Animal assisted interventions in the children's hospital: protocol for a scoping review

Background

Children and young people hospitalised for surgery or medical treatment can find the experience as a most distressing event in their lives if not managed appropriately by healthcare professionals and their families (Bjork et al., 2005; Coyne, 2006; Darbyshire, 1994; Gariépy & Howe, 2003; Gibson et al., 2010). Traditionally, anxiety was managed largely through pharmacological treatments resulting in negative consequences in terms of side effects of medications and ongoing costs or demands on the health care service. Non-pharmacological interventions including play and distraction therapies have positive effects on a child’s recovery and general management of care in hospital (Al-Yateem et al., 2016; Gariépy & Howe, 2003). Gibson et al. (2010) identified that all child participants in their study reported some dislike of the hospital environment. Young children in hospital requested toys from home and older children found some comfort in photographs of pets as well as soft furnishings including their own pillows and bed covers helped in improving the hospital environment to be more homely (Gariépy & Howe, 2003; Gibson, et al., 2010; Lambert, et al., 2014). Coyne’s qualitative study; of 11 children aged seven to 14 years, located in four paediatric units in the United Kingdom; reported children missing aspects of their home life specifically, “Miss my mum, my dog, my sister, the atmosphere, my own bed” (Coyne, 2006 pp. 329). Family members, including family pets, are important supports which help children to relax and give them a sense of familiarity to navigate the busy and stressful hospital environment.

The hospital environment while daunting and sometimes considered ‘a scary place’ for children, it is also a busy and stressful place for the children’s parents, siblings and healthcare staff working each day in what is considered an under resourced environment (Bjork et al., 2005; Bridgeman et al., 2018; Gibson et al., 2010). Families often experience chaos and extreme loneliness throughout episodes of hospitalisation and their lives are broken, similar to, “an earthenware pot dropped and broken into pieces” (Bjork et al., 2005 pp. 270). The outcome of Gariépy & Howe’s (2003) mixed methods research study comparing children attending a hospital based treatment clinic and a healthy cohort of children in a crèche found that children need to be provided with facilitated time to access toys and activities on a regular basis to help them process their anxiety and stress caused by their illness, treatment and ongoing health concerns. Gariépy & Howe (2003) suggested future research involving observation and controlled intervention would be of benefit, particularly on an individual basis, so that the child could develop a trusting relationship with the researcher and work through which intervention best suits their needs according to their age and stage of development.

Consideration should be given to other interventions such as innovative non-pharmacological interventions or complementary therapies which include Animal Assisted Interventions (AAIs). There is ambiguity in the international literature in relation to the definition and adaptation of the terms AAI (which is the umbrella term) animal assisted activities (AAA) and animal assisted therapy (AAT). Some studies use either concept or use them interchangeably. The subsequent scoping review will provide a clear definition of these terms from the literature. The following definition of AAI from The International Association of Human-Animal Interactions Organizations (IAHAIO, 2018 p.5) has been adopted by the review team:

    ‘’An Animal Assisted Intervention is a goal oriented and structured intervention that intentionally includes or incorporates animals in health, education and human services (e.g., social work) for the purpose of therapeutic gains in humans. It involves people with knowledge of the people and animals involved. Animal assisted interventions incorporate human-animal teams in formal human services such as Animal Assisted Therapy (AAT), Animal Assisted Education (AAE) or under certain conditions Animal Assisted Activity (AAA). Such interventions should be developed and implemented using an interdisciplinary approach.’’

In AAIs, the animals themselves are the health intervention. An initial search of the literature showed that AAIs enhance positive feelings in people, raise oxytocin levels, promote improved mood and foster trusting relationships (Fine, 2015). A recent protocol and meta-analysis by May et al. (2020) aimed to quantify the impact of brief canine therapy within the discipline of psychology. Significant positive impact of animal assisted therapy (AAT) on subjective anxiety of hospitalised children was reported by May et al. (2020). While this systematic review and meta-analysis was undertaken within the paediatric context it focused primarily on the psychological and physiological responses of children, reporting the impact of canine therapy on outcomes associated with pain and anxiety. Studies in the review were limited to randomised controlled designs (May et al. 2020). Further investment into the scientific literature of this safe, novel and efficient AAT was recommended by May et al. (2020). The proposed scoping review is broader in its approach and will include all study designs and all types of AAIs, not only canine therapy.

A preliminary search of the international literature completed in early 2020 revealed the following studies. A critical review by an Australian team Chur-Hansen et al. (2014) found only nine studies worthy of inclusion in their review. The authors reported, ‘methodological challenges’, in their review and indicated the need for future research to be more rigorous, to add to the evidence base in this area of AAI (Chur-Hansen et al. pp. 5). Since then, Vagnoli et al. (2015) investigated the effectiveness of AAI as a distraction for reducing Italian children’s pain and distress during and after phlebotomy. Significant differences were found between the intervention and control group for example serum cortisol levels were significantly lower denoting less stress/anxiety. Limitations in this trial included the small sample size of each group. Children who participated were aged four to 11 years and were not previous dog owners. In future research, consideration could be given to child participants, choosing whether or not they want to participate in the selection of an appropriate comparison intervention based on child participatory research methods.

Calcaterra et al. (2015) explored the post-operative benefits of AAT on children’s stress and pain in the acute children’s hospital setting in Germany. Data collection involved recording of baseline parameters, salivary cortisol levels, electroencephalogram and an assessment of pain. No significant difference were reported in cortisol levels and the authors recommended alternative hormone level measures be considered in future studies. Future studies should consider more comprehensive monitoring of hormone levels as well as cortisol levels and recruit a larger sample.

A key piece of literature from America by Hinic et al. (2019) evaluated the effect of a brief pet therapy visit and an active comparison intervention (jigsaw puzzle) on anxiety in hospitalised children. Findings support the AAI in reducing anxiety for children and their parents. Again a small study but with a comparison intervention. More rigorous studies of psychological and physiological outcomes both in the immediate and long-term phases were advised. The value of exploring more qualitative elements over a longer timeframe may also be worthy of study.

The Royal College of Nursing (RCN) in the United Kingdom (UK) have published guidance for Health Care settings introducing therapy dogs (RCN, 2018). An evaluation of an AAI service established in 2012 in one children’s hospital from UK demonstrated extremely positive results. Parents, staff members and children (n=200) surveyed reported the service to be ‘very worthwhile’ (98%) (Uglow, 2019 p.512). The benefits of AAI largely outweigh the risks and with relevant protocols in place the initiative should be repeated in other hospitals (Uglow, 2019).

Dalton et al. (2020) and Gerardi et al. (2018) highlight the need for a One Health approach to ensuring minimal risk to human and animal participants in AAI programmes. It is very important to minimise risks such as bites and cross infection in the hospital context especially with vulnerable children. SN the veterinarian expert will advise the research team in relation to guidelines and policy required prior to implementation phase of the study. In Ireland anecdotal evidence points to pet therapy taking place in hospices, nursing homes, general hospital Intensive Care Units (ICUs) and one children’s hospital. Peata and Irish Therapy Dogs, the Irish charities, have pet visitation programmes in place to many healthcare settings which are currently stalled due to coronavirus disease 2019 (COVID-19) (Peata, 2020).

Interesting themes meriting further exploration are emerging from the literature. A need exists for additional research studies that are well planned and follow a more definitive protocol have been suggested. Our review will map the existing literature available through peer-reviewed journaals irrespective of the quality. We also want to probe the literature to determine; Why has AAI been used? Where? And how effective was it? Were there implementation considerations? Were there particular research methods utilised and recommendations for future research?

A scoping review may be useful for informing the design of such projects. A scoping review would enable a deeper exploration of the scientific literature on how AAI might contribute to the child’s wellbeing during and after hospitalisation. It may also reveal some risks associated with AAI that may act as barriers to implementation. Any theories about the human-animal bond which the researchers might discuss in their articles can be mapped alongside other contextual data such as geographical location and types of animal interventions. The six stages in the Scoping Review Framework introduced by Arksey & O’Malley (2005) will help guide the review protocol and subsequent scoping review.

Aims/objectives

The aims of the systematic scoping review are:

Stage 1. Identification of the Scoping Review Research Question

The population, concept and context (PCCo) framework was utilised to help form the research question for this scoping review which is supported by Anderson et al. (2008) and the Joanna Briggs Institute (Peters et al., 2017; Peters et al., 2020):

Stage 2. Identifying relevant studies

For a systematic review, it is important that as many relevant studies are sourced, rather than all studies (Craven & Levay, 2019). The review question has been developed using the PCCo framework, so that the search terms can closely match the themes within the literature, to retrieve focused relevant studies, rather than all studies on the topic. Including all literature from date of conception on the topic of AAI in children’s hospitals will reduce the risk of bias (Craven & Levay, 2019). Seminal works on human-animal studies stem from the 1980’s which was also the same time the first journal devoted to human-animal studies - Anthrozoos was published (DeMello, 2012). Therefore, it makes sense to limit the search to include literature published within the past 40 years.

Stage 3. Study selection

Each search will be saved and imported into a file on Endnote X9. The advantage of Endnote is that a research diary of each search can be made by dating each file upon import of search results and the number of articles retrieved can then be added to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flowchart advocated by the Joanna Briggs Institute (Peters et al., 2017 & Peters et al., 2020). A PRISMA flowchart will be produced following the completed searches which will enable transparency of reporting, demonstrate how decisions were made about excluding citations and allow for easy replication and comparison of any future searches.

Citations stored on Endnote will be imported to Covidence for ease of screening by the review team (RH and TK). Rationale for exclusions will be clearly tracked and logged by Covidence. Any disagreements can be quickly resolved by the third researcher (SN).

There is debate in the literature about the need for more than one researcher to undertake the initial screening of the citation titles and abstracts from the long list of search results (Levac et al., 2010; van den Berg et al., 2013). Since a scoping review retrieves, “all relevant data regardless of study design,” potentially thousands of results could be obtained (Arksey & O’Malley, 2005 pp.20). Two reviewers (RH & TK) will double screen search results for inclusion based on title and abstract in line with other reviews published.

Stage 4. Data charting

The second stage of screening results will be carried out independently by two researchers (RH & TK) using a reporting checklist or data charting form as it is known by for scoping reviews (Levac et al., 2010; Peters et al., 2017). A sample of ten studies charted independently by both reviewers will be compared and discussed to pilot the tool and assess if results are consistent with the research question. This approach was advocated by Daudt et al. (2013) to improve charting of results so that the review question can be answered appropriately. Citation titles and abstracts included in the second screening will be full text results which will be shared with each reviewer through Covidence. This strategy has been reported in the literature as being an effective method (Daudt et al., 2013). A third reviewer (SN) will be available to discuss any differences or ambiguities in results. A sample data charting form; adapted from the Cochrane collection template and informed by Nicholson et al. (2019); is attached as Table 2. Since the process of scoping reviews is an iterative process so too will be the need to discuss the suitability of the data charting form once screening has commenced and is discussed by the review team. Any changes to the form will be noted in the researcher’s research diary along with any decisions about screening as a result of any meetings, reflections and actions taken (Boland et al., 2017; Daudt et al., 2013).

Stage 5. Collating, summarising and reporting the results

Each data charting form will be given a unique number to aid identification and discussion across the review team as advised by Daudt et al. (2013). A description and summary of the review findings will be the form of analytical interpretation of the review results which will be enhanced through discussion with the review team and supervisor to draw out meaningful results (Vijayamohan, 2015). Peters et al. (2020) are definitive in stating that, “qualitative content analysis in scoping reviews is generally descriptive in nature” and therefore this review protocol will be in keeping with the Joanna Briggs Institute most recent publication. The use of innovative charting tools such as word clouds will be considered to visually represent definitions of animal assisted activities as an example. Other charted results will require more traditional narrative analysis as discussed by Levac et al. (2010).

Stage 6. Consultation

Consultation for this scoping review will be in the form of a reference panel to support the reviewers with the review. Networking with the Authors’ University and School of Veterinary Medicine has already yielded excellent sources of information on animal welfare which will be an important concept to guard later in the research study. One member of the research team (SN) has expertise in the area of animal welfare and will be key to guiding and ensuring that the welfare of animals as well as research participants will be considered throughout the project. This review is part of a larger study and the scoping review will feed into the design of a primary research study. Any consultation with children will require ethical approval and this will be obtained before any consultation takes place later in the research project.

Discussion and conclusion

A scoping review protocol has been outlined and discussed in relation to the current literature and evidence available (Daudt et al., 2013; Levac et al., 2010; Peters et al., 2017 & Peters et al., 2020). The value of implementing Animal Assisted Interventions into a children’s hospital requires careful planning, review of the evidence and risk assessment. The rationale for choosing a scoping review over other reviews is to map the scientific evidence for AAIs in children’s hospitals to inform any further research. From the initial search; carried out early 2020; mixed methods studies and systematic reviews on the topic of AAI were reported. However, the findings revealed a lack of consistency in research approaches and a need for a scoping review is warranted so that any further research can be planned appropriately to address any gaps in the scientific knowledge. The knowledge base of AAIs is still being created and evaluated. This scoping review will contribute to cataloguing the scientific evidence for AAIs in the children’s hospital context and inform a research project.

Data availability