Professional Documents
Culture Documents
A Dissertation
Presented to the
Faculty of the
School of Health Administration
Kennedy-Western University
In Partial Fulfillment
Of the Requirements for the Degree of
Doctor of Philosophy in
Health Administration
by
Sarah Velde
Seattle, Washington
Acknowledgments
The author would like to thank the following people for their help,
expertise, direction, support and cooperation of this important research:
Dianne Bell & the Bellevue Delta Society, Rosalie Frankel, Christi Dudzik,
Francis Martin, Megan Wolf and her dog Zorro, Marilyn Lawrence, Ann
Howie, Heidi Ranger, Andrea Wall, Judith Lipton, Heather Toland,
Francine Won, Shirley Desmon, Laurie Hardman, Danielle Vega, Taryn
Hefler, Mark Garcia and Rene Pizzo.
The author would also like to thank the Kennedy-Western
University student advisory staff as well as the proposal and final paper
reviewers for reading and reviewing the proposal and final project.
Abstract of Dissertation
The Development and Validation of a Research Evaluation
Instrument to Assess the Effectiveness of AAT Programs
By
Sarah Velde
Kennedy-Western University
Problem
Formal animal-assisted therapy (AAT) programs currently have few
or no scientific tools widely available to help guide the course of AAT and
measure its overall effectiveness on patients; thus, AAT is in need of more
documentation and evaluation. The purpose of this study was to
thoughtfully construct a worthwhile, scientifically sound AAT effectiveness
evaluation tool for use by health professionals and volunteers who utilize
and deliver AAT.
Methods
A review of literature provides a comprehensive background on
how AAT evolved as an alternative clinical therapy and examines many
past AAT-related studies. As part of the planning and construction phase,
the new tool was first circulated among a group of reviewers in the AAT
profession for suggestions on improvement. The tool was then utilized in
TABLE OF CONTENTS
CHAPTER 1
INTRODUCTION ........................................................................1
Statement of the Problem...........................................................6
Purpose of the Study ..................................................................6
Importance of the Study .............................................................7
Scope of the Study .....................................................................8
Rationale of the Study ................................................................9
Definition of Terms ...................................................................10
Overview of the Study ..............................................................13
CHAPTER 2
REVIEW OF RELATED LITERATURE.....................................16
Physiological Benefits, Stress Reduction and Relaxation.........21
Improving Quality of Life...........................................................31
Pets as Prescriptions................................................................56
A Closer Look at AAT and Pet Visitation Programs.. .64
Animal-Assisted Activities (AAA) ....................... .64
Animal-Assisted Therapy (AAT) ........................ .71
Risks and Problems Associated with AAT................................88
CHAPTER 3
METHODOLOGY .....................................................................97
Approach ................................................................................100
Data Gathering Methods ........................................................104
Database of Study ..................................................................108
Validity of Data .......................................................................109
Originality and Limitation of Data............................................112
Summary ................................................................................115
CHAPTER 4
DATA ANALYSIS ...................................................................116
Discussion of Initial AAT Tool Revisions ................................117
Implementation Results ..........................................................121
Key Informant Findings...........................................................126
Follow-up Survey Results.......................................................139
Discussion of Final AAT Tool Revisions .................................142
Delta Society Considerations ................................................144
CHAPTER 5
SUMMARY, RECOMMENDATIONS & CONCLUSIONS........146
BIBLIOGRAPHY ....................................................................................154
APPENDICES ........................................................................................175
LIST OF TABLES
Table
1. Panel of Reviewers ...........................................................................117
What is man without the beasts? If all the beasts were gone, man would
die from great loneliness of spirit.
- Chief Sealth (Seattle), Duwamish Tribe, 1850
Chapter 1
Introduction
In ancient and primitive times, animals and humans have relied on
each other for existence, survival and camaraderie. Throughout the
centuries, animals have gone from being owned simply for basic necessity
and product to being owned purely for ones fun and enjoyment. The role
of animals has changed, as it has evolved into many different expressions
such as physical, social, emotional or cognitive. A great deal of research
has been carried out relating to pet ownership, pet attachment and how it
facilitates healthy living, well being and enriches quality of life. In fact,
animals have come so far as to aid patients in formal therapeutic settings
such as hospitals, clinics and physical therapy and/or rehab unitshence,
coining the term animal-assisted therapy, or AAT. Determining the
effectiveness of AAT will be the focus of this research.
Today, nearly 60% percent of millions of households in the Western
world have some type of animal, of which the majority are cats and dogs
(Edney, 1995). Millions of pets reside in the homes of Americans; there
are more than 63 million cats, 55 million dogs, 25 million birds, 250 million
fish, and 125 million other assorted creatures that people own and care for
as pets (Hirschman, 1994). Three percent of American households have
a pet reptile of some sort (Wood, 2004). In 1993, the United States
Census Bureau reported that 75% of U.S. households had pets (U.S.
Bureau of the Census, 1993). In fact, U.S. families have more pets than
children. Dogs are more commonly seen in families with young children
(Albert & Bulcroft, 1988). Bulcroft (1990) found 87% of 1000 people
surveyed strongly felt their pet was a member of the family, therefore
concluding that most Americans feel pets are a natural and valued part of
family life (p. 14). Triebenbachers similar study involving grade school
students found that those surveyed felt the same away about pets as
family (1998). A similar and more recent study regarding pets as family
members by Cohen (2002) found that women were less lonely and had
fewer problems in general in living with a pet than men. They also
reported that an average of 16 hours per day with their pet indicated
stronger and higher bonding levels among the women studied. After
discussing the findings at length, Cohen summarized that . . . pets are
firmly inside the family circle (2002, p. 632).
Animal companions are important to all ages. Siegels (1995) study
among 877 teenagers found that half resided in families with pets of some
sort, in which over half of these teens surveyed indicated that their pets
were very significant and important. Interestingly, Johnson and Meadows
(2001) justify todays pet ownership rates, as in a recent article they wrote
as the majority of society has become more technologically dependent
and dispersed through greater mobility, extended family support may be
less available. This phenomenon may in part explain the statistic that
more than half of households include pets (Johnson and Meadows,
2002, p. 617). Bustad (1996) also shared this view, as he stated that:
The importance of animals to the well being of people is
becoming more and more evident. This is especially true as
we realize that at no time in history have so many members
of Western society been devoid of healthy interaction among
themselves and with the environment.
opportunities
and
compartmentalization
has
pet is often an excellent companion for the sick, for the long chronic cases
especially (as cited in an article by Willis, 1997, 78). When an animal is
present, people tend to share stories and readily engage in
communication about pets they used to have.
Day by day, both animal companions and animals used specifically
for therapeutic reasons have made endless positive contributions for
people of all ages and from all walks of life. Physically they have helped
facilitate rehabilitation and healing processes and have enabled us to
become more active and energeticthus reducing blood pressure and
cholesterol levels. Socially they have inspired and motivated us to more
readily communicate with others and reduce boredom. Emotionally they
have provided us the opportunity to become less lonely, depressed and
anxious. Cognitively they have aided us in exercising our thinking skills
and memory. The combination of these four goal-oriented domains
constitute animal-assisted therapy (AAT), a relatively new approach where
animals are incorporated as part of an alternative or adjunct therapy to the
more traditional approach. Because of perceived high patient satisfaction
and perceived patient-therapist-handler success rates, AAT is quickly
becoming more widely accepted and utilized in many health care
organizations across the country.
Problem Statement
Formal AAT programs in the United States currently have few or no
scientific tools in place to help guide the course of AAT and measure
effectiveness on patients. From the fields perspective, AAT is in need of
more documentation and evaluation. Clinical therapists, volunteers and
animal handlers on all levels who utilize and deliver AAT have expressed
a demand for a new, prolific evaluation instrument to use in conducting
AAT sessions.
design, content, validity, reliability and further utilization of the new tool.
In-depth opinions, thoughts and perceptions from key therapist and animal
handler volunteers delivering AAT was sought regarding the use of the
AAT effectiveness evaluation tool. After implementation of the newly
developed instrument commenced, coded data regarding the new tool
was transposed to a study database and examined for reliability and
validity issues. This undertaking was not invasive in any way.
Definition of Terms
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successes and failures of AAT, and may simply desire more research in
order to support already existing evidence of how specifically trained
therapy animals impact patients.
A second audience would consist of lay people who have an avid
interest in this topic, such as veterinarians, allied health care researchers,
and patients and their families who are considering AAT as an alternative
treatment modality.
In the following pages, a thorough review of the literature provides
evidence and findings of past and present literature on the topics of pet
ownership and attachment and the therapeutic value of both animalassisted activities (AAA), and AAT. The benefits and risks of using
animals to facilitate and maintain physical and mental health of humans in
general will be reviewed and described in great length from a historical
context to present day situations. Literature about the quality of life and
various health outcomes for people of all ages and backgrounds who have
owned or have access to animal companions will also be described. A
vast array of clinical studies completed by AAT field experts and other
health professionals will be presented, compared and contrasted as well.
Subsequent to study implementation and data gathering, results
from the study will be presented, displayed and discussed in great detail,
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Chapter 2
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3) Pleasurable activity;
4) Source of constancy; and
5) Opportunity for laugher and play.
Most veterinary educators and practitioners now focus on the
health benefits of companion animal ownership in their curriculums. The
scientific side of AAT and its benefits were first explored in minute detail
by the Delta Society in 1984 (Willis, 1997). The Delta Society is a national
organization that specifically studies and researches the effect of humananimal interactions. Today, in a more recent context, the fact that human
and animal interactions can result in physiological and psychological
benefits is increasingly being accepted, researched and discussed. The
late Leo Bustad, veterinarian and past director of the Delta Society, had
these important words of wisdom to share with the public:
A dog can be a wonderful cheerleader.
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decreased as well while being petted (Dale, 2004). The same was said
for the dogs prolactin levels. This proves that a human-animal
relationship is indeed beneficial to both parties involved. Even as far back
as 1929 readings of a dogs arterial blood pressure decreased as a result
of human touch, and later the dogs primary neurochemicals involved with
human interaction and bonding were increased (Cusack & Smith, 1984).
With all the excitement around the newly published results around
the therapeutic benefits of pet ownership and AAT, the NIH shortly
thereafter funded a comprehensive conference/workshop to increase
awareness, strengthen and promote more AAT research. Jennings (1997)
reaffirmed that the benefits from AAT and pet ownership parallel Healthy
People 2000s goals and objectives around promoting and increasing
physical activity and/or fitness and the prevention and treatment of mental
health disorders.
Goleman and Gurin (1995) reported on a study carried out by
Siegel (1990) finding that elderly pet owners visited their physicians fewer
times in a year than those who did not own pets. In a 1-year health
behavior study among elderly Medicare enrollees, Siegel (1990) contacted
enrollees every 60 days about their number of doctor visits. Of the 938
enrollees, about one-third (37%) were pet owners. Siegels (1990) results
showed that pet ownership among the enrollees was one of the major
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predictors of clinic visits during the study period and that pet ownership
among the elderly may decrease the demand for health care services, as
well as may have helped people cope during stressful and difficult life
events they encountered during that year. Patients in this study generally
reported that they got great comfort from their pets during stressful times
(Goleman and Gurin, 1995, p. 338). In the study, almost 75% percent of
the enrollees had indicated they felt their pet provided feelings of security
and companionship. In this particular study, people felt dogs provided the
best support.
According to important research by Serpell (1991), a series of 4
questionnaires over a prospective 10-month study of 71 new adult pet
owners (47 adopted dogs and 24 adopted cats), survey results indicated
that subjects (especially dog owners) continuously reported fewer minor
health problems such as the common cold, influenza, and backaches;
respondents did not focus on their health problems. They also took more
walks, thus improving their physical status, and reported a long lasting,
improved general health status over the next several months. Positive
results of dog ownership on every level were more significant than those
of cat ownership, as the author speculates this was because of security
reasons leading to improved self-esteem and increased confidence.
Mason (1994) reported on a 1992 cross-sectional survey by Anderson
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a study done by Akiyama, Holtz and Britz (1987) showed that widows who
owned pets had less physical health ailments and less depression than
those who did not. In contrast, however, researchers Miller and Lago
(1989) earlier found that pet ownership in elderly women had no effect on
their physical health.
According to Barba (1995), stress reduction is one outcome of a
formal AAT program. Animals provide many distractions to keep the focus
off oneself, giving people something to focus on rather than the stress
they are enduring. Cole and Gawlinski (1995) studied this and later
witnessed the changes in stress levels in an intensive care unit, as patient
posture changed from stiff to relaxed, and facial expressions became
pleasant and content in the presence of animals.
Researchers Allen, Bascovick, Tomaka and Kelsey (1991)
measured the blood pressures and other physiological stress indicators of
45 women while each performed a set of stressful and challenging mental
tasks such as counting backwards from a high number in a timed and
quick manner. When these women subjects completed the tasks in the
presence of researchers and friends, their stress level was recorded as
high. However, when these same women had their pet dogs near them
while completing the daunting mental tasks they illustrated absolutely no
reaction to stress. As cited by both Friedmann et al (1983) and Cole and
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found that pet ownership and attachment were associated with lower
levels of depression. Animals used in therapy have ranged from domestic
cats and dogs to horses and dolphins. Arkow (1988) stated that animals
have provided many benefits to older adults, as they stimulate social
interaction. Animal companions do not judge; they simply give
unconditional affection to those who allow it, and are therefore treated like
members of the family.
Many studies have found that older adult pet owners who live alone
take better care of themselves. A survey by Cole (1998) among Modern
Maturity magazine subscribers found 95% of them owning a pet, with 89%
of respondents owning a pet solely for companionship. Suthers-McCabe
(2001) supports that finding stating companionship is the most frequently
cited benefit of older pet owners (p. 94). People also keep pets for
security reasons, and those having disabilities may need specially trained
animals to aid them in their activities of daily livingsuch as meal
preparation, walking, dressing and bathing. In general, the elderly
population has reported that pets have fulfilled their needs and have
helped them remain reality based; pets have improved, enhanced and in
some cases restored their self-concept and self-worth while bonding to
them. Whether in private homes, nursing homes or senior community
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long-term care has been the Eden Alternative. The Eden Alternative is
another way to promote happiness and well being within a nursing home.
Many nursing home administrators have been choosing to employ one or
more aspects of the Eden Alternative concept in their facilities.
Dr. William Thomas first illustrated the differences between care
and treatment in his book about the Eden Alternative. As medical director
of a New York nursing home, Thomas was the first physician and pioneer
to implement such a program. In nursing homes, many times care is
carried out as treatment; there is so much treatment, but too little care.
However, in Thomass book, taking care is defined as helping one to live
and grow. Thomas (1996) stated that if we are going to be serious about
taking care of nursing home residents rather than just treating their ills,
many things must change. . . we must face up to the three neglected
plagues: loneliness, helplessness and boredom (p. 23). Ultimately,
Thomas would like to see all nursing homes adopt this mission and be
overall better places to live.
In 1991, Thomas facilitated an approach to accomplish this vision.
It was called the Eden Alternative, and it was first accepted and funded by
the New York Department of Health. The Eden Alternative builds on the
current health care system, but has three different principles based on
biological diversity, social diversity, music and nature. Feeling that it was
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Thomass obligation to fulfill the lives of the residents, he declared that the
primary goal of the Eden Alternative was to do away with the plagues of
nursing homesloneliness, helplessness and boredom. He
accomplished this by incorporating companion animals into long-term
community settings to live with the residents. Thomas hopes to succeed
where treatments and medications fail. In order to promote biological
diversity, Thomass long-term care facility initially adopted more than 100
birds. Each resident was allowed to have a bird in their room if they so
chose. A number of dogs, cats, rabbits and chickens were soon
introduced as well. The Eden Alternative also attempts to improve the
quality of life by involving plants, gardens and children.
A primary idea of the Eden Alternative is to educate the public to
see nursing homes as communities for human beings instead of
institutions for the frail and elderly. The Eden Alternative demonstrates
ten core principles which administrators and staff are encouraged to carry
out. According to Dr. Thomas, nursing homes employing this concept
should:
1. Understand that loneliness, helplessness and boredom account
for the bulk of suffering in a typical nursing home;
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One to two birds per each resident; birds are generally safe,
cost-effective and long lived; and
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among 375 inmates. Further, Fitzgerald (1986) also found that with the
introduction of animals into the prison, violence, suicide attempts and
destructive behavior decreased. AAT researchers Connor and Miller
(2000) announced that their future research efforts may focus on the
possibility of inmates training dogs for adoption from local humane
societies.
Although it is not essential for animals to have verbal
communication from their human owners, a University of Pennsylvania
study found that 98% of pet owners actually talked to their pets (Glass,
1996). Glass also reported that there has been research indicating that
most animals understand emotion and have compassion, as when
animals show compassion and seem to understand how you feel, you
have a tendency to communicate with them much more (1996, p. 15).
Glass elaborated subsequent to the study that animals have helped those
who continually repress their emotion, as dogs in particular have been
very helpful in motivating people to express themselves (1996). As stated
previously, this was recognized and documented during Levinsons
psychological sessions. In order to effectively communicate with their
pets, humans need to demonstrate ongoing respect, appreciation,
understanding and body language.
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Pets as Prescriptions
For some time, physicians have been encouraging pet adoption
and recommending pets to people who are lonely or who have
experienced a great loss. The most common prescribing specialties are
oncology and cardiology, and the pets most often recommended are cats,
dogs, birds and fish. One physician cited by Cross (1998) stated that
anytime you can use a pet with a person who feels isolated, it helps make
a connection for them in the world (p. 60).
More often than not, physicians prescribe pets in order for patients
to have a quicker and better recovery. In fact, a local psychiatrist often
suggests pet adoption to her cancer patients who are experiencing
symptoms of depression as well as other patients having invisible
disabilities (J. Lipton, personal communication, April 29, 2005).
Physicians not only have prescribed pets for psychological reasons, but
for physical reasons as well. For example, walking a dog is great
exercise, petting or playing fetch with a pet helps strengthen injured
fingers and limbs, and simply playing with an animal improves motor
coordination.
In the Kal Kan Report (1986), almost half of all responding
physicians, psychiatrists and psychologists reported they had prescribed
or recommended pets to people between the ages of 50 and 65 who were
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during an AAT session is usually one-on-one between the patient and the
trained animalmost commonly a dog. Connor and Miller (2000) state
that work, sport and herd dogs should strongly be considered for AAT as
they have been found to stand out among the rest of the breeds in relation
to therapy work. The reason dogs are primarily used in AAT is because
their behavior is the most predictable and the easiest to test. . .
temperament and training of the individual dog are the two most important
factors in a great therapy dog (Connor and Miller, 2000, p. 23).
Key features of AAT as described by the Delta Society (2004)
include 1) objectives and goals are specific for each individual, and 2)
patient progress and development are evaluated. McCulloch (1983) also
recommends having a plan in place to coordinate AAT with other
treatment modalities, to prepare a cost-benefit analysis and to maintain
realistic expectations throughout the program. Animals used in AAT can
be any size or breed, however, it is essential that they like to be around
people, be well trained/well mannered and have a stable temperament
and disposition.
Therapeutic benefits these animals are capable of providing via
therapy can include petting, feeding, attaching a collar, brushing and
walking to improve range of motion and motor coordination. Giving
obedience commands can help improve speech skills. Opportunities to
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recall details and describe past pets can help enhance cognitive, memory
and social skills, as well as can comparing 2 totally different pets. AAT is
a goal-oriented intervention program. Primary goals of AAT include:
Physical
-improve fine motor, ambulatory and wheelchair skills
-improve vital signs, standing balance and equilibrium
-auditory stimulation
Mental
-increase verbal interactions, attention skills, memory recall
and self-esteem
-develop recreational skills
-reduce loneliness and/or anxiety
Educational
-increase vocabulary
-improve memory and understanding of sizes, colors, etc.
Motivational
-improve involvement in social interactions/activities
-increase exercise
-develop trust (Delta Society, 2004).
As stated previously, AAT programs are utilized in a wide variety of
settings. For example, critical care units incorporate AAT specifically for
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6. Feed dog water: patient retrieves dog dish, opens water bottle
and pours water into dish. Patient then uses sign language
commanding dog to drink.
Each activity incorporates the patients cognitive, physical,
emotional and social abilities. At the beginning of each activity the
therapist explains the rules. Returning patients will be asked if they
remember the rules from their previous visit and to recite them.
Throughout the activities the therapist and handler continually ask the
patient thought-provoking questions relating to the activity at hand such as
How many more throws should we do?, How many kicks have we
done?, Whose turn is it? or How many balls has the dog caught?
Positive reinforcement is continuously used throughout the session and
clearly patients concentrate on their abilities rather than limitations (L.
Adams and M. Wolf, personal communication and observation, December
16, 2004).
Another handler and dog visit 5 different facilities a week and see
up to 20 patients a day. Over half the time, the visits are goal-oriented
sessions in the rehab and/or psych units. Of note, an experienced handler
will be able to easily recognize when his or her dog is getting tired or
stressed out from the visits, as they exhibit shallow panting or become
fidgety. If this is the case, a break is in order for both dog and handler (C.
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injuries and Alzheimers disease, the chronically ill and the mentally
challenged. The organizations goal is to improve the quality of life for
people with those disorders and/or diseases. Willis (1997) stated that the
New England Assistance Dog Service rehabilitation program has a similar
concept with an 88% success rate, primarily serving people with severe
disabilities.
Two popular dog visitation programs in Minnesota include Bark
Avenue on Parade and Pals on Paws. Volunteers from these
organizations provide friendly dog interactions to those who are elderly, ill
and disabled. They also bring the dogs to long-term care facilities,
hospitals and senior community settings in order to promote cheerfulness
and optimism among staff, visitors and patients. A similar program called
POOCH (Pets Offer Ongoing Care and Healing) has been quite popular at
Cedars-Sinai for a number of years. Paws Across Texas provides
companion dogs and volunteer handlers especially for AAT purposes.
Also of mention are the Skeeter Foundation and the Chenny Troupe, 2
important organizations that encourage and fund AAT research.
Although pet food companies have financed research studies in the
past, current funding to study the health benefits of animals has been
quite minimal, as research grants have usually been only in the ballpark of
$10,000 or less (Monson, 1995) and the NIH has been known to turn
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1. Avoid reptiles;
2. Be around older, calmer dogs and cats;
3. Stay away from cats with FIV (feline immune deficiency virus);
4. Wash hands after petting or playing with animals;
5. Be informed about flea control; and
6. Ensure therapy animals are indoor animals.
As previously noted, the most common animals associated with
and trained for AAT are dogs, but because cats and birds are also used in
some instances and are gaining more popularity, zoonotic risks associated
with those species will be looked at as well. Haas (1997), Schantz (1990),
Ettinger and Feldman (1993), Hart, Trees and Duerden (1996) and Angulo
et al (1994) reported the most common zoonoses associated with dogs
are:
Fleas;
Heart worm;
Hook worm;
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Tapeworm.
Fungi; and
Ring worm.
Again, authors Brodie, Biley and Shewring (2001) point out that
good hygiene such as frequent hand washing, regular litter box changes
and feline diet control will result in weak transmission rates. In facilities
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Bacteria (Clamydia);
Salmonellosis; and
Influenza virus.
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kept indoors and closely supervised at all times in order to prevent bites
by a wild animal that may have the rabies virus.
The American Academy of Allergy, Asthma and Immunology (1995)
reports that 15% of the population is allergic to dogs and cats; however,
young children exposed to animals from birth to age 1 have lower
incidences of asthma and allergies later in life. In North America, 6% of
people seen by clinical allergy specialists have allergic reactions (i.e.
rashes, etc.) strictly from animals (Elliot, Tolle, Goldberg and Miller, 1985).
This is a relatively low percentage. Of course, precautions such as careful
and preliminary research regarding animal selection (cats cause the
majority of allergic reactions), obtaining a comprehensive patient
screening/history and frequent bathing and grooming of the animals can
all contribute to safe and successful AAT in a controlled and supervised
setting.
Just in the past 15 years, much more research has been dedicated
to the risks of zoonotic diseases among the sick and elderly. However, to
date little information has been published regarding the figures or statistics
reported on the number of bites from animals enlisted in AAT programs.
In the meantime, health care administrators and staff have simply noted
the most troublesome breeds. Actually, Guay (2001) reported that
spaying and neutering can decrease bite rates by two-thirds. Further on
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this topic, Khan and Farrag (2000) reported that a California hospital had
zero zoonotic infections from 3,281 dog visits to 1,690 patients over a 5year period. Similarly, they also reported that a childrens hospital had no
increase in the rate of zoonotic infections or incidents over a 2-year
period.
From 1991 to 1993, no unusual incidents such as injury, accidents
or illness occurred from AAA and AAT at Saint Peter Hospital in
Washington, and only 2 minor injuries occurred in the third year of
implementation (Howie, 1994). Likewise, accounts from 50 state agencies
and 284 Minnesota long-term care facilities have shown that both visiting
and residing pets were safe for patients and residents in these facilities,
and that no serious incidents or allergic reactions were apparent for 1
yearexcept for 2 minor injuries (National Center for Biotechnology
Information, 2004). Currently, a University of Texas study is exploring this
topic further.
Authorities caution against obtaining an exotic pet for therapeutic
and casual purposes, as they are known to possess unpredictable and
aggressive behavior and are not meant to be kept as pets in captivity.
Exotic species could also quite possibly bring unknown diseases into the
United States. This has not stopped a London hospital, however, from
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periodically bringing in such animals such as lion and tiger cubs, snakes
and various other reptiles to its patients.
Administering and maintaining rigid animal infection control policies
and guidelines and appointing appropriate committees to accurately report
incidents and/or injuries will help contribute to safe and successful AAT
program. An example of such policies from both Harborview Medical
Center and Childrens Hospital in Seattle Washington are included in
Appendix B. Once standards are in place, ongoing evaluation,
improvements and revisions should occur. AAT policies should not be
confused with service dog or assistance animal policies.
In addition to zoonotic concerns, the Delta Society warns that the
use of AAT may not be appropriate among groups of people having the
potential for jealousy, possessiveness or competition among the
animal(s). Furthermore, patients who are quick to demonstrate unrealistic
expectations related to their recovery may not be the best candidates for
AAT.
The review of literature has touched on the historical use of animal
companions and the demographics and characteristics of pet ownership
and pet attachment. It has also described in great deal the physical,
psychological, social and cognitive benefits derived from AAT. From
pediatrics to geriatrics, and throughout several different diseases and
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Chapter 3
Methodology
This study aimed to gather valuable information regarding the
effectiveness of AAT through the extensive planning, development and
validation of a new evaluation instrument. This initial research was
primarily of exploratory nature, as this initial undertaking intended to be a
starting point in which to conduct further AAT effectiveness evaluation
studies. The overall goal of this study was to produce a prolific, scientific
and functional AAT effectiveness tool for therapists and their animal
handler counterparts (sometimes called Pet Partner teams) who deliver
AAT programs. The hope is that this instrument, in final form, will be
useful in conducting and measuring the effects of AAT on patients, and
will be utilized on a much larger scale in the near futureperhaps to
someday satisfy third-party payment provisions. The primary study
objectives consisted of 1) characterizing the features of AAT programs
and procedures in the western United States, 2) thoughtfully planning and
constructing a valuable and scientifically-sound AAT effectiveness
evaluation instrument for therapist-handler teams delivering AAT, and 3)
testing the new tool in live daily practice in order to account for reliability
and validity issues.
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outcomes.
Therefore
investigators
should
be
99
Approach
In order to gauge interest, the Delta Society helped locate
appropriate AAT volunteer teams, therapists, and animal handlers from
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101
102
103
104
105
106
Do you think the tool would satisfy third party payment requests?
Would you use this tool again? Would you recommend it to other
AAT professionals?
107
How can the tool be modified, revised and improved? Should any
questions be discarded?
108
Validity of Data
One of the most important steps in planning and developing a new
instrument was to determine it validity, or to ensure it measured what it
was intended to measure. The level of validity was affected by the
instrument itself, the questions that were asked, the behavior(s) assessed
and the qualifications of the users who tested the instrument; these factors
109
were carefully controlled for throughout this research by ensuring that the
right questions were asked in the most appropriate and accurate way
possible.
In order to have a valid form it needs to provide dependable and
consistent results, or be reliable. Reliability constitutes validity, thus
producing a reliable tool during this research is of utmost importance. The
level of reliability was affected by the instruments length, objectivity and
knowledge and confidence of its users. These factors were controlled for
throughout this research as well, as a form that yields inconsistent results
would be unable to report accurate data about what is actually being
measured.
In order to accurately and successfully account for validity and
reliability issues, the investigator followed Benson and Clarks (1982)
systematic steps/phases in instrumentation development: 1) planning, 2)
construction, 3) evaluation, and 4) validation. A professional consultation
with an experienced psychometrician would have been quite costly and
time consuming, so relying on past and current psychometric literature
served as an adequate reference for purposes of this particular research.
Benson and Clark (1982) state that the most important phase in
instrument development and validation is planning, as this is where the
content and behavior to be assessed and user group are to be specified.
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111
112
results. Original data collected from this initial exploratory research can
therefore serve as a starting point in which to build future related studies
and construct more comprehensive future AAT effectiveness evaluation
materials.
Research such as this does have limitations; instituting 1 test run to
estimate and evaluate reliability and validity issues does not fully
guarantee that the new AAT instrument tool will be a success. Along with
patience, validation requires continuous and focused efforts. Benson and
Clark state validation is a continual process, one in which an end point is
rarely achieved, but is only successively approximated (1982, p. 799).
Developing a scientifically sound instrument such as this for use by AAT
professionals was time consuming and will more than likely become a
work in progressrequiring multiple research efforts by many. Although
results from this implementation could allude to similar response rates in a
larger scale study, it cannot be fully assumed because there has been no
previous extensive statistical groundwork in this situation, and pilot study
numbers are usually smaller. Further, future roadblocks may not come
into full view until a larger, widespread and more comprehensive
undertaking is in the midst of being conducted.
Because the time allotted to complete this final paper was relatively
brief due to university requirements, data were unable to be collected in a
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114
Summary of Chapter 3
This research was conducted in order to evaluate the effect of AAT
by designing and testing a newly developed AAT evaluation instrument.
Additionally, efforts were made to gather the attitudes, thoughts and
perceptions of therapists and handlers about utilizing the new instrument
in practice. Methods included analyzing anonymous data from the new
tool in both qualitative and quantitative fashions, holding personal
interviews and debriefing sessions with key therapists and handlers
following implementation, and administering a brief follow-up
questionnaire to this group of AAT tool users in order to account for
reliability and validity issues. The hope is that this new tool can be easily
modified and implemented on a larger scale in order to fit the needs of a
more universal audience consisting of AAT professionals and
organizations wishing to begin and evaluate their own AAT practices.
115
Chapter 4
Data Analysis
As discussed previously, designing, testing and validating a new
instrument was the most useful and effective choice of design due to the
short duration of the project, the study goal, objectives and the given
population. Following an initial round of revisions by the form reviewers,
AAT experts such as therapists, social workers and Pet Partner volunteer
animal handler teams tested the effectiveness of AAT by estimating the
adequacy and usefulness of the new tool while in daily practice. They
then had the chance to convey their opinions and suggestions for
improvement via key informant interviews and a brief follow-up survey.
Upon retrieval of all study data, multiple queries were run and
common themes were extracted in order to accurately and successfully
account for validity and reliability. Each persons response to both the
interview and short survey were analyzed for common remarks, patterns
and themes, and also to identify and expose ambiguities and/or
unnecessary data fields in order to revise and rescale the new AAT
instrument.
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Table 1
Panel of Reviewers
Role
AAT Trainer/Consultant
Geographic Location
Washington
AAT Instructor/Evaluator
Washington
Washington
Washington
Clinical Researcher
Washington
Registered Nurse
New Jersey
Washington
Physical Therapist
Washington
117
Table 1 continued. . .
9
10
Delta Society
Pet Partner Volunteer
Occupational Therapist
Florida
Oregon
11
Oregon
Table 2
First Round Revisions to AAT Tool Draft
Revision
Suggestion / Modification
#
1
Move Age, Female/Male & Dx up one line under Client/
Patient ID#
2
118
Table 2 continued. . .
7
10
11
12
13
14
15
16
17
18
19
20
21
119
The form looks great--it will be a great tool and easy to use.
120
Implementation Results
The form was tested in the volunteer user group of therapists and
animal handlers for a period of 6 weeks during the months of June and
July 2005. The attempt was to collect as many completed AAT forms for
various analyses on forms data and to gather comments about usage and
validity. AAT therapist and handler volunteers from Washington, Oregon
California and Arizona utilized the revised tool in daily practice in their AAT
sessions. Including both experienced therapists and Pet Partner
volunteers maximized the variations and spectrum of data captured in this
study (see Table 3 below for details).
Table 3
Volunteer User Group Demographics
Role/Specialty
1
Geographic
# Yrs AAT
Location
Gender Experience
Therapy
Animal
California
mini-horse
California
mini-horse
Clinical Psychologist
California
10
dog
California
Oregon
F
F
10
14
dog
dog
121
Table 3 continued. . .
5
Recreational Therapist
Washington
12
dog
Washington
dog
Arizona
N/A
dog
122
Table 4
Number of AAT Visits per Volunteer
Volunteer
# of AAT Visits
# of Repeat Visits
18
24
Table 5
AAT Client/Patient Demographics
Age range
7 to 88 years
123
Table 5 continued. . .
Gender
Session type
54 Individual, 3 Group
Length of session
range
2 to 60 minutes
Number of repeat
sessions
14 (25%)
Range of primary
diagnoses
Range of goals
# Physical skills
observed
# Cognitive skills
observed
# Social / Emotional
skills observed
# Speech / Language
skills observed
Played with animal
124
21 (37%)
13 (23%)
Client/patient eager
and accepting of
animal and AAT
44 (78%)
1 (1%)
125
was even taken for a walk. From all received forms there was only 1
refusal to AAT. Subsequent to analyses, physical ability and
social/emotional skills were most highly observed during the sessions,
with volunteers reporting an average performance quality rating of
average to good and good to very good, respectively. Per volunteer
group reporting, all domains (physical, social/emotional, cognitive,
speech/language) consistently averaged a need for improvement and
further follow up. The most common diagnosis seen in therapy sessions
during this time was stroke, a cardiovascular disease where blood vessels
leading to the brain become clotted or are blocked.
In summary, these data portray that nearly anyone despite of age,
gender or clinical diagnosis can participate in, enjoy and benefit from goaloriented AAT sessions of various lengths.
126
use and validity and reliability was captured and recorded. Comments
from research questions asked of form users are summarized below.
127
128
As a volunteer making shorter visits traveling from room-toroom it was time consuming and burdensome.
3. Do you believe the new tool was effective in helping meet patient
goals/needs? Did it properly address the functional domains
(cognitive, physical, social, emotional) in determining patient goals?
129
The tool gave direction to the overall visit, but found the
recommendation for follow-up choice to be too narrow.
130
131
7. Do you think the tool has potential to satisfy third party payment
requests?
Yes.
9. Would you use this tool again in practice? Would you recommend
it to other therapists and/or handlers?
132
10. How can this tool be improved? Describe any modifications and
revisions.
133
134
universal AAT guide, form or template, this study indeed confirms the
need of this undertaking in order to successfully and carefully construct
one common AAT evaluation guide that would be available for AAT
professionals nationwide.
As depicted in the summaries above, both therapists and handlers
felt the new AAT tool provided focus to their sessions and was a useful
guide and an effective mechanism in conducting therapy sessions. Some
volunteers even felt it made their job easier and assisted them on focusing
on what they should exactly evaluate. While some handlers felt that the
tool was easy to use, a few remarked it was lengthy and burdensome
because they primarily conducted short sessions to assess only 1 or 2 of
the functional domains at a time. Handlers executing these short sessions
specifically requested that the cognitive, social/emotional and
speech/language domains be narrowed down in listing the skills and
abilities. On the other hand however, therapists conducting longer
sessions assessing all domains remarked that the domains did not include
a wide enough spectrum of skills to be evaluated, as they at times have
their own patient goals in mind.
All users generally believed that the new toolcoupled along with
the consistent efforts of patients and therapistswas effective in helping
meet patient goals/needs and that it reliably addressed the 4 functional
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136
The users reached a consensus that the tool captured enough AAT
evaluation information in order to be valid and reliable to satisfy third party
payment requests. Because insurance companies want early discharges,
the hospital could then use the completed assessment tool to determine
and predict discharge. Another consensus among all produced the feeling
that the tool measured what it was initially intended to measure and was
reliable and valid in serving its purpose. There was a flutter of concern,
however, about how to accurately measure long-term goals in the
absence of repeat sessions, but that is out of anyones control if the
client/patient is discharged early.
The popular notion from volunteers in the user group was that they
would definitely use this tool again in daily practice as a reference guide to
help conduct their AAT sessions. Many voiced that it would be helpful in
providing additional focus and direction. In terms of future use, volunteers
interviewed stated they would recommend it to therapists and AAT
providers. Handlers in the test group commented that often times they are
not provided with the most recent and/or comprehensive patient medical
histories. Thus, those conducting shorter sessions therefore would rather
utilize and complete a similar but more general form which allows space
for notes and observations they could later deliver to the therapist or place
in the patients medical chart.
137
138
All summaries, anecdotes and remarks from this group of test run
volunteers were very sensible, meaningful and worthwhile. In order to
construct the most valid, reliable and scientifically-sound evaluation tool
while satisfying the revision requests of all parties involved, all proposed
revisions were carefully considered and subsequently applied to the final
AAT evaluation tool template (Appendix L). This process is explained
later in this chapter.
Table 6
Results from Follow-Up Survey
139
Question
Range of AAT experience
Average time to complete AAT tool
Response
1 to 14 years
11 minutes
3
Yes
No
80%
20%
80%
20%
100%
0%
67%
33%
50%
50%
50%
50%
75%
25%
140
141
this group was that the tool may add additional paperwork to already busy
therapists and handlers who keep tight clinic and travel schedules.
Generally, therapists felt the current tool should remain as is
pending some minor revisions for actual therapists and allied health care
staff. The handlers, on the other hand, felt they did not have the level of
expertise, training and resources that licensed therapists do in order to
make clinical decisions and rate abilities. This sub-group indicated they
would be more comfortable recording general notes and observations on a
shorter, less detailed assessment form. Per these viewpoints, the ongoing
and emergent theme was that a new, condensed version of the AAT
evaluation form should be developed and made available specifically for
AAT animal handlers (or Pet Partner volunteers) to record observations
and notes, while the current version is more universally appropriate for
hospital-based therapists and counselors.
142
while remaining objective for the study, yet mindful as not to create extra
paperwork for AAT professionals. The hope is for the revised and final
AAT tool evaluation template to be utilized as a guide for sites, therapists
and handlers to modify for their own specific work and needs. It allows for
manipulation of data fields. It can be shortened or lengthened. Sections
can be added or eliminated according to each individual, department or
site need.
In order to satisfy multiple revision requests, the tool was first
lengthened to allow each domain (physical, cognitive, social/emotional,
speech/language) to have its own page. This allowed for more space to
record baseline performance, notes and observations for each skill and
ability, and to also add skills related to diseases, disorders, illnesses and
injuries that are not listed. A few of the skills and abilities relating to group
participation and unconsciousness were deleted, as they were rarely
checked or observed during the test run. The majority of users in the
implementation group steadfastly commented that there is always need for
follow-up and that the no follow-up needed option should not be listed,
thus those sections were omitted and space to instead record a date for
next appointment or interim assignment was provided in its place. An
AAT session number was appropriately added to accompany the repeat
visit field since future users on a long-term basis would most likely have
143
144
145
Chapter 5
146
147
148
149
150
future resources needed for designing similar tools and for conducting
larger AAT studies.
Regarding further research, the next logical step would be to repeat
the study using the newly created AAT guidance and evaluation tool in a
wider scope. This should be accomplished by expanding the geographical
area to include the entire United States; hence, a larger sample size of
therapists and handler teams and AAT tools from which to extract data.
The AAT tool, study background and design, forms and instructions and
follow-up surveys should be displayed electronically and available for
immediate Internet download via the Delta Societys website. Because
the current study was not lengthy enough to collect longitudinal data from
repeat visits, the follow-up trial should be extended by at least 3 months in
order to collect and analyze this information. Further, the current study
due to educational timeline and deadline requirementswas conducted
during the summer months, which are usually considered slow and many
people are on vacation; therefore, a future study and data collection
should occur during the fall, winter or spring in order to produce more
data. Lastly, if finances allow, it would be beneficial to hire an
experienced psychometrician to scrutinize and edit the final AAT
evaluation instrument. Clearly preparation for this subsequent follow-up
research would involve extra time, resources and finances, but more
151
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153
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Appendices
175