Peer Support Services Research Articles

Facilitating a Positive Culture for the Disclosure of Workers’ Disabilities within a Higher Education Institution

Background: Within the UK, an individual is disabled if he or she has an impairment that has a substantial and long-term negative effect on their ability to undertake daily activities. Once a disability is disclosed the employer has a legal duty to make reasonable adjustments at work for the employee (there are similar requirements in the EU and the USA). However, because of the stigma often associated with disability many individuals are fearful of disclosure as they may be discriminated against. This apparent fear seems to be reflected in the disability disclosure rate for English universities, which in 2014 was 3.9%. Aims and Objectives: This action research study aims to encourage a disability friendly culture so that the disability disclosure rate within an English higher education institution can be improved upon. This is achieved through the provision of a volunteer social intervention program that enables workers to make an informed decision regarding disclosure; and enables co-workers, supervisors, and managers to explore their responsibility towards disabled staff in the workplace. Method: A pilot intervention program has been initiated. This includes the provision of a confidential peer to peer support service for disabled staff; and a series of disability awareness seminars for co-workers, supervisors, and managers. A mixed methodology is used to evaluate these interventions. This includes a qualitative analysis of reported cases and a quantitative analysis of responses to a participant satisfaction survey. Results: Feedback from users of the peer to peer support service and those who participated in disability awareness seminars has confirmed the effectiveness, relevance, and suitability of the pilot intervention program. Discussion: The trustworthiness of the study is confirmed. Limitations are also highlighted. It is accepted that the results of the pilot study should be treated with caution as participating numbers are low. Conclusion: The research team have been able to confirm the potential of peer to peer support and disability awareness in establishing a disability friendly culture for the institution. However, at this stage no attempt has been made to establish cause and effect. Therefore, further empirical evidence is needed to confirm the benefits of this type of intervention.

Perceptions of Survivorship Care among Latina Women with Breast Cancer in Los Angeles County.

Cancer "survivorship" is a distinct and important aspect of the cancer experience. More research is needed about survivorship care in underserved populations such as Latinas. This study examined issues of breast cancer survivorship care among Latinas to understand their experiences and needs, to inform the design of future programs. Six English- and six Spanish-language focus groups were conducted, with a nonprobability sample. About 74 Latinas who varied in terms of characteristics including stage, time since diagnosis, and English proficiency were recruited through support groups, health fairs, and promotoras. A semi-structured question guide was used to examine experiences with follow-up care, barriers, and meaning associated with breast cancer survivorship. Results indicate numerous gaps and unmet needs in Latinas' survivorship care experiences, including problems with finances, continuity of care, unmet needs for information, and symptom management. Participants identified sources of support including patient navigators, and assigned both positive and negative meanings to survivorship. This research lays a foundation for future work to develop interventions addressing Latina breast cancer survivors' unmet needs. Recommendations include enhancing peer and professional support services for patients, family, and caregivers. Further work is also needed to promote the implementation of survivorship care plans.

Protocol for a cluster randomised controlled trial of an intervention to improve the mental health support and training available to secondary school teachers - the WISE (Wellbeing in Secondary Education) study.

BackgroundTeachers are reported to be at increased risk of common mental health disorders compared to other occupations. Failure to support teachers adequately may lead to serious long-term mental disorders, poor performance at work (presenteeism), sickness absence and health-related exit from the profession. It also jeopardises student mental health, as distressed staff struggle to develop supportive relationships with students, and such relationships are protective against student depression. A number of school-based trials have attempted to improve student mental health, but these have mostly focused on classroom based approaches and have failed to establish effectiveness. Only a few studies have introduced training for teachers in supporting students, and none to date have included a focus on improving teacher mental health. This paper sets out the protocol (version 4.4 20/07/16) for a study aiming to address this gap.MethodsCluster randomised controlled trial with secondary schools as the unit of randomisation. Intervention schools will receive: i) Mental Health First Aid (MHFA) training for a group of staff nominated by their colleagues, after which they will set up a confidential peer support service for colleagues ii) training in MHFA for schools and colleges for a further group of teachers, which will equip them to more effectively support student mental health iii) a short mental health awareness raising session and promotion of the peer support service for all teachers. Comparison schools will continue with usual practice. The primary outcome is teacher wellbeing measured using the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS). Secondary outcomes are teacher depression, absence and presenteeism, and student wellbeing, mental health difficulties, attendance and attainment. Measures will be taken at baseline, one year follow up (teachers only) and two year follow up. Economic and process evaluations will be embedded within the study.DiscussionThis study will establish the effectiveness and cost-effectiveness of an intervention that supports secondary school teachers’ wellbeing and mental health, and improves their skills in supporting students. It will also provide information regarding intervention implementation and sustainability.Trial registrationInternational Standard Randomised Controlled Trial Number: ISRCTN95909211 registered 24/03/16Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3756-8) contains supplementary material, which is available to authorized users.

A pilot cluster randomised controlled trial of a support and training intervention to improve the mental health of secondary school teachers and students - the WISE (Wellbeing in Secondary Education) study.

BackgroundSecondary school teachers are at heightened risk of psychological distress, which can lead to poor work performance, poor quality teacher-student relationships and mental illness. A pilot cluster randomised controlled trial (RCT) – the WISE study – evaluated the feasibility of a full-scale RCT of an intervention to support school staff’s own mental health, and train them in supporting student mental health.MethodsSix schools were randomised to an intervention or control group. In the intervention schools i) 8–9 staff received Mental Health First Aid (MHFA) training and became staff peer supporters, and ii) youth MHFA training was offered to the wider staff body. Control schools continued with usual practice. We used thematic qualitative data analysis and regression modelling to ascertain the feasibility, acceptability and potential usefulness of the intervention.ResultsThirteen training observations, 14 staff focus groups and 6 staff interviews were completed, and 438 staff (43.5 %) and 1,862 (56.3 %) students (years 8 and 9) completed questionnaires at baseline and one year later. MHFA training was considered relevant for schools, and trainees gained in knowledge, confidence in helping others, and awareness regarding their own mental health. Suggestions for reducing the length of the training and focusing on helping strategies were made. A peer support service was established in all intervention schools and was perceived to be helpful in supporting individuals in difficulty – for example through listening, and signposting to other services - and raising the profile of mental health at a whole school level. Barriers to use included lack of knowledge about the service, concerns about confidentiality and a preference for accessing support from pre-existing networks.ConclusionsThe WISE intervention is feasible and acceptable to schools. Results support the development of a full-scale cluster RCT, if steps are taken to improve response rates and implement the suggested improvements to the intervention.Trial registrationInternational Standard Randomised Controlled Trial Number: ISRCTN13255300 retrospectively registered 28/09/16.Electronic supplementary materialThe online version of this article (doi:10.1186/s12889-016-3737-y) contains supplementary material, which is available to authorized users.

Patterns and predictors of engagement in peer support among homeless veterans with mental health conditions and substance use histories.

Patterns and predictors of engagement in peer support services were examined among 50 previously homeless veterans with co-occurring mental health conditions and substance use histories receiving services from the Veterans Health Administration supported housing program. Veteran peer specialists were trained to deliver sessions focusing on mental health and substance use recovery to veterans for an intended 1-hr weekly contact over 9 months. Trajectories of peer engagement over the study's duration are summarized. A mixed-effects log-linear model of the rate of peer engagement is tested with three sets of covariates representing characteristics of the veterans. These sets were demographics, mental health and substance use status, and indicators of community participation and support. Data indicate that veterans engaged with peers about once per month rather than the intended once per week. However, frequency of contacts varied greatly. The best predictor of engagement was time, with most contacts occurring within the first 6 months. No other veteran characteristic was a statistically significant predictor of engagement. Older veterans tended to have higher rates of engagement with peer supporters. Planners of peer support services could consider yardsticks of monthly services up to 6 months. Peer support services need a flexible strategy with varying levels of intensity according to need. Peer support services will need to be tailored to better engage younger veterans. Future research should consider other sources of variation in engagement with peer support such as characteristics of the peer supporters and service content and setting. (PsycINFO Database Record

Peer support services in the behavioral healthcare workforce: State of the field.

This article examines how the history and philosophy of peer support services has shaped current mental health and substance use service delivery systems. The growth of peer-run and recovery community organizations in the changing health care environment are discussed, including issues related to workforce development, funding, relevant policies, and opportunities for expansion. These initiatives are designed to increase access to recovery-promoting services. We conducted an environmental scan and analysis of peer support services within the behavioral health care field in the United States, with particular attention to initiatives of the Substance Abuse and Mental Health Services Administration. Published manuscripts, policy statements, and reports were reviewed. There is abundant and growing literature illustrating how peer support services have become an integral component of behavioral health care systems in many states. Peer support services have the potential to increase access to recovery-oriented services for people with mental and substance use disorders served by the public behavioral health care system. Numerous initiatives in various states are being undertaken to build this workforce. Workforce and financing challenges exist, yet opportunities, including among others those made possible by the Affordable Care Act, will continue to strengthen the peer support workforce within behavioral health service delivery systems. (PsycINFO Database Record

Participation in peer support services and outcomes related to recovery.

This article presents findings from a naturalistic study that explored the impact of peer support participation on recovery-related outcomes over a 6-month period. In particular, this study hoped to fill gaps in the literature regarding the process through which personal change occurs in peer support organizations. Fifty people newly involved in services provided by Baltic Street AEH (Advocacy, Employment, Housing), a consumer-operated organization, participated in the study. Participants were interviewed at entry and 3- and 6-month follow-up. Attendance records were reviewed to determine the number of days attended, and the sample was divided into 2 categories: minimal or nonattenders (n = 25) and moderate or high attenders (n = 21). The relationship between attendance and outcomes related to recovery over time was examined using a mixed effect regression analysis, allowing data to be included for participants with at least 1 follow-up interview (n = 38). Relative to minimal or nonattenders, moderate or high attenders showed statistically significant improvements over time in internalized stigma, self-esteem-self-efficacy, and community activism-autonomy. No statistically significant differences were observed between groups in hopelessness, social functioning, symptom severity, coping with symptoms, or substance use. This study demonstrates the potential impact of engagement in peer support services on some subjective aspects of mental health recovery. Namely, change mechanisms could be hypothesized to include identity transformation (from patient to peer). Future directions should continue to investigate potential mechanisms of change with larger samples in randomized studies. (PsycINFO Database Record

The role of the peer specialists: Unanswered questions.

This article raises questions regarding defining the role of peer specialists and related employment practices. The questions raised may be used to guide future research. Areas needing further investigation were identified through personal and professional experience, discussions with colleagues, and a review of published literature on peer workers. Questions are raised regarding the definition of "peerness"; the variety and contradictions in definitions of the role of the peer specialist; existing and potential avenues for career advancement; credentialing standards; the design, implementation, and evaluation of existing and effective peer support service models, including integration of peer workers in other service models; and best practices for supporting the well-being of peer workers and their nonpeer colleagues. More and higher quality research data are needed in order to inform and contribute to the use and support of peer specialists in promoting positive system transformation. (PsycINFO Database Record

Priorities for the development and evaluation of support after suicide bereavement in the UK: results of a discussion group

We present the results of a group discussion conducted to identify research priorities among people bereaved by suicide regarding support needs. The authors’ research team had recently published evidence from a UK-wide sample of young bereaved adults showing that those bereaved by suicide had a greater probability of suicide attempt than those bereaved by other causes of sudden death. For this study, ten UK-based adults bereaved by the suicide of a partner or family member were invited to join a group discussion to identify and prioritise an intervention to evaluate. These priorities were discussed in the context of unmet needs for support, identifying a need to develop and evaluate: immediate outreach after suicide; diversification and development of peer support services; and individual psychological support for those who feel suicidal. The group also suggested five key outcome measures: isolation; stigma; psychological health; day-to-day social functioning; and functioning in a work or caregiver role. The views presented in this discussion are a valuable contribution to the design of research that will inform national public health policy and the suicide prevention strategy for England.

Feasibility of Outpatient Advance Care Planning Discussions: Adventures of a Primary Care Physician (S761)

pose significant challenges to collaboration with community providers. (5) Care providers for HV at EOL must compete for attention and resources with other pressing challenges within VA. Conclusion. Lack of housing suited to HV with rapidly declining health and isolation of homeless and EOL providers from each other are among the most pressing challenges. Implications for Research, Policy or Practice. The Forum is developing proposals to facilitate already functioning, informal collaborations among HV and EOL care providers, maximize VA-community partnerships, and expand peer support services by formerly homeless Veterans.

The impact of breastfeeding peer support for mothers aged under 25: a time series analysis.

Breastfeeding has known positive health benefits for babies and mothers, yet the UK has one of the lowest breastfeeding initiation rates in Europe. Despite national guidance that recommends provision of breastfeeding peer support, there is conflicting evidence regarding its effectiveness, especially in high-income countries, and a lack of evidence among young mothers. This study evaluates the effectiveness of a breastfeeding peer support service (BPSS) in one UK city in increasing breastfeeding initiation and duration in young mothers. Routinely collected data were obtained on feeding method at birth, 2 and 6 weeks for all 5790 women aged <25 registered with a local general practitioner and who gave birth from April 2009 to September 2013. Segmented regression was used to quantify the impact of the introduction of the BPSS in September 2012 on the prevalence of breastfeeding at birth, 2 and 6 weeks, accounting for underlying trends. Results showed that breastfeeding prevalence at birth and 2 weeks began to increase month-on-month after the introduction of the BPSS, where previous figures had been static; prevalence at birth increased by 0.55 percentage points per month (95% CI 0.10-1.00, P = 0.018) and at 2 weeks by 0.50 percentage points (95% CI 0.15-0.86, P = 0.007). There was no change from an underlying marginally increasing trend in prevalence at 6 weeks. In conclusion, our findings suggest that a one-to-one BPSS provided by paid peer supporters and targeted at young mothers in the antenatal and post-natal periods may be beneficial in increasing breastfeeding initiation and prevalence at 2 weeks.

Brief Report: Long-term Outcomes and Their Determinants in Patients on Antiretroviral Treatment in Ethiopia, 2005/6-2011/12: A Retrospective Cohort Study.

Antiretroviral treatment (ART) programs in many resource-limited settings have expanded treatment toward universal access. Ethiopia is one of the countries that has been scaling up ART toward universal access, but with very few data on long-term outcomes and their determinants. The objective of this study was to identify the level of long-term outcomes and their determinants in patients on ART in Ethiopia. A retrospective cohort study was conducted in 3 health facilities (2 hospitals and 1 health center) between July and September, 2014. Loss to follow-up, death, attrition, and retention were the primary outcomes. Data were collected from patient registers and medical records for the period 2005/6-2011/12. A total of 11,731 patients were included in the study. The overall retention rate was 78 per 100 person-months. Retention rates were 82%, 74%, and 72% at 24, 60, and 84 months on ART, respectively. Retention was associated with male sex, adolescent age, marital status, advanced HIV disease, illiteracy, and peer-support services; however, long-term retention was associated independently with only male sex [with adjusted hazard ratio (aHR) 0.68 (0.56 to 0.77)], married patients [with aHR 0.62 (0.54 to 0.72)], and peer-support services [with aHR 1.62 (1.58 to 1.66)]. ART programs have lost most of their patients during the first 24 months on ART. It is, therefore, imperative that HIV/ART programs ensure people are tested, linked to care, and initiated on ART early. ART programs should also design and implement interventions, including peer-support services, which are targeted to male, adolescent, unmarried, and illiterate patients.

An ARC-Informed Family Centered Care Intervention for Children's Community Based Mental Health Programs.

The experience of parents in helping their children access and use mental health services is linked to service outcomes. Parent peer support service, based on the principles of family-centered care, is one model to improve parent experience and engagement in services. Yet, little is known about how best to integrate this service into the existing array of mental health services. Integration is challenged by philosophical differences between family-centered services and traditional children's treatment services, and is influenced by the organizational social contexts in which these services are embedded. We describe an organizational and frontline team intervention that draws on research in behavior change, technology transfer, and organizational social context for youth with serious emotional disturbance. The two-pronged intervention, called FAMILY (FCC and ARC Model to Improve the Lives of Youth) is guided by the evidence-based Availability, Responsiveness, and Continuity (ARC) organizational intervention, targeted primarily at program and upper management leadership and includes a family-centered care (FCC) intervention, targeted at frontline providers. The approach employs multilevel implementation strategies to promote the uptake, implementation and sustainability of new practices. We include examples of exercises and tools, and highlight implementation challenges and lessons learned in facilitating program and staff level changes in family-centered service delivery.

Maximizing Utilization of Peer Specialists in Community Mental Health: The Next Step in Implementation

The successful implementation of peer support services in community mental health centers requires the maximum utilization of peer specialists in order to meet the needs of the consumer, the agency and the peer specialist so that they receive the full benefits of their employment. This study identifies factors that positively and negatively impact the referral to and utilization of peer support services by traditional providers and strategies for achieving optimal utilization.

Building social capital through breastfeeding peer support: insights from an evaluation of a voluntary breastfeeding peer support service in North-West England.

BackgroundPeer support is reported to be a key method to help build social capital in communities. To date there are no studies that describe how this can be achieved through a breastfeeding peer support service. In this paper we present findings from an evaluation of a voluntary model of breastfeeding peer support in North-West England to describe how the service was operationalized and embedded into the community. This study was undertaken from May, 2012 to May, 2013.MethodsInterviews (group or individual) were held with 87 participants: 24 breastfeeding women, 13 peer supporters and 50 health and community professionals. The data contained within 23 monthly monitoring reports (January, 2011 to February 2013) compiled by the voluntary peer support service were also extracted and analysed.ResultsThematic analysis was undertaken using social capital concepts as a theoretical lens. Key findings were identified to resonate with’bonding’, ‘bridging’ and ‘linking’ forms of social capital. These insights illuminate how the peer support service facilitates ‘bonds’ with its members, and within and between women who access the service; how the service ‘bridges’ with individuals from different interests and backgrounds, and how ‘links’ were forged with those in authority to gain access and reach to women and to promote a breastfeeding culture. Some of the tensions highlighted within the social capital literature were also identified.ConclusionsHorizontal and vertical relationships forged between the peer support service and community members enabled peer support to be embedded into care pathways, helped to promote positive attitudes to breastfeeding and to disseminate knowledge and maximise reach for breastfeeding support across the community. Further effort to engage with those of different ethnic backgrounds and to resolve tensions between peer supporters and health professionals is warranted.

A systematic review of the effectiveness and cost-effectiveness of peer education and peer support in prisons.

BackgroundPrisoners experience significantly worse health than the general population. This review examines the effectiveness and cost-effectiveness of peer interventions in prison settings.MethodsA mixed methods systematic review of effectiveness and cost-effectiveness studies, including qualitative and quantitative synthesis was conducted. In addition to grey literature identified and searches of websites, nineteen electronic databases were searched from 1985 to 2012.Study selection criteria were:Population: Prisoners resident in adult prisons and children resident in Young Offender Institutions (YOIs).Intervention: Peer-based interventions.Comparators: Review questions 3 and 4 compared peer and professionally led approaches.Outcomes: Prisoner health or determinants of health; organisational/process outcomes; views of prison populations.Study designs: Quantitative, qualitative and mixed method evaluations.ResultsFifty-seven studies were included in the effectiveness review and one study in the cost-effectiveness review; most were of poor methodological quality. Evidence suggested that peer education interventions are effective at reducing risky behaviours, and that peer support services are acceptable within the prison environment and have a positive effect on recipients, practically or emotionally. Consistent evidence from many, predominantly qualitative, studies, suggested that being a peer deliverer was associated with positive effects. There was little evidence on cost-effectiveness of peer-based interventions.ConclusionsThere is consistent evidence from a large number of studies that being a peer worker is associated with positive health; peer support services are also an acceptable source of help within the prison environment and can have a positive effect on recipients. Research into cost-effectiveness is sparse.Systematic review registrationPROSPERO ref: CRD42012002349.

Peer to Peer – Support in Severe Mental Disorders: Affective Disorders, Psychosis and Personality Disorder – a Randomized Controlled Trial

Introduction Individuals with serious mental illness (SMI) are at considerably higher risk for morbidity and mortality than those in the general population. In these diagnoses – a refinement of intervention is required, the user perspective overall is still underrepresented. Objectives In mental health Services there is an international trend toward recovery-orientated interventions, like Peer-support (PS) in formal mental health services. There is a raising but still insufficient evidence for it's benefits Aims In Germany this is the first try to implement and research peer support services area-wide in psychiatric facilities to provide a low-threshold service that aims individual recovery. This project forms a part of 'psychenet ', a project supported by the Federal Ministry of Education and Research of Germany during 2011 – 2014 and investigates the effect of peer support on psychosocial factors, functioning and hospital admissions. Methods In a controlled multi-centre-trial involving 10 hospital facilities in Hamburg − 216 in- and outpatients suffering from affective disorders, psychoses or personality disorders get randomized to either receive additional Peer-Support at most half a year aligned to individual requirements or treatment as usual. A mixed method repeated measurement analysis is conducted. Results Subjects refill questionnaires and get rated by clinicians at three points of measurement: Entry of the half year of intervention, after the intervention and in a six month follow up. Psychosocial Outcomes, global functioning, and in and outpatient days were assessed. There is a significant positive Effect for the PS of the primary outcome. Results will be presented

Evaluation of two community-controlled peer support services for assessment and treatment of hepatitis C virus infection in opioid substitution treatment clinics: The ETHOS study, Australia

AimPeer support services have been shown to be beneficial in increasing uptake and adherence to treatment in other areas but few examples of these services exist in hepatitis C (HCV) care. This study examined the performance of two community-controlled peer support services operating within a larger study aimed at increasing access to HCV care and treatment for opiate substitution treatment (OST) clients, ETHOS. MethodsSemi-structured interviews were conducted in two clinics with three groups of participants: clients (n=31), staff (n=8) and peer workers (n=3) and examined the operation of the service in relation to process, outputs and impacts. ResultsThere was a very strong positive response to the peer worker services reported by staff and clients who had and had not interacted with a peer worker. A number of changes were reported that were not explicit goals of the service including providing access to additional services for clients and staff, peer workers acting as mediators between clients and staff and a less tangible notion of a changing “feel” of the clinic to a more positive and client-friendly social and physical space. Explicit goals of the service were also reported in peer workers supporting clients to consider and prepare for treatment (via blood tests and other assessments) as well as provide information and support about treatment. ConclusionsThe peer support service was acceptable to clients and clinic staff. All groups of participants noted that the service met its goals of engaging clients, building trusting relationships and providing instrumental support for clients to access HCV treatment. Peer workers may also contribute to more effective deployment of health resources by preparing clients for clinical engagement with HCV health workers.

QL-17 * COMMUNITY BRAIN TUMOUR FORUMS: LESSONS FROM THE FRONT LINE

BACKGROUND: Informational demands of patients and families affected by brain cancer are well documented. Access to accurate well-balanced material is a vital element in ensuring their participation in their healthcare journey. Since 2011, Austin Health has partnered with other organisations to present current, relevant clinical and supportive care information to a self selected community audience. METHODS: Program content was drawn from high prevalence clinical issues, support groups and anecdotal feedback from a variety of sources. Forums have developed from a 3-hour evening session to full day forums with invited speakers and exhibitors. Importantly, it has been vital to promote to buy-in of health institutions, peer support services and charities. We balanced opportunities to hear from experts, specialised support services and consumer sharing experiences. RESULTS: Since 2011, 3 forums have been conducted attracting 205 participants in total. Post forum evaluations were conducted, with a response rate of 52%. All presentations rated greater than 4.76/5. Clinical trials, research and brain tumour science presentations were rated as most valuable. Logistical challenges include competing interests of different organisations, and agendas of attendees. Balancing technical verses layman language, evidence based information verses alternate treatment options, and ensuring effective facilitation of sessions has led to program content revision. The use of post-forum evaluations allowed us to identify a range of areas that were an unmet need, which included such information as role of clinical trials and an understanding of specific cognitive syndromes and their impact on patient and family. CONCLUSION: Community brain tumour education forms a positive step to ensuring patients and families are well resourced, with opportunities to broaden support options. Bringing together of clinicians, consumers and philanthropy has led to coordinated relevant information being available to consumers unable to access neuro-oncology care coordination.

Access to health and support services: perspectives of people living with a long-term traumatic spinal cord injury in rural and urban areas

Purpose: To examine the perspectives of persons living with traumatic spinal cord injuries (tSCI) on their access to health and support services. The specific aims were to identify the perceived gaps in access, classify the nature of the perceived gaps and compare differences in perceptions of access between urban and rural participants. Method: Using a descriptive, qualitative approach, semi-structured interviews were conducted with 23 adults living with tSCI, 13 of whom had paraplegia. Ten participants resided in rural areas and 16 were male. Thematic analysis allowed for the identification of patterns, which were then categorized according to the dimensions of access. Results: Opportunities to engage in health-promoting activities through a broad range of health and support services were at times limited, particularly by issues of affordability. In addition to core healthcare services, participants reported the need for complementary therapies, sports and leisure, peer support, equipment and mobility related services. Availability and accessibility of services was limited in some cases for rural participants, although rural residence conferred other valued benefits. Narratives of “not being heard” by providers were common. Conclusions: Maintaining health and well-being in people with tSCI demands access to both conventional health care and support services.Implications for RehabilitationAccess to both health and support services are important to maintaining the health and wellness of people with spinal cord injury.People with spinal cord injuries take an active role in coordinating their health, at times assuming various roles to compensate for perceived shortcomings of health care providers.Negotiating balances of power with gatekeepers in the health and insurance sectors was a key function of the coordinating role assumed by people with spinal cord injury.In order to effectively address the needs of this population, a coordinated interdisciplinary out-reach service, which includes peer support, must cross boundaries to engage sectors beyond traditional health care services, such as insurers and wellness providers.