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

1. INTRODUCTION

The WHO Quality Rights project (QR) [1] aims to implement the United Nations Convention on the Human Rights of Persons with Disabilities (CRPD) (UN 2006) [2, 3], in the field of psychosocial disability. Its purpose is “to improve access to quality mental health and social services and to promote the rights of people with mental health conditions, and psychosocial, intellectual and cognitive disabilities” [1].

Tunisia signed (2007) and ratified (2008) the CRPD [4], aiming to improve the level of respect for the human rights of people with disabilities (including psychosocial ones).

The project “Tunisia and Sardinia in support of the quality of human rights of people with psychosocial disabilities”, funded by the Sardinian Cooperation, aims to support the application of the QR program in Tunisia. This project conducted a pilot intervention to train a group of professionals, human rights experts and people with experience in psychosocial disability, with the principles of CRPD and the use of instruments of the QR project (“ToolKit”) [5] through an intensive one-week course in Tunisia. The purpose was to create the first group of trainers available for future experience.

The participants of the intensive course completed a questionnaire, before and at the end of the course; the questionnaire evaluated the participant's knowledge and attitudes regarding human rights in mental health and the CRPD. The group of training participants then conducted a standardized assessment of Quality of Care focused on compliance with human rights in a Razi Hospital ward in accordance with QR rules and application of the QR ToolKit. The group then discussed the results with the staff of the ward and hypothesized possible implementation plans.

The aim of the study was to measure the knowledge and attitudes of the training participants (and future trainers) before and after the course, present the results of the evaluation of the psychiatric ward, compare them with a similar evaluation conducted four years earlier and discuss the results and differences between the two assessments over time in the light of the state of the country’s public health system and socio-economic conditions.

2. METHODS

3. RESULTS

For each of the 26 items of the questionnaire, Table 1 shows the average score and the standard deviation of answers reported at time T0 (pre-training) and T1 (post-training). The questionnaire was completed by 19 participants before the training, and by 15 participants at the end of the training.

Participants under training showed a general tendency to greater sensitivity towards the patient's point of view and against the use of coercive practices near the end of the training. Most items show a modification of the scores in this sense. However, a statistically significant before-after difference was achieved only in items: J – People who use mental health services should have the power to decide on their treatments (increased score P=0.004); M – People with psychosocial disabilities need someone to plan all their activities (decreased score P=0.049); N – The opinions of people with psychosocial disabilities should have more weight with regard to their treatments than the views of health professionals (increased score P=0.007); O – It is unacceptable to put pressure on users of a mental health service to take treatment they would not like (increased score P=0.04); T – Controlling users of mental health services is necessary to maintain order (decreased score P=0.014).

Tables 2-6 show the results, divided by theme, obtained following the evaluation of Razi hospital, carried out during 2018. Based on the results obtained in the individual criteria, it was possible to evaluate the score for the standards, and from the scores of the standards, it was possible to obtain the overall score for each theme, i.e., the score for specific rights of the CRPD related to each theme. With regards to Theme 1 (Table 2) “The right to an adequate standard of living” (Article 28 of the United Nations Convention on the Rights of Persons with Disabilities, CRPD), only standard 1.4 (“Service users are given food, safe drinking water and clothing that meet their needs and preferences“) resulted as partially achieved, all other standards resulted initially achieved, except standard 1.7 (“Service users can enjoy fulfilling social and personal lives and remain engaged in community life and activities“) that was ‘not started’. With regards to Theme 2 (Table 3) “The right to the enjoyment of the highest attainable standards of physical and mental health“ (Article 25 of the CRPD), standard 2.1 (“Facilities are available to everyone who requires treatment and support“) resulted fully achieved. The other standards were initially achieved; standard 2.3 (“Treatment, psychosocial rehabilitation and links to support networks and other services are elements of a service user-driven recovery plan and contribute to a service user’s ability to live independently in the community“) resulted in ‘not started’. Concerning the theme “The right to exercise legal capacity and the right to personal liberty and the security of persons“ (Articles 12 and 14 of the CRPD) (Table 4), standard 3.4 (“Service users have the right to confidentiality and access to their personal health information“) was found partially achieved, while all the other standards were ‘not initiated’ except for standard 3.3 (“Service users can exercise their legal capacity and are given the support they may require to exercise their legal capacity“) which was partially achieved. As regards Theme 4, “Freedom from torture or cruel, inhuman or degrading treatment or punishment and from exploitation, violence and abuse“ (Articles 15 and 16 of the CRPD) (Table 5), standard 4.4 (“No service user is subjected to medical or scientific experimentation without his or her informed consent“) was totally achieved, standard 4.3 (“Electroconvulsive therapy, psychosurgery and other medical procedures that may have permanent or irreversible effects, whether performed at the facility or referred to another facility, must not be abused and can be administered only with the free and informed consent of the service user“) was partially achieved; standards 4.1 (“Service users have the right to be free from verbal, mental, physical and sexual abuse and physical and emotional neglect“) and 4.5 (“Safeguards are in place to prevent torture or cruel, inhuman or degrading treatment and other forms of ill-treatment and abuse“) were partially achieved and standard 4.2 (“Alternative methods are used in place of seclusion and restraint as means of de-escalating potential crises“) was ‘not initiated’. All standards included in Theme 5 (“The right to live independently and be included in the community“ (Article 19 of the CRPD) (Table 6) resulted ‘not initiated’.

Table 7 shows the synthetic score by theme and the comparison between the scores of 2014 and 2018 at Razi Hospital. In four themes, the scores were identical over time, but in Theme 2 (“The right to enjoyment of the highest attainable standards of physical and mental health“ - Article 25 of the CRPD), the score decreased from partially achieved to initiated.

4. DISCUSSION

Participants of the intensive one-week training on CRPD and human rights in mental health showed a significant improvement in knowledge or attitude, as reflected in a significant change in scores in 5 questions out of 26 of the questionnaire. These 5 questions have in common the participants’ 'beliefs about user control and users' freedom of choice. Although the difference reached statistical significance only in 19% of the questions, an improvement (in some cases at the limits of statistical significance) was also observed in many other questions, or in the clear majority, and it can be said that those who participated in the training are more willing to leave freedom of choice to those who use mental health services. It also appears to have changed to the belief that it is important not to try to control or replace the user since this can often prove harmful.

The data obtained from the 2018 assessment of the Razi hospital in Tunisia in accordance with QualityRights Toolkit show a condition in which the achievement of the rights declared by the CRPD is only partial or insufficient. Concerning the implementation of Article 28 of the CRPD, that is, the right to an adequate standard of living, the results clearly demonstrate that most of the standards show deficiencies and / or an initial level of achievement. The only standard that has been partially achieved relates to food, water, and clothing provided to users of the facility, while as regards, the standard on social life and participation of users in the community, it has been found that no efforts have yet been made to achieve it. Concerning the implementation of article 25 of the CRPD, that is, the right to enjoy the highest achievable level of physical and mental health, most of the standards are classified as objectives that are starting to be implemented. Only the standard regarding the availability of facilities for all those who require care and support is classified as fully achieved, while the standard of the presence of a plan for recovery and user participation in the drafting of the latter is classified as uninitiated. The achieving of rights provided for in Articles 12 and 14 of the CRPD, i.e., the right to exercise legal capacity and the right to personal freedom and personal security, show some delay. In this “theme”, the two standards, the first concerning preferences of users regarding their treatment and the second concerning procedures put in place to avoid detention and treatment without consent, are classified as unrealized. The third standard, regarding legal capacity, is classified as starting to be achieved. Only the last standard, which concerns the right to privacy and access to one's personal health information, is classified as partially achieved. The results concerning Articles 15 and 16 of the CRPD, i.e., the right to freedom from torture or from cruel, inhuman or degrading treatment or punishment and from exploitation, violence and abuse, are not univocal. In this theme, the first and last standards are classified as objectives that are being started. There is then a totally realized standard; No user is exploited for medical or scientific experimentation without his or her consent. The standard requiring alternative methods to insulation and restraint in the structure are unrealized. The standard concerning electroconvulsive therapy and its non-abuse is classified as partially realized. Article 19 of the CRPD, i.e., the right to live independently and be included in the community, is the one that shows the most negative results. In fact, all standards and all criteria have been classified as unrealized objectives.

Taken together, the evaluation shows significant delays in the implementation of the rights advocated by the CRPD. If in Themes 1, 3, 4 and 5, the evaluation shows no differences compared to 2014, it showed in Theme 2, an even lower level than four years before; from “achieved partially” in 2014 to “achievement initiated” in 2018 [6].

It must be kept in mind that the evaluation team in 2014 was composed in a different way. The evaluation was then carried out only by the structure’s staff, while in 2018, external experts were also involved and, above all, they were able to directly evaluate users and family members. This was not the case during the 2014 assessment and the different compositions may have increased the level of severity of the judgments.

However, the worsening specifically concerned items that the team members themselves complained of, especially in relation to the difficulty in obtaining drugs of primary necessity and to the decrease in staff that mainly involved people employed in rehabilitation and networking. Hence, the difficulty in the opening to the outside world and problems in the work of social inclusion.

It cannot be said that the scarcity of resources related to the serious economic and political crisis that Tunisia [7] is going through can be considered the only cause of the delays highlighted. However, it is likely that in a context of general crisis and uncertainty for the future, the scarcity of resources and the decrease in staff, in particular of professionals dedicated to psychosocial intervention [8, 9] may have been one of the factors that demotivated the team towards recovery and social inclusion [10-12].

An indirect demonstration of this demotivation emerges from the fact that the staff of Razi hospital has seen in recent years an impoverishment due to the departure of many professionals for jobs abroad.

An important fact is that the evaluation conducted in 2014 does not appear to have led to any improvement and it may be a demonstration that conducting an assessment without staff training and carrying out improvement plans may be ineffective.

CONCLUSION

The evaluation conducted in 2018 reveals significant delays in the implementation of the rights advocated by the CRPD. In themes 1, 3, 4 and 5, the evaluation shows no differences compared to 2014, but as concerns Theme 2, we find an even lower level than four years before.

The scarcity of resources related to the serious economic crisis that Tunisia is going through cannot be considered the only cause of the delays highlighted. It is likely that in a context of general crisis and uncertainty for the future, the scarcity of resources and the decrease in staff (in particular of professionals dedicated to psychosocial intervention) may have been one of the factors demotivating the teamwork towards recovery and social inclusion.

However, the training on Quality Rights appears, at least in part, to have changed the knowledge and attitudes of many staff members, and this may open positive scenarios for the future. The commitment that staff and users have made in this action is another element that shows a desire for improvement.

The paper does not imply that we were expecting a change in the quality of care of the service, which is not the case because we are aware that assessments can only help to understand the level of the respect of human rights in a done facility and limited training, alone, does not allow to begin a process of change. The results and the needs emerged indicate that there is need of consolidated training throughout Tunisia (with the inclusion of all stakeholders) and specific transformation plans for the services would be required to see the change in human rights respect and quality of care – as was done in Gujarat and as is happening in other countries [13].

REFERENCES