Program Coordinators from 56 of the 66 existing ACT programs (85% response rate) completed the telephone survey, each of which took from 45 minutes to an hour. Respondents were 75% female (n = 42), 25% male (n = 14). Non-respondents were evenly distributed geographically; 79% (n = 45) classified their ACT team as "urban", and 21% (n = 11) "rural". Respondents (ACT Program Coordinators) had from four to 33 years of experience in the mental health field (mean = 19.5; median = 20.0; SD = 6.45), and from four weeks to 17 years in their current position (mean = 4.2 years, median = 4.0, SD = 3.20). Fifty-one percent of respondents identified their professional background as nursing, 29% as social work, and 10% as occupational therapy.
In general, we found some operational variation across individual programs. This is not surprising since ACT programs are intended to meet the specific needs of the communities served [24
]. No ACT program was identified by the Program Coordinators as being fully compliant with all 33 standards. However, compliance means of 9.0 or higher were reported for 16 of the standards, with means between 8.0 and 8.9 for 11 standards, and means of less than 8.0 for the remaining six standards (15). When asked to indicate the extent to which respondents feel that their program's sponsoring organization has supported and/or empowered their ACT program, the mean = 8.3, where 1 = "Not at all" and 10 = "Completely" (Median = 8.0, SD = 1.48). Fifty-four respondents answered this question, where the minimum value was "5" (n = 3), the maximum "10" (n = 17), and 14 answered "8".
Community Advisory Bodies
The standard with the lowest perceived level of compliance (of all 33 standards) was the standard which requires each ACT program to have a Community Advisory Body (CAB), with a mean of 5.7 (median = 7.0, SD = 3.32). This same standard was also rated the least important of all the standards to the effective functioning of the ACT program with a mean of 6.0 (median = 6.5, SD = 2.62). Further, twelve of the Program Coordinators (25%) rated their ACT program's level of compliance with this standard as "1" (not at all compliant), while eight (14%) rated compliance as "10" (completely compliant).
Rural ACT teams are, on average, reported to be doing significantly better than their urban counterparts at complying with the standard for having a CAB, but they are still not in full compliance. The mean for rural programs is 7.5 (median = 8.0, SD = 2.46), while the mean for urban programs is 5.1 (median = 4.5; SD = 3.52). The difference in the means is significant (p = 0.047). Program Coordinators of rural programs also indicate they believe the requirement to have a CAB is more important than do the Program Coordinators of the urban teams (means of 6.3 versus 5.7 respectively), although this difference is not statistically significant.
The three major themes that emerged from the interviews with respect to the barriers to fully implementing the Community Advisory Body were: external issues; standard related issues; and, organizational/structural related issues. Fifty-one Program Coordinators provided a total of 165 reasons for lack of full compliance to this standard. These reasons for non-compliance range from simply "Not getting around to it" to "it [CABs] doesn't work". Table presents a summary of coded responses, with sample comments regarding the barriers identified by respondents that prevent their ACT programs from being fully compliant with the standard for CABs.
Summary of Barriers to Compliance with Standard for Community Advisory Body
The standard regarding the provision of peer support services through the use of a Peer Support Specialist received the second lowest compliance rating of the 33 standards, with a mean of 6.2 (median = 8.0, SD = 3.74). Sixteen of the Program Coordinators (29%) rated their ACT program's level of compliance with this standard as "1" (not at all compliant). However, when asked to indicate how essential this standard was to the effective functioning of the ACT Program, it was rated much higher (mean of 8.1; median = 8.0, SD = 2.16). The difference between the means for level of compliance and how essential respondents felt the standard to be was highly significant (t(47) = p < .001).
Urban ACT programs (n = 45) are doing slightly better than their rural (n = 11) counterparts at complying with this standard, although on average neither group is fully compliant. Specifically, the mean on the 10-point scale for urban ACT programs was 6.2 (median = 8.0, SD = 3.76), while the mean for rural programs was 5.2 (median = 5.0, SD = 3.68). The difference in means is not statistically significant. However, the rural Program Coordinators felt this standard was slightly more important to the functioning of the program than did the urban Program Coordinators, with means of 8.7 and 7.8 respectively (difference not statistically significant).
The three major themes that emerged from the interviews with respect to the barriers to fully implementing the Peer Support Specialist role were: human resource related issues; organizational/structural related issues; and, standard related issues. Forty-seven respondents provided a total of 73 comments regarding barriers to full compliance with the standard for Peer Support Specialists. The reasons provided for non-compliance range from "we are resolving union issues" to "having trouble recruiting". Table provides a summary of the coding and analysis of the reasons for not having a Peer Support Specialist on their ACT program team, and includes sample quotes from respondents to exemplify the concerns expressed within each of the major coded categories.
Summary of Barriers to Compliance with Standard for Peer Support Specialist
Pearson correlations were used to examine the association between the perceived compliance with, and the perceived level of importance of, the two community participation standards (Table ). The four variables were positively and significantly correlated with one another. Specifically, moderate, positive correlations were found between level of compliance with having a Peer Support Specialist and level of compliance with having a CAB and, level of compliance with having a Peer Support Specialist and level of importance of the CAB.
Pearson Correlations between Importance and Compliance for Community Participation Standards
Table also presents our findings of positive correlations between: the level of compliance with and the perceived importance of having a Peer Support Specialist; the level of compliance with and the level of importance of having a CAB; and, the perceived importance of having a Peer Support Specialist and the level of importance associated with having a CAB.
Additionally, a positive and significant correlation was found between perceived sponsoring organization support and the level of importance ascribed to having a CAB (r = .36, p < .05).
Finally, significant and positive correlations were found between level of compliance with the standard to have a CAB and with each of the standards related to the provision of: crisis assessment and intervention, 24 hours a day, seven days a week (r = .44, p < .001); concurrent mental health and addiction disorder services (r = .30, p < .05); social/interpersonal and leisure skill training (r = .29, p < .05); family-centred services, including education, conflict resolution, and related support (r = .33, p < .05); and, performance improvement and program evaluation which includes criteria and methods for assessing client outcomes, client and family satisfaction, and fidelity to the ACT model (r = .33, p < .05).