Nepal is facing escalating infection rates of HIV/AIDS, a major global public health threat. Continuum of services is an identified strategic component of Joint United Nations Programme on HIV/AIDS (UNAIDS) commitment to end this public health crisis by 2030 and achieve the Sustainable Development Goal 6 (SDG 6). Pharmacists are integral members of the continuum of care in HIV/AIDS but the idea is novel to Nepal. Realizing need to explore and identify potential roles of pharmacists in HIV/AIDS care delivery, this study aimed to gain an insight into the views of stakeholders on the roles of pharmacists in this arena.A qualitative approach was used where 14 key informants were interviewed using a semi-structured interview protocol. Participants were selected through a sequence of purposive sampling and snowball sampling technique. The interviews were conducted, transcribed verbatim and analyzed using thematic analysis.Potential roles of pharmacists reside in adherence monitoring, pharmacovigilance, provincial and district level ART centers. Pharmacists and other stakeholders held divergent views on the pharmacist’s role in dispensing and counseling antiretroviral medications. Barriers to the pharmacists’ involvement were lack of workforce, advocacy and government support, frailty of professional organizations, self-limited scope, policy constraints, structural limitations, biasedness, and societal unawareness. Pharmacists themselves and organizations such as National Government Organizations (NGOs) and International Government Organizations (INGOs) were identified as the facilitators.Stakeholders are willing to expand role of pharmacists in HIV/AIDS care in Nepal. Nevertheless, some crucial impediments exist. Primarily, an aggressive and assertive advocacy is needed from pharmacists themselves and their professional organizations to establish their roles in HIV/AIDS care delivery. Additionally, unearthing potential of pharmacists as contributors in HIV/AIDS care delivery or any other chronic disease management equally demands a strong support from the government officials as well as the other health care professionals. HIV/AIDS continues to be the major global public health issue claiming 40.1 million lives as of year 2021 . After sSince the detection, Nepal has put substantial efforts such as launching the first National AIDS prevention and control program in 1988 . FurtherThe National Strategy on HIV/AIDS 2006–2011) had strongly emphasized the importance of a continuum of services from prevention to treatment and care where pharmacists play a crucial role. Internationally, an ambitious treatment plan aiming to end the AIDS epidemics by 2030 is being implemented whereby all Health Care Providers involved in HIV care have their clear and defined roles in the service . Along t had stroPharmacists are recognized as one of the essential and integral members of the HIV care team widely across countries like the USA and Canada . There wThis was a qualitative study where we diverged into the exploratory aspects of pharmacists’ involvement in HIV care as there was no prior findings to rely on. Thus, to explore stakeholders’ understanding about pharmacist’s current role, potential roles, barriers and facilitators, we designed a qualitative study. The study sites included the organizations that are working for HIV/AIDS patients. Major organizations include: the office of National Centre for AIDS and STD Control (NCASC), Department of Drug Administration (DDA), Nepal Pharmacist Association (NPA), Nepal Pharmacy Council (NPC), Save the Children, Ministry of Health and Population (MOHP), and Logistic Management Division (LMD).Ethical approval (NHRC- Registration no. 834/2020 P) was obtained from Nepal Health Research Council (NHRC) before the data collection. Following the approval from NHRC, the study objectives were explained to the respondents, and written informed consent was obtained from each participant before the interview. In addition, permission was taken from the respondents to record the interview with an assurance of maintenance of confidentiality.Most of the study participants were the individuals working in the organizations related to HIV/AIDS. One of the authors (BKC) was involved in HIV/AIDS care sector in his earlier phase of career. Through him some key informants from the policy making level and from service provider level were identified initially. The official website of National centre for AIDS and STD control (NSASC) was also utilized to identify initial key informants, such as pharmacists involved in HIV/AIDS care delivery. Similarly, policymakers including the director of NCASC, the secretary of the Ministry of Health and Population, the director of the Department of Drug Administration, the Nepal Pharmacy Council, and the Nepal Pharmaceutical Association were identified via their respective institutional websites. On this basis, an initial list of key informants was compiled.The second phase involved contacting the key informants via Facebook or in-person after scheduling an appointment. On Facebook, two NCASC-employed pharmacist informants were located and sent a message pertinent to the study’s objectives. Following their affirmative response, a formal appointment with the director of NCASC was scheduled. The purpose of the study was thoroughly explained to the director during the meeting, and a formal letter requesting the collection of data was submitted. After approval, appointments were requested from pharmacists and the NCASC director. Similarly, other policymakers were approached through formal appointment and the same procedure was followed. A total of 14 participants were interviewed. Two predetermined key informants did not participate because they deemed another informant to be more credible and referred them. The other informants were selected following snowballing technique. The respondents for this study are mentioned in The appointments for interview were taken according to the informant’s convenience. Time and place for interviews were selected by the key informants. All the interviews were conducted face-to-face, and only interviewer and interviewee were present during interviews. At the end of each interview, the informants were asked for any potential informant. The contact number of the potential informants were sought, and they were contacted through telephone call. Then, appointment of the interview was taken. Four interviews were done after office hours in the cafeteria, one in the office canteen, two virtually via zoom, and seven during formal office hour in the key informant’s respective office.Interview guides were used to conduct the interviews. Three interview guides were developed both in English and Nepali: one for pharmacists  related dispensing, counselling and adherence monitoring in Nepal, why do you think so?” was split to two questions “In the context of Nepal, who is involved in dispensing, counselling and adherence monitoring of ARVs?” and “In your opinion, is it necessary to involve Pharmacist in activities like dispensing, counselling, adherence monitoring related to ARVs?” The two pilot interviews were excluded from the final data analysis. Data was collected from March 2021 to June 2021. AS conducted all fourteen interviews. All the interviews were audio-recorded, and field notes were taken during the interview. The interviews ranged from 30 minutes to one hour. No further interviews were conducted after data saturation. When AS began to hear similar responses, data saturation was believed to have been reached, indicating that it was time to stop collecting data and begin analysing what had already been gathered [To analyze the data, Braun and Clarke’s six step process—familiarizing with the data, generating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report—was used . To famiThe analysis of interview excerpts revealed five themes related to the topic of this study, the potential roles of pharmacists in HIV/AIDS care delivery in Nepal. The themes include Current roles, Disagreement among stakeholders, Potential roles, Barriers, and Facilitators. All these themes along with the excerpts are presented below:The theme—current roles—highlights the role of pharmacists in HIV/AIDS care provision in Nepal, and also entails the existing status of pharmacists in Nepal. Our findings indicate that pharmacists are currently involved only in central logistic management. All respondents directly involved in HIV/AIDS care reported that two central offices, NCASC and Save the Children, are responsible for the procurement and distribution of ARVs to various ART centers in Nepal. Pharmacists only participate in logistic management in these central offices. The respondents directly involved in care, both pharmacist and non-pharmacists identified the similar roles.one of my roles is procurement, storage and supply chain management “#KI03. Another said “during procurement, we look over quality assurance and technical evaluation their main role is procurement and supply management” #KI02. Yet, the other revealed, “Our role or our job is not directly clinical, but is the procurement of HIV-related drugs, their successful storage and distribution” KI05. Summing up, it can be concluded that pharmacists are confined to non-clinical engagements.The following excerpts summarize the roles of pharmacists. One pharmacist stated “their main role is procurement, warehousing and supply management” #KI08. And, another respondent remarked, “After procurement, we ask the pharmacists to do the quality assurance” #KI09.Non-pharmacist respondents’ statements also substantiated what pharmacists stated. One said, “We provide support to ART centers…. they reach out to us regarding the pediatric dose, so we calculate the dose….” #KI04. Another stated, “Sometimes, we calculate pediatric dose" #KI03. Here, two pharmacists specified supportive role as pediatric dose calculation, while non-pharmacist respondent just acknowledged their support to the ART centers vaguely, “Problems keep coming from the district. Even though we all tackle the problem together, they are the main ones. They are the first contact.” #KI12. The pronoun used here, “they,” refers to the pharmacists. The pharmacists being the “main ones” and “first contact” acknowledge the role of pharmacists but does not accredit the pharmacists exclusively.Only pharmacist respondents identified providing training on logistic management as their current roles whereas both pharmacist and non-pharmacist respondents highlighted providing support to the ART centers. As articulated by a pharmacist “To sum up, this theme shows the current roles of pharmacist in HIV/AIDS care delivery in Nepal is Logistics management, which involves procuring ARVs, ensuring their quality, warehousing them, managing the supply chain, ensuring a smooth flow of logistics, providing training, and support to the ART centers.There are… wait… 1… 2 pharmacists” #KI03; and another stated, “there are 1, 2, 3….5 pharmacists now” #KI04. The responses, “There are… wait… 1… 2 pharmacists,” and “there are 1, 2, 3…5” may be revealing uncertainty of the pharmacists about the fellow members working in the same field. What they apparently speak is the existence of a very small number of pharmacists, and the insignificance given to pharmacists.Additionally, despite the fact that the majority of informants (80%) were aware of the current number of pharmacists involved in HIV care, even the responsible pharmacists were unsure of the number. For example, one pharmacist said, “The theme- disagreement among stakeholders- highlights the existing dispensing and counselling practices on ARVs, and key informants’ opinions on the same.Only the respondents directly involved in HIV/AIDS care were aware of the current ARV related dispensing and counselling practices. Dispensing and counselling were reportedly carried out by trained ART counsellors with nursing or public health background, or Health Assistants (HA) and Auxiliary Nurse Midwife (ANM). The respondents clearly stated the roles which is mentioned in the excerpts below:KI06: Dispensing and counselling are done by HA, the staff nurse. They are trained.KI01: PCL nursing dispenses. At some centers, there is Bsc. Nursing, BN, or those with public health degree…and in some places, there is HA. However, maximum there are either HA or staff nurse.Pharmacist respondents’ statements presented above strongly point to the reality that they were the potential untapped resources for undertaking this responsibility.are not allowed to dispense or counsel. It is illogical…. there should be a pharmacist…. pharmacists have in-depth knowledge, and they can counsel patients accordingly” #KI14. And, another pharmacist stated “…pharmacist, we mean medicine expert… dispensing and counseling is the role of the pharmacist” #KI14. Both these assertions place pharmacists as the major responsible persons for ARV dispensing and counseling. Pharmacists also emphasized that their involvement in ARV dispensing and counseling would create a positive impact in terms of increased adherence and better facilities. One pharmacist said “pharmacist can deliver far more and better facilities to the patients” #KI01.There was a general disagreement among pharmacists and non-pharmacists respondents regarding the role of ARV related dispensing and counselling. Pharmacists were of the opinion that their involvement in ARV dispensing and counseling would create a positive impact in terms of increased adherence and better facilities. Pharmacists were adamant that the roles of dispensing and counseling are theirs, citing their respective expertise to support their claim. One pharmacist suggested “Others if a specified person is well-trained, then we cannot argue that the person cannot perform well, but certainly, pharmacists are well-placed” #KI11While majority of pharmacists revealed strong opinions of pharmacists regarding their potentially beneficial roles; some, however, were ambivalent. Respondents identified dispensing and counseling as pharmacist roles but did not deny that any trained individual could perform those duties as well. One pharmacist stated “This role is different. This role belongs to monitoring, evaluation, treatment, and care, and I do not think this is pharmacists’ role.” #KI09 The outright denial, which is a representative quote, can be considered as a manifesto of non-pharmacists’ take on the issue of dispensing and counseling on ARV.Non-pharmacist respondents in contrary to the pharmacist respondents held a contrary view. The respondents in public health felt that dispensing and counseling on ARV is not pharmacist’s role. “Absence of roles” “Absence of visible roles” and “Absence of a need for pharmacists in dispensing and counselling” were concurrent codes in their statements. One respondent said “there are counselors plus staff nurses or those with a medical background …. I do not think pharmacists counsel the patient, most probably, counseling can be done only by the trained counselors.” #KI08. This excerpt demonstrates that the informant does not consider pharmacists to be medical professionals. It is implied that only those with a medical background are qualified to dispense and counsel, and pharmacists are ineligible.Pharmacists were deemed superfluous in dispensing and counselling ARVs. Staff nurses and health assistants were the ones who took ownership of this role. One respondent asserted, “There are 80 ART centers, and we have not been able to retain even doctors in all of them because of budgeting issue, so, lets’ not speak about others. So, one there is budgeting, and another there is no role visible role of the pharmacists.” #KI12 Here, the informant describes how budgeting has been an issue to retain professionals. The informant in the excerpt KI12 emphasized especially doctors quoting "even doctors" which clearly can be assumed that only doctors are considered important.Additionally, budgeting was cited another reason for not hiring a pharmacist in dispensing and counselling. One stakeholder quoted “The theme—potential roles—spotlight the informants’ perspective on the roles that pharmacists can play in HIV/AIDS care delivery. The theme has two subthemes, a) logistics management, and b) pharmacovigilance and adherence monitoring.If pharmacists are involved, then there are many benefits like warehousing, storage, and QA” #KI020. Similarly, one non-pharmacist respondent said “Pharmacists are needed in the provincial sectors. That kind of knowledge will help them take measures to smoothen the supply chain” #KI08. Both these statements point to the importance of involving pharmacists in logistic management.While our results show the current roles of pharmacist at central level logistic management, majority of participants emphasized the importance of pharmacists in logistical management at other levels, such as district, provincial, and regional ART centers. They cited the efficiencies of pharmacists and their expertise in logistics management as crucial roles, and they were confident that their participation at other levels would be advantageous. For instance, one pharmacist said “There is a huge role in pharmacovigilance” #KI05. Another stated, “… .it is necessary to manage the side effect of those medicines…. So, in that sector, like pharmacovigilance, QA…. if there is someone from a pharmacy background because they have that kind of knowledge and… they have worked in manufacturing so, they can support manage the program." #KI03 The assertion in the first quote and its reiteration along with the rationale reveal that the pharmacists believe pharmacovigilance and adherence monitoring as their own responsibilities.Around 53% of respondents indicated that pharmacists could play a role in pharmacovigilance and adherence monitoring. Of the 53%, 50% used the term pharmacovigilance directly, while the remaining referred adverse drug reaction and adverse effect monitoring. Similarly, adherence monitoring was also highlighted to be one of the potential roles of the pharmacist. One pharmacist responded “The theme- barriers- spotlight the hindrances to the pharmacists’ involvement in HIV/ AIDS care delivery in Nepal. It is further categorized into three subthemes, a) pharmacist-related weakness, b) government-related weakness, and c) society-related weakness.We have not been able to put forward our voices to the authority. I do not think our professional organizations like GPAN, NPA have been working on that level” #KI04. Another respondent explained, "the reason why pharmacists are not in ART centers is because of weaknesses in the policy level, meaning those among our professionals who are involved in policy level, it is because of their weaknesses” #KI03. Similarly, policy makers pointed to this reason. One of them reasoned “…. it is because of insufficient advocacy. Maybe you have your professional association or organizations, so you have to increase your self-value through them” #KI12. The understanding of the policy maker echoed in another pharmacist’s explanation: “We have pharmacist associations and different kinds of organizations, and these organizations have failed to advocate” #KI11.The pharmacist’s perceived inability to advocate through authority figures such as pharmacy professional organizations and those involved in higher-level governmental bodies was cited as a reason for pharmacists’ lack of success in the field. Many important barriers related to this aspect were identified by the key informants. The most prominent code in this subtheme was lack of advocacy. Majority of the respondents pointed out the lack of advocacy from the professional organization, such as GPAN , NPC , and NPA . The following excerpt represents the voice of many pharmacists: “There is no such demotivation factor but only unwillingness among pharmacists that is holding them back” #KI03. Similarly, self-limitation of the pharmacists in manufacturing company and hospital pharmacy was popularly expresses barrier by the respondents. For example, one respondent said, “As soon as someone finishes their degree, they go straight to the manufacturing company” #KI05. Similar ideas were expressed by another respondent, “Pharmacists’ are more engaged in the industrial side, and few of them are going to the hospital, but the clinical part is untouched” #KI14.Secondly, pharmacists’ own shortcomings such as lack of awareness, interest, willingness and a self-contained scope of the practice was reported as a major barrier. One pharmacist said “there is no research base at all. So, they should explore their roles rather than only doing what they are asked” #KI12. Yet, another pharmacist said “They are not exploring their role…. we do not have a solid research base….” #KI03. In both these excerpts, the failure to initiate research is highlighted as a major barrier.Another barrier identified from the data was pharmacists’ lack of initiative to explore their roles in important areas as research. One policymaker quoted “The reason of pharmacist not flourishing in HIV is firstly the number.…” #KI06. The explanation for this lack was presented by one policy maker, “There was no pharmacist topic previously, so this is new. Maybe it is because there are no pharmacists. There are no pharmacists in our sector, but we need them…” #KI12.Finally, another barrier under this subtheme was the lack of pharmacists in Nepal. One pharmacist said “government does not appoint us. We are hired by Global Funds and Save the Children, but we work for the government” #KI01. The ‘government’ referred here is federal level government of Nepal; the government is alleged for not recruiting the pharmacists. A very sad note was expressed by another respondent, “there are posts but few. I do not know if it is appropriate to say this as a government officer, but as a youth pharmacist, I would say it is saddening” #KI15.This subtheme relates to the government’s shortcomings as a barrier to pharmacists participating in HIV care. “No government allotment” was the most frequently used code in this section, with 93% of participants stating that pharmacists are not assigned to HIV-related services. Pharmacists highlighted the lack of government’s allotment of their position in government services as one of the challenges encountered during the service. Participants expressed their dissatisfaction with the lack of government allocation. The following two remark, representing the voice of many pharmacists, stated “the policymakers are a bit biased. Let’s say if I were in that authoritative position then, I would prioritize my profession only” #KI03. Second excerpt: “the healthcare system in Nepal seems to be somewhat biased like they consider doctors to be an important person and have been unable to integrate other sectors” #KI14. Third excerpt: “doctors have been dominating since the beginning” #KI05. The target of pharmacists’ blame in these responses is apparently Nepal government and the governmental bodies. The following response from a pharmacist reiterates the view:All the pharmacist participants indicated the pervasiveness of bias and domination in healthcare field as possible weakness on part of government. The code of ‘biasedness’ often appeared along with the code of domination. The following are the representative responses of the pharmacists. First excerpt: “There are 2–3 factors for this. One, lack of awareness. Second, there is no such vision or focus from government or say policy level”“KI05.#Dispensing, counselling is done by staff nurses and HA. They made this policy, I guess around ten years ago, and, at that time, they had no idea about the need for pharmacists.…” #KI01. Yet another respondent claimed, “there are no specific policies” #KI06. Importantly, pharmacists believed that if their roles were specified in policies, it would minimize the biasedness. One pharmacist stated “If roles are clearly defined, everyone’s space is made clear, and roles are assigned per expertise in the existing health structure of the nation, then the biasedness will gradually minimize. “#KI14The policymaker respondents and non-policy maker respondents had divergent views regarding governmental constraints. The non- policymaker respondents assessed the current policies to be outdated, biased and non-specific. For instance, one respondent said “I have heard that there is the provision for pharmacists’ involvement in the policy, but that has not been reflected in the organogram” #KI12. This response demonstrates the policymakers’ uncertainty regarding the policy. However, this response is backed by another policymaker who stated “There is a lack of structural requirements. For example, there should be a position for pharmacists where patients are treated, but the allotment arrangement could not be made, which is why there is an insufficient workforce leading to pharmacists being unable to provide services. So, a policy is not restricting, but the structure is creating problems” #KI11.On the contrary, the policymaker respondents were of the view the organizational structure rather than policy was responsible for the biases. One policymaker cited “Structure is made by the health ministry and Nepal government altogether. Health ministry has to propose. The related body determines the structure from a general health post to the tertiary care hospital and different departments. In this case, health ministry should propose, and that is lacking” #KI11Here, the structural constraints are pointed out to be the major problem creators, not the policies. The respondent further elaborated as “In the context of Nepal, we have not got social recognition yet. “#KI15 Societal unawareness and lack of social recognition were two prominent codes associated with this theme. Social oblivion was identified as one of the pharmacists’ challenges. The following representative quote elucidates the theme, “our society or community are still unaware of the arrays of services we are capable of providing. They follow doctors and what you see now is the reflection of the whole society” #KI06.This subtheme is concerned with pharmacists’ social recognition. One pharmacist said “The theme- facilitators- spotlight the perceived factors that facilitate the involvement of pharmacists’ in HIV/AIDS care delivery in Nepal. This theme contained two subthemes, a) pharmacist and b) organization.I feel happy to see the patients get the medicine on time” #KI01 The causal relation of pharmacist’s happiness and the patient receiving medicine on time clearly speaks to the fact that pharmacists’ find themselves satisfied even at small incidents. It was also articulated that their work in the field resulted in recognition of their significance. Another pharmacist stated “As I started working, people began to realize my roles and importance… we have given results which is why nowadays they have started hiring pharmacists.” #KI05. Both these statements, which are representative samples, imply that pharmacists consider their self-esteem as a facilitator.The first subtheme foregrounds pharmacists’ perspectives on self-satisfaction and recognition as a factor motivating or encouraging their involvement in PLHIV services. Pharmacists expressed an optimistic view of their capabilities and contribution. One pharmacist said “: Participants expressed a favorable attitude toward the organizations working for HIV/AIDS patients. Global Fund and Save the Children were considered pioneers in involving pharmacists in HIV/AIDS-related services. Pharmacists cited that these organizations contributed positively to their increased involvement in care.Global fund operates throughout the world, and since its operation in Nepal, people have come to know about the pharmacist especially their need in drug sector and distribution sector. This has led to many organizations hiring pharmacists’ especially in drug distribution and procurement.” #KI05. A number of outcomes such as people knowing about the pharmacists, and organizations hiring pharmacists are attributed to non-governmental organizations. Similar ideas were expressed by another pharmacist: “In other countries, pharmacists are widely involved in HIV, which is why Global Fund hired pharmacists… . they brought that concept in Nepal…. then everyone realized the need of pharmacist.” #KI02. As in the previous excerpt, the role of Global Fund is acknowledged forthrightly.The following excerpts, for example, emphasize the role of non-governmental organizations: “This study examined the status of pharmacists in HIV/AIDS care delivery in Nepal as perceived by the stakeholders . In the context of HIV/AIDS, no earlier study in Nepali context comparable to the present one was found. The data obtained from stakeholders addressed our research question regarding pharmacists’ current and potential roles in HIV/AIDS care and the barriers and facilitators to pharmacists’ involvement in the same. As of September 2021, there are 4945 registered pharmacists and 5342 registered pharmacist assistants in Nepal , A regisImportantly, the pharmacists providing HIV-related services are not government employees but are recruited by an international non-governmental organization, Global Fund. This reality was recognized by the participants and they emphasized the importance of expanding their roles and numbers. The primary reason for such a low number of pharmacists in HIV could be due to oversight of government to the ART centers. In addition, our findings showed that the pharmacists in Nepal are currently engaged in the logistics management of the ARVs at the central level. Respondents had a favorable view of pharmacists’ contribution to logistics management. Similarly, the International Pharmaceutical Federation (FIP) has emphasized that pharmacists play a significant role in supply chain management and that their participation can strengthen the medications supply chain . MoreoveWe inferred that stakeholders see adherence monitoring and pharmacovigilance as potential roles for pharmacists in patient care. While several studies have linked healthcare professionals, including pharmacist-led adherence monitoring to improved treatment outcomes –19, 21 pThe pharmacovigilance of ARVs in developing countries is of paramount importance as the toxicity profiles of ARVs in these countries are obscure . PLHIV aPharmacists and other stakeholders held divergent views on the pharmacist’s role in dispensing and counselling antiretroviral medications. This finding can be discussed in the light of several earlier studies. Some have shown ART-related task-shifting from pharmacists to non-pharmacists personnel . StudiesJustifying the contrary, pharmacists’ intervention, such as counselling, is reported to ensure benefit to the patients from their therapy . PharmacThe findings from our study suggested that there is a lack of awareness among non-pharmacist participants regarding pharmacists’ roles in dispensing and counselling. Such views may be due to the lack of an appropriate dissemination of the messages to the public. A dearth of pharmacists in HIV workforce was mentioned as a major problem. Failure of the policy to subtly define the role of pharmacists can be a possible reason justifying the problem. Additionally, budget constraints were referred as another reason for not recruiting pharmacists. Lack of government support as reflected by non-existent government allotment of pharmacists in the NCASC and ART centers can be an additional factor. Similarly, pharmacist’s own lack of interest and enthusiasm to contribute in the field can be another possible reason.Our findings indicated that the stakeholders  who constitute the entire system were the impediments to pharmacists’ engagement in HIV care. Numerous studies have categorized the barriers to pharmacists’ involvement as pharmacist, government and society related –42 whichIt is evident from our research that there is an understanding among stakeholders regarding the potential role of pharmacists in HIV/AIDS care; yet, this has not been implemented. To overcome the barriers, at least three measures can be recommended based on this study. To begin, policies that clearly define the functions of various health care personnel, including pharmacists should be formulated. Second, governments ought to implement the policies and expand the roles of pharmacists in various ART centers. Finally, there should be self-motivated engagement of the pharmacists.Self-motivation and organizational support were identified as facilitators of pharmacists’ involvement in HIV care. Pharmacists cited compensation, compassion, and their growth over time as major facilitators. In addition, organizations such as the Global Fund and Save the Children were viewed as facilitators, as these organizations have recognized pharmacists’ roles and hired them for logistic management. Similar to this study, other studies have demonstrated that pharmacists’ involvement in providing care is facilitated by self-motivation, support from fellow pharmacists and the healthcare team, easy access to patients, and organizational support , 43, 44.This study explored the current role of Nepalese pharmacists in HIV/AIDS care, scrutinized the barriers and facilitators to their involvement, and identified potential areas for pharmacists to expand their role in HIV/AIDS care. Current situation reflects a dearth of pharmacists in HIV care delivery in Nepal with sheer confinement to the logistic management of ARVs. The pharmacists are reported to be involved only in central logistic management. Dispensing and counselling of ARVs, pharmacovigilance, adherence monitoring, and involvement at regional, district, and provincial levels are the potential roles spotlighted by the participants. Self-motivation, compassion for work, organizational support, growth over time, and the involvement of the Global Fund and Save the Children were identified as facilitators of pharmacists’ involvement in HIV care. Major barriers include stakeholders such as pharmacists, government, and society who constitute the entire system. The finding that the pharmacist and non-pharmacist stakeholders held contradictory views on the potential roles of pharmacists as dispensers and counsellors of ART is of serious concern.. The pharmacists in Nepal have still a long way to go as more barriers than facilitators to pharmacists’ involvement in HIV care exist. Pharmacists thus bear the responsibility to explore and establish their roles in the identified potential areas and contribute to UNAIDS global initiation to end AIDS epidemic by 2030.S1 File(DOCX)Click here for additional data file.S2 FileEthical approval from NHRC.(PDF)Click here for additional data file.S3 FileCodebook.(DOCX)Click here for additional data file.S4 FileSample of informed consent form.(DOCX)Click here for additional data file.S5 FileSample obtained from participants.(PDF)Click here for additional data file.


Low back pain (LBP) is one of the most common reasons for disability globally. Digital interventions are a promising means of supporting people to self-manage LBP, but implementation of digital interventions has been suboptimal. An artificial intelligence-driven app, selfBACK, was developed to support self-management of LBP as an adjunct to usual care. To better understand the process of implementation from a participant perspective, we qualitatively explored factors influencing embedding, integrating, and sustaining engagement with the selfBACK app, and the self-perceived effects, acceptability, and satisfaction with the selfBACK app.Using a qualitative interview study and an analytic framework approach underpinned by Normalization Process Theory (NPT), we investigated the experiences of patients who participated in the selfBACK randomized controlled trial (RCT). Interviews focused on the motivation to participate in the RCT, experiences of using the selfBACK app, and views about future intended use and potential of using digital health interventions for self-management of LBP. Participants were purposively sampled to represent diversity in age, sex, and implementation reflected by a proxy measure of number of app-generated self-management plans during the first three months of RCT participation.Twenty-six participants aged 21–78, eleven females and fifteen men, with two to fourteen self-management plans, were interviewed between August 2019 and April 2020. A broad range of factors influencing implementation of selfBACK within all constructs of NPT were identified. Key facilitating factors were preferences and beliefs favoring self-management, a friendly, motivational, and reassuring supporter, tailoring and personalization, convenience and ease of use, trustworthiness, perceiving benefits, and tracking achievements. Key impeding factors were preferences and beliefs not favoring self-management, functionality issues, suboptimal tailoring and personalization, insufficient time or conflicting life circumstances, not perceiving benefits, and insufficient involvement of health care practitioners. Self-perceived effects on pain and health, behavior/attitude, and gaining useful knowledge varied by participant.The high prevalence of LBP globally coupled with the advantages of providing help through an app offers opportunities to help countless people. A range of factors should be considered to facilitate implementation of self-management of LBP or similar pain conditions using digital health tools.The online version contains supplementary material available at 10.1186/s12998-022-00452-2. Low back pain (LBP) is one of the most common reasons for disability globally , 2, and selfBACK is an artificial intelligence-based smartphone app that aims to facilitate self-management of LBP , 27. TheIn this paper, we qualitatively explore the implementation of selfBACK on (i) factors influencing embedding, integrating, and sustaining engagement with the selfBACK app, and (ii) the self-perceived effects, acceptability, and satisfaction with the selfBACK app.We conducted a parallel process evaluation alongside a randomized controlled trial (RCT), which involved provision of self-management support for LBP through a smartphone app , 31  had 13 or 14 plans, 30% (n = 50) had 7 to 12 plans, and 18% (n = 29) had less than 7 plans. Drawing on Malterud et al.’s concept of information power , e.g. neThe possibility of participating in an interview was included in the information letter and consent form signed by participants at entry to the RCT. Participants were contacted by phone and, if they were interested, a formal invitation was sent by email or text message. One-to-one interviews were conducted in participants’ homes, workplaces, or university offices or via telephone.A semi-structured topic guide was utilized, focusing on key areas expected to elicit information relevant to aims of the study  –37. NPT The selfBACK trial, including the qualitative process evaluation, was registered with ClinicalTrials.gov (NCT03798288) and approved by national ethical committees in Denmark (S-20182000-24) and Norway (2017/923-6) . All parFigure Factors facilitating and limiting the implementation of selfBACK emerged in relation to all four constructs of NPT. We identified 14 facilitating and 12 limiting factors influencing embedding, integrating, and sustaining engagement with the selfBACK app .Participants’ personal preferences and beliefs at the time of deciding to participate in the intervention affected their sense-making work. Embedding selfBACK was facilitated by having an already active lifestyle and being accustomed to exercising and physical activity, and by recognizing a need for self-management as an adjunct to HCP care:“I’m against medications, so I don’t do any and I won’t have any. I don’t believe medications are any good, so instead I had to figure out how to get rid of my low back pain.” .Conversely, not liking physical activity or believing that group training was superior to exercising on their own limited embedding. Having a positive mindset despite pain, and a strong urge to get better as well as a reluctance to use pain medication or surgery also facilitated the embedding of selfBACK.Insufficient information about the project, e.g. purpose of the trial or trial duration, were barriers to some participants. Finally, some participants wanted to limit their overall daily screen time, which in turn affected embedding selfBACK.“Yes, a bit like an exercise partner who asks ‘hey, shouldn’t we go work out today?’ and then you actually might get going. Where on the other hand, if you were on your own, you might forget about it or take the easy way out.” .The relational work of integrating selfBACK in daily life was facilitated by perceiving the app as a friendly and motivating supporter; an in-the-pocket friend that kept reminding them to be physically active, providing information and reassurance, and congratulating accomplishments. Being instructed exactly how to manage their pain, and recognizing advice and exercises already given by their HCP provided reassurance. selfBACK was seen as a casual and non-intrusive helper participants could consult as needed: it was not too pushy, and they could decide for themselves how to accomplish their goals:“My workday ended, I had had a long day, I think I was at the university around 4.30 or 5 pm. Then I had to read something, then I had to sign something, and then I had to use my civil registration system number to log in to the app, and then he had to show me the app, and then there was the wristband, and then I had to look around and see what the app could do, and then… then, ‘here you are, go home and use it’. I mean, that was not enough.” .Some participants did not explore the entire content of the app and were, thus, unaware of certain supportive app content, which limited their use of the app. For example, a few participants asked for an exercise library (which was part of the toolbox) as they would have liked to be able to perform exercises from previous plans. Another barrier was uncertainty about the purpose of different features of the app, like not understanding why the tailoring session had to be completed weekly. Some ascribed this to the comprehensive onboarding process and the amount of information given when agreeing to participate in the RCT and setting up the app .“My“It [updates] was great because then new exercises appeared. And they impacted some different things, I felt. That was good.” .The operational work of routinely engaging with selfBACK was facilitated by the perceived fit of the app content to the individual’s needs. Participants liked that they could customize the content, e.g. by swapping exercises, adjusting their goals, or turning off notifications. The tailoring also meant that many participants felt continuously challenged and interested as exercise difficulty levels and step goals progressed. Participants appreciated the variation of content, weekly updates, and the balanced focus on what was needed, as this participant explained:However, when tailoring and personalization were perceived as irrelevant or mismatched for the individual user, engagement was limited. For some, the tailoring sessions were perceived as a nuisance as they could not be bypassed, occurred too frequently, or the questions did not adequately cover the participants’ situations. Others felt the content was repetitive or their plans too ambitious and the goals unrealistic. The app’s focus on exercises and steps was also perceived as irrelevant by participants who preferred biking, swimming, or skiing.“It’s just 20 min. You can spare that in the evening. That’s a… a nice feeling of doing at least something productive. You’re able to allocate 20 min per day or at least a couple of times per week.” .Participants liked that selfBACK was accessible at anytime from anywhere, which meant they saved both time and money by not having to pay for a gym membership or spend time on transportation. Furthermore, participants reported that following the plans required minimal effort as they were broken down into manageable goals and attainable time slots:Ease of use , notifications, and visual prompts (e.g. seeing the selfBACK logo on phone screen) facilitated engagement. Trustworthiness of selfBACK further facilitated engagement. Participants described the professionalism and evidence-base as reassuring, which made them trust that following the advice from selfBACK would not worsen their LBP. This was further aided as the invitation to participate came from their trusted HCP. Furthermore, support from the research team and talking with friends and family about selfBACK supported engagement with the app.“I’m so tormented by my knee, if I have to lie down to perform some of the exercises, I can hardly get back up. I have to roll onto the other foot and find a piece of furniture to pull myself up by because my knee is so weak. So the exercises for my low back pain, I’m not able to perform them as long as my knee is in such a bad condition.” .Barriers to integrating selfBACK activities into daily life included insufficient time as participants had to set aside time for it even when they were busy or had other commitments, or conflicting life circumstances like moving, starting school, or being away on holiday. Comorbidities (e.g. diabetes/neuropathy or fractured bones) and comorbid pain also limited some participants in engaging in selfBACK activities, as one participant explained:Many participants described technical hiccups, such as faulty step count synchronization (from the step-detecting wristband to the selfBACK app), login issues, or finding the screen size too small to properly see the videos. Although a few were discouraged by these technical issues and asked for more technical support, the majority of participants felt these issues did not significantly limit their engagement with the app. Such issues were believed to be normal for technologies. A few participants even described that a daily routine of fixing faulty step synchronization to achieve daily step goals increased engagement. Additional functionality issues limiting engagement included discomfort wearing the wristband and not understanding all of the app content when not speaking the language of the app fluently.Whether or not participants sustained their engagement with selfBACK was dependent on their perception of the effect and benefit of use. Experiencing a positive effect on pain and health, behavior or attitude, or gaining useful knowledge contributed to sustained engagement just like trusting that using selfBACK would prevent relapses of LBP. On the contrary, participants who had not experienced positive effects of using the app or who had experienced an increase in pain did not sustain their engagement with the app.“It’s been so effective that I actually forgot my visit to the physiotherapist […] I thought, that’s a really great sign. I hadn’t experienced that in several years; if 6 weeks went by instead of 4, then I experienced a significant impairment of my back. So now, just within this half-year or 4 months, I’ve been in this project, I’ve rescheduled. Now we try 6–7 weeks between visits.” .Participants experienced effects from using selfBACK in several ways. Their primary focus was on pain intensity or disability level, and many participants experienced improvements in these. Multiple participants reported a recovery from LBP, and described going back to normal life, including attending work, being able to pick up previous sports, like running, or no longer having to avoid pain evoking positions. One participant, who had visited his HCP regularly every month for several years, even forgot his appointments as he had improved considerably:“I’m not feeling the same kind of pain anymore. I don’t feel sorry for myself in the same way I used to […] it has meant that I’m more aware that my own effort has a large effect on how my back will feel going forward.” .Several participants described how sustaining engagement with selfBACK had improved their general health. Participants reported improved fitness levels, weight loss, improved strength, balance and flexibility, heightened energy levels, and improved sleep cycles. Behavioral and attitudinal effects were described by both participants who had and had not experienced effects on pain outcomes. Initiation of exercising habits, engagement in more and regular physical activity, or small changes like parking further away, or standing up doing office work was reported by some. Others explained how their mindset had changed—feeling more in control of the pain, having a more positive mindset and a better experience of living with LBP. Some described being more conscious about physical activity levels and the necessity of being physically active, as this participant explained:”Well, you’re able to follow exactly how you’re doing in reaching your goal. Compared to just thinking to yourself ‘I have to walk this much today’ then you’re able to follow how far you are from achieving that goal, in percentages. I think that’s positive!” .Lastly, many participants described gaining new knowledge about LBP and self-management; knowing now what to do about it. Interactivity and visibility of achievements, for example, the step tracking, rewards, and accomplishment progress, further facilitated sustained engagement, as these participants expressed:“The things you have to do on your own at home, that’s more bothersome, because the other things [group training], I have to leave [the house] for that. […] I also have an exercise bike at home, it’s been years since I used it last! And that’s the thing about being on your own, it’s a struggle. .Some participants described how they struggled to sustain engagement with selfBACK due to the lack of a fixed time point for doing selfBACK activities and having to rely on their own motivation, as these participants explained:“I was hard up, I mean I couldn’t… I live in a new first-floor apartment and the car is parked just outside, and even walking the few steps down and out to the car was an overcoming for me. I was very passive and could barely walk.” .During the three months intervention period, the participants described becoming familiarized with the exercises and self-management. As a result, increasingly over time, they failed to log their exercises in the app and limited their use of it. Many participants described forgetting to use the app when LBP decreased, or only performing exercises when pain flared up. Conversely, too much pain also limited engagement:“It hasn’t been good enough for me that it was purely an app. I mean, I missed being followed up.” .A handful of participants requested more interactions with their HCP to discuss e.g. correct performance or alterations of exercises shown in the app. Although selfBACK was never intended to replace the HCP, using the app as an adjunct did not make sense to these participants:Ultimately, selfBACK relied on participants committing to LBP self-management, which these participants did not feel confident enough to do on their own. Additionally, experiencing conflicting advice between the app and the HCP was a barrier to sustained engagement.“I actually think it works really well. Because I think the persistent reminder of getting you to understand that it’s important you keep doing something despite pain works really great in the app.” .Appraisal work was facilitated by features of the app. Participants described selfBACK content as ‘just right’; the combination of content was exactly what they needed to manage their LBP. Repetition of content aided comprehension, especially for the educational messages, as one participant explained:Participants benefitted from the tailoring session as it allowed them to reflect on changes in their pain, something they would not have considered without prompting. Furthermore, for some participants, receiving self-management advice in written form, rather than during a  HCP consultation, was beneficial. Recognizing the wider benefits of selfBACK positively affected participants’ sustained engagement: the novelty of managing LBP with support from an app, the potential socioeconomic benefits of having larger populations use the selfBACK app, and having it as an adjunct to usual care in a primary care setting.Generally, participants were pleased with selfBACK and would recommend it to others. They liked having selfBACK as an adjunct to usual care as several participants pointed out; they had not lost anything agreeing to participate in the RCT—it was a win–win situation for them. Most participants, therefore, did not have any specific expectations of selfBACK other than generally wanting help for self-managing their LBP. The participants who were less satisfied with selfBACK seemed to be those who would have liked integration of the app in their usual HCP care or solely wanted to attend their HCP. Participants gave specific recommendations for improvements to the selfBACK app Table .Table 3RA small proportion of data fell outside our coding framework. The personal attribute of being or not being competitive facilitated or limited implementation, respectively. Similarly, some participants were motivated by reaching goals and getting rewards, whereas others were not. Implementation was also facilitated by feeling committed to the research project and/or the research team.We have explored factors influencing how people with LBP embedded, integrated, and sustained engagement with the selfBACK app, and how they perceived effects, acceptability, and satisfaction with the app. Self-perceived effects on pain and health, behavior/attitude, and gaining useful knowledge varied by participant. Participants generally expressed satisfaction with the selfBACK app and saw it as an acceptable adjunct to usual care. We identified a broad range of factors influencing the use of selfBACK within all four constructs of the NPT. Our findings suggest that engagement with the app was facilitated when participants had preferences and beliefs favoring self-management, found the app to be a friendly, motivating and reassuring supporter, recognized the app as tailored and personalized to their needs, convenient and easy to use, and trustworthy. Participants also positively appraised the app when they experienced positive effects on pain and their thinking about pain. Conversely, participants who did not buy into the self-management concept, who found the app difficult to use, did not feel the personalization met their needs, had insufficient time or conflicting life circumstances, lacked positive effects, or sought more interaction with an HCP were less likely to positively appraise and engage with the app.We found that participants with pre-existing positive self-management beliefs more often positively appraised the content of the app and used it more. Previous studies have similarly shown that users of eHealth interventions for chronic pain  and mentKey facilitators of app utilization found in our study and other studies include ease of use and convenience for participants , 41, 42 Several participants in our study described how the ‘just right’ combination of content was exactly what they needed to manage their LBP and how the educational parts made them change their thinking about pain. According to Dwarswaard et al., several factors influence how people build self-confidence and become empowered , and ultThe participants reported a range of technical problems. Similar functionality issues have also been shown to be barriers to use in other studies , 42, 47.and to participate in an interview study about their experiences. Although efforts in ensuring a balanced diversity in number of self-management plans aimed to capture participants who had been less satisfied and/or discontinued use for some reason, the study sample may be assumed to consist of quite motivated participants. Recruiting participants from an RCT means that we have not reached participants for whom using an app for self-management would never come into question and their voices are yet to be heard.This study benefitted from researcher triangulation  with quaParticipants’ level of implementation of selfBACK did not follow a linear process from the initial interest when their HCP invited them to participate, to finding it easy to use, to perceiving benefits and therefore sustaining engagement. Instead, participants described the process as iterative and circular, e.g., thinking that generally, apps for supporting health behavior were clever with a potential to help countless people with LBP in the present or future, to recognizing the convenience of equipment-free home exercises, to finding the selfBACK app friendly, motivational and reassuring, and then to perceiving effect on their pain, which matches the constructs of NPT and their interconnection. It is noteworthy that very little data fell outside the NPT coding framework and any that did, consisted of inherent personal attributes such as being/not being competitive or feeling a strong commitment to serving research. This suggests that NPT was a useful theoretical framework to apply in the analytic process to understand participants’ experiences of LBP and use of the selfBACK app. Many other implementation frameworks and theories exist  that migAs most participants were satisfied and perceived benefits from implementing selfBACK, our findings should support clinicians in exploring patients’ interest in using selfBACK or similar apps for self-management of LBP as an adjunct to usual care.Self-management of chronic pain, including LBP, is a key treatment strategy, but something many patients struggle to achieve. Although self-management of LBP with selfBACK was supposed to work as an adjunct to usual care, this was achieved by some but for others, not integrating HCP follow-up limited implementation. HCPs remain key players in supporting self-management behavior , and we In this study, we have reported on implementation of the selfBACK app from a participant perspective only, but as key players in supporting self-management, it is vital we also aim to understand the perspective of HCPs. Future research should explore HCPs’ barriers for use of the selfBACK and similar apps, as well as means and incentives to overcome identified barriers. In continuation, clinical practice barriers relating to provision of digital interventions, and organizational and systemic healthcare system barriers should be targeted.Digital health interventions have been suggested as essential for overcoming future challenges of limited resources in the healthcare sector. Despite the potential value, there is only limited research to support cost-effectiveness. We recommend future research focus on the economic impact of selfBACK and other digital interventions on patients’ healthcare utilization and need for social services or workers compensation.Based on the findings of this study, practice and future research recommendations include the following:We identified a number of key factors involved in embedding, integrating and sustaining engagement with the selfBACK app. Participants were generally satisfied with the selfBACK app and many experienced positive effects. The high prevalence of LBP globally coupled with the advantages of providing help through an app offers opportunities to help countless people dealing with LBP in daily managing their pain. A range of factors should be considered to facilitate implementation of self-management of LBP or similar pain conditions. These findings should help inform development of future pain/LBP self-management apps.Additional file 1. General interview guide and Normalization Process Theory domains.Additional file 2. Full taxonomy with exemplar quotes. Participant numbers refer to Table


This review aimed to provide an aggregative synthesis of the qualitative evidence on patients’ experienced coercion during voluntary and involuntary psychiatric hospitalisation.A qualitative review.Embase.com, Ovid MEDLINE(R) ALL, APA PsycINFO Ovid, Web of Science Core Collection and the Cochrane Database of Systematic Reviews.The search was conducted, in five bibliographic databases: Following the Joanna Briggs Institute approach, a systematized procedure was applied throughout the review process, from data search to synthesis of results. The reporting of this review was guided by the standards of the PRISMA 2020 statement. The quality of the included studies was critically appraised by two independent reviewers using the JBI Critical Appraisal Checklist. Included findings were synthesized using meta-aggregation. Confidence in the review findings was assessed following the Confidence in the Output of Qualitative research synthesis  approach.A total of 423 studies were identified through the literature search and 26 were included in the meta-aggregation. Totally, 151 findings were extracted and aggregated into 27 categories and 7 synthesized findings. The synthesized findings focused on: the patients' experience of the hospitalisation and the associated feeling of coercion; the factors affecting this feeling, such as the involvement in the decision-making process, the relationships with the staff and the perception of the hospital treatment as effective and safe; the coping strategies adopted to deal with it and the patients’ suggestions for alternatives. All synthesized findings reached an overall confidence score of “moderate”. The seven findings were downgraded one level due to dependability limitations of the included studies.Based on these findings, seven recommendations for clinical practice where developed, such as fostering care ethics, promoting patients' voice and shared decision-making, and enhancing patients’ perceived closeness, respect and fairness. Five recommendations for future research were also prompted, for instance improving the methodological quality and cultural variation of future qualitative studies, and exploring the psychosocial impact of experienced coercion on patients. For these recommendations to be effectively implemented, a profound change in the structure and culture of the mental health system should be promoted. The involvement of patients in the design, development and scientific evaluation of this change is strongly recommended. Indeed, several studies have shown the limit of using formal coercion as a proxy of experienced coercion .Inpatients may feel coerced into treatment because of more subtle non-statutory forms of coercion they subjectively experience during the admission process. Many studies have highlighted that professionals frequently resort to the use of treatment pressures , also caA thorough understanding of experienced coercion and the factors influencing it is essential, especially in light of the strong negative impact it may have on therapeutic relationship ,16, patiGiven the risk at stake as well as the worldwide increasing use of coercion , over thThe aim of this paper is to provide an aggregative synthesis of the qualitative evidence on patients' experienced coercion during voluntary and involuntary psychiatric hospitalisation based on which to develop better-targeted recommendations for clinical practice and research on how to prevent and reduce perceived coercion. The decision to focus the review on qualitative studies stems from the proven ability of this approach to capture the most specific and in-depth details of such a subjective and complex experience . Previou22.1In order to explore patients’ feeling of being coerced during hospital admission, we conducted a literature review and synthesis of qualitative studies following the Joanna Briggs Institute approach . The rep2.22.2.1This review included all qualitative studies exploring coercion experienced by adult psychiatric patients during admission to a psychiatric hospital. Since the feeling of being coerced can be due to both formal and informal coercion, studies involving involuntarily as well as voluntarily admitted patients were taken into account. Involuntary admission was defined as the legal process through which a person can be detained against their will in a psychiatric hospital. All diagnostic groups were eligible, with the exception of organic disorders and mental retardation. Furthermore, studies were excluded if they focused exclusively on people affected by eating disorders or learning disabilities. Studies on mixed samples, such as patients, professionals and relatives, were considered only if the results for the patients’ subsample were clearly distinguishable.2.2.2The current review considered all studies whose main topic was coercion as subjectively experienced and perceived by patients during the hospitalisation process. Thus, papers were excluded if they focused on: 1. other issues of the hospitalisation process; 2. the experience of specific coercive measures, such as seclusion, restraint or forced medication; 3. specific stages of the hospitalisation, such as tribunals’ hearings, assessment or transport under mental health legislation without exploring the broader process.2.2.3Only studies exploring the experience of coercion during admission to a psychiatric hospital were eligible. Studies including other settings, such as outpatient services, nursing home, forensic hospitals, or other residential facilities were not considered.2.2.4Papers based on qualitative data were included in the review regardless of the study paradigm  and design . Descriptive qualitative studies were also eligible. Qualitative components of mixed methods studies were considered if the qualitative findings were reported separately. Papers reporting on the same sample were eligible if the analyses were performed from a new perspective and with different objectives. In these cases, only the new themes were taken into account in the synthesis.2.3Embase.com, Ovid MEDLINE(R) ALL, APA PsycINFO Ovid, Web Of Science Core Collection and the Cochrane Database of Systematic Reviews. No language or date restrictions were applied. Additional records were identified through backward citation chasing. The detailed search strategies are available in Supplementary file 1.The search strategy was developed with the support of a medical librarian (JRA). The search was conducted on June 15, 2022, in five bibliographic databases: 2.4After removal of duplicates, two researchers (B.S. and M.B.) independently screened all titles and abstracts. In case of disagreement, study inclusion was discussed in the presence of a third reviewer, until agreement was reached. Only peer-reviewed articles written in English, French or Italian were assessed. Systematic reviews, books, book chapters, theses and dissertations, reports and commentaries were excluded. Relevant studies were read in full and screened based on the predefined inclusion criteria.2.5The methodological quality of the studies considered for inclusion was assessed using the JBI Critical Appraisal Checklist . This in2.6Data extraction and synthesis were performed using the NVivo 1.5 software. Following the JBI approach , data exIncluded findings were synthesized using meta-aggregation . FollowiThe first author performed data extraction. Results categorization and synthesis were, on the contrary, discussed and their appropriateness confirmed by the whole research team, which included a peer-researcher. This procedure allowed multiple perspectives to be taken into account in the aggregation process, deepened the understanding of the phenomenon and enhanced the validity of the synthesis process.2.7Confidence in the review findings was assessed following the Confidence in the Output of Qualitative research synthesis  approach . For eacDependability levels were estimated using the question #2, question #3, question #4, question #6 and question #7 of the Critical Appraisal Checklist . All quaCredibility evaluates the degree of “fit” between the authors’ interpretations and the supporting data ,46. EachA confidence final score of high, moderate, low or very low was established for each synthesized finding.33.1A total of 423 studies were identified through database search (n = 410) and other sources (n = 13). After duplicates removed, 188 papers were screened and 120 excluded based on title and abstract. The remaining 68 full-texts were assessed and 42 removed based on inclusion criteria. Four more studies were removed because participants’ voices were not adequately represented . Finally, 26 studies were included in the synthesis .Fig. 1PR3.2Critical appraisal results are detailed in 3.3Study characteristics are presented in 3.4Totally, 151 findings were extracted from the 26 studies and included in the synthesis . All fin3.4.1This finding synthesized 52 different results extracted from 20 papers. Five categories were included in this synthesized finding: “being violated and losing control”, “being protected and cared for”, “feeling ambivalent”, “feeling unwell” and “type of coercion”.“Losing control is a double-edged sword. It’s losing functions which are necessary for healing. I was relieved of the responsibility. They saw that I could take no more. It’s like a mother who takes over when you don’t have any more in you. You become a child again; you have a similar emotional register, the feeling that there’s nobody out there. It’s negligence to do nothing; it would have been a new betrayal for me who had no parents to take care of me. It was, in fact, my first encounter with care. I really felt cared for.”  to keep me safe than let me have my freedom” .” [ care].” These feelings sometimes even led patients to perceive involuntary care as voluntary ,58:“… af“All your rights are taken away, it’s horrible, you are not in control anymore.”  should ask you what medication is working for you. Who else would know! I told them that I felt I was on too many medications, but they would not listen. It is a mental drag. It could be the way I was expressing myself, as I find it difficult to find my words. Medication is one of the things the patient knows, because they are the ones going through it. I just wanted them to listen to my concerns about the medication, but they wouldn’t.”  are nowadays I suppose, they are fellow human beings as they should be.” , and they took a very caring attitude. They seemed concerned…When I got here [hospital] then, it was the nurse that actually brought me in, that kind of ran me through everything that kind of signed me in to the ward. It was caring as well. She was actually talking to me…I just think that engagement in itself helped relax me.”  So those were the ways that they used to punish me.”  P: I was happy. Because nobody ever cared enough about me to do that…Because he heard what I had to say. He wasn’t all right with me attempting to do what I had to do. He told me my life was worth something.”  believe the family members (…). And when the family members speak to the doctors, the doctors never talk to the patient, they don’t believe the patient.”  drugs on the ward...it’s quite easy to get drugs in there …”  and I have always agreed. Although he insisted on his view and I insisted on mine, we could find solutions. It’s one of the reasons why I trust him blindly as a professional, and he trusts me, and it’s a very good thing, because I feel I have a friend for life there. So it’s about human relations.” , and this trauma is the one that’s going to cause more severe and more problems.” . The fear of the fact that this abuse or whatever can happen again. That other people can decide how well I am without me expressing it. Other people can take charge, you know.”  very easily. I felt very betrayed by my wife…I can’t trust her any more…Obviously it has affected my relationship…That made me a very disillusioned person.”  was only 9 o’clock. There were people on the street…that seen all this happening which was … very embarrassing…people judge you as well on that actual admission or involuntary admission. There’s a stigma with it no matter what anybody says.” [y says.” Patients’ social life was also strongly affected by the experience of coercion ,57,63,67“I said, ‘‘somewhere down the road, I will publicly take them to court’’ ...all of the hospitals, some of the doctors who treated me against my will and didn’t want to hear me…not to seek revenge but to draw attention to this issue and in light of the future for many other psychiatric users, who could experience the same thing, not being heard like I was.” [ I was.” In some cases, the negative experience offered the motivation to publicly engage with other service users and try to change the system :“I said,“I had no self-respect when I left there whatsoever.” [soever.” “It leads to an absolute inferiority complex, I have the feeling that I am not worth talking to other people, already thinking that I am not worth it, well, we can say destroying my personality.” [nality.” However, more frequently they reported that the hospital experience had severely affected their identity and psychological integrity, engendering a loss self-esteem and self-confidence, and making them feel worthless and insecure ,63,67,72“I don't find it good that it is on record…I can't get life insurance…and my driving licence is limited in time and to prolong it costs a lot of money.” [ money.” Finally, hospitalisation was experienced as a disruption of patients’ life, affecting their daily habits and working life ,67. Long3.4.7This finding synthesized 8 results extracted from 5 papers. Four categories were included in this synthesized finding: “outpatient services and mobile teams”, “human contact with professionals and other patients”, “voluntary admission and shorter coercive measures” and “personal strategies”.“There should be a way to be treated at home.” [t home.” Patients perceived a variety of alternatives as less coercive and thus more helpful when in crisis. Some stated that they would have preferred to be treated in their own environment instead of in hospital ,68:“Ther“I know this example about a team that intervenes in situations of crises, a good team, that convinces, that the police is not needed to convince people to go to the hospital and there are data saying that people recover faster after that, and it would pay to have such a team, with trust, and they explain why it is necessary to go to the hospital.” [spital.” Outpatient services and mobile teams, such as home treatment teams, crisis intervention teams and Assertive Community Treatment teams, were often mentioned as effective alternatives, as well as psychotherapy and counselling ,56,67,68“What I need is not only medication. I need my family’s care and support and to be close to friends and neighbours. I need other people to speak out and to share with me similar painful experiences.” [iences.” For some patients, human contact and closeness with professionals, relatives and other patients sharing the same experiences were the only things they needed when in crisis ,67,68:“W“I said to the nurses they could call for the physician on duty to come and take away the extra supervision, as I felt fit then. If I am going to have extra supervision when I feel fit then I will soon be depressed again.” [ again.” When hospitalisation was necessary, it had to be voluntary and based on non-coercive treatments and, if coercive measures could not be avoided, they had to last as short as possible ,56,68:“I“… a way I have dealt with a lot of things is to write things down…that for me has been very helpful, to write down my experiences…my emotions and my feelings and that’s something you know I can look back on and understand …” [stand …” Finally, some personal strategies, such as sleeping long hours, listening to music or writing, were also reported as effective non-coercive alternatives to deal with crisis ,54:“… a 3.5Confidence scores of the synthesized findings are presented in 4This review provided a thorough understanding of patients' experience of coercion during hospital admission. Seven synthesized findings were identified from 26 studies, depicting the patients' experience of coercion. Patients described the hospitalisation and its restrictions either as a form of care and protection against the negative effects of their illness, or as a violation of their rights and autonomy, leading to a feeling of loss of control and powerlessness (synthesized finding 1). Involvement in the decision-making process (synthesized finding 2); relationships with staff (synthesized finding 3) and satisfaction with hospital treatment (synthesized finding 4) showed to play a key role in patients’ experience of admission. Several coping strategies were deployed in order to deal with the feeling of being coerced (synthesized finding 5). Nonetheless, patients reported significant negative consequences in several areas of their lives (synthesized finding 6) and called for the implementation of less coercive and more effective alternatives (synthesized finding 7).4.1The tension between violation and protection described by patients mirrors the ethical dilemma between the fundamental bioethical principles of respect of autonomy and beneficence that is often reported in the debate about coercion. Previous studies have shown that professionals also displayed ambivalent attitudes towards the use of coercion and struggled at times to find a balance ,74. IndeHospitalisation could be perceived as a form of protection or as a violation by both voluntarily and involuntarily hospitalized patients, confirming the limitations of using formal compulsion as a measure of perceived coercion ,16,76,774.2The importance of patients’ voice, information and involvement in the decision-making process is in line with what observed in previous studies ,83. Pati4.3procedural justice” was identified as the strongest predictor of perceived coercion by Lidz et al. [Collaboration is also a key ingredient of therapeutic alliance, defined as the degree of agreement between professionals and patients on therapeutic goals and tasks ,87. Besiz et al. . This rez et al. . All theAccording to the procedural justice theory, being treated fairly is of crucial importance in shaping interactions, independently of their outcomes . This is4.4Although to a lesser extent than and often in conjunction with fairness, elements related to treatment effectiveness were however reported by patients as having an impact on their experience of coercion. Mainly, patients complained about the extensive use of medication in place of activities and therapies fostering human contact and empathy. The interplay between perceived coercion, perceived fairness, perceived effectiveness and satisfaction with care should be further studied in order to disentangle these partially overlapping concepts and better understand how they influence each other.4.5When restrictions are perceived as fair, respectful and implemented by professionals with whom a positive relationship based on collaboration and trust has been established, acknowledgment and agreement are possible. Otherwise, patients resort to other coping strategies, none of which effective in reducing the negative impact of the experience. Patients' verbal and behavioural opposition is often interpreted by staff as an expression of their mental disorders, to which they respond with even more coercion. The ensuing resignation can increase patients’ feelings of disempowerment and amplify their loss of self-esteem, often already severely undermined. Conforming to the system and pretending acceptance can hinder the development of a truthful therapeutic alliance, with a consequent higher risk of service disengagement. Finally, fear of rejection and social discrimination may explain the urgent need expressed by some patients to move on and leave the hospital experience behind, severing all ties with healthcare services.4.6Stigmatization was frequently reported by patients because of the inpatient coercive experience. This result is in line with what observed in previous studies, showing that coercion, both perceived and formal, increased the feeling of stigma, which, in turn, led to lower self-esteem, another negative outcome outlined in our review ,99.A higher risk of disengagement from services may also stem from the traumatic impact that the coercive experience had on some patients, causing their condition to worsen rather than improve. This result is of utmost relevance in light of the well-known already high levels of trauma exposure of people with severe mental disorders ,101. Oth4.7Patients suggested the use of a variety of less coercive and more helpful alternatives when in crisis. Among these, outpatient interventions, such as Assertive Community Treatment teams , Home Tr4.8The main strengths of this review are the structured, systematized and replicable search strategy, the rigour of the methodology and the independent screening and critical appraisal of the included studies. Moreover, the synthesis process was informed by the discussion with the research team, including a peer-researcher. Some limitations should also be mentioned. Firstly, all synthesized findings were downgraded on dependability due to the lack of information on methodological aspects in the included studies, decreasing the level of evidence on which recommendations were developed to “moderate”. Secondly, most of the included studies were conducted in Europe and there were no studies from low-income countries. This could be due to the exclusion of the grey literature and of articles written in other languages than English, French and Italian, which could have led to miss some important study. Therefore, the generalizability of our results might be reduced.55.11.Foster care ethics (synthesized finding 1). In order to reduce the tension between protection and violation and to promote ethical decision-making, care ethics should be promoted in healthcare settings. Care ethics is an ethical approach that put interpersonal relationships and the needs of others at the core of ethical decision-making [n-making . In thisn-making . Therefon-making ,117. Then-making . Care etn-making ,117,119.2.Promote patients' voice and shared decision-making (synthesized finding 2). Approaches to strengthen patients' voice and shared decision-making should be supported at all levels  [atients) . Detaileatients) . Involunatients) ,123 coul3.Enhance patients' perceived closeness, respect and fairness (synthesized finding 3). Throughout the hospitalisation, professionals should build a positive, respectful, trustful and supportive relationship with patients. Even when patients' discernment capacity is absent in certain areas, it might be preserved in others. Professionals should be always able to identify and activate the healthiest parts of the patients and work on their resources. To strengthen the relational bond, they need to foster dialogue, promote collaboration and preserve patients' self-esteem. When verbal communication is not possible, physical closeness and practical help could be alternative paths to develop a trustful relationship. Communication skills trainings, including motivational interviewing techniques, should be provided to all stakeholders. Regular contact with professionals should also be granted. For this purpose, staff continuity should be ensured and the amount of administrative tasks reduced. Human contact rather than control should be promoted. Thus, hospital rules should be kept to a minimum and applied flexibly. Patients should be offered as much as possible the freedom to move and choose how they prefer to manage certain aspects of their daily life, such as what to wear, what time to go to bed, which activities to follow, etc. Professionals must be reliable, competent, willing to listen, interested and sincerely concerned. Greater attention should be payed to patients' dignity and respect. Patients must feel taken into account as whole human being and treated fairly, despite their disorders or the coercive measures in place. Professionals should regularly discuss these issues with all voluntarily and involuntarily admitted patients to ascertain the emergence of feelings of humiliation and de-subjectivation. Understanding the patient's subjective perception of the situation is essential in order to be certain that their personal values are taken into account and respected. These elements, combined with the implementation of shared decision-making strategies (see recommendation 2), can enhance the patients' perception of procedural justice even when coercion is enacted.4.Promote patients' satisfaction with treatment by enhancing hospital perceived effectiveness and safety (synthesized finding 4). Treatments offered to patients must be adapted to their subjective needs and preferences, and their impact constantly monitored and discussed with them. Besides medication, patients should be offered alternative treatments, such as individual and group psychotherapies, occupational therapy, etc. Several daily activities should also be available to help patients to relax, divert their thoughts and feel active during their stay. Through activities, patients can also experience positive social interactions with both professionals and other patients, helping the development of relationships of trust and confidence. Ward organisation in small and quiet units should be fostered, to increase patients' feelings of peace and safety. When violence occurs within the ward, debriefing sessions should be arranged to address the impact these events may have had on the directly or indirectly involved patients.5.Foster true collaboration and improve negotiation skills (synthesized finding 5). Professionals should pay more attention to the strategies adopted by patients to cope with the experience of admission and the reasons behind them. Opposition may stem from the "righteous anger” some patients feel when confronted with a system perceived as unfair and oppressive. In these cases, showing openness and understanding towards the reasons for their anger and using de-escalation techniques instead of coercive interventions could help to rapidly reduce aggressiveness levels and open a window for communication and negotiation. Police involvement and use of force, which may enhance patients anger and sense of oppression, should be minimized and aggressiveness management skills trainings offered to all professionals taking part in the admission process. At the same time, patients' cooperation may in some cases be dictated not by genuine acceptance, but rather by second purposes or resignation. Professionals should always encourage patients to express themselves freely, reassure them about the risk of possible retaliations and stimulate their negotiation skills in order to achieve a true therapeutic alliance.6.Reduce the negative consequences of experienced coercion (synthesized finding 6). Experienced coercion should be monitored regularly for both voluntarily and involuntarily admitted patients in order to prevent its consequences and increase patients' satisfaction. Furthermore, professionals should take into consideration not only the symptoms of the disorders leading to the hospitalisation and to the eventual use of coercion, but also those generated by the experience itself, whether emotional, cognitive or behavioural. All patients having formally or informally experienced coercion should be given the chance to discuss their experience with a trusted professional. Post-coercion debriefing sessions could be helpful on this matter [s matter . The pros matter ,126. Fin7.Promote the development and implementation of alternative interventions (synthesized finding 7). Access to alternative outpatient interventions, such as Assertive Community Treatment teams [nt teams , Home Trnt teams  and Crisnt teams , should Based on the seven synthesized findings of the review, several recommendations for practice are suggested:5.21.Improve the methodological quality and cultural variation of future qualitative studies. Our review revealed that, despite the large number of qualitative studies published on this topic, especially in the past decade, several presented methodological shortcomings. Future studies should strengthen their methodological quality, especially in terms of reporting the research methodology and the influence of the researcher on the research. Moreover, since most of the included studies were from Europe, especially UK and Ireland, and there were no studies from low-income countries, further research from a greater variety of countries is needed to fill this gap.2.Promote research on experienced coercion involving voluntary patients. Very few qualitative studies focused on the experience of coercion of voluntary patients. Exploring the feeling of coercion of this group of patients would be of crucial importance in order to better understand more subtle forms of coercion, improve professionals' awareness about their use, and reduce their negative effects.3.Clarify how determinants of experienced coercion interact with each other and with the experience outcomes. Further research should try to disentangle the interplay between experienced coercion, perceived fairness, perceived effectiveness and satisfaction with treatment in order to develop best-targeted interventions. The role of insight should also be clarified.4.xplore the psychosocial impact of experienced coercion on patients. Further quantitative and qualitative studies should aim to a better understanding of the link between experienced coercion and patients' self-esteem, stigma and self-stigma.E5.Develop and evaluate targeted intervention to reduce experienced coercion and its negative impact on patients. Besides alternative interventions to coercion, future studies should aim to develop and test programs able to support patients during and after involuntary treatment, to help them process the experience of coercion and to reduce its negative impact on their future engagement with services.Based on the review findings, several recommendations for research are suggested:6The experience of coercion is a complex phenomenon, only partly explained by having been subjected to coercive measures. Due to its potentially detrimental impact on patients’ prognosis, satisfaction and engagement with care, the development of interventions and clinical practices able to tackle its determinants and minimise its consequences is mandatory. This review, through the first aggregative synthesis of the qualitative evidence in this field, improved the understanding of experienced coercion. Several recommendations for research and practice were suggested based on its results. For these points to be effectively implemented, policymakers must support them through their vision and policies, promoting a profound change in the organisation and culture of the mental health system. Patient involvement in the design, development and evaluation of this change, as well as in research activities, is strongly recommended.All authors listed have significantly contributed to the development and the writing of this article.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.No data was used for the research described in the article.The authors declare no competing interests.