cases identified in community studies and those identified in tertiary care. This study set out to evaluate whether the use of clinicians as interviewers may provide estimates in a community survey close to those observed in primary or specialized care. METHODS: This is a community survey on a randomly selected sample of 2338 adult subjects. The Advanced Neuropsychiatric Tools and Assessment Schedule (ANTAS) was administered by clinicians, providing lifetime diagnosis based on the DSM-IV-TR. Health-related quality of life (HR-QoL) was measured with the Short-Form Health Survey (SF-12). RESULTS: Overall, 55 (2.3%) subjects met the criteria for GAD, with greater prevalence in women (3.6%) than in men (0.9%): OR = 4.02; 95%CI: 1.96-8.26. Up to 40% of those with GAD had at least another diagnosis of mood, anxiety, or eating disorders. The mean score of SF-12 in people with GAD was 32.33 ± 6.8, with a higher attributable burden than in other conditions except for major depressive disorder. CONCLUSIONS: We found a relatively lower lifetime prevalence of GAD than in community surveys based on lay interviewers and a structured interview. The identified cases of GAD showed a strong impact on the quality of life regardless of co-morbidity and high risk in women, suggesting a profile similar to the one identified from studies in primary and specialized care.

The WHO QualityRights initiative: building partnerships among psychiatrists, people with lived experience and other key stakeholders to improve the quality of mental healthcare.

Psychiatrists have an essential role to play in promoting human rights in mental healthcare. The World Health Organization's QualityRights initiative, in partnership with different stakeholders, is improving the quality of psychiatric care in different countries.

Implementing WHO-Quality Rights Project in Tunisia: Results of an Intervention at Razi Hospital.

BACKGROUND: The aims were: 1) to measure the attitudes of learners (and future trainers) before and after a course on WHO-Quality Rights (QR); 2) to evaluate a psychiatric ward, by previously trained staff on QR, comparing it with a previous evaluation and discussing an improvement plan. METHODS: 1) Training sample: 19 subjects (8 males), 41.4±10.6 years, including jurists/lawyers, health professionals, and experts.The QR team developed the 26-item tool to assess the knowledge and attitudes of participants.2) Evaluation of quality of care and respect for human rights in the ward was carried out on 20 staff representatives, 20 family members and 20 users with QRToolkit. RESULTS: 1) Learning in QR has partially changed the knowledge and attitudes of trained people.2) The evaluation shows significant delays in the implementation of the rights advocated by the United Nations Convention on the Human Rights of Persons with Disabilities (CRPD). In Themes 1, 3, 4 and 5, the evaluation shows no differences compared to 2014, but in Theme 2, the level was lower than four years before. CONCLUSION: The scarcity of resources due to the economic crisis that Tunisia is going through, cannot be considered the only cause of the delays highlighted. However, it is likely that in a context of uncertainty for the future, scarcity of resources and a decrease in staff (i.e., professionals dedicated to psychosocial intervention) may have demotivated the team towards recovery. The improvement in knowledge and attitudes of many staff members after the training may open future positive scenarios.

Broad Spectrum project: factors determining the quality of antibiotic use in primary care: an observational study protocol from Italy.

INTRODUCTION: The overuse of antibiotics is causing worldwide spread of antimicrobial resistance (AMR). Compared with other countries, Italy has both high antibiotic consumption rates and high rates of AMR. Due to the fact that around 90% of antibiotics are prescribed by general practitioners (GPs), this study aims to measure the impact of knowledge, attitudes and sociodemographic and workplace-related factors on the quality of antibiotic prescriptions filled by GPs in the Italian Region of Sardinia. METHODS AND ANALYSIS: Knowledge, attitude, sociodemographic and workplace-related factors deemed to influence physicians prescribing behaviour will be evaluated in a cross-sectional study conducted among all GPs of the Italian Region of Sardinia (n=1200). A knowledge and attitudes questionnaire (Knowledge and Attitudes on Antibiotics and Resistance - Italian version: ITA-KAAR) accompanied by a sociodemographic form will be linked to drug prescription data reimbursed by the National Health System. European Surveillance of Antibiotic Consumption quality indicators for outpatient antibiotic use will be calculated from drug prescription records. Every GP will be deemed to have demonstrated an adequate quality of prescriptions of antibiotics if half of the indicator score plus one is better than the median of the region. A multivariate Poisson regression model with robust variance estimation will be used to evaluate the impact of the determinants of antibiotic prescriptions on the actual prescribing quality of each physician. ETHICS AND DISSEMINATION: The project has been approved by the ethics committee of the Regional Health Trust of Sardinia (176/2019/CE, 24 September 2019). The results will be useful to inform evidence-based interventions to tackle irrational antibiotic use in the community.