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ANIMAL-ASSISTED THERAPY m OLDER ADULTS:
DEVELOPMENT OF A SCREENING TOOL ‘

Schotarty Project for the Degree of M. S. N.
MICHIGAN STATE UNIVERSITY
MICHELLE L; DALTON '
1999

* LIBRARY
Michigan State
University

 

 

 

PLACE iN RETURN BOX to remove this checkout from your record.
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DATE DUE DATE DUE DATE DUE

 

U ' ‘ Q}

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6/01 cJClRC/DaiODUOpBS-DJ 5

 

ANIMAL-ASSISTED THERAPY AND OLDER ADULTS:
DEVELOPMENT OF A SCREENING TOOL

BY
Michelle L. Dalton

A SCHOLARLY PROJECT

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

MASTER OF SCIENCE IN NURSING

College of Nursing

1999

ABSTRACT

ANIMAL-ASSISTED THERAPY AND OLDER ADULTS:
DEVELOPMENT OF A SCREENING TOOL

BY
Michelle L. Dalton

Cost-effective health promotion and illness reduction
interventions are needed more than ever as the United States
population ages and life spans lengthen. The animal-
assisted therapy (AAT) screening tool was developed to
identify potential candidates for participation in community

based AAT programs.

DEDICATION

In memory or my mother, who instilled in me
a love for animals

iii

ACKNOWLEDGMENTS

Many thanks to my committee chairperson, Celia Wills,
and committee members, Linda Spence and Linda Keilman, for
their expertise, encouragement, and enthusiasm for this

project.

iv

TABLE OF CONTENTS

LIST OF TABLES . . . .
LIST OF FIGURES . . . .
INTRODUCTION . . . .
Companion Animal
AAT Literature . .
PROJECT FOCUS . . . . .

CONCEPTUAL FRAMEWORK .

APPLICATION TO THE PROJECT
Individual Characteristics

Behavioral Outcome

LITERATURE REVIEW . .
Psychological .
Physiological .
Sociocultural .
Literature Summary

PROJECT DEVELOPMENT . .
DISCUSSION . . . . . .
LIST OF REFERENCES . .

APPENDIX . . . . . . .

Lite

rature

and
Behavior-Specific Cognitions

&

E

xperiences
Affect

Page

0
NM“

10
11

11
14

19
24

LIST OF TABLES

Page

TABLE 1: Animal-Assisted Therapy: Questionnaire . . . . . 27

TABLE 2: Animal-Assisted Therapy: Follow-up . . . . . . . 29

vi

FIGURE 1:

LIST OF FIGURES

Pender's Revised Health Promotion
"Odel (RHPM) O O O O O O O O O 0

FIGURE 2: Adaptation of Fender's RHPH . . .

vii

Page
. 5
. 9

INTRODUCTION

The older adult population is the fastest-growing
segment of the United States population (Barkauskas,
Stoltenberg-Allen, Baumann, 8 Darling-Fisher, 1998). As the
number of older adults rises, illness reduction and health
promotion concerns associated with increasing age are
becoming more important. As the U.S. population ages and
life spans lengthen, cost-effective health promotion and
illness reduction interventions are needed more than ever.
Animal-assisted therapy (AAT) is drawing increased attention
within the health care community as one means to promote
health and reduce illness.

Failing physical or mental health, loss of family and
friends, and withdrawal from social activities are common
issues that can negatively impact the health status of older
adults (Barkauskas et al., 1998). Barkauskas et al. (1998)
acknowledges that the boundaries of late adulthood and old
age are difficult to define. While one adult may appear old
at 40, another may appear young at 65 (Barkauskas et al.,
1998). Evidence is accumulating that interaction with pets
can contribute to health in later life (Boldt 8 Dellmann-
Jenkins, 1992), helping to offset the adverse effects of
these psychosocial changes. Older adults in particular may
benefit from AAT during a time of adjustment to retirement,
loss of family or friends, and change in economic status

(Brickel, 1986).

WW
Historically, the benefits of pets on human health were

demonstrated in the 1980's. Between 1983 and 1989, multiple
studies were published in which relationships between human
health and the presence of companion animals in households
were addressed (Garrity, Stallones, Marx, & Johnson, 1989;
Ory & Goldberg, 1983; Jenkins, 1986). In response to
increased public interest, and the growing amount of
research literature, the National Institutes of Health (NIH)
conducted a technology screening workshop on the health
benefits of pets (NIH, 1988). The conference group summary
reported there was persuasive evidence to conclude pets are
likely to be medically beneficial to older adults'
cardiovascular and social health (NIH, 1988). Companion
animals may not be the cure-all for problems associated with
later life, but their positive influences to some older
adults' health status should not be dismissed (Boldt &
Dellmann-Jenkins, 1992).
W

Support for the health benefits of AAT has been
demonstrated in the 1990's (Lapp, 1991; Siegel, 1990;
Jessen, Cardiello, & Baun, 1996). Socialization with others
has been found to improve among those who socialize with
pets (Lapp, 1991). Ownership of pets has been found to be
associated with significantly reduced use of physician

services (Siegel, 1990), and Jessen et al. (1996) reported a

significant decrease in depressive symptoms as self-reported
by older adults with companion birds.

Based upon these research data, AAT may be utilized
effectively as health promotion and/or illness reduction
strategies in community dwelling older adults. Advanced
Practice Nurses (APNs) in primary care are in the setting in
which they are most likely to see many of the older adult
patients in whom the positive outcomes of AAT have been
demonstrated. Consequently, APNs have the potential to play
.key roles in supporting AAT as health promotion and illness
reduction strategies in older adults.

PROJECT FOCUS

The purpose of this project is to develop a screening
tool to be used by APNs in identifying potential candidates
for participation in community based AAT programs. The
screening tool will be used to address health promotion
needs in primary care visits by older adults, as a means to
determine their appropriateness for participation in AAT.
Individuals in this population frequently display
characteristics which can be positively influenced by
participation in AAT, including: social isolation, decreased
self-esteem, decreased physical and/or mental health,
perceived lack of control over health, and loss of family or
friends (Jessen et al., 1996; Kongable, Buckwalter, 8
Stolley, 1989; Huschel, 1984; Siegel, 1990). Older adults
deemed appropriate for participation in AAT will be referred

to a community based AAT program.

3

CONCEPTUAL FRAMEWORK

An adaptation of Pender's (1996) Revised Health
Promotion Model (RHPH) forms the basic conceptual framework
of the project. Pender's RHPH (Figure 1) includes concepts
relevant to health behavior and outcomes of self-care
education. The RHPH focuses on the participation of the
patient in implementing health promoting behaviors and in
changing the environmental context for health behaviors
(Pender, 1996).

The ability to be proficient and capable of a
particular behavior has been shown in prior research to
motivate individuals to participate in that behavior
(Pender, 1996). The perception of being in control of one's
health and the desire to be in control can increase health
promoting behaviors (Pender, 1996). Greater health
promoting behaviors have been found to be associated with
perceived internal control of health than with the
perception that health is controlled by chance or luck
(Pender, Walker, Sechrist, & Frank-Stromborg, 1990).

The RHPM depicts the multidimensionality of individuals
interacting with the environment as they pursue health
(Pender, 1996). Health promoting behaviors are repetitive
actions that compose an important part of a person's
lifestyle. The individual acts on the environment in order
to progress to improved levels of health. At the
environmental level, change in the environment is implied as

a goal of health promotion (King, 1994).

4

Individual
Characteristics
and Experiences

 

Prior Related '

Behavior

 

 

 

Personal
factors:

psychological
sociocultural

 

 

 

Figure 1. From

A)

4
—|

Pender's Revised Health Promotion Model

Behavior-Specific Behavioral
Cognitions Outcome
and Affect

 

Perceived f
benefits .
of action

 

 

 

Immediate competing

Perceived demands
barriers (low control)

to action

 

 

 

biological _}

 

 

 

Perceived I

and preferences
(high control)

 

 

 

 

self-efficacy I

 

 

I

T

Activity- I

 

 

related
affect r , , 4

Commitment Health

 

 

V .

 

 

to a promoting

plan of action behavior

 

 

 

 

Interpersonal
influences

(family, peers,
providers); norms,
support, models

A

 

 

 

 

 

 

Situational
influences;
options

demand characteristics

aesthetics

 

 

 

T

 

 

W (p. 67), by N. Fender, 1996, Stamford, CT:
Appleton & Lange. Copyright 1996 by Appleton & Lange. Reprinted with pemiission (Appendix

The individual's definition of health likely influences
the extent to which the individual participates in health
promoting behaviors (Walker, Sechrist, & Pender, 1987). The
perceived benefits of health promoting behaviors affect the
level of participation in the behaviors (Walker et al.,
1987). An improved feeling of well-being may motivate a
person to participate in actions that improve health status.

The key concepts addressed in this project include:
health promotion, companion animal, AAT, and health outcomes
of AAT. Health promotion refers to activities performed to
sustain or increase health which have the potential for
long-term health benefits (Pender, 1996). As a health-care
strategy, health promotion is a relatively new concept.
Modern health promotion began with the Lalonde Report
(Raeburn, 1992). The Lalonde Report (1974) identified
environmental factors and lifestyle habits as primary
determinants of one's health status.

The health promotion intervention recommendations of
the Public Health Service in the Healthy People 2000 Report
(1990) focus on the potential effects of personal health
choices made within the environment and on the impact of
consumer initiatives for self-care. The American Nurses
Association (ANA) produced a Social Policy Statement
indicating nursing is concerned with individual and group
adaptation to existing and potential health problems, health
influences of environments, and health promotion through

nursing intervention (ANA, 1995). The objective of health

6

promotion is for each person to reach and maintain his or
her optimal functioning (Belmont, Henderer, & Bennett,
1990). The overall goal of health promotion in the elderly
is the prevention or rate reduction of disease progression,
as well as the reduction of death or disability (Ferrini &
Ferrini, 1989).

Health promotion is concerned with well-being from the
perspective of the individual (Raeburn, 1992). King (1994)
defined the purpose of health promotion as increasing well-
being. The World Health Organization (1986) defined health
promotion as a process in which people are enabled to
increase control over the determinants of health and
consequently improve their health. A classic definition of
health promotion is the organized application of
educational, social, and environmental resources to
facilitate an individual's adoption and maintenance of
behaviors which enhance wellness and reduce the risk of
disease (Petosa, 1986). For the purposes of this project,
Petosa's definition of health promotion will be utilized
(Petosa, 1986).

A companion animal, or pet, is an animal kept for
pleasure or companionship. AAT programs strive to produce a
prescribed effect on identified patients through interaction
with animals (Delta Society, 1996). During the AAT session,
patients will pet the dog and talk to the dog and its
handler. The health outcomes of animal-assisted therapy for

this project are the physiologic, psychologic, and social

7

improvements resulting from participation in AAT. AAT
produces its effect through distraction, verbal and tactile
interaction, reminiscence, and stress reduction. Numerous
authors have studied the health benefits of AAT (Anderson,
Reid, & Jennings, 1992; Allen, Blascovich, Tomaka, & Kelsey,
1991; Fritz, Farver, Kass, & Hart, 1995). The articles
reviewed for this project address these health benefits and
were selected based upon their applicability to Fender's
RHPM.
APPLICATION TO THE PROJECT
The framework for AAT shown in Figure 2 is based on

Pender's (1996) RHPH and this author's application of it to
the screening of older adults for participation in community
based AAT. Individual characteristics and experiences,
behavior-specific cognition and affect, and behavioral
outcomes have been adapted to those characteristics of the
older adult who may be candidates for participation in AAT.
The health outcomes identify potential health benefits to
the older adult participating in AAT.
Indixidualshazacteristicmfixperiences

_ Prigr_rglated_hehagigrs. It has been demonstrated in
empirical studies that the best predictor of behavior is the
frequency of the same or similar behavior in the past, and
habits are thought to impact health promoting behavior as
well (Pender, 1996). The patient's previous positive
interactions with companion animals may predispose him or

her to participate in AAT. The adapted model for this

Individual Behavior-Specific Behavioral w

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Characteristics Cognitions Outcome Outcane
and Experiences and Affect
Perceived
_ benefits _
of action
PEI-centred demands
amers ——J (low control)
to semen and preferences
I (high control)
Perceived
”mummy”—
Activity-
related l—J
affect
Commitment
to a
plan of action

 

 

 

 

 

 

 

 

 

 

 

 

Situational

influences;

_ options i-J

demand characteristics
aesthetics

 

 

 

 

 

 

 

 

Figure 2. Adapted from W
(p. 67), by N. Pender, 1996, Stamford, CT: Appleton & Lange.

Copyright 1996 by Appleton & Lange. Adaptations shaded.

project is the foundation upon which the AAT screening tool
is built. Prior related behaviors and personal factors of
the patient, and interpersonal influences of family, peers,
and the APN affect whether the patient participates in the
health promoting behavior, or AAT. Additionally,
participation in AAT may result in the heightened likelihood
of participation in other health promoting behaviors.
Persona1_fagtgrs. Personal factors included should be
limited to those relevant to the target behavior (Pender,
1996). The AAT framework for this study identifies personal
factors of the patient as being limited to: biological -
older adults, decreased physical health; psychological -
decreased mental health, impaired self-esteem, and perceived
lack of control over health; and sociocultural - social
isolation, and loss of family or friends during this
changing life stage. These personal factors were selected
based upon the frequency with which they are seen in older
adults and because they have been shown to respond to AAT.
W
Interpersonal_inf1ngnges. The interpersonal influences
of peers, family, and health care providers may impact
health promoting behaviors (Pender, 1996). In the adapted
model, the patient may be influenced by the expectations of
significant others, or norms; instrumental and emotional
encouragement by the APN, or social support; and learning
through observation of others performing a certain behavior,

or modeling. The expectations of the older adult's

10

significant others to participate in health promoting
behaviors, the observation of one's peers participating in
AAT, and the instrumental and emotional support of the APN
may all influence the older adult to participate in AAT.
Behaxieral_0ntseme

Health_prgmgting_hehagigr. Health promoting behavior
is the action outcome in the RHPH (Pender 1996). In this
project, the behavioral outcome for the older adult is
participation in AAT. Participation in AAT may result in
participation in other health promoting behaviors.

LITERATURE REVIEW

Psychological
Comnanien_animal_literatnre. In a study of Alzheimer's

disease patients, caregivers reported fewer behaviors
indicative of aggression and agitation in those patients who
interacted with a pet than in those who did not (Fritz,
Farver, Kass, 8 Hart, 1995). The quasi-experimental design
consisted of 64 subjects, 25 males and 38 females age 53-92,
with a mean age of 74.6. All subjects had been diagnosed
with “possible” or “probable” Alzheimer's, were still living
at home, and had been evaluated at least once in the
previous year (Fritz et al., 1995). Thirty-four (53%) of
the subjects were reported to have contact with a pet at the
time of the most recent evaluation. Caregivers completed
questionnaires in which they reported fewer episodes of
verbal aggression and anxiety among patients exposed to pets

than in those not exposed to pets. It is not known if fewer

11

episodes of verbal aggression and anxiety would be
maintained over time and progression of the disease. Sample
characteristics that may have positively influenced study
outcomes include the fact that caregivers reported the‘
patient behaviors. The study authors questioned whether the
caregivers could have been comforted by the presence of the
pet, resulting in a decreased perception of the patients'
behaviors (Fritz et al., 1995). Study results imply regular
contact with pets may reduce some of the non—cognitive
symptoms commonly seen in Alzheimer's patients (Fritz et
al., 1995). Older adults referred to community based AAT
may experience similar benefits.

AAT_li;eratnzg. Three classic articles examined the
psychological aspects of participation in AAT (Huschel,
1984; Jessen, Cardiello, 8 Baun, 1996; Baun, Bergstrom,
Langston, 8 Thomas, 1984). Muschel (1984) conducted a study
to determine benefits of animal visits with nursing home
residents. In this quasi-experimental study of terminally
ill cancer patients in a nursing home, AAT was associated
with the increased comfort and adaptation of most of the
study participants. Participants were selected based on
their stated interest as well as physical and mental ability
to participate. Of 20 participants selected, 15 completed
the program, which consisted of ten weekly 90-minute
sessions. Participants were used as their own controls.
Sample characteristics that may have positively influenced

the outcomes of AAT include: terminal illness, nursing home

12

residents, stated interest, and the physical and mental
ability to participate in the study. Measures included a
questionnaire developed to measure anxiety or despair the
participants were experiencing, as well as personality
features; Five Thematic Apperception Test cards; pictures of
people with animals, which were shown to the participants;
and observation of participant behavior. When change scores
were analyzed, it was found that 12 of the 15 participants
voiced decreased fears, despair, and loneliness (Huschel,
1984). A majority of the participants had been diagnosed
with cancer for several years and had made little progress
through the stages of grief. unschel concluded the
patients' present ability to move more easily through
Kubler-Ross's stages supported the efficacy of AAT. In the
present project, community dwelling older adults referred to
AAT may benefit similarly.

In the second seminal quasi-experimental study, 40
older adults in a skilled rehabilitation unit randomly
assigned to experimental and control groups were questioned
to assess the effects of birds on their depression,
loneliness, and morale (Jessen, Cardiello, 8 Baun, 1996).
Self-reported measures of these variables were assessed on
admission using the Philadelphia Geriatric Center Herale
Scale, the Geriatric Depression Scale and the Revised UCLA
Loneliness Scale then compared with those obtained 10 days
later. A statistically significant difference was found

between groups for scores on depression, with lower

13

depression in the group with a caged bird, p-.01. It was
noted, however, the presence of a bird was not associated
with improvement on measures of loneliness or morale.

Sample characteristics which may have positively influenced
AAT outcomes include: older adults, skilled rehab unit,
ability of the participants to read, write and speak, stated
willingness to have a bird in their rooms, and a score of 24
or greater on the Mini-Mental State Exam. Additionally, the
study did not address whether the companionship of a bird is
associated with positive benefits for individuals residing
in settings other than skilled rehabilitation units. Jessen
et al. (1996) concluded the negative effects of change of
residence on older adults may be lowered by the presence of
a companion bird. Similar outcomes could be realized in

community dwelling older adults participating in AAT.

Minimise].
Wm. Petting a 609 With Which a

companion bond has been established has an effect on the
physiologic response of blood pressure (Baun, Bergstrom,
Langston, 8 Thomas, 1984). The quasi-experimental design of
the landmark study consisted of 24 subjects, 5 men and 19
women age 24-74, with a mean age of 46.7 (80812.5). They
had not been previously diagnosed with hypertension nor were
they on medications known to affect blood pressure, heart
rate or respiration. All subjects had lived with a dog for
at least six months and perceived oneself to be at least

moderately attached to the dog. A control group was not

14

utilized. Systolic and diastolic blood pressures were
measured when subjects petted a dog with which a companion
bond existed, when petting an unknown dog, and when reading.
There were statistically significant differences between the
three protocols for both systolic and diastolic blood
pressures (Baun et al., 1984). The greatest decreases in
blood pressures were associated with subjects who petted a
dog with which they shared a companion bond. Study periods
were limited to nine-minute intervals. It is not known
whether the trend to decrease blood pressures would continue
if study periods were lengthened, or whether the length of
the trend would be impacted by the length of the study.
Sample characteristics which may have positively influenced
the study outcomes include: participants had a dog with
which they had established some degree of bonding, and
participants had lived with the dog for at least six months
and rated themselves as at least moderately attached to the
dog. Study results imply positive blood pressure responses
when petting a dog with which a companion bond has been
formed (Baun et al., 1984). Similar positive outcomes could
be realized in those older adults referred to community
based AAT programs.

Anderson, Reid, and Jennings (1992) reported
significantly decreased systolic blood pressure and
triglyceride levels in pet owners compared to non-pet
owners. Men and women aged 20-60 were self-referred to a

free health screening clinic. Blood pressure, plasma

15

cholesterol, and triglycerides were compared in pet owners
(n-784) and non-owners (n-4957). Systolic blood pressure
was lower in men of all ages who were pet owners. No
overall significant difference was noted in systolic blood
pressures of female pet owners and non-pet owners, but in
female pet owners over age 40, systolic blood pressures were
significantly lower than in those under age 40. Male pet
owners' plasma cholesterol and triglyceride levels were
significantly lower than were those in non-owners. No
significant difference was found in plasma cholesterol
levels of female pet and non-pet owners. However, plasma
triglyceride levels were lower overall in pet owners, and
lower still in female owners over age 40. One sample
characteristic, which could have positively influenced AAT
outcomes, includes the fact that 13.6% of the participants
owned one or more pets. The study concluded that decreased
levels of accepted risk factors for cardiovascular disease
' were exhibited in pet owners and were not related to
socioeconomic status, smoking, diet, or body mass index
(Anderson et al., 1992). Participation in community based
AAT may result in similar outcomes.

The presence of a pet moderated the autonomic responses
of subjects engaged in mental arithmetic tasks in a study by
Allen, Blascovich, Tomaka, and Kelsey (1991). The quasi-
experimental design consisted of 45 women, age 27-55, with a
mean age of 38.6. All participants were self-referred,

white non-smokers who described themselves as dog lovers.

16

The health status of the study participants is not known.
Part one of the two-part study took place with the subject
alone at a psychophysiology laboratory. Pulse rates, skin
conductance tests, and blood pressures were measured while
subjects completed mental arithmetic and questionnaires
including the Pet Attitude Scale (Templar, Salter, Dickey, 8
Baldwin, 1981) and a questionnaire regarding pet ownership.
In part two of the study, the experiment was repeated with
the subjects at home under one of three randomly assigned
conditions: 1) with the subject's dog present, 2) with the
subject's close human friend present, or 3) with the subject
alone. Subjects were utilized as their own controls.
Sample characteristics which could have positively
influenced the study outcomes include: subjects were self-
referred, subjects were self-described dog lovers, all were
lifelong animal enthusiasts, and all had had pets in their
lives since early childhood. Results indicate subjects
demonstrated less physiological reactivity during stressful
situations when their pet was present than when alone or
with a close human friend present (Allen et al., 1991).
Similar physiologic responses may be realized in older
adults participating in community based AAT.

AAT_11;eratnrg. Harris, Rinehart, 8 Gustman (1993)
conducted a quasi-experimental study in which it was found
that an AAT program can affect the blood pressure measures
of homebound elderly patients who have owned a pet in the
past. Sixteen subjects completed the eight week long

17

program. Four weekly visits byia registered nurse (RN) were
conducted as a control, followed by four weekly visits by
the RN, volunteer, and therapy dog. Significant decreases
in mean diastolic and systolic blood pressure and pulse
rates occurred among those patients who participated in AAT.
It was concluded in this study that blood pressure measures
of homebound elderly patients who have owned a pet in the
past can be significantly affected by AAT (Harris et al.,
1993). These outcomes may be experienced in older adults
participating in AAT. Sample characteristics which could
have positively influenced the study outcomes include:
homebound older adults, the majority of the study
participants lived alone, and all had owned pets in the
past.'

In Wilson's (1991) quasi-experimental study of the
effects of pets on the psychologic results of stress, the
presence of a pet is associated with physiologic and
psychologic changes in some people. The 92 subjects, self-
selected college students, were aged 18-39 with a mean of
23.2 i 4.57. The majority of the subjects were female,
Caucasian, single, and living in single-family homes or
apartments. None of the subjects were hypertensive, taking
medications known to affect blood pressure or heart rate, or
allergic to dogs. Subjects were randomly assigned to one of
six treatment orders. Three situations were tested -
reading aloud, reading quietly, and interacting with a

friendly, unknown dog. Measurements consisted of blood

18

pressure and heart rate, State and Trait Anxiety by
Spielberger Self-Evaluation Questionnaires, and pet
ownership characteristics and attitudes by Pet Attitude
Inventory. Wilson (1991) concluded that the effects of the
treatment were significant, p<.001, for State Anxiety, and
Trait Anxiety levels remained fairly constant throughout all
treatments. While interacting with or talking to a pet was
found to be more stressful than reading quietly, it was less
anxiety producing than reading aloud. As these findings
were not consistent with previous data, Wilson (1991)
determined talking aloud could be a cofounder. Sample
characteristics which could have positively influenced the
study outcomes included a majority of study participants
who: were pet owners, had owned a pet in the past, indicated
time spent with the pet was enjoyable, stated their refusal
to give up the pet, or indicated the primary reason for not
owning a pet was restrictive leasing. It was concluded that
pets provide a source of comfort and companionship for many
individuals (Wilson, 1991).

Sociocultural

Comoanion_animal_literature. A quasi-experimental
study by Rogers, Hart, 8 Boltz (1992) reported dog owners

took twice as many daily walks as non-owners and expressed
significantly less dissatisfaction with their social,
physical, and emotional states. Subjects were recruited
through the managers of mobile home parks occupied primarily

by older adults. All subjects voiced neutral or positive

19

attitudes about pets and were willing to help in a study
about dog ownership. The sample consisted of five women and
one man, aged 65-78 with a median age of 69, who resided at
six separate parks. A control group of four women and two
men, aged 65-78, median age 67, resided in the same parks
but did not own dogs. Subjects were interviewed about their
walks and usual walking routine and asked 31 questions from
the Older Americans Resource Survey developed by Duke
University (1978). All participants were questioned about
number of walks, conversations during walks, and well-being,
and a content analysis of conversations was performed.

Study participants who did not own dogs gave questionnaire
responses that implied decreased well-being four times as
often as dog owners did. Responses among non-owners
included decreased regular social interaction with relatives
or friends, a greater number of recent days of illness, care
taking assistance, and a decreased rating of overall general
health. The scope of the study did not include the
screening of pre-existing psychological factors, which may
have contributed to differences between pet owners and non-
pet owners. Sample characteristics that could have
positively influenced the study outcomes include: older
adult subjects, and a stated positive or neutral attitude
toward pets. Rogers et al. (1992) concluded that elderly
dog owners use their dogs as conversational companions and

' acquaintances, and often refer to the dog whether it is

present or not. Participating in a community based AAT

20

program may facilitate increased socialization among older
adults.

. AAT_literatnre. In an observational study, Pick (1993)
reported the presence of a dog was positively associated
with an increase in social interaction among residents in a
nursing home. In the convenience sample, 36 male residents
attended one or more therapy sessions led by a social worker
with broad knowledge of the study procedures but not its
purpose, in order to control for possible intervention bias.
Defined social and non-social behaviors were measured by
point sampling with and without a dog present. verbal-
person interactions varied significantly between conditions.
When a dog was present, 10% of the behaviors displayed by
participants were verbal interactions with others. During
sessions without a dog present, it was five percent. The
study was limited to males only; therefore, it is not known
whether the results would be replicated in the usual nursing
home population, which is primarily female. Sample
characteristics which could have positively influenced the
study outcomes include: the participants were accustomed to
the presence of an animal, were “higher functioning“ and
able to communicate verbally (Fick, 1993). Pick (1993)
concluded that group therapy goals were positively
influenced by the presence of a dog. Similar outcomes would
likely be experienced by older adults in community based

AAT.

21

Residents of a veteran's home who had a diagnosis of
Alzheimer's disease were observed for effects of the
presence of a pet on social behaviors (Kongable et al.,
1989). Study results revealed that the presence of a dog
increased the number of total social behaviors (Kongable et
al., 1989). Twelve elderly residents ranging from age 66-88
comprised the sample group; 10 residents were male and 2
were female. All were diagnosed with Alzheimer's disease,
required supervision or assistance with activities of daily
living, and had resided at the home for at least one month.
All but one had owned a pet in the past. Kongable et al.
(1989) concluded that increased social behaviors were
associated with a dog being present. However, when the
therapy dog became a permanent resident of the unit, no
further significant increases were noted. It is not known
from this study whether certain individuals would benefit
more from one-to-one contact with pets than from group
contact. It is likely that similar outcomes would result in
older adults participating in community based AAT.

Social isolation and loss of family or friends were two
problems examined in a study of the benefits and liabilities
of pet ownership among the homeless (Kidd 8 Kidd, 1994).

The study reported that homeless adults demonstrated strong
attachments to their pets, particularly in those adults who
had owned pets as children. The quasi-experimental design
consisted of 105 homeless adult subjects aged 17-25, with a

mean age of 35.2. There were 54 men, 27 pet-owners and 27

22

non-owners; and 51 women, 25 pet owners and 26 non-owners.
Health status of the subjects is unknown. study subjects
were approached at city parks, on the street, and at soup
kitchens and questioned about themselves and their pets, if
any. Standardized tests were not used and pet “attachment”
was evaluated qualitatively through verbalizations and
behaviors of the subjects (Kidd 8 Kidd, 1994). Sample
characteristics which may have positively influenced the
study outcomes include: the majority of the subjects had
owned pets in childhood, all were homeless and likely to
have experienced some degree of isolation and loss of family
or friends, and all pet owners were extremely attached to
their pets. A majority of the subjects who owned pets
indicated they had no other relationships with other living
beings (Kidd 8 Kidd, 1994). Significantly more of the
homeless pet owners than non-owners had owned pets as
children. The study results imply that pets fill an
important social need in homeless adults, many who lack
relationships with other people (Kidd 8 Kidd, 1994).;
Participation in AAT by older adults may result in similar
benefits.

A quasi-experimental study by Lapp (1991) revealed
neither attachment nor a long-term relationship was
necessary in order to have a positive human-animal
communication exchange. Educational sessions were conducted
by nursing students using animals from the local humane

society with older adult residents of rent-subsidized

23

housing several times per year at the residents' request.
Students other than those who conducted the educational
sessions gathered evaluation data from the residents. The
data indicated that 81% of participants held or played with
one or more pets present and 90% verbalized thoughts of pets
they had in the past. The study did not address whether
increased social behaviors continued beyond the pet therapy
sessions, nor was a control group used. One sample
characteristic which could have positively influenced the
study outcome is the fact that all of the study subjects had
requested participation in the program. Lapp (1991)
concluded that residents tended to socialize more when a pet

was present. These data imply that increased interaction

 

among community dwelling older adults will likely result

from referral to AAT programs.

Wu
ComoamonzanimaLliterature It is known that the

presence of a pet can moderate aggression and agitation
(Fritz et al., 1995), positively influence the physiologic
responses of blood pressure (Baun et al., 1984; Anderson et
al., 1992), and result in increased social behaviors (Kidd 8
Kidd, 1994; Rogers et al., 1992). It is not known whether
aggression and agitation or blood pressure levels would be
moderated by the presence of a pet over time (Fritz et al.,
1995; Baun et al., 1984; Anderson at al., 1992), or whether
pro-existing psychological factors contributed to

differences between pet owners and non-owners. It needs to

24

be determined whether the mood moderating effects of pets
can be sustained over time in healthy persons and in
community dwelling older adults, and whether psychological
factors impact response to companion animals. .

Anima1:assisted_therapy. It is known that
participation in AAT can: increase the comfort and
adaptation of terminally ill patients and depressed patients
(Muschel, 1984; Jessen et al., 1996), positively influence
blood pressure and other physiologic changes (Harris at al.,
1993; Wilson, 1991), and increase the number of social
behaviors and interactions in long-term care patients (Fick,
1993; Kongable et al., 1989). It is not known whether
similar results would be realized in community dwelling
older adults, and this needs to be determined. The
literature reviewed for the project supports the efficacy of
AAT, especially in individuals who have enjoyed a
relationship with a pet in the past.

PROJECT DEVELOPMENT

2:gjggt_figa1. The goal of this project is to develop a
screening tool to be used by APNs in identifying potential
candidates for participation in community based AAT
programs. Participation in AAT includes increased social
interaction, enhanced self-esteem, increased or maintained
level of health, and increased perception of control over
health. Literature is lacking which provides a screening
tool for instituting AAT in primary care settings for use

with community dwelling older adults.

25

We. The target Population 18

community dwelling older adults. Research has documented
positive outcomes in this population (Boldt 8 bellman-
Jenkins, 1992). A profile of a person who might benefit
from AAT is: older adult z 65, socially isolated, decreased
physical and/or mental health, impaired self-esteem,
perceived decreased control over own health, and previous
positive interactions with companion animals. Selection of
the target population is based upon the increased focus on
health promoting interventions and the growing population of
older adults.

The APN will utilize the screening tool (Table 1) with
older adults who express an interest in maintaining or
improving his or her level of physical, emotional, or social
health (#10). The patient will be eligible for
participation in AAT based upon responses indicated on the
questionnaire (# correspond to questions on the screening
tool): prior related behaviors - previous positive
interactions with companion animals (#1 8 #2); and personal
factors - biological: older adults, decreased physical
health (#7); psychological - decreased mental health (#8),
decreased self-esteem (#9) and/or perceived lack of control
over health (#4); sociocultural - social isolation (#5 8
#6), loss of family, friends, or pets (#3). Candidates for
participation in AAT will be referred to a community based

AAT program.

26

Table 1.
Animal:Assisted_Therao¥i_Qneationnaire

 

DO IOU LINE PETS?

The purpose of this questionnaire is to identify persons who
like pets, would like to improve their health, and are
interested in participating in an animal-assisted therapy
group. Please answer the following 10 questions by circling
the number in the column under yes or no, and give it to the
nurse practitioner when she sees you.

.--m—,

1" 1 0 Have you ever had a pet?
2. 1 0 Did you enjoy it?

 

 

friends, or pets who have died?

 

. 0 1 Do you feel in control of your health?

 

. 1 0 Do you feel lonely?

 

6. t) 1 Do you see family/friends as often as you'd
like?

7. t) 1 Do you feel your physical health is as good
as it has been in the past?

I8. (3 1 Do you feel your mental health is as good as

| . 1 0 Have you ever been close to family members,

 

 

it has been in the past?
9. t) 1 Do you feel good about yourself?

 

 

10. 1 0 Are you interested in improving your health?
TOTAL

 

 

 

 

yalidit¥_assessment. Face validity of the AAT

screening tool was accomplished through consultation with a
panel of experts consisting of the scholarly project
committee members, and review of the tool by classmates and
older adult volunteers. Content validity was estimated from

the review of the literature on AAT. Additionally, experts

27

in the field of AAT will be asked to verify content validity
of the screening tool.

nata_analy§is. Scoring of the AAT screening tool will
be accomplished through summation of responses. A score of
:3 will be used as a criterion for referral to AAT. Each
patient referred to AAT will be sent a stamped, self-
addressed post card after four weeks. A telephone follow-up
will be instituted if response rate is low. The patient
will be asked to respond to questions based on the AAT
screening tool (Table 2), and invited to make additional
comments, if desired. A score of 23 will be accepted as a
positive response to participation in AAT. This cut-off
score could be tested in further research.

Apprgagh_and_prggedures. -An in-service regarding the
project and screening tool will be held with clinic staff
prior to implementation of the tool. The purpose of the in-
service is to educate and motivate staff regarding AAT in
general and the screening tool in particular. It is
important that all staff be aware of the project so they may
answer questions from patients and significant others.
Lunch will be provided at the in-service to encourage staff
attendance. The agency may already have an affiliation with
a larger health system for providing continuing education
units (CEU), and this would be a readily negotiated route

for providing CEU's to staff in attendance.

28

Table 2.

 

The purpose of this card is to evaluate your response to the
animal-assisted therapy group you were referred to. Please
answer the following questions by circling the number in the
column under yes or no. Your comments are encouraged.
Please mail the postage-paid card when completed. Thank
you.

.--m—

1. J. 0 Are you attending animal-assisted therapy
(AAT)? If no, skip to the “Your Comments"
section. We are interested in knowing more
about the reason(s) people who were referred
decided not to attend.

2. . 1. 0 Do you enjoy it?

 

 

3. J. 0 Are you less lonely since attending AAT?

 

4. 1. 0 Do you feel better about yourself since
attending AAT?

 

5. 1. 0 Do you feel more in control of your health?

 

6. 1. 0 Has your physical health improved since
attending AAT?

 

7. J. 0 Has your mental health improved since
attending AAT?

TOTAL

 

 

 

 

 

Your comments:

 

 

The clinic receptionist and medical assistant (MA) will
be asked to assist in distributing and completing the
screening tool. Based on date of birth, the screening tool

will be attached to the charts of those patients age 65 and

29

older when the receptionist prepares the charts for the next
business day. The MA will ask the patient to complete the
screening tool in the examination room while waiting to be
seen by the APN, and will assist the patient in completing
the tool, if necessary. The patient will give the completed
screening tool to the APN. The project is initially limited
to a total of 15 patient referrals. The number of patients
is limited to prevent the referral of more patients than the
AAT group is able to accept.

. Evaluation will be based upon the use of the screening
tool by the APN in a primary care setting, in visits by
community dwelling older adults with health promotion needs.
Evaluation of the screening tool will be achieved through
its review by the clinic receptionist and MA for ease of use
and potential clerical complications; the office manager
regarding time and cost issues; patients and significant
others regarding tool design, readability, clarity, ease of
use, and time issues; the physician regarding medical
concerns; the pet therapist regarding the screening tool
questions and referral to AAT; and nursing and other experts
in the field of AAT and screening tools regarding
completeness, applicability, clarity, reliability, and ease
of use of the tool. Suggestions for improvement or
modification will be analyzed for feasibility and possible
incorporation into the final product prior to institution of
the screening tool. In addition to this, the predictive

validity of the tool may be assessed by follow-up comparison

30

of patients who attend AAT versus those who do not. Key
outcomes to be compared include: social interaction, self-
esteem, level of health, and perception of control over
health. I

Feasibility_issnes. Feasibility issues to be
considered in implementing the screening tool include ease
of use, time, and cost effectiveness. The tool is a 10-
question large-print form, which can be completed in a few
minutes. The format of the tool will allow the APN to
quickly scan the responses to determine whether the patient
is a candidate for referral to community based AAT.

The costs associated with implementing the screening
tool will be limited to printing or photocopying expenses,
personnel expenses related to the time spent by the
receptionist and MA in distributing and completing the tool,
and time spent by the APN to review the completed tool and
refer candidates to AAT. An incentive system for the clinic
staff will be instituted to encourage distribution and
completion of the tool. Minimal personnel expenses are
anticipated as the tool is designed for ease of use and
takes only a few minutes to review. There are potential
cost benefits related to the use of the tool. Promoting
health and reducing illness of older adults may decrease
overall health care costs.

DISCUSSION
The APN functions in many roles in which the screening

tool may be utilized as health promotion and illness

31

reduction strategies. As an educator, the APN can educate
patients, significant others, the public, and other health
care providers about potential benefits of participation in
AAT. As a facilitator, the APN can facilitate participation
in AAT through referrals to community based programs. As a
manager, the APN manages the patient's overall care and can
monitor the patient's response to AAT. As a consultant, the
APN can act as a source of information about AAT to
patients, significant others, and other health care
providers. As a counselor, the APN can provide instrumental
and emotional encouragement to patients and significant
others regarding participation in AAT. As an advocate, the
APN can provide information on alternative health care
options, including AAT. Finally, as an assessor, the APN
can assess potential candidates for AAT.

Like a healthy diet or exercise, the use of AAT for
health promotion and illness reduction can produce positive
outcomes for older adults. The APN is ideally positioned in
a primary care role to assess those who may benefit from
AAT. Holistic screening of patients and emphasis on patient
education and counseling enables APNs to develop care plans
that meet the goals of health promotion and illness
reduction that are consistent with patient values (Snyder 8
Mirr, 1995).

An important aspect of APNs is the use of clinical
tools based on research evidence. Many regulatory statutes

of states contain provisions that nurse practitioners

32

practice under written practice guidelines (Henry, 1992).
The development and utilization of a screening tool for AAT
meets this requirement.

APNs are concerned with helping their patients to
maintain or improve their optimal physical, emotional,
and/or social health. AAT may provide psychological and
physiological benefits, foster self-esteem, produce a
calming effect, and stimulate social interaction or
reminiscence of past pet ownership (Kongable et al., 1989).
Based upon the literature reviewed for this project, AAT can
result in positive health outcomes for older adults.

AAT is inexpensive and produces positive changes in
health status, which results in decreased costs for
individuals and society as a whole.' Data collectively
suggest that pet ownership may decrease the demand for care
for medically nonserious problems (NIH, 1988), which might
have more of an impact than estimated; i.e., a small
reduction in depressive symptoms may reduce costs, and
improve health and functional status significantly.
Significant improvements in general health were noted
following adoption of a pet (Serpell, 1989). Improved
physical and emotional health (Rogers et al., 1992), stress
reduction (Wilson, 1991), and fewer primary care visits
(Siegel, 1990) all result in decreased costs.

AAT is a health promotion and illness reduction
strategy that is relevant to research, teaching, and primary

Care practice. Further research of AAT is needed to obtain

33

more information about its health promotion and illness
reduction benefits and use in community dwelling older
adults. Nurse educators must continue to inform students
about alternative health promotion and illness reduction
strategies such as AAT. In particular, primary care nursing
provides many opportunities for the integration of a variety
of health promotion services into patient encounters
(Pender, Barauskas, Hayman, Rice, 8 Anderson, 1992). AAT is
one such service. APNs are ideally positioned to facilitate
the therapeutic use of companion animals with those older
adults deemed appropriate for such an intervention.

. There is strong evidence supporting the psychological,
physiological, and sociocultural benefits of AAT in older
adults. As the older adult population increases, the number
of those who experience loneliness, isolation, and impaired
health grows. A companion animal can be a source of
unconditional love, approval, and comfort, and provide a
sense of purpose to the older adult. As the health benefits
and cost effectiveness of AAT becomes more widely recognized
it is hoped that it will become a common health promotion

intervention.

34

LI ST OF REFERENCES

LIST OF REFERENCES

Allen, K., Blascovich, J., Tomaka, J., & Kelsey, R.
(1991). Presence of Human Friends and Pet Dogs as ’
Moderators of Autonomic Responses to Stress in Women.

WWW“) , 582-589-

American Nurses Association (1995). Nursing: A Social
Policy Statement. Kansas City, MD, 9-20.

Anderson, N., Reid, C., & Jennings, G. (1992). Pet
Ownership and Risk Factors for Cardiovascular Disease.

W. 298-301-

Barkauskas, V., Stoltenberg-Allen, N., Baumann, L., &

Darling-Fisher. C- (1998). W.
(2nd ed.). Mosby: St. Louis.

Baun, M., Bergstrom, N., Langston, N., & Thomas, L.
(1984). Physiological Effects of Human/Companion Animal
Bonding- MW”) . 126-129-

Belmont, M., Henderer, K., 8 Bennett, J. (1990).
Health Promotion for the Elderly. In Lewis, C. (Ed.),

Aain9i_The_nealth_care_Challenne (2nd ed., pp. 241-252).
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Boldt, M., & Dallmann-Jenkins, M. (1992). The impact
of companion animals in later life and considerations for

Practice. W9) . 228-
239.

. Brickel, C. (1986). Animal-assisted therapies: A
review of the literature and clinical implementation

considerations. Wfl/H. 309-332-

Delta Society, 2nd ed. (1996). Standards of practice
for animal-assisted activities and animal-assisted therapy.
Renton, WA: Author.

Duke University Center for Study of Aging and Human
Development. (1978). Multidimensional functional
assessment: The OARS methodology (2nd ed.). Durham, NC:
Duke University Press.

Ferrini, 15., & Ferrini, R. (1989). W
m. Dubuque, IA: Brown.

Pick, K. (1993). The Influence of an Animal on Social
Interactions of Nursing Home Residents in a Group Setting.

WW“) . 529-533-

35

Fritz, C., Farver, T., Kass, P., 8 Hart, L. (1995).
Association with Companion Animals and the Expression of
Noncognitive Symptoms in Alzheimer's Patients. Jan:nal_nf
Nsrxous_and_uental_niseasei_lnl(7). 459-463-

Garrity, T., Stallones, L., Marx, M., 8 Johnson, T.
(1989). Pet Ownership and Attachment as Supportive Factors
in the Health of the Elderly. Anthrgzggs‘_1, 35-44.

Harris, M., Rinehart, J., 8 Gerstman, J. (1993).
Animal-Assisted Therapy for the Homebound Elderly. Holistic

Nurse_zractitioneri_a(1), 27-37.

' Henry, P. (1992). Analysis of Standard Procedures and
Protocols: A Legal Viewpoint.
1(3), 122-123.

Jenkins, J. (1986). Physiological Effects of Petting a
Companion Animal. 2sxnholoeical_nenortsl_§a. 21-22.

Jessen, J., Cardiello, F., 8 Baun, M. (1996i. Avian
Companionship in Alleviation of Depression, Loneliness, and
Low Morale of Older Adults in Skilled Rehabilitation units.

Psxcholonical_Eenortsi_la. 339-348.

Kidd, A., 8 Kidd, R. (1994). Benefits and Liabilities

of Pets for the Homeless. EExcheloeisal_nsnortsl_14. 715-
722.

King, P. (1994). Health Promotion: The Emerging

Frontier in Nursing. Iournal_of_Ad1anced_Nursinn+_zn. 209-
218.

Kongable, L., Buckwalter, K., & Stolley, J. (1989).
The Effects of Pet Therapy on the Social Behavior of
Institutionalized Alzheimer' 3 Patients. Argh11e§_gf

Psychiatric_Nnrsinci_1(4). 191-198.

Lapp, C. (1991). Nursing Students and the Elderly:
Enhancing Intergenerational Communication Through Human-

Aninal Interaction. Holistis_Nnrsin9_£rastissi_512)p 72-79-

Muschel, I. (1984). Pet Therapy with Terminal Cancer
Patients. sgcial_Casew9rki_The_Jonrnal_of_£ontemnorar¥

Social_florki_ln. 451-458-

National Institutes of Health (1988). Summary of

Working Group. Health_flgnefits_gf_2ets. Washington: U.S.
Government Printing Office.

Ory, M., 8 Goldberg, E. (1983). ~Pet Possession and

Well-being in Elderly Women. Research_on_Acingi_5(3), 389-
409.

36

Pender, N., Walker, 8., Sechrist, K., 8 Frank-
Stromberg, M. (1990). Predicting Health Promoting

Lifestyles in the Workplace. Nursina_nessarchi_12(6). 326-
332.

Pender, N., Barauskas, V., Hayman, L., Rice, V., 8
Anderson, E. (1992). Health Promotion and Disease
Prevention: Toward Excellence in Nursing Practice and

Education. Nursinn_9utlocki_in(3). 106-112-

Pender. N. (1996). Health_2rcnotien_in_Nnrsinc
Practice (3rd ed.). Stamford, CT: Appleton 8 Lange.

Petosa, R. (1986). Emerging Trends in Adolescent
Health Promotion. Hccith_ycincci_in(3), 22-28.

Public Health Service (1990). Healthy People 2000:
National Health Promotion and Disease Prevention Objectives.
Washington: 0.8. Government Printing Office.

Raeburn, J. (1992). Health Promotion Research with

Heart: Keeping a People Perspective. Canadicn_1cnznci_cf
2nh119_flcdlihl_fil(81)p 520'524-

Rogers, J., Hart, L., 8 Boltz, R. (1992). The Role of
Pet Dogs in Casual Conversations of Elderly Adults. Inc

Journal_of_Social_Ps¥shelon¥i_lll(3). 265-277-

Serpell, J. (1989). Humans, animals, and the limits of
friendship. In Porter, R. 8 Tomasell, S. (Eds.), Diciccgicc

cf_£ricndship (pp. 111-129). London: Routledge.

Siegel, J. (1990). Stressful Life Events and Use of
Physician Services Among the Elderly: The Moderating Role of
Pet Ownership. Jonrnal_of_2srsonalit¥_and_Social

Earsholos¥i_§a(6), 1081-1086.

Snyder, M., 8 Mirr, M. (Eds.). (1995). Adycnccd
- . New
York: Springer Publishing Company.

Templer, D., Salter, C., Dickey, S., 8 Baldwin, R.
(1981). The construction of a pet attitude scale.

Earsholonical_necordi_ll. 343-348._

Walker, 8., Sechrist, K., 8 Pender, N. (1987). The
Health Promoting Lifestyle Profile: Development and

Psychometric Characteristics. Nursinc_Rcccczchi_1§(2), 76-
81e '

Wilson, C. (1991). The Pet as an Anxiolytic

Intervention. The_lsurnal_of_Nerxous_and_Hental_niseasei
112(8), 482-488.

37

World Health Organization. (1986). Health_2:cmcticn

Copenhagen: World Health Organization.

38

APPENDIX A

'||||||'”|” I

   

APPLETONS: LANCE

 

Simon & Schuster

International and Business & Professional Group
I”? [Elm SU‘UL'L PO. Box 120041

Stmnmrd. CT 06912404]

Bill-lth-fitll 0 Fax: 2034064601

September 29, 199:
Michelle L. Dalton. BSN, RN, c

1035 N. Rail: Avenue
Ludington, Ml 49431

DearMaDalton:
Mmrwmmmmmmmmmm
Andrea's): Noia 3. Pender, RN, PhD, mm

Title: Health promotion in gm Practice: mo Edition

Figure(s)fl'able(s): Figure 3-2

in your Michigan State University College of Nursing thesis, “PET-Facilitated Therapy and Older
Adults: Development of a Protocol.” to be completed in 1998.

Pennission ismtedmbjecttoyanreeoamhconfimingdmtthemwial inqueationisoriginal

to our text. Permission is outed on anon-exclusive, one-time only or life ofeditionbasia, with

distribution rights throughout the world in print only. Permission mast be requested aeparately

for other adaptations, electronic right: and derivative works. Permission is granted subject to:
Useofaoreditlinewhichmustincludethenameoftheauthor, fideoftheboohodition.
copyrightholda(Appleton&Lange),mdyearofpublioation. Themeditlhtemustappear
on the same page as our text or illustration.

If you have any questions, please feel free to contact me.

Sincerely,
CM 4— W

Permission: Editor
Phone (203) 406-4627

DALTONDOC

39

APPENDIX B

 

 

an

'0

    
  
   
   
 
  
  
  
  
   
    
     
   

DO YOU LIKE PETS?

 
 
  
 
 
  
 
 
  

The purpose of this questionnaire is to
identify persons who like pets, would like
to improve their health, and are interested
in participating in an animal-assisted :
therapy group. Please answer the following
10 questions by circling the number in the
column under yes or no, and give it to the
nurse practitioner when she sees you.

Yes No
1 0 Have you ever had a pet?
I 0 Did you enjoy it?
1 0 Have you ever been close

to fam11y1members, friends,
or pets who have died?

 

0 1 Do you feel in control of
your health?

1 0 Do you feel lonely?

 

A o 9i
.3

 

     

40

 

 

Do ybu see family/friends as
often as you’d like?

'Do you-feel your physical
health is as good are “it has
been in the past?

Do You feel your mental
health is as good as it. has:
been in-the past?

.. Do you feel good about
yourself?

'Are_you interested in
improving your health?

TOTAL

 

 

 

IIfiifilfl'fll‘li.HIM]rflfllT?T‘TlTillIllLlfil‘l‘lmifisII

3 1293 02427 1326

 

4‘