Background: Parental mental illness is common, costly, can lead to children developing mental disorders and impaired lifetime outcomes, and places a substantial burden on caregiving partners. Family Talk (FT) is a widely implemented, 7-session, whole-family programme, with promising evidence of effectiveness in targeting the intergenerational transmission of mental illness. However, to date, very little qualitative research of family experiences of FT has been undertaken. The objectives of this study were to: (1) investigate the experiences of families attending FT; and (2) explore the key facilitators and barriers to engagement in mainstream mental health settings.Methods: This study was nested within a randomised controlled trial (RCT) of Family Talk [N = 86 families ] implemented in 15 adult, child and primary care mental health sites in Ireland. Semi-structured interviews were conducted with a purposive sample of 45 participants, including 23 parents with mental illness (PMI), 7 partners and 15 children/young people aged 9 to 18 years. Interview data were transcribed verbatim and analysed using constructivist grounded theory.Results: Over two thirds of families across sites reported substantial benefits from participation in FT, including reduced stigma, giving children and partners a voice, increased service-user confidence, and improved family communication/relationships. Key facilitators identified by families included: programme delivery by a competent, non-judgmental clinician; the whole-family approach; and family readiness to engage. Barriers to engagement included stigma, family crises/relapse, service constraints, impact of COVID-19, and a need for further child, family and follow-up sessions/supports.Conclusion: This study is the first qualitative analysis of family experiences of FT to be conducted within the context of an RCT and national programme to introduce family-focused practise for families with PMI. The findings illustrate that FT is beneficial across cultural/policy contexts, different mental disorders and can be implemented across adult and child mental health settings, including children with existing mental health challenges. Key barriers and facilitators to implementation were identified by families, all of which should help to inform the future implementation of FT, and other similar interventions, both in Ireland and elsewhere. It is estimated that 23% of all families have at least one parent who has, or had, a mental illness; this has been shown to increase the risk of children developing a mental disorder during their lifetime range 41 to 77%), whilst multiplying five-fold their utilisation of health and social services, and placing a substantial emotional, financial and parenting burden on caregiving partners  to 77%, .The transmission of risk from parents to children involves a complex interplay of genetic, prenatal, family and environmental/social influences and is significantly mediated by the impact of parental symptoms on parent-child interactions . WorryinAlthough the prevalence and burden of parental mental illness (PMI) is a cause for public concern, there is increasing evidence that integrated prevention and early intervention family-focused programmes/practise (FFPs) can help decrease the risk of developing mental disorders for children by up to 40%  and reduFamily Talk (FT) was developed by William Beardslee and colleagues in the USA in the 1980's and is a manualised, 7-session, strengths-based, psycho-educational, whole-family approach designed to enhance family understanding and communication about parental mental illness, improve family interpersonal relationships, and promote family resilience and utilisation of social supports . The intDue to its small but growing evidence base, FT has been implemented in recent years in several countries to support families where a parent has mental illness  . InternaPromoting Research and Innovation in Mental hEalth seRvices for fAmilies and children), the primary aims of which were to: (1) identify/develop, implement, and evaluate family-focused interventions for families with PMI; and (2) inform a “think family” care delivery agenda within mental health services in Ireland. Following an initial scoping study that demonstrated a lack of structured support for this population in the RoI, it was agreed with stakeholders that clinicians across 15 AMHS, CAMHS and child protection/welfare service sites would deliver Family Talk as part of a randomised controlled trial (RCT), with embedded qualitative and economic analyses  in 15 sites across the RoI, involving adult, child, and primary care mental health services, and Tusla child protection services . Familien = 56) or to a treatment as usual control group (n = 30). Assessments were carried out at baseline and at six month follow-up periods. At six-month follow-up, attrition was 37%, the rate of which doubled due to the impact of the COVID-19 lockdown restrictions (22.8 vs. 45%). More details on study parameters can be seen in the study protocol  for interview on the basis of key demographic variables  socioeconomic status). A series of 37 one-to-one semi-structured interviews and 3 group-based family interviews were undertaken at 6 month follow-up with a total of 45 participants from 23 families, including 23 parents with mental illness (PMI), 7 partners and 15 children/young people aged 9 to 18 years. . Fourteen families attended all FT sessions while nine dropped out after completing less than three sessions, and were interviewed to provide a “negative case” analysis. In the RCT sample, mean attendance in the intervention group was 4.4 sessions (SD = 1.2), with 53% attending all sessions.For the qualitative study, a purposive sampling method was used to approach prospective participants (SD = 8.2) and were predominantly female (18/23), Caucasian (22/23), and socially disadvantaged (15/23); approximately half (11/23) were lone parents and the largest proportion reported anxiety/depression (n = 14/23), followed by bipolar disorder (n = 4), Borderline Personality Disorder (n = 2) and psychosis (n = 3). Six of the seven partners who agreed to be interviewed were married. Ten of the 15 child participants were male with a mean age of 13.2 years (SD = 2.8), and approximately half (8/15) reported attending, or were on a wait list for, CAMHS. The children in the larger RCT tended to be more evenly distributed by gender and were also a little younger , whilst 42% were attending either CAMHS or psychology/family services  had a mean age of 41.6 years  was obtained from four research ethics committees including the HSE, the research institution where the research was carried out [name withheld for anonymous peer review], and two of the services with whom the research team worked .n = 38), SMcGa (n = 7)], with lived experience of PMI, and with qualifications in psychology, mediation and psychotherapy. Given the stigma and impact of PMI, every effort was made to create a warm and non-judgemental atmosphere to ensure that participants felt understood. In addition, rapport had been established prior to the interviews as both researchers had prior contact with families during the baseline and 6 month RCT assessments . Parents received a €25 gift voucher as a token of thanks for participating in the qualitative interview and children received a €10 voucher. Interviews were audio recorded with consent and transcribed verbatim.Consent/assent forms were administered to parents and children, outlining details of the PRIMERA study, its potential benefits/risks, and where to seek help if necessary. Parents provided written informed consent for their children to participate and then their children provided written informed assent. Interview schedules were devised for each of the three participant groups in order to guide, and provide a framework for, interviews. These included questions such as “Tell me about your experience of FT, “What did you like about it?,” “What would you change about FT?” and “Would you recommend FT to other families?” Families who completed <3 sessions were asked their reasons for not completing FT. Interviews lasted between 15 and 40 min, with 33 (73%) conducted in participant's homes, and 12 (27%) via online platforms during the COVID-19 lockdown restrictions. There was some evidence of possible gatekeeping in three families with the PMI limiting access to family members. In addition, two parents requested to sit in on the children's interview. The interviews were conducted by experienced researchers  vantage point how it affected them and try to give them what they wanted to try to move on.” (PMI 4)“She [daughter aged 11 years] said she wasn't a very good daughter. When I was getting cross or why things weren't harmonious in the house, she felt that it was her fault.” (PMI 16)“I was able to think of them more as people rather than my children that I'd be trying to protect, keep them safe from everything…Anything that they needed to talk about or worried about, and without fear of repercussion. Being able to say it in a safe place was good, for all of us really. There were tears and everyone at the end of it felt good and felt heard and respected in it.” (PMI 13)“I just felt brilliant after it and I was able to tell them how proud I was of them and how much I love them. I can't just put words on it. But it has changed us for the better.” (PMI 15)“The direct involvement of children also helped parents to re-evaluate their understanding of children's prior behaviour; instead of assuming that silence indicated the child's lack of awareness of the illness or lack of care for the parent, the PMIs realised that a child's silence is more often an attempt to protect the family and/or to avoid burdening them.Beforehand I was saying, oh they don't want to talk to me… It's that they didn't want to be putting extra worry on me about anything because I had a mental health issue.” (PMI 6)“I did not realise my eldest was being bullied for 2 years in school during my illness. He kept it to himself because at the time, he worried about me killing myself.” (PMI 1)“Service-user parents also indicated that the sessions improved their communication with, and support from, their partners, as well as from their children. Overall, improved family interactions and relationships appeared to assist mental health recovery and personal and parental confidenceIt gave me a sense of kind of, well not accomplishment…it was a huge sense of like, I'm doing this, I'm going to help [the children]…Having been through it, it gave me strength in a way.” (PMI 2)“All but three the children (12/15) reported that they found FT to be helpful despite their initial reservations about attending and the emotional challenge of participating in individual/family session . Children indicated that they felt empowered by the opportunity to: voice “hidden” concerns about PMI, family dynamics, and other issues; and to develop a deeper understanding of their parent's mental illness. Previously undisclosed concerns included: distress with the PMI's behaviour  and/or with arguments and tension at home, feeling overburdened by caretaking activities, being bullied, educational disruption, child depression, suicidal ideation, feelings of blame, fear, sadness and injustice/anger. Eldest and only children were more likely to carry a largely unacknowledged burden in caring for family members, especially during heightened presentation of symptoms. Caretaking responsibilities included: caregiving, cleaning, shopping, cooking, financial responsibilities, and looking after the emotional well-being of siblings and the other parent. The dominant unspoken message of silence around PMI, combined with an often unavailable partner , left children feeling overwhelmed and unsupported.Dad was absolutely working his ass off to try and get money for us and taking care of Mam and running in and out of hospital. And doing school with us, trying to get us to do our homework and everything. He needed a lot of help. From a young age, myself and my sister had to take on a role, me more so because Dad was working and trying to provide. Mom was either in bed or in hospital, so I'd be like at school, have to come home, mind my siblings, my sister had to cook.” “I do get in a terrible mindset when it comes to my Mum's mental health because it's not nice… impacts on all of us as a family.” “I ask Mum for a lot of days off school because I get fed up with all the bullies...I used to have dark thoughts, not wanting to wake up.I do worry a lot. Because my Mum doesn't really have another person to help her, I'm normally that other person.” “I pretty much have been in a really bad state since I was about nine, really low depression and suicidal. The only reason I didn't tell my parents was because my Mum's sick, my Dad doesn't care. It's not that they don't care, it's just that my Dad was working. I was kind of like, my Mum's in bed sick. I can't be talking to her, she needs to get better first.” “Many children indicated that their parents were unaware how much they had been affected by tense/volatile home situations, and had hidden their concerns to avoid burdening parents. As parents became more cognisant of children's needs, family members were motivated to reduce levels of anger/arguments, and to relate to each other in more warm, caring and fun ways, thereby leading to reduced stress and worry and increased child well-being. For instance, family members made more efforts to connect with each other by having regular meals, spending time with each other, and being generally more cooperative and supportive. Siblings also advocated for each other's well-being in sessions, which helped to improve sibling relationships following FT. While there was still some evidence of parentification among children following FT, several expressed relief that FT had broken the silence, secrecy and stigma around mental illness within their families, and that as well as feeling that parents were now listening to them, they also experienced increased empathy and compassion for their parents whom they perceived as “trying their best” in challenging circumstances.I found it was helpful for the family, like to talk about this, because usually when we're home, we don't really talk about it properly.” “I felt like the course has helped quite a lot to be honest. Family life has just got a lot easier. We're not arguing as much, we're not shouting. It's just easier to talk to people now...You have the resources to actually talk about it and try and sort it out.” “It was definitely worth doing. Because without the course we mightn't have known anything about it. And for him [Dad] to understand that we understand what he has. It's kind of improving him and us.” “He [FT clinician] was asking how I was getting along with my Dad and my Mam, and I said, “Ok, we fight a lot, then it improved” and then we were called back in, and we were just saying, “Me and my Dad improved,” and he [FT clinician] said, “That's good.” “I think everyone's being a lot less aggressive, everyone's just trying to be a bit nicer to each other. I think everything's kind of been a lot calmer, especially with my Dad, he's been a lot calmer recently and he's started to kind of take other people's opinions and ideas into account.” “It helped me a lot. It made me feel better.” “While partners corroborated the benefits noted above, the largest single gain from their perspective, was that FT provided them with a forum in which they could voice their experience of partnering and co-parenting with a PMI, often for the first time, despite their partner being in mental health services sometimes for up to 20 years. All partners spoke of the stresses of caregiving, financial and household responsibilities, feelings of loneliness, frustration and helplessness, and strains on their marital relationships. Partners indicated that their isolation was amplified by exclusion from the PMI's treatment/care plan, and that they lacked the knowledge or skills to help their partner. Maintaining the focus on the service user's ill health also negatively influenced some partners' self-care, with three partners (3/7) managing their own mental health difficulties including anxiety, depression and alcohol misuse.You feel like you're carrying a whole house on your shoulders. You feel like a right tool. I can't do anything right. I can't say anything right. I can't help…I don't know what to do.” (Partner 6)“I needed to ring someone, just for advice or help. But there was nobody.” (Partner 4)“Over the last 4 or 5 years, we even talked about splitting up.” (Partner 3)“All partners described relief at having their experiences validated by the FT clinician and acknowledged by the PMI. While heated discussions and angry outbursts were common in the initial sessions, they were seen as worthwhile as it increased understanding and empathy between parents on the burdens that each was carrying. Five partners indicated that their relationship with the PMI had improved following FT. Partners also expressed to the PMI that they wanted to know how best to support them and wanted to be involved in their careplans. The dialogical approach of FT sessions helped to encourage a team approach to supporting the PMI, helping both parents feel more connected.It's an opportunity for him [husband] to hear me voicing the impact that it has on me in a very calm manner, because I'm in front of somebody else. It also takes away some of the guilt or the blame for me on his side… when you are more involved in the treatment.” (Partner 3)“These sessions were great because we were both able to see where the other person was coming from.” (Partner 1)“I think it [Family Talk] is 100% needed. As I said, there was nobody out there for me or the kids that I knew about… I can't compliment it enough. It's just the best thing that happened.” (Partner 4)“The majority of PMIs and partners indicated that it was the skill of FT clinicians that mediated the benefits for families. Parents welcomed the non-judgemental and strengths-based approach adopted by clinicians, and their skill in facilitating multiple perspectives across several developmental ages. In addition, the PMIs (12/16) appreciated the clinician-led, psycho-educational aspect of the programme, which led to a deeper understanding and normalisation of their mental health challenges.Family Talk was very positive because there was somebody, a trained professional who had seen this before-it was in a way normalised. The kids were worried they were the only family in Ireland who had this problem.” (PMI 5)“Everything that I talked about and went through, I had full support from her [FT clinician]. I can't even tell you how good she was. I can't say it enough. She was unbelievable.” (PMI 12)“Everyone can say how they felt without any fear...Everyone felt very good afterwards and it was like a weight lifted… It's like a friendship with someone [clinician] that knows what you're talking about.” (PMI 13)“All family members believed that FT worked because it involved the whole family, and allowed multiple, often hidden, stigmas, concerns and burdens to be revealed and shared, thereby validating each person's lived experience, whilst also empowering them to be more supportive of each other. Participants indicated that the focus on the family unit had helped them to look beyond their individual burdens and to feel deeper understanding and empathy for each other.It [FT] opened up the family and they talked about what they wanted to say and everything and you knew exactly where you stood, and it was up to you then to change the wrong things to try change them to the right things...It was brilliant because it brought out everything, the good and the bad, which was good.” (Partner 7)“I just remember it was good for our family to actually talk properly without any kind of aggression, without any blame… everyone could just say how they saw things and people would put in their input without anyone kind of being upset about it. It was good to have like outside influences making sure everything was just calm.” “Parents also indicated that timing, setting and their readiness for FT were important factors in engagement. If approached too early, they said that they might have denied the impact of their illness on their family/children. They also required a lead-in time to build up the courage and find words for the difficult initial conversations with their partners and children in order to convince them to participate. Furthermore, in order to engage properly with the programme, they indicated that they needed to have recovered from their worst symptoms. Parents also valued the flexibility of holding sessions within their homes or within clinics.We did it during the summer and it was ideal, we walked to it [clinic] through the park and went for coffee afterwards, just the whole experience of going was great for the family.” (PMI 4)“This time last year I wasn't feeling well so I was able to focus on it this time.” (PMI 9)“Key barriers to participation occurred during one of three phases, each of which was identified here as a subtheme including: (a) initial engagement; (b) attending the intervention; and (c) the concluding phase. An overview of challenges to participation can be seen in The most common barrier for families attending FT was parental attitudes/beliefs and stigma around mental illness. Parents were hesitant about participating for the following reasons: they felt stigma and shame in openly discussing their mental health challenges in the family context; they believed they were protecting children from the impact of their illness by not discussing it; they feared what their children would say; and a few were not ready to acknowledge that their illness might affect their children. Families required extensive preparatory input from clinicians to allay their fears to persuade them to engage with FT.The hardest part was actually admitting to him [the child] that I suffer with mental health problems. I hid away because for a long time, I have suffered with the stigma that goes with it.” (PMI 15)“There's a very big stigma there. To make it easier to get through to him [partner], I think having someone else outside [clinician]. Through that, I felt a lot safer to try Family Talk.” (PMI 12)“Several children also highlighted their reservations about attending FT in terms of not understanding its purpose, fearing the focus would be on their wrongdoings (perceived or otherwise), and distrusting the viability of open discussion with typically uncommunicative parents. A couple of parents admitted that they had deliberately not clearly explained the purpose of FT to their children, for fear they would not attend.I would have preferred a bit more information. I didn't know what to expect and when we went in to speak with the girl who was doing it, I didn't know if the questions were going to be directed at us or about our parents. I was getting agitated because I was confused.” “I wasn't clear what it was about so I didn't know what to say.” “In addition, service constraints  disrupted/delayed FT delivery which meant that some families had an FT clinician with whom they were unfamiliar, meaning that additional time was needed to build rapport and trust before starting the intervention.I had never met her [FT clinician] so I think if maybe we had one or two sessions before just to get her to know a little bit better.” “Four of the interviewed families did not start FT due to family challenges and service constraint issues including: relapse in parental mental health; dealing with family crises ; deciding not to inform children about FT; being discharged from CAMHS before they could start FT; and suspension of FT delivery due to COVID-19 lockdown restrictions. It was interesting to note that discharge from CAMHS was cited as a reason for non-engagement because this reflects the lack of managerial priority given to family work and a perception by some CAMHS clinicians that working with parents is outside their service remit.We really wanted to do Family Talk but our daughter told us she was sexually assaulted so it wasn't the right time.” (PMI 20)“We were meant to go to it [FT] but then we were discharged [from CAMHS] and that was the end of it.” (PMI 18)“The findings suggest that FT was challenging for many families despite the non-judgemental support provided by FT clinicians. Several parents/partners reported difficulties in speaking openly in sessions and/or listening to the experiences of family members, although most ultimately felt that it was worthwhile because it improved family communication. Partners and parents were shocked by their children's previously undisclosed revelations, what children had observed, and the internal narratives being used by children to make sense of the family situation . There was also some unease that clinicians might “selectively” reveal what children had disclosed in the child session, leaving parents feeling uninformed. Furthermore, a couple of service-user parents believed that their partners had undiagnosed mental illness, and consequently were unhappy that the focus was primarily on their own mental health challenges.It was an eye opener. It was upsetting at the time, because to hear your child say certain things, it's really upsetting. But upsetting in a good way.” (Partner 4)“We think we're protecting and sheltering them and, in the meantime, we're doing more damage.” (Partner 6)“Similarly, most children (10/15) reported emotional challenges in engaging with FT. For instance, most children had no prior relationship with the FT clinician and some perceived them as asking too many personal questions too quickly, without allowing time for trust and rapport to build. Four children said that they felt shy and/or embarrassed when answering clinician's questions. A couple of children also indicated that they did not want to answer questions as their parent had not discussed their mental illness with them before the FT child session. Another child left the individual session and informed his mother that he had not revealed anything because the school encourages pupils “not to talk to strangers.” A few children found the family session emotionally volatile but ultimately helpful, while one teenager was initially upset in learning details of their parent's illness. Despite these challenges, the skill of clinicians in engaging children  had helped build a safe space for all but two to open-up and to engage with the process.Sometimes she'd ask personal questions that I wouldn't feel comfortable answering...My mouth goes shut.” “I was just sitting there quietly not really talking or saying anything. I felt completely thrown under the bus. I wasn't surprised. I would have liked more information.” “It was kind of emotional but then it got helpful and pleasurable. We got to say what we wanted to say. Dad has become more open. He shows his emotions now. He used to bottle them up a lot before.” “Interestingly, within four families, there were widely varying experiences of the perceived utility of FT. In three families, both children and partners reported considerable benefits but the PMI did not. One PMI said that she “did not want to hear what others [in her family] were saying and blanked out,” whilst another was wary of discussing mental health with his children in terms of diagnostic labels and believed the intervention, particularly with the children, was of insufficient duration and should have been delivered years earlier. Both of these parents had severe/enduring mental illness, were currently feeling very unwell, and had a history of being unhappy with mental health service provision. In the fourth family, FT was delivered in the morning when the PMI was heavily medicated, thereby limiting her level of engagement. Furthermore, while the child reported many benefits, both the PMI and her partner found it less helpful. The PMI was disappointed that FT had not focused on her daughter's mental health difficulties or her husband's “control issues,” while her partner said he found it difficult to share his concerns as he believed it would aggravate his wife's emotional instability. These varied experiences highlight that each family member presents with a unique history and motivations and can present a range of challenges for clinicians when considering a family's readiness for FT.Family Talk might not have helped Mum as much but it helped us.” “I just don't think we got a whole lot from it. It is very one sided to be honest… when an issue did come up, if there was something with regards to myself or my husband, they just constantly kept bringing it back to “Well, how does that affect [child]?” (PMI 10)“was getting so emotional because of her own opinions about things and stuff…I wasn't going to start dumping my own out there because it could have got messy and emotional. I didn't want to escalate any kind of like emotions. It was emotional enough. I was just kind of dealing with what was being brought up by [partner] and [child].” (Partner 1)“[The PMI] The COVID-19 pandemic restrictions have been shown to have had a considerable impact on population mental health and on those with pre-existing mental illness, both in Ireland and internationally –44. SeveI don't think we could have dealt with months of isolation if we hadn't done FT. We make time for each other now at this stage. We watch family films or to sit down for dinner, meals.” (PMI 13)“It wasn't the same but we were able to talk with him [clinician] on zoom. It was a while before the children could be seen so it wasn't ideal.” (PMI 5)“n = 5) gave the following reasons. One said that FT was too emotionally upsetting, with another feeling a sense of blame for causing her children's mental health issues. A number of other factors also contributed to disengagement including family crisis, relapse in symptoms, and having too many competing priorities. Additional delays/disruption in FT delivery due to the COVID-19 restrictions also led to some degree of disillusionment and disengagement from mental health services. This was more common in areas where mental health clinicians were partially redeployed to frontline COVID-19 duties and could only provide minimal telephone support to service users “It felt like she was attacking me and it was my fault how the girls are...I don't need that.” (PMI 19)“n = 12) found the programme to be too short and expressed a desire for more child, family and follow-up sessions to build family communication. Families had high expectations of FT, which appeared to be linked to their need for more (often unavailable) psychological and family support from mental health services. Three families reported that they were referred to further mental health supports , while two others were given a list of alternative supports including national mental health charities. Most, typically, parents reported that FT clinicians provided closure by affirming their availability if future issues arose but the lack of follow-up was problematic for some partners who were not offered additional support and who were unable to pay for private treatment outside of statutory service provision. However, it is important to note that three attendee families were interviewed during the first COVID-19 lockdown which severely limited their access to mental health and community services and to other social/family supports at that time. Nonetheless, there were numerous indications that this population would likely benefit from longer-term (family-focused) mental health support.Despite benefiting from FT, most attendee families (It didn't feel like [it] was ready to be finished.” (Partner 3)“I think more sessions with the family…and more time with the children would have really helped. The three of them went in one by one for 20 min. So it might have been a little bit rushed for them, they might not have had enough time.” (PMI 16)“Family Talk is minimal… A taster...I think the hospital might have family therapy…But on a private basis so…” (PMI 2)“This study is the first qualitative analysis of family experiences of FT conducted outside Sweden, the first situated within the context of an RCT of FT, and as part of the first nationwide endeavour to introduce FFP to adult and child mental health services in the RoI. The qualitative findings, in line with those reported in Swedish psychiatric settings –37, indiImportantly, the findings reported here, indicate that FT is acceptable and beneficial for families across different cultural/policy contexts, mental health settings, types of mental disorders, and among children with and without existing mental health challenges. Firstly, unlike Scandinavian countries where legislation has been introduced to safeguard children of PMI and where FT is implemented on a national level, the RoI lacks any “think family” policy/practise guidance for this population whilst service and public awareness of the need to support this population is erratic/unsystematic. There are also continuing high levels of mental health stigma in Ireland, which is an important barrier to help seeking , 45, 46.Secondly, even though AMHS may appear the most natural fit for FT/FFP and provide a common context for the implementation of FFPs , 48, 49,Thirdly, there did not appear to be any notable variations across family experiences here in terms of the PMI diagnosis, thereby highlighting the suitability of FT for disorders beyond parental depression, which was the original focus of the programme . Whilst a small number of adult service users who attended all FT sessions felt that it had not been helpful, their children/partners, and other service users with similar disorders, reported a range of benefits. Similarly, two PMIs, suffering from depression and Borderline Personality Disorder respectively, indicated that they disengaged from FT after two to three sessions as they felt blamed/upset by the idea that their mental illness may affect their children. Previous qualitative studies have indicated that while FT may work across a range of disorders, those with Borderline Personality Disorder or low-functioning psychosis are more likely to struggle with establishing a therapeutic alliance and/or exhibit a lack of understanding/insight into the impact of their mental illness on their children , 37. Lowhttps://fampod.org/file.php/1/collaborations/Columbia_Application_of_PIP.pdf). An interesting study by Marston et al. showed that when parents were given a family-focused DVD, but did not receive the support of a clinician, their understanding of the impact of their illness improved, but they did have the confidence to open up a dialogue about the illness with their children  had much to say about their involvement. This interval was necessary due to blinding in the RCT which had to be retained until after the 6 month assessment had been completed. Lastly, 7 of the 23 families were interviewed during the first COVID-19 lockdown, which severely restricted access to services and led to increased levels of psychological distress in the general population in Ireland  created recall difficulties for three of the younger children in our sample, although the remainder  and should, ideally, be implemented as part of a suite of lower and higher intensity FFPs . There iFurther qualitative and quantitative research on family and clinician experiences of FT implementation is required across different cultural/policy contexts, mental health and family settings, types of mental disorders and level of child mental health difficulties. Further research is also needed on the types of families that are more likely not to engage with FT, and to identify measures and/or supports that might increase engagement. For instance, there may be value in developing and evaluating training videos that teach recruitment strategies to see whether they improve engagement. In addition, qualitative analyses may inform RCT evaluations of FT/FFPs; for instance, RCTs could include as outcome measures, benefits identified in qualitative analyses, such as reduction in stigma, parental confidence/competence, service-user mental health, partner well-being, and family functioning. Moreover, facilitators and barriers to implementation identified in qualitative studies could be tested as moderator/mediator variables in quantitative research.Mairead.Furlong@mu.ie.The datasets presented in this article are not readily available because where participants provided consent/assent, an anonymised version of their data will be stored in the Irish Qualitative Data Archive. Ethical approval from an approved higher level institution will be required if the data is to be used in future research. Requests to access the datasets should be directed to The studies involving human participants were reviewed and approved by four ethics committees: the Social Research Ethics Committee in Maynooth University, Ireland (Reference number SRESC- 2018-100), the HSE Research Ethics Committee, Tusla Ethics Review Committee, and the Saint John of God's Research Ethics Committee. Parents/legal guardians provided written informed consent for their children to participate in the study, followed by their children providing written informed assent to participate.CM, MF, and SMcGi conceived and designed the study. CM conducted interviews and coded transcripts, with 25% of transcripts independently coded by MF, SMcGa, and SO'C. CM prepared the initial draft, with subsequent drafts undertaken by MF, with input from SMcGi, CM, and SMcGa. All authors contributed to the article and approved the submitted versionThe PRIMERA research programme is funded by the Health Service Executive and the Maynooth University Higher Education Authority COVID-19 Costed Extension Fund.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Since the COVID-19 pandemic hit, lockdowns have been implemented to fight off infections in countries around the world. Whilst this measure is without a doubt effective against spreading infection, it might also decrease participation in exercise. For older adults, exercise is particularly important in the prevention of falls, and sudden detraining because of a lockdown or due to other causes might have detrimental consequences. This systematic review study aims to assess what is currently known on detraining effects for balance outcomes. Nine studies were included within this review. Results suggest that detraining effects could already be significant as early as 4 weeks after stopping the intervention. Programs that specifically focus on improving balance were more robust against detraining, with most positive effects still being present after 8 weeks. However, even with a specific focus on balance, studies started to show some signs of detraining. The current study is limited by the low number of included studies in the review, indicating a need to further confirm these results. Around the world, populations are ageing , leadingThe concept of detraining has been described in previous literature as “the partial or complete loss of training-induced anatomical, physiological, and performance adaptations, as a consequence of training reduction or cessation” , p. 80. The aim of the current study was to review the available scientific literature on detraining effects after a sudden stop of an exercise program on outcomes related to fall risk. To operationalize this aim, we shall consider fall risk in two ways. Firstly, as a direct measure of fall risk, studies reporting on fall rates would be accepted into the review. Second, as an indirect measure, studies reporting on fall risk assessments will be accepted. This second definition might pose some methodological challenge, since indirect measures of fall risk are numerous  and mighThis systematic review was carried out in accordance with the Preferred Reporting Items for Systematic Reviews guideline  and undeThe initial search was performed on 20 August 2020, by using the following databases: Web of Science , Scopus, PubMed, PEDro, and Cochrane Library. Searches were conducted in English. The option “advanced searches” was chosen for searches in Web of Science, PubMed, and Scopus with regard to the articles’ title, abstract, and keywords. A simple search was done in Cochrane library and PEDro. The Boolean operators used were “OR” within the construct, and “AND” between constructs. The following search terms were used:(detraining OR inactivity)AND“postural control” OR “postural stability”). Only studies written in English were considered. In terms of outcomes, only studies that measured balance control in humans after a period of detraining were included. Here, we consider any study that reports on the effects of a sudden stop to exercise participation to fit this description. No limitations were set to the characteristics of the participants , with the exception that clinical groups in which balance might be affected  were excluded from the review. No limitations were set for the year of publishing. In the first screening step, duplicates were removed using EndNote software. Further screening steps were performed after exporting to Microsoft Excel. Two authors were responsible for the screening process (S.M. and E.S.) and screened first the titles and later the abstracts and, finally, on the full text to sort out papers based on the inclusion criteria. Two authors were responsible for data extraction (S.M. and S.A.). The following factors were extracted for any study that was included in the present review: study design, training duration, detraining duration, measurement tools, groups, age of participants, study results with respect to effect of training, effect of detraining, conclusion, and future recommendations.Methodological quality in all studies was assessed using the Crowe Critical Appraisal Tool . SinFrom the systematic search, 386 papers were identified as potentially eligible for inclusion. Following the article selection steps , nine pan = 1 paper) to 6 weeks (n = 1), 8 weeks (n = 3), 12 weeks (n = 2), 60 days (n = 1), and the highest reported duration of detraining was half a year (n = 1). One included study did not report on detraining from an intervention, but rather “detraining from everyday life” by administering 60 days of bed rest. All of the other papers provided details of an intervention with a length of 8 weeks (n = 1), 10 weeks (n = 1), 12 weeks (n = 2), 16 weeks (n = 3) or 40/80 weeks . DetailDue to the differences in outcome measures and lengths of detraining, it is futile to quantify exact effects of detraining on a week-by-week basis. This is further complicated by studies that did not report on their effects directly post intervention, so it is unclear whether their detraining values later on indicate significant declines after the exercises were ceased . The fiExercises for which lasting benefits were reported after specified detraining periods were, firstly, an 8-week aquatic balance training  and timed up and go (TUG) performance; after 8 weeks of detraining ). SecondIn terms of long-term effects, it is interesting to note the benefits of a strength training protocol reported by Sherk et al.  on maximResults from the quality assessment are depicted in The current study aimed to assess current literature on detraining effects after discontinuing an exercise program on indicators of fall risk. Through our systematic review protocol, a total of nine studies were considered eligible for inclusion in this study. Four studies showed effects that seemed relatively robust against the effects of detraining ,20,22,23It might be argued that bedrest is conceptually different than detraining and, therefore, should not be included in this review. We do not seek to discuss the definition of the concept of detraining in this study and emphasize that out operationalization of this concept (“any study that reports on the effects of a sudden stop to exercise participation”) is just one way to work with this concept. This definition was adhered to because even studies that might not fit the strictest definition of detraining might illustrate important mechanisms for fall prevention in a practical sense. Even though a lock down is not as severe as a bedrest prescription, for older adults who are in risk groups (and may not dare to go outside), this measure will still result in severe increases in sedentary behavior. It is, therefore, promising to see that the effects of bedrest can be offset by even very short bouts of intense exercise . HoweverThe results from the quality assessment showed that the methodological quality of the articles overall was high, with a high variability of scores in the “sampling category”. Future studies in this field would do well to provide a detailed description of their sampling strategy, for instance, by including details on a recruitment strategy, sample size calculation, and target population. It is interesting that the current study set no restrictions to the age of included participants, and yet, all but one study showed a sample aged 62 years or older. This was most likely caused by the inclusion of search terms related to fall risk, as this is commonly assessed using an older cohort. This does limit the generalizability of our results to say most about this older cohort. The generalizability of the results is further limited by the fact that detraining might occur for older adults who regularly participate in physical activity, but it should be noted that, in general, this cohort is known to show high levels of sedentary behavior . One inherent limitation to the study’s design is that our search might not have identified all studies done on detraining, as some authors might not have specifically used this term in their study’s protocol. That is, if a study describes an intervention with pre-test, post-test, and a relatively late retention test, then this could potentially be a useful addition to the current study. However, this is difficult to capture in a systematic search, as terms related to the word “retention” are not specific to this experimental design and significantly increase the number of hits towards the unmanageable. As such, it was decided to specifically focus the search on studies that mention the terms “detraining” or “inactivity” in order to achieve more focused set of search results. This has led to the inclusion of only nine studies, which might limit the applicability of the current results. These results should be further confirmed in future studies before drawing strong conclusions in regards to detraining and fall prevention. The current study can be used to guide future studies in this field. Specifically, future studies could hypothesize that training with a challenge to balance might be less susceptible to detraining effects compared to general training and that training effects would be sustained for about 8 weeks. The current study provides preliminary evidence for the sustained effects of balance training 8 weeks after cessation of specific balance training. However, at this 8-week timepoint, even in the more successful programs, there were outcome variables that started to show significant reductions in performance. It could, thus, be expected that detraining would also start to affect participants in the more successful programs after 8 weeks. Should these results be confirmed in future studies, then it would imply that restrictions that limit the availability of balance training programs might have a negative effect on fall rates for older adults that regularly participate in fall prevention exercise, if they are longer than 8 weeks.


Although an abundance of gerontological research has focused on subjective well-being, quality of life, and life satisfaction, we know little about what matters most to older adults in sub-cultural groups. The purpose of this study was to explore what matters to older Chinese adults.The study used a qualitative interpretive design, drawing influences from phenomenology and constructed meaning through participants’ lived experiences.cultural foundations and categorical themes emerged. This study emphasized the importance of hearing the voices of Chinese older adults and how they viewed well-being, quality of life, life satisfaction, and health care.After data analysis, a core theme of The findings of this study have added to the body of existing knowledge of what matters most to older adults. These insights may advance nursing as it pertains to culturally congruent health care. Challenges faced by older Chinese adults as newcomers or immigrants to North America, specifically Canada, are well documented . ContribThe main purpose of this study is to explore what matters to Chinese older adults, particularly in relation to subjective well-being, quality of life, and life satisfaction. The objectives of this study were (a) to determine what Chinese older adults value in their lives; (b) to document and understand their lived experiences through individual interviews; (c) to examine their Canadian living experience as newcomers and/or immigrants; and (d) to delineate the cultural needs of Chinese older adults. The participants’ voices in this study will help to illuminate the everyday strengths and challenges of growing old in areas where the culture is different from their country of origin.Canada’s population is projected to become significantly more ethnically and culturally diverse by 2031 . ChineseChinese immigrants’ transition to Canada has disrupted their traditional notions of social support from family, friends, and society . LeavingRecent studies have focused on capacity-building for older adults to aid their sense of purpose in life, increasing their ability to positively cope with health issues . Gao et The study uses a qualitative interpretive design, with influences from phenomenology, constructing meaning through participants’ lived experiences. Four main components of the research design are: theoretical scaffolding through evolving literature reviews, sample selection criteria, data collection through interviews, and data interpretation using a phenomenological approach. Phenomenology provides a meaning-oriented image that serves to help people reflect on their experiences and encourages a deeper understanding of these experiences . To gainTo align with qualitative research principles, we considered the credibility, transferability, dependability, and confirmability of our research design . CredibiThe sampling of participants occurred from two Western Canadian cities. Convenience sampling with snowball selection was used to recruit participants who (a) self-identified as having Chinese heritage; (b) were aged 70 and older; (c) lived independently in a Canadian city; and (d) made their own decisions to participate in the study. Invitational posters were placed in ethnic grocery stores, community centers, and social media platforms. A total of 11 participants were interviewed for the study. Confidentiality was assured to the participants, and pseudonyms with the prefix of “Auntie” or “Uncle” are used, as these are respectful ways to refer to older adults in Chinese culture. Research teams from each city coordinated the research process to ensure consistency in the study. Ethics approvals were obtained from two Canadian Universities.A set of interview questions was created by the research team and provided to each participant see . The sevThe interviews were completed in either Mandarin or Cantonese, depending on the participants’ choosing and the questions were presented to them in advance. The interviews were transcribed into written Chinese, then translated into English for further analysis. A double translation method was used to ensure data accuracy. Without knowing the original transcript, an independent Chinese-English translator was responsible for translating all 11 interview transcripts back into Chinese. By comparing the newly translated document to the original transcription, the researchers ensured that the interviews’ content was correctly interpreted.A systematic thematic approach guided the data collection and inductive data analysis process , with adThroughout the analysis process, the findings were organized and reorganized to explore the descriptions and experiences as described by the participants. A variety of steps were taken to enhance the validity of the study. A reflexive journal was maintained for the purpose of bracketing throughout the research process . Within The interpretive description methodology also requires a communication style designed to build rapport, and an allowance for altering initial interpretations ; each ofcultural foundations was interwoven throughout the findings and provided the structure for the participants’ ways-of-being in the world. Four categorical themes of “it’s the little things that matter,” “making the best out of life,” “taking care of each other,” and “the need to understand” were identified as priorities in the lives of older adults in this study.A core theme and four categorical themes were identified through the data analysis. The core theme of cultural foundations emerged. Participants identified the importance of culture and frequently referred to ways of life when they lived in China, Hong Kong, and Taiwan, and how those influences interact with their lives in Canada. The cultural foundations were evident through examples such as dietary preferences and lifestyle choices that bring comfort, family values, and general “ways of-being” with others. Being able to rely on their cultural foundations gave participants the structure for their lives that they need. This core theme of cultural foundations informs the findings of this study.During the data analysis, a core theme of It’s the little things that matter is an overall statement that describes the complexity of Chinese older adults integrating everyday activities into their lives in Canada. Three sub-themes are evident within this theme: the language gap in making daily life decisions, culturally congruent activities into daily routines, and self-balance of Eastern cultural attachments with Western lifestyles.The first sub-theme of the language gap addresses the impact of English as an additional language on a sense of control and confidence in making everyday life decisions. While riding the bus, Auntie Ting shared “when the bus announces the next station, I don’t know what it’s saying . . . I can look at it, but I don’t know what it means.” Auntie Suk-Ping reinforced the language gap in health needs by stating: “the future will be difficult because I cannot say the English term for my illness . . . being an older adult here is so difficult.”The second sub-theme of having culturally congruent activities in their daily lives shines through in participants’ preference of activities they choose to engage in and where they seek out information. Auntie Pui Shan spoke about playing mah-jong : “I play it every night on my laptop,” while Uncle Ming explained he learned the majority of the news through Chinese media: “by watching Chinese TV shows and radio stations, that’s how I get my information.” English speaking media are used “to learn English” (Auntie Ting), while the majority of health information is gained through “Chinese TV, Chinese newspapers, magazines, news” (Auntie Zhengqiu).Participants spoke about the third sub-theme of seeking self-balance of Eastern cultural attachments while living a Western lifestyle. The traditional Eastern concept of filial piety is actualized differently due to the influence of Western living arrangements. Participants live in their own dwellings, away from children: “my daughters live in the States . . . they all have their own families and have to work” (Auntie Suk-Ping). Uncle Xing stated, “we don’t want to rely on them [children], so we live on our own and we do things on our own.” Auntie Yuk Lam shared “my two sons don’t give us money. My daughter gives us money, but not a lot, the money is for her dad to have tea.” Older adults sought out support from their children as needed, “places I don’t know how to get to, [my daughter] usually helps out. She accompanied me when I got my US Visa” (Auntie Ting). Auntie Oi Ling summarized “Generally speaking, we do not bother them unless it’s something special. Just something important, special, like the bank, we would call them and communicate with them. Because we cannot understand things over the phone.”Making the best out of life refers to participants’ resilience to adapt to life changes, being open-minded, and having a positive attitude toward life, home situations, or health challenges. As life evolved, they made meaning of their circumstances and events that occurred with aging, through cultural philosophies. Auntie Pui Shan described: “because I don’t really care about life or death, I’m very open to the idea. I’m 80 years old; I might die anytime. Even if I die tomorrow, it doesn’t matter, just be open-minded.” Auntie Zivi further indicated: “God never said that life would be perfect, that’s impossible. Your life is like the ocean; there will be waves and calm times, so I have to accept the changes in life. This allows me to be more peaceful.”The Five Olds. Because of the participants’ resilience in making the best of their circumstances, they saw the Five Olds in their lives. The Five Olds, or Wu Lao, are a foundation for being, and refer to the importance of having money, a partner/spouse, friends, a home, and health in one’s life (see The five olds (Wu Lao), guide how old people should live their lives . . . the first one is “old partner” (Lao Ban). So, like old people, husband and wife who can take care of each other, “old health” (Lao Jian), “Jian” as in health means that old people must have a healthy body. Then there is the “old home” (Lao Ju), which means to have a place to live . . . “old money” (Lao Ben) means to have money. And then there are “old friends” (Lao You). These are the five olds. Us old people agree these are the basic necessities (Uncle Xing).This theme also includes the sub-theme life see . If oldeWe take care of each other is the theme that shows participants’ appreciation of relationships and social support networks; valuing family, neighbors, and friends that are new and old, near and far. Auntie Yuk Lam talked about the strength of spousal relationships,if you are close to your parents, they cannot be with you your entire life, if you are close to your children, they will grow up and have their own family. So, the closest person to you will always be your husbandand further explained “we don’t have to eat alone. The two of us talk about our grandchildren and reflect on our old days . . . the two of us rely on ourselves.” Auntie Zivi explained how having connections with neighbors helps contribute to a sense of safety, with the use of a well-known Chinese idiom “遠親不如近鄰” (a near neighbor is better than a distant family cousin). The meaning of this idiom is that a close and trusted neighbor is of more value than relatives who live far away, and it speaks to the importance of one’s social network to offer assistance and support during times of need. In addition to neighbors, Uncle Xing shared how hard it is to make new friends after immigrating to a new country: “we know some people here, but so few of them are true friends. We think that friends are important, it’s different from family, friends can help you a lot, it’s like having another option in life, another journey.” Uncle Ming further explained the power of connecting with friends “even though we both live alone; he is only here to help me out if I need anything . . . [A]s for me, I would make some soup for him if he gets sick, we take care of each other.”The need to understand refers to the desire for knowledge, learning, and growth evident in the data. These desires to know appeared to be driven by culture, and provided a foundation for learning, surviving, and thriving within the Canadian landscape. Several participants referred to their involvement with community organizations, and how “Canada’s work in the community has affected me greatly . . . the government helps new immigrants, helps them with adjusting to this new environment” (Uncle Ming). Auntie Ooi Ling expressed that life was more fulfilling whenwe interacted with the outside world. [We] eventually knew about organizations we could go to if we needed help. We like to know what is happening, that was when we became familiar with things . . . it was related to our interaction with society.Auntie Ting referred to specific life skills that are needed in Canada: “everything, like how to do my taxes. I try to go to everything [seminars] . . . I want to learn everything,” and the feeling of self-fulfillment that this learning provides, “I’m proud of myself. I did a lot of things last year, very eventful in a short time period.” Auntie Ting further expressed desire “to try things that I never got to do before, dancing, cooking, and English—they all have benefits.” And finally, participants spoke about the need to hear differing viewpoints as they were learning, “everyone has different interpretations on things . . . all perspectives have their values, so I try to listen to them all” (Auntie Ting).Examining those factors relevant to what matters most to older adults is an important question to address. This qualitative study has considered this very question with a specific, yet diverse, group of Chinese Canadian older adults spread across two distinct geographic areas in Western Canada. Four themes emerged from this work:It’s the little things that matter;Making the best out of life (and the sub-theme of the Five Olds);Take care of each other;The need to understand.Theme one speaks to the notion of cultural foundations as vital in anchoring Chinese older adults as they cope with their circumstances. Maintaining some element of their country of origin and their cultural practices offers them solace and anchors their sense of resilience to face the challenges of living in Canada. These foundations provide them with the psychological buffers to adapt to the myriad of differences between mainland China, Hong Kong, Taiwan, and Canada. Our initial impression of the second theme was more of an attitudinal positioning of the older adults’ resignation to, and acceptance of what they had. However, further insight into these participants is captured with an idiom expressed by Uncle Xing. The Chinese social proverb of the Five Olds  elegantly and succinctly captures some of the pivotal issues vital to these older adults’ health and wellness. According to Another Chinese idiom exemplifies the third theme, “a near neighbor is better than a distant cousin.” The initial interpretation of this idiom is unidirectional, where help received from a neighbour is better than an inaccessible family member. However, a more in-depth look into this idea suggests an inherent need for connection where support is offered via one’s network of friends, and vice versa. The continued exchange forms the basis of connectedness and reflects the need for a social network. Supported by In the “need to understand” theme, there is evidence that Chinese Canadian older adults have an interest in being a part of their surroundings. They also wish to linguistically understand the Canadian health care system and how to access services to maximize and maintain health. What also emerged from the data was an appreciation for the variety of health and wellness initiatives that promote interconnectedness, physical activity, mental acuity, and a general sense of well-being. There was a sense that the older adults felt that their journey was ongoing, and not static. With this insight, it is incumbent on health care system planners to consider how to support the needs of Chinese Canadian older adults in the development of their health literacy as exemplified by the Five Olds or Wu Lao. First and foremost, a key care planning principle will be to incorporate a person-centered culturally congruent approach. Second, health information needs to be available in the Chinese language and integrated into existing care systems that are frequented by Chinese older adults. An alternative plan is to have culturally congruent materials available for those who do not have access to technology. Third, having a health care system that allows them to clarify their understanding of their health situations would be important. Hence, a bidirectionality of communication, allowing for active exchange between the Chinese older adults and Canadian health care providers, may be an essential aspect that emerges from this study. Finally, an ideal situation would be the availability of health care providers fluent in a number of Chinese dialects or ready access to medical translators.This insight is vital to impart to student nurses. During their training, formal instruction on what “matters most” to Chinese Canadian older adults will imbue in students an understanding that this population of older adults have a desire to integrate into Canadian society, but they need culturally familiar tools to assist them to advocate for their health and wellness. It is equally important for students to understand the importance of networks, relationships, and security for this population, and nursing educators need to consider how to incorporate this into their curricula and encourage students to use various media to disseminate health information.The findings from this study link health/wellness with interconnectedness, which is “what matters most” to Chinese Canadian older adults. An exploration of how this notion impacts the health of Chinese Canadian older adults, on a larger scale, could form the basis of a future study.This study has several limitations, and its findings need to be carefully interpreted. The small sample size of the study may not be representative of general Chinese older adult immigrants in Canada. The study took place in 2 of 11 provinces in Canada. The participants’ responses were not differentiated by their sociodemographic characteristics such as gender, age of immigration, level of education, place of origin , and household income. These characteristics may have significant influences on the older immigrants’ ability to adapt and adjust from traditional Chinese to Western culture. Future study could provide insights on the correlation of acculturation experiences on perceived quality of life for Chinese older adult immigrants in Canada.In summary, the results of this study suggest a need for health care providers to develop mindfulness when caring for Chinese older adults. The meaning of cultural health values and beliefs are deeply rooted and have profound impact on the outcomes of individuals’ health and healing journeys. What may seem insignificant may, in fact, make a world of difference in the quality of life for Chinese older adults. Culturally congruent nursing practice elevates positive care outcomes and enhances the quality of life of individuals, no matter where they are from.


The aim of this study was to appraise a recently developed preparedness model for the provision of oral health care during a threat such as the COVID-19 pandemic from the perspectives of oral health care providers, administrators/staff, and patients.how to prepare for oral care during a pandemic, while answering open-ended questions about the model content and visual presentation. Interviews and group discussions occurred between April 2020 and January 2021, were audio recorded, and transcribed verbatim. An inductive coding process was used to identify themes, subthemes, and categories of information until saturation was achieved.An exploratory qualitative inquiry via at-a-distance semi-structured interviews and group discussions engaged a purposefully selected sample of oral health care workers and patients in British Columbia (BC), Canada. Participants were asked to appraise a preparedness model by considering Seventy-four participants, including 19 dentists, 15 dental hygienists, 10 certified dental assistants, 9 administrators, and 21 patients, suggested modifications to the recently developed preparedness model. Individual interviews (41 participants) and group discussions (33 participants in groups ranging from 2 to 9 attendees each) lasted for an average of 53 min. Eighty-four hours of audio recordings led to more than 1110 single-spaced pages of transcripts. The thematic analysis identified 82 codes, 12 categories, and four main themes: life-long learning, critical thinking, personal and professional risk, and patient-centred care. These themes were understood within provider characteristics and social and environmental contexts. Participants highlighted the need for the model to focus on information and communication, developing awareness and understanding, inferring risks, and performing oral health care during a threat such as a pandemic or disease outbreak. A modified portrayal of the model was suggested to better represent participants’ perspectives.A recently developed preparedness model for the provision of dental care during an unfolding threat like the COVID-19 pandemic was appraised and modified by oral health care workers. Future studies are warranted to evaluate the modified model for use in the event of another unfolding threat collaboratively with providers, patients and stakeholders. As of May 1 2021, the COVID-19 pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has spread to more than 200 countries and territories, caused over 3 million deaths, and infected more than 150 million people worldwide . Nonethe“the knowledge and capacities … to effectively anticipate, respond to, and recover from, the impacts of likely, imminent or current hazard events or conditions” (p. 21)  have to know what is the best thing to do, and deliver the proper care to me … it is a constant learning process for them I think” .While the fact that providers should ““in order to make sense of the information that is out there, you have to be critical and ask yourself ‘is this possible? is this information correct?’, so you can evaluate what you are reading or listening to”. In the words of a 39-year-old male dentist with over 12 years of experience, “you develop awareness by understanding what is being said and by whom, so you can better appraise the whole situation … you think critically about it”.This theme emerged as some participants reflected on the development of awareness about COVID-19, particularly when asked how the model could help them navigate the pandemic. A currently working 41-year-old female front desk staff member commented, “I was flipping channels the other day and one of those programs pop up, that have a celebrity host …this time discussing the negative impact of lockdowns without referring to any source of information. It is scary to think that programs like this, much like the news from social media, are influencing peoples’ thinking”.Various participants mentioned words like “critical”, “knowledgeable”, “judicial”, “rational”, and “unbiased” when referring to how one would develop awareness, and when considering the qualities of a good oral health care provider. In particular, a 37-year-old female patient who would be attending a dental appointment within 10 days of the interview pondered social media, TV programs, and awareness: “did not want to take any chances”. Others, including a 33-year-old male patient who saw a dental hygienist 6 months after the COVID-19 pandemic was declared, felt it was a matter of common sense and hinted at the expectation that providers be on top of things, as mentioned earlier:“Look, as a health professional I would only expect my hygienist to be protected and to protect me during the appointment…I had no problem in answering questions about COVID, in having my temperature checked, in wearing a mask until I sat on the chair ... and seeing her [dental hygienist] with that yellow suit-like covering, and a visor ... so we can all be vigilant against this disease and not make assumptions.”Although participants did not question the implication of saliva droplets and aerosols on the transmission of SARS-CoV-2, the risk of infection was front and centre for virtually all those we interviewed. Patients, more than any other group, felt anxious about resuming their dental treatment, and many said they would wait to get vaccinated as they “we hear that we are at a higher risk of infection than others, but in reality the actual transmission is lower in a dental appointment, as I read”.Many of the oral health care workers were perhaps less concerned about the risk of SARS-CoV-2 transmission in a dental setting, given the usual universal precautions and the now heightened public health measures and use of personal protective equipment (PPE). In particular, a 39-year-old male dentist working in two offices for the past 13 years commented that “I guess we all can get this disease, we all can be at risk, but look at the situation in many nursing homes … they got the disease and many died, their bodies did not fight back…it was sad”.According to a 43-year-old female certified dental assistant (not working at the time), the idea of risk and disease development surfaced while reflecting on the situation in nursing homes: “now, more than ever, I want my dentist working with me and booking me in only if there is a need…like, if I’m in pain or have an infected tooth. If it is just to check things out or get a prescription, that would be totally fine over the phone”.The idea of centering care around the patient’s wishes and preferences was highlighted by numerous participants when considering the nature of the treatment. We were told by a 32-year-old male patient, when looking at the modalities of treatment in Fig. “You are not going to the office in person, how is that the same as an appointment if they cannot see what is inside your mouth?”P1 “Yeah, but I don’t think it would be for every case, I mean, sometimes you must go in person”P2 “Exactly”P1 “But what if we can show it with our cameras, from our phones…everybody has one. Wouldn’t that count as a quick check?”P2 The idea of tele-dentistry was received with mixed feelings. The exchange of ideas, presented below, took place between two patients being interviewed in a group. These two patients also discussed the issue of billing for an over-the-phone consult versus in person while considering the provider’s time needed in either situation.“I may be seeing fewer patients now, but I get a sense that they are much more into their daily oral care at home, they are investing in that—last week I was booking a patient for a recall, and he declined while asking me which electric tooth brush to buy, and if a water flosser would help.”For a 35-year-old female dental hygienist with more than 10 years of experience and currently working, at-home prevention was highlighted: “extensive and with a lot of information … holistic but perhaps too much to digest and use” . Modifications were suggested from the other participants. One of the main points brought up was the fact that Fig. “I see the predictors as good concepts, but how can it show the evolution or change of the information influencing them? I mean, if you infer the risk about an infection, you base [it] on the knowledge you have at the moment. But that knowledge may change as we know more. And that would impact the way we infer the risks. So, it has to allow us to go back and re-assess ” .Very few participants agreed with original portrayal in Fig. “I would draw arrows that allow you to go back a step or two and not only a one-way flow, as things change and what was true one day, might not be on another”. A clear example of this change in information and knowledge was the use of facial coverage/masks, at least in BC, as one participant noted: “if you look back, the use of masks in indoor spaces like stores was suggested by the Health Minister, but not mandatory. Now, look at what happened: you will not be allowed inside a store if you do not have face coverage” .In turn, various participants suggested double-sided arrows or retroactive pathways to convey the idea of re-assessing a previous step based on new or modified information. For a 46-year-old female dental hygienist with 22 years of experience, “those aspects of the provider characteristics are key, yes, but too many words there … they sort of overshadow the model” . More specifically, one participant suggested “moving that information [provider characteristics and social and environmental context] to the top and bottom, almost like overseeing the actual model if you will” . Many patients did not agree with the colour-coded scheme to show positive or negative ideas, as conveyed by a 42-year-old male patient currently seeing an oral health care provider: “I mean, take media for example, it can be a good thing [green] when it is based on science, but a bad thing [red] when based on fake news.”When asked about the visual representation and need to rearrange Fig. “The new model is much clearer, and the back-and-forth flow of information is shown by the multiple arrows, together with the top and bottom double-sided arrows showing continuity” .“it is a new portrayal, yes … the text inside the now larger arrows illustrates the importance of those things, particularly the life-long learning that we all have to embrace and not just wait for things to happen” .With the suggestions provided during the interactions, a modified portrayal of the model was developed Fig.  and sent“well, it does not look as professional as the first one…I mean, I would try making this model look like the first one, graphically speaking” . Lastly, 21 participants suggested the model could represent any disease or infection, not just COVID-19. We heard from a currently working 35-year-old female dental assistant that “I know we are in this pandemic now, but shouldn’t this model be used in any other similar event? I mean, knock on wood, but I think this will not be the last pandemic we have”.But for at least one participant, the modified portrayal was not as professional-looking as the original one: The aim of this study was to appraise a recently developed preparedness model to aid in decision-making for the provision of oral health care during a threat such as the COVID-19 pandemic from the perspectives of oral health care providers, administrators/staff, and patients. Such preparedness requires the development of communication plans and collaboration, while remaining flexible and adaptive to changes in disease development. In agreement with our previous findings , 6, the According to the participants, the proposed model should be used not only for COVID-19, but for any other outbreak. The use of a preparedness model is not new, however. From natural disasters  to terro“lifelong learning … provide[s] timely, efficient, and state-of-the-art patient care … where knowledge … [is] rapidly changing” (page 562) [The theme of life-long learning is not new in health literature. According to Panda and Desbiens, age 562) , which iage 562) , 45 can age 562) . Life-loage 562)  particulOne’s life-long learning journey  goes hanFinally, patient-centred care emerged when participants discussed the different levels of oral health treatments available. Patient-centred care is not only about taking care of individuals with dignity and respect, but also involving them in all decisions about their health . Hence, This study aimed at achieving rigour through reflexivity, data saturation, and member checking. Rigor attempted to ensure that the research design, method, and conclusions presented herein were clear, of public access, replicable, open to critique, and free of bias  as we haDespite the findings, our study has several limitations. Although the number of participants was significant and we reached saturation, they do not represent all oral health care workers or patients in BC or Canada; therefore, generalisation of the findings needs to be done with caution. The four major themes presented in Fig. This study appraised a recently developed preparedness model for the provision of dental care during an unfolding threat such as COVID-19 from the perspectives of dental professionals, administrators/staff, and patients. Thematic analysis led to four main themes: life-long learning, critical thinking, personal and professional risk, and patient-centred care. These themes were understood within provider characteristics and social and environmental contexts. Participants highlighted the need to continued focus on information and communication, developing awareness and understanding, inferring risks, and performing oral health care during a threat such as a pandemic or disease outbreak. The appraisal led to modifications into a new portrayal of the preparedness model. Future studies are warranted to evaluate the modified model for use in the event of another unfolding threat collaboratively with providers, patients, and stakeholders.