Tese de Doutoramento Saúde Pública Global 2024 Faculdade de Ciências Médicas, Universidade NOVA de Lisboa

Background: The use of coercion in mental health care, while intended to benefit patients and improve their mental health, raises significant ethical and clinical concerns. It is a controversial practice that violates the rights of Persons with Mental Health Conditions (PMHCs) and goes against the recommendations of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD). Despite the ongoing debates and arguments, there is no consensus on eliminating coercive measures in mental health care. However, there is growing pressure from all stakeholders to minimize their use. This Ph.D. research was conducted in Nigeria and Portugal, representing low and-middle-income and high-income contexts, respectively. It encompasses diverse contexts that highlight both shared challenges and unique circumstances. Objectives: The objective of the PhD research was to systematically explore how contextual factors influence the use of coercion in mental health care. The research aimed to achieve the following: 1) Review the available empirical evidence on contextual factors contributing to coercion; 2) Evaluate the perspectives of service users and mental health professionals about coercion in Nigeria and Portugal; 3) Identify contextual factors influencing coercion in Nigeria and Portugal; 4) Propose recommendations to reduce coercion. Methods: The research project consisted of three phases. First, a narrative review was conducted to examine the contextual factors that influence involuntary admissions. In the second phase, an analysis was conducted to assess the compliance of Nigeria's proposed mental health and substance abuse bill 2019 and the National Mental Health Act 2021 with the recommendations of the UNCRPD, focusing on the regulation of coercive measures. Additionally, the experiences and perspectives of 30 service users and 30 mental health professionals in two Nigerian psychiatric hospitals were explored through focus group discussions and semi-structured interviews, respectively. In this phase, a qualitative integrative analysis was also conducted to gather suggestions from both service users and mental health professionals on ways to reduce coercion. The third phase focused on studying the contextual factors influencing coercion in Portugal, involving five focus group discussions with 40 mental health professionals from five psychiatric departments. This phase also included evaluating the attitudes of 119 mental health professionals in Portugal using the Portuguese version of the Staff Attitude towards Coercion Scale (SACS). Furthermore, the psychometric properties of the Portuguese version of the Admission Experience Survey (P-AES) were assessed, and the subjective experience of coercion among 208 patients receiving care in five Portuguese psychiatric departments was evaluated using this instrument. Lastly, the study also examined the predictors of changes in the subjective experience of coercion during admission. Results: The PhD research yielded ten scientific papers, consisting of nine original articles and one commentary. The initial phase of the study revealed that various factors beyond patient characteristics, such as mental health legislation, demand and supply of mental health resources, impactful events like economic recessions and COVID-19, and staff-related factors like attitudes, traits, and qualifications, along with public attitudes and stigma, contribute to the use of coercive measures in mental health care. These factors interact with each other, rather than independently, to reinforce their impact on the reliance on coercive measures for the care of PMHCs. The second phase of the research demonstrated that while Nigeria's mental health laws are not fully compliant with UNCRPD recommendations, significant improvements have been made to the existing laws, considering the socio-cultural context of the country. Alongside the outdated mental health law, limited accessibility to mental health care and social services, deeply rooted stigma and misconceptions surrounding mental health conditions, and public attitudes play a role in the use of coercive measures in Nigerian mental health care. Service users and providers' suggestions to reduce coercion in Nigeria focused on improved communication, increased resources for mental health, and the implementation of policies and regulations to regulate coercive measures, aligning with existing interventions to decrease coercion in mental health care. In the third phase, mental health professionals in Portugal identified socio-legal factors, staff-related factors, inefficient services, and insufficient resources as contextual factors influencing the use of coercion in Portuguese mental health care. The validated SACS showed acceptable psychometric properties and indicated that Portuguese mental health professionals exhibit pragmatic attitudes towards coercion, with observed differences in attitudes based on age and years of work experience. The P-AES also exhibited satisfactory psychometric properties, with the bifactor model displaying better fit properties compared to previously proposed models. The subjective experience of coercion among service users in Portugal increased during the second assessment. Changes in the subjective experience of coercion were predicted by the perceived admission status rather than the legal admission status, and the initial procedural justice at admission. Conclusions: The findings of the PhD research advance current understanding of how contextual factors contribute to the reliance on coercive measures for care of PMHCs. The thesis underscores the significance of resolving fundamental problems within the mental health care system to effectively deliver high-quality mental health care that preclude the need for coercive measures. By involving all stakeholders, and fostering collaboration, all countries, regardless of income level, can strive for reform and establish mental health systems that prioritize rights, dignity, and recovery