Post-training Follow-up Research Articles

Bodyweight-supported treadmill training for retraining gait among chronic stroke survivors: A randomized controlled study

ObjectiveTo evaluate the role of bodyweight-supported treadmill training (BWSTT) for chronic stroke survivors. DesignProspective, randomized controlled study. MethodsPatients with a first episode of supratentorial arterial stroke of more than 3months’ duration were randomly allocated to 3 groups: overground gait training, treadmill training without bodyweight support, and BWSTT (20 sessions, 30min/day, 5days/week for 4weeks). The primary outcome was overground walking speed and endurance and secondary outcome was improvement by the Scandinavian Stroke Scale (SSS) and locomotion by the Functional Ambulation Category (FAC). We analyzed data within groups (pre-training vs post-training and pre-training vs 3-month follow-up) and between groups (at post-training and 3-month follow-up). ResultsWe included 45 patients (36 males, mean post-stroke duration 16.51±15.14months); 40 (89.9%) completed training and 34 (75.5%) were followed up at 3months. All primary and secondary outcome measures showed significant improvement (P<0.05) in the 3 groups at the end of training, which was sustained at 3-month follow-up (other than walking endurance in group I). Outcomes were better with BWSTT but not significantly (P>0.05). ConclusionBWSTT offers improvement in gait but has no significant advantage over conventional gait-training strategies for chronic stroke survivors.

Combined exercise training reduces fatigue and modulates the cytokine profile of T-cells from multiple sclerosis patients in response to neuromediators

Fatigue is a common and disabling symptom of multiple sclerosis (MS), a classical Th1- and Th17-mediated autoimmune disease. There is no effective pharmacological treatment for fatigue, but some reports point towards beneficial effects of physical activity on management of the fatigue in MS patients. As both MS and fatigue have been associated with dysregulated cytokine network production, the objective of the present study was to evaluate the impact of a physical activity program consisting of a 12-week series of combining Pilates and aerobic exercises on fatigue severity, determined by FSS, and cytokine production, quantified by ELISA, by T cells from MS patients (n=08) with low disability (EDSS≤2). The results showed decrease in FSSs in all patients at the end of physical activity intervention. Regarding the cytokines, a significant reduction of IL-22 release was observed in polyclonally-activated T cells form MS patients post-training follow-up. Interestingly, while the physical activity attenuated the ability of dopamine in up-regulating Th17-related cytokines, it enhanced the anti-inflammatory effects of serotonin, evidenced by high IL-10 production. In summary, all results suggest that programmed physical activity has beneficial effects on management of fatigue in MS patients, and it could be related, at least in part, to its ability in regulating neuroimmune parameters into T cell compartment.

Provider Training to Screen and Initiate Evidence-Based Pediatric Obesity Treatment in Routine Practice Settings: A Randomized Pilot Trial

IntroductionThis randomized pilot trial evaluated two training modalities for first-line, evidence-based pediatric obesity services (screening and goal setting) among nursing students. MethodParticipants (N = 63) were randomized to live interactive training or Web-facilitated self-study training. Pretraining, post-training, and 1-month follow-up assessments evaluated training feasibility, acceptability, and impact (knowledge and skill via simulation). Moderator (previous experience) and predictor (content engagement) analyses were conducted. ResultsNearly all participants (98%) completed assessments. Both types of training were acceptable, with higher ratings for live training and participants with previous experience (ps < .05). Knowledge and skill improved from pretraining to post-training and follow-up in both conditions (ps < .001). Live training demonstrated greater content engagement (p < .01). ConclusionsThe training package was feasible, acceptable, and efficacious among nursing students. Given that live training had higher acceptability and engagement and online training offers greater scalability, integrating interactive live training components within Web-based training may optimize outcomes, which may enhance practitioners' delivery of pediatric obesity services.

Online role-play simulations with emotionally responsive avatars for the early detection of Native youth psychological distress, including depression and suicidal ideation.

Gatekeeper training is a widely used prevention method for training local community members to recognize the signs and symptoms of suicide and to support appropriate referrals for mental health. Training community "gatekeepers" is critical for increasing access to care for those youth who are in need, as youth often turn first to family and friends for help. This study examines the outcomes at pre-training, post-training, and 3-month follow-up for American Indian and Alaska Native (AI/AN) students, teachers, and faculty completing online role-play gatekeeper training simulations. The simulations use emotionally responsive avatars that have memory and personality, and respond like real students experiencing psychological distress in realistic situations. Data from 86 matched pairs showed significant increases in self-identified gatekeeper attitudes of preparedness, likelihood (behavioral intent) and self-efficacy to engage in helping behaviors (i.e., identifying those in psychological distress, talking to them, and supporting a referral for services) 3 months after training. This study provides promising evidence for use of online avatar-based training with AI/AN communities and has the potential to address many of the current challenges with gatekeeper training in Indian Country.

Evaluation of participatory training in managing mental health for supervisory employees in the financial industry.

Industry-specific primary prevention measures for promoting mental health of workers were undertaken in 2008 and 2009 as a result of participatory training involving 130 supervisory employees in workplaces of the financial industry. These measures included the following five points suggested to be effective in the industry: 1) proper opportunities for training and career building, 2) control of work time and improving work organization, 3) standardization of tasks, 4) job rotation for sharing work responsibilities, and 5) increasing communication and mutual support. A post-training follow-up survey revealed that participatory, action-oriented training facilitated sharing of feasible measures and mutual support, leading to the development of measures easily introduced and established at each workplace. We concluded that mutually supportive group work of teams composed of members who held similar duty positions and were engaged in similar operations, using the Mental Health Action Checklist as a guiding tool, was effective for realizing implementation of optimally practical and specific measures.

Immune Function and Muscle Adaptations to Resistance exercise in Older Adults: Study Protocol for a Randomized Controlled Trial of a Nutritional Supplement.

BackgroundImmune function may influence the ability of older adults to maintain or improve muscle mass, strength, and function during aging. Thus, nutritional supplementation that supports the immune system could complement resistance exercise as an intervention for age-associated muscle loss. The current study will determine the relationship between immune function and exercise training outcomes for older adults who consume a nutritional supplement or placebo during resistance training and post-training follow-up. The supplement was chosen due to evidence suggesting its ingredients [arginine (Arg), glutamine (Gln), and β-hydroxy β-methylbutyrate (HMB)] can improve immune function, promote muscle growth, and counteract muscle loss.Methods/designVeterans (age 60 to 80 yrs, N = 50) of the United States military will participate in a randomized double-blind placebo-controlled trial of consumption of a nutritional supplement or placebo during completion of three study objectives: 1) determine if 2 weeks of supplementation improve immune function measured as the response to vaccination and systemic and cellular responses to acute resistance exercise; 2) determine if supplementation during 36 sessions of resistance training boosts gains in muscle size, strength, and function; and 3) determine if continued supplementation for 26 weeks post-training promotes retention of training-induced gains in muscle size, strength, and function. Analyses of the results for these objectives will determine the relationship between immune function and the training outcomes. Participants will undergo nine blood draws and five muscle (vastus lateralis) biopsies so that the effects of the supplement on immune function and the systemic and cellular responses to exercise can be measured.DiscussionExercise has known effects on immune function. However, the study will attempt to modulate immune function using a nutritional supplement and determine the effects on training outcomes. The study will also examine post-training benefit retention, an important issue for older adults, usually omitted from exercise studies. The study will potentially advance our understanding of the mechanisms of muscle gain and loss in older adults, but more importantly, a nutritional intervention will be evaluated as a complement to exercise for supporting muscle health during aging.Trial RegistrationClinicaltrials.gov identifier: NCT02261961, registration date 10 June 2014, recruitment active.

Training mental health nurses to provide motivational interviewing on an inpatient eating disorder unit.

This study examined whether: (1) brief training in motivational interviewing (MI) can prepare mental health nurses (MHNs) to provide MI to patients; and (2) this MI impacts on patients with respect to premature discharge. Six MHNs on an inpatient eating disorder unit were trained in MI, and their treatment adherence and competence were evaluated at post-training and 2-month follow-up. Premature discharge was examined by comparing a 3-month period in 2009 before MI administration with 2010 when MI was being administered. MHNs significantly improved their MI adherence and competence. Satisfaction with the training was high as was patient satisfaction with MI. Premature discharge rates significantly decreased. Brief training in MI is sufficient to significantly increase competency and adherence in the practice of MI by MHNs, which may in turn be effective in improving patients' treatment adherence by reducing premature discharge rates. Future research will need to utilize a randomized controlled design in order to further investigate these findings.

Changing minds, changing lives from the top down: an investigation of the dissemination and adoption of a Canada-wide educational intervention to enhance health care professionals' intentions to prescribe physical activity.

The purposes of the current study were to (1) describe the restructuring and dissemination of a Canada-wide intervention curriculum designed to enhance health care professionals' prescription of physical activity to patients with physical disabilities, and (2) examine interventionists' social cognitions for, and their acceptance and adoption of, the new curriculum. A participatory curriculum development process was utilized, resulting in a theory- and evidence-based curriculum. Interventionists (N = 28) were trained in curriculum delivery and most (n = 22) completed measures of Theory of Planned Behavior (TPB) constructs assessing their cognitions for delivering the new curriculum at pre- and post-training and at 6-month follow-up. Interventionists also completed a Diffusion of Innovations (DOI) measure assessing their opinion of whether the new curriculum met characteristics that would facilitate its adoption and use. Interventionists reported strong TPB cognitions for curriculum use before training. Significant increases emerged for some TPB constructs (ps ≤ 0.025) from pre- to post-training, and significant decreases were seen in some TPB constructs (ps ≤ 0.024) between post-training and 6-month follow-up. The interventionists rated the new curriculum as high on all the DOI characteristics. The theory-driven, participatory development process facilitated interventionists' social cognitions towards and adoption of the new curriculum. Positive increases in TPB cognitions from pre- to post-training were not maintained at follow-up. Further research is needed to determine if these changes in cognitions are indicative of a curriculum "reinvention" process that facilitates long-term curriculum use. Understanding curriculum adoption and implementation is a crucial step to determining the potential population impact of the intervention.

A Comparison of Covert and Videotape Modeling Strategies for Training Complex Mechanical Assembly Tasks

Experimentation was conducted comparing videotape self-modeling and videotape peer/other modeling to self-directed mental rehearsal (a covert modeling procedure) and a no-training (physical practice) control condition in training a mechanical device assembly task. Eighty male and female college students were introduced to the assembly task in a timed pretest trial and then videotaped performing the assembly task in a second trial. Over the next 4 days, subjects were randomly assigned to training conditions and repeatedly trained and tested in the mechanical device assembly task. The effects of training methods upon assembly times, self-efficacy expectations regarding assembly task performance, and subjective impressions of the nature and usefulness of training were examined. Superior assembly performance over initial training and at 4 months post-training follow-up was observed for the self-directed mental rehearsal training condition and discussed.

Training children in pedestrian safety: distinguishing gains in knowledge from gains in safe behavior.

Pedestrian injuries contribute greatly to child morbidity and mortality. Recent evidence suggests that training within virtual pedestrian environments may improve children's street crossing skills, but may not convey knowledge about safety in street environments. We hypothesized that (a) children will gain pedestrian safety knowledge via videos/software/internet websites, but not when trained by virtual pedestrian environment or other strategies; (b) pedestrian safety knowledge will be associated with safe pedestrian behavior both before and after training; and (c) increases in knowledge will be associated with increases in safe behavior among children trained individually at streetside locations, but not those trained by means of other strategies. We analyzed data from a randomized controlled trial evaluating pedestrian safety training. We randomly assigned 240 children ages 7-8 to one of four training conditions: videos/software/internet, virtual reality (VR), individualized streetside instruction, or a no-contact control. Both virtual and field simulations of street crossing at 2-lane bi-directional mid-block locations assessed pedestrian behavior at baseline, post-training, and 6-month follow-up. Pedestrian knowledge was assessed orally on all three occasions. Children trained by videos/software/internet, and those trained individually, showed increased knowledge following training relative to children in the other groups (ps<0.01). Correlations between pedestrian safety knowledge and pedestrian behavior were mostly non-significant. Correlations between change in knowledge and change in behavior from pre- to post-intervention also were non-significant, both for the full sample and within conditions. Children trained using videos/software/internet gained knowledge but did not change their behavior. Children trained individually gained in both knowledge and safer behavior. Children trained virtually gained in safer behavior but not knowledge. If VR is used for training, tools like videos/internet might effectively supplement training. We discovered few associations between knowledge and behavior, and none between changes in knowledge and behavior. Pedestrian safety knowledge and safe pedestrian behavior may be orthogonal constructs that should be considered independently for research and training purposes.

Targeting Paretic Propulsion to Improve Poststroke Walking Function: A Preliminary Study

ObjectivesTo determine the feasibility and safety of implementing a 12-week locomotor intervention targeting paretic propulsion deficits during walking through the joining of 2 independent interventions, walking at maximal speed on a treadmill and functional electrical stimulation of the paretic ankle musculature (FastFES); to determine the effects of FastFES training on individual subjects; and to determine the influence of baseline impairment severity on treatment outcomes. DesignSingle group pre-post preliminary study investigating a novel locomotor intervention. SettingResearch laboratory. ParticipantsIndividuals (N=13) with locomotor deficits after stroke. InterventionFastFES training was provided for 12 weeks at a frequency of 3 sessions per week and 30 minutes per session. Main Outcome MeasuresMeasures of gait mechanics, functional balance, short- and long-distance walking function, and self-perceived participation were collected at baseline, posttraining, and 3-month follow-up evaluations. Changes after treatment were assessed using pairwise comparisons and compared with known minimal clinically important differences or minimal detectable changes. Correlation analyses were run to determine the correlation between baseline clinical and biomechanical performance versus improvements in walking speed. ResultsTwelve of the 13 subjects that were recruited completed the training. Improvements in paretic propulsion were accompanied by improvements in functional balance, walking function, and self-perceived participation (each P<.02)—all of which were maintained at 3-month follow-up. Eleven of the 12 subjects achieved meaningful functional improvements. Baseline impairment was predictive of absolute, but not relative, functional change after training. ConclusionsThis report demonstrates the safety and feasibility of the FastFES intervention and supports further study of this promising locomotor intervention for persons poststroke.

Mental health first aid for eating disorders: pilot evaluation of a training program for the public

BackgroundEating disorders cause significant burden that may be reduced by early and appropriate help-seeking. However, despite the availability of effective treatments, very few individuals with eating disorders seek treatment. Training in mental health first aid is known to be effective in increasing mental health literacy and supportive behaviours, in the social networks of individuals with mental health problems. Increases in these domains are thought to improve the likelihood that effective help is sought. However, the efficacy of mental health first aid for eating disorders has not been evaluated. The aim of this research was to examine whether specific training in mental health first aid for eating disorders was effective in changing knowledge, attitudes and behaviours towards people with eating disorders.MethodsA repeated measures, uncontrolled trial was conducted to establish proof of concept and provide guidance on the future design of a randomised controlled trial. Self-report questionnaires, administered at baseline, post-training and 6-month follow-up, assessed the effectiveness of the 4-hour, single session, mental health first aid training.Results73 participants completed the training and all questionnaires. The training intervention was associated with statistically significant increases in problem recognition and knowledge of appropriate mental health first aid strategies, which were maintained at 6-month follow-up. Sustained significant changes in attitudes and behaviours were less clear. 20 participants reported providing assistance to someone with a suspected eating disorder, seven of whom sought professional help as a result of the first aid interaction. Results provided no evidence of a negative impact on participants or the individuals they provided assistance to.ConclusionsThis research provides preliminary evidence for the use of training in mental health first aid as a suitable intervention for increasing community knowledge of and support for people with eating disorders to seek appropriate help.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12611001181998

Development and interrater reliability testing of a telephone interview training programme for Australian nurse interviewers

The final phase of a three phase study analysing the implementation and impact of the nurse practitioner role in Australia (the Australian Nurse Practitioner Project or AUSPRAC) was undertaken in 2009, requiring nurse telephone interviewers to gather information about health outcomes directly from patients and their treating nurse practitioners. A team of several registered nurses was recruited and trained as telephone interviewers. The aim of this paper is to report on development and evaluation of the training process for telephone interviewers. The training process involved planning the content and methods to be used in the training session; delivering the session; testing skills and understanding of interviewers post-training; collecting and analysing data to determine the degree to which the training process was successful in meeting objectives and post-training follow-up. All aspects of the training process were informed by established educational principles. Interrater reliability between interviewers was high for well-validated sections of the survey instrument resulting in 100% agreement between interviewers. Other sections with unvalidated questions showed lower agreement (between 75% and 90%). Overall the agreement between interviewers was 92%. Each interviewer was also measured against a specifically developed master script or gold standard and for this each interviewer achieved a percentage of correct answers of 94.7% or better. This equated to a Kappa value of 0.92 or better. The telephone interviewer training process was very effective and achieved high interrater reliability. We argue that the high reliability was due to the use of well validated instruments and the carefully planned programme based on established educational principles. There is limited published literature on how to successfully operationalise educational principles and tailor them for specific research studies; this report addresses this knowledge gap.

Translating Knowledge Through Blended Learning: A Comparative Analysis of Face-To-Face and Blended Learning Methods

This study is a comparative analysis of the impact of traditional face-to-face training contrasted with a blended learning approach, as it relates to improving skills, knowledge and attitudes for enhancing practices for achieving improved employment outcomes for individuals with disabilities. The study included two intervention groups: one participated exclusively in a half-day traditional face-to-face training program entitled Disability is Diversity; the other participated in both the traditional program and also accessed a series of additional online tutorials to reinforce knowledge translation. The pre-/post-analysis of participants indicated a statistically significant increase in knowledge and intentions of improving employment outcomes for people with disabilities across both groups. A six-month post-training follow-up provided important details about the continued impact of training on improving employment for individuals with disabilities. Specifically, participants who participated in the blended learning model were more likely to advocate the use of leading practices compared to those who attended only the traditional program. Thus, use of a blended learning model appears to increase capacity building of practicing professionals as they approach employment issues for people with disabilities as an issue of diversity, leading toward improved employment outcomes.

A new frontier in spaced retrieval memory training for persons with Alzheimer's disease

The objective of this pilot study was to investigate how a memory training technique called “Spaced Retrieval” (SR) might be effectively applied in helping persons with Alzheimer's disease improve their recall of recent events. Capitalising on the interdependence among spared and impaired memory systems, it was hypothesised that SR training with support at encoding and retrieval would facilitate the retention and recall of meaningful recent events. Eight participants with a diagnosis of Alzheimer's disease or related disorder were recruited for this study. The study employed a quasi-experimental multiple baseline treatment design across participants, items, and behaviours. SR training was provided in three domains: Semantic, Prospective, and Episodic recent memory. The results show important training gains made by all participants across conditions at post-training follow-up. In the Episodic condition, participants were able to recall specific details about recent events following training. This study provides preliminary evidence that individuals with mild to severe cognitive impairment can learn and recall new episodic information through Spaced Retrieval training. If replicated, these findings would support the use of Spaced Retrieval as an intervention tool to help individuals maintain their functioning in the area of episodic recent memory.

CSM 2012 Orthopaedic Section Platform Presentations (Abstracts OPL1–OPL64)

CSM 2012 Orthopaedic Section Platform Presentations (Abstracts OPL1–OPL64)

Coping with challenging behaviours of children with autism: effectiveness of brief training workshop for frontline staff in special education settings

The present study examined the effectiveness of three staff training elements: psychoeducation (PE) on autism, introduction of functional behavioural analysis (FBA) and emotional management (EM), on the reaction of challenging behaviours for frontline staff towards children with autism in Hong Kong special education settings. A sample of 311 frontline staff in educational settings was recruited to one of the three conditions: control, PE-FBA and PE-FBA-EM groups. A total of 175 participants completed all three sets of questionnaires during pre-training, immediate post-training and 1-month follow-up. Findings showed that the one-session staff training workshop increased staff knowledge of autism and perceived efficacy but decrease helping behavioural intention. In spite of the limited effectiveness of a one-session staff training workshop, continued staff training is still necessary for the improvement of service quality. Further exploration on how to change emotion response of staff is important.

Diagnosis of tuberculosis in Ghana: The role of laboratory training

The laboratory is considered the cornerstone of tuberculosis (TB) control programme. International review of Ghana's programme in the late nineties identified the laboratory services as the weakest component. Sputum smear microscopy (SSM) being the main method of diagnosing pulmonary TB in Ghana, the training objectives were to: (i) strengthen the knowledge and skills of laboratory personnel on SSM (ii) impart necessary techniques in biosafety and (iii) introduce a Quality Assurance (QA) system in order to strengthen SSM services. Personnel were selected for training during a nationwide situation analysis of SSM centres in 2000/2001. Four training sessions on SSM/QA were held between 2001/2004. A total of 80 personnel were trained: 10 regional TB coordinators and 70 laboratory personnel. The participants upon return to their respective regions also organized training within their districts. This approach resulted in another 100 district TB coordinators and 200 laboratory personnel being trained. Improvement in smear preparation, staining and reading ability of the participants were observed during the post-test and subsequent visit to their respective laboratories. The training has led to strengthening of TB laboratory services in the country and has contributed to increase in case detection from 10,745 in 2000 to 11,827 in 2004 and 14,022 in 2008. It was observed during the post-training follow-up and quarterly supervision visits that morale of the personnel was high. Continuous training and re-training of laboratory personnel on SSM and QA at regular intervals do play an important role for effective and efficient TB control programme.

Changes in health workers' malaria diagnosis and treatment practices in Kenya

BackgroundChange of Kenyan treatment policy for uncomplicated malaria from sulphadoxine-pyrimethamine to artemether-lumefantrine (AL) was accompanied by revised recommendations promoting presumptive malaria diagnosis in young children and, wherever possible, parasitological diagnosis and adherence to test results in older children and adults. Three years after the policy implementation, health workers' adherence to malaria diagnosis and treatment recommendations was evaluated.MethodsA national cross-sectional, cluster sample survey was undertaken at public health facilities. Data were collected using quality-of-care assessment methods. Analysis was restricted to facilities with AL in stock. Main outcomes were diagnosis and treatment practices for febrile outpatients stratified by age, availability of diagnostics, use of malaria diagnostic tests, and test result.ResultsThe analysis included 1,096 febrile patients (567 aged <5 years and 529 aged ≥5 years) at 88 facilities with malaria diagnostics, and 880 febrile patients (407 aged <5 years and 473 aged ≥5 years) at 71 facilities without malaria diagnostic capacity. At all facilities, 19.8% of young children and 28.7% of patients aged ≥5 years were tested, while at facilities with diagnostics, 33.5% and 53.7% were respectively tested in each age group. Overall, AL was prescribed for 63.6% of children aged <5 years and for 65.0% of patients aged ≥5 years, while amodiaquine or sulphadoxine-pyrimethamine monotherapies were prescribed for only 2.0% of children and 3.9% of older children and adults. In children aged <5 years, AL was prescribed for 74.7% of test positive, 40.4% of test negative and 60.7% of patients without test performed. In patients aged ≥5 years, AL was prescribed for 86.7% of test positive, 32.8% of test negative and 58.0% of patients without test performed. At least one anti-malarial treatment was prescribed for 56.6% of children and 50.4% of patients aged ≥5 years with a negative test result.ConclusionsOverall, malaria testing rates were low and, despite different age-specific recommendations, only moderate differences in testing rates between the two age groups were observed at facilities with available diagnostics. In both age groups, AL use prevailed, and prior ineffective anti-malarial treatments were nearly non-existent. The large majority of test positive patients were treated with recommended AL; however, anti-malarial treatments for test negative patients were widespread, with AL being the dominant choice. Recent change of diagnostic policy to universal testing in Kenya is an opportunity to improve upon the quality of malaria case management. This will be, however, dependent upon the delivery of a comprehensive case management package including large scale deployment of diagnostics, good quality of training, post-training follow-up, structured supervisory visits, and more intense monitoring.

The Development and Evaluation of a Parent Empowerment Program for Family Peer Advocates.

Family-to-family services are emerging as an important adjunctive service to traditional mental health care and a vehicle for improving parent engagement and service use in children's mental health services. In New York State, a growing workforce of Family Peer Advocates (FPA) is delivering family-to-family services. We describe the development and evaluation of a professional program to enhance Family Peer Advocate professional skills, called the Parent Engagement and Empowerment Program (PEP). We detail the history and content of PEP and provide data from a pre/post and 6-month follow up evaluation of 58 FPA who participated in the first Statewide regional training effort. Self-efficacy, empowerment, and skills development were assessed at 3 time points: baseline, post-training, and 6-month follow-up. The largest changes were in self-efficacy and empowerment. Regional differences suggest differences in Family Peer Advocate workforce across areas of the state. This evaluation also provides the first systematic documentation of Family Peer Advocate activities over a six-month period. Consistent with peer specialists within the adult health care field, FPA in the children's mental health field primarily focused on providing emotional support and service access issues. Implications for expanding family-to-family services and integrating it more broadly into provider organizations are described.