Animal-assisted interventions in COPD

To understand the potential benefits of animal-assisted interventions (AAIs) in the mental health of people with chronic obstructive pulmonary disease (COPD), this exploratory patient-oriented assessment utilized four focus groups and a digital story. The focus groups involved COPD healthcare professionals, COPD family caregivers, and those living with COPD, and the digital story was developed in partnership with our COPD patient advisory group which comprised of COPD patients and caregivers. From the focus groups, six themes relevant to mental health were identified: (1) loss of identity and purpose, (2) difficulty managing health, (3) negative impacts on routine, (4) internalized blame and external stigma, (5) need for companionship, and (6) experiences of anxiety and stress. The outcomes support the need for future research of AAIs in COPD care.

INTRODUCTION: Although chronic obstructive pulmonary disease (COPD) is common, preventable, and treatable, the individuals affected by it can suffer immensely. Many people with COPD are diagnosed with anxiety, and are more likely to develop depression and almost twice as likely to die by suicide than people without COPD.1 Individuals with COPD seek compassion about their disease as there still remains stigma for those who use tobacco; and among those with prior tobacco use or other work and/or environmental exposures, there are feelings of blame or anger for what has become their lung disease.2 While there has been progress in understanding the pathophysiology of and effective treatments for COPD, there is no cure for it.  

A well-supported approach to reducing symptoms and improving the quality of life for people living with COPD is pulmonary rehabilitation, a patient-tailored intervention that consists of exercise training, education, and self-management programming focused on patients’ physical and mental health.3 Although pulmonary rehabilitation has been shown to reduce COPD symptoms, including anxiety and depression, uptake of and retention in the intervention is very limited.3 Furthermore, those with related severe psychological symptoms are unlikely to attend pulmonary rehabilitation.3 Because the literature indicates that further supports are needed for people with COPD to attend pulmonary rehabilitation which could benefit their mental health, our team explored whether an animal-assisted intervention (AAI) could be applied to this area. 

An AAI involves the incorporation of animals in various contexts to improve human health, including therapy, education and visiting.4 AAI activities can include a client, therapy animal (most commonly a dog), animal handler, and/or a therapist or other relevant professional. Therapy dogs are typically friendly family dogs that pass a test allowing them to volunteer visit alongside a human handler with people who do not have access to a dog (e.g., hospital patient). Illustrative studies in AAI include Chang et al.5 and Dell et al.,6 who respectively undertook a systematic review/meta-analysis of animal-assisted therapy as a therapeutic intervention with older adults and evaluated an animal visitation intervention in a hospital emergency department. In the 2020 assessment, the animal-assisted therapy intervention produced positive outcomes in physiological, psychosocial, cognitive, and behavioral domains, whereas the 2019 controlled trial identified a clinically significant reduction in pain, depression, and anxiety among patients visiting with a therapy dog. Both studies showcase the strengths associated with the integration of therapy dogs in human health care. There are numerous benefits associated with AAIs, but none to date have been published in the COPD area where the opportunity to decrease anxiety and improve quality of life is important, specifically among older adults. 

To begin to understand the usefulness of AAIs in COPD populations, our team conducted a first-of-its kind exploratory, patient-oriented project involving focus groups and digital storytelling (Human Research Ethics Board ID 1737 and Human Research Ethics Board ID 2819, respectively). This was a necessary pre-step to implementing and evaluating a unique practice innovation in this area. The focus groups investigated (1) the key challenges of living with COPD, and (2) the potential benefits of AAIs to assist individuals living with COPD. A complementary digital story was developed with our team’s COPD patient advisory group, comprised of COPD patients and caregivers, to gain further insight into the topic.

METHODS: Over the summer months in 2020, four online, 90-minute focus groups were held with COPD healthcare professionals (7 participants), COPD family caregivers (5 participants), and people living with COPD (two groups of 6 participants). During each focus group, participants were asked five open-ended questions that were developed by the patient and family advisory group: (1) Describe your past and present experience with COPD, (2) Describe your past and present experience with animals or pet therapy, (3) What are some things that you feel are missing from COPD care?, (4) Have you ever considered involving animals into COPD care?, and (5) If so, what would these animal assisted interventions look like?; How could integrating animals into COPD care improve physical, mental, emotional wellbeing? The focus groups were recorded, and participant responses were transcribed and made non-identifiable by way of assigning each participant a number. Inductive thematic analysis was applied to the collected data, to derive meaning from dialogue without any preconceptions.7

RESULTS: Our analysis identified six themes about the challenges of living with COPD across all focus groups: (1) loss of identity and purpose, (2) difficulty managing health, (3) negative impacts on routine, (4) internalized blame and external stigma, (5) need for companionship, and (6) experiences of anxiety and stress. These themes are relevant to mental health and, importantly, participants shared that they perceived pets, including therapy dogs, to have brought comfort and companionship as well as decreased levels of anxiety and depression.

Combining AAI and exercise therapy was a common suggestion from the focus groups. The healthcare providers discussed pulmonary rehabilitation specifically, and identified therapy dogs to help garner interest among patients: “as an opportunity to get somebody into the program…maybe that would open up and make people a little bit more trusting and more interested.”  Another shared: “having a dog at pulmonary rehab when somebody’s more anxious and nervous about going out in public would give [COPD patients] the opportunity to walk or just be with someone while they’re being introduced to the program.”

The caregivers reflected on how companion animals have helped their loved ones or clients living with COPD manage their health. Specifically, dogs encouraged patients to go for walks outside, and taking care of a pet could “give a happier focus and something positive to do.” A caregiver added: “you have to look after an animal and maybe take it for a walk, and all that, I believe, would help so much just to get over the depression.” It was also noted that pulmonary rehabilitation programs could be “very repetitious,” so the presence of a therapy dog in this therapy “breaks the monotony of having to do the exercises.” Among the patients, integrating AAI in pulmonary rehabilitation was considered a motivating factor for attendance, as one patient shared: “I would look forward to if there was some sort of a program or something in relation to animal therapy or something like that. That would be just tremendous.” Further, the inclusion of therapy dogs was suggested to be complementary to pulmonary rehabilitation: “[a dog would help] to follow through with doing even simple exercises, and even sometimes a little socializing.”

A digital story was created by the patient and family advisory group to explore internalized blame and external stigma associated with COPD, which was a key, overarching finding of the focus groups. This arts-based investigation involved participants sharing their narratives, photos, and voiceovers about their companion animals, which was integrated into a short video under their direction. Our focus groups and digital storytelling project ultimately support the need to further explore the potential benefit of an AAI among COPD patients (See the final digital story at: https://www.youtube.com/watch?v=gKyw-rHICQk)

DISCUSSION AND RECOMMENDATIONS: Based on our team’s project and the extant literature, we propose that people living with COPD have unmet psychosocial needs that may be addressed in part from an AAI, and there are numerous opportunities to integrate AAIs within the existing COPD care pathway. For example, the AAI could include therapy dogs alongside healthcare providers in a pulmonary rehabilitation program to encourage patients to engage with the intervention, enhance the patient/provider connection, and reduce levels of patient anxiety while they attend. Due to our project being exploratory in nature, more research is necessary to bring attention to and develop an evidence-base to improve the mental health of people living with COPD by integrating this unique intervention into their care. What we have found, however, is complementary to the AAI and companion animal literature (e.g., Friedmann et al.8, Higgins et al.9, Wesenberg et al.10). Our patient-oriented team encourages the COPD field to consider the potential beneficial impacts of this novel intervention and to join our team in developing and studying AAIs to improve the mental health of people living with COPD.

SOURCES: Julia J. Visentini (BSc Hons.), Erika D. Penz (SM, M, MSc, FRCPC), Colleen A. Dell (PhD), Maria T. Cruz (MA) University of Saskatchewan, Saskatoon, Canada

CORRESPONDING AUTHOR:

Dr. Erika Penz, Associate Professor: Division of Respirology, Critical Care and Sleep Medicine & Respiratory Research Centre University of Saskatchewan Email: erika.penz@usask.ca Tel: 305-844-1140 

REFERENCES:

1. Global Initiative for Chronic Obstructive Lung Disease. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease (2023 Report). https://goldcopd.org/wp-content/uploads/2023/03/GOLD-2023-ver-1.3-17Feb2023_WMV.pdf. Published 2023. Accessed November 13, 2023.

2. The Canadian Lung Association. Stigma report 2018. https://www.lung.ca/sites/default/files/StigmaReportSeptemberFINAL.pdf. Published 2018. Accessed November 13, 2023. 

3. Gordon CS, Waller JW, Cook RM, et al. Effect of pulmonary rehabilitation on symptoms of anxiety and depression in COPD: A systematic review and meta-analysis. Chest. 2019;156(1):80-91. https://doi.org/10.1016/j.chest.2019.04.009

4. Serpell, JA. Chapter 2: Animal-assisted interventions in historical perspective. In: Fine AH,ed. Handbook on Animal-Assisted Therapy: Foundations and Guidelines for Animal-Assisted Interventions. 3rd ed. Academic Press; 2010:17-32.

5. Chang SJ, Lee J, An H, et al. Animal-assisted therapy as an intervention for older adults: A systematic review and meta-analysis to guide evidence-based practice. Worldviews Evid Based Nurs. 2020;18(1):60-67. https://doi.org/10.1111/wvn.12484 

6. Dell CA, Chalmers C, Stobbe M, et al. Animal-assisted therapy in a Canadian psychiatric prison. Int J Prison Health. 2019;15(3):209-231. 10.1108/IJPH-04-2018-0020

7. Maguire M, Bird D. Doing a thematic analysis: A practical, step-by-step guide for learning and teaching scholars. All Ireland J Teach Learn High Ed. 2017;8(3):3351-33514. https://ojs.aishe.org/index.php/aishe-j/article/view/335

8. Friedmann E, Galik E, Thomas SA, et al. Relationship of behavioural interactions during an animal-assisted intervention in assisted living to health-related outcomes. Anthrozoös. 2019;32(2):221-238. https://doi.org/10.1080/08927936.2019.1569905

9. Higgins JW, Temple V, Murray H, Kumm E, Rhodes R. Walking sole mates: Dogs motivating, enabling and supporting guardians’ physical activity. Anthrozoös. 2015;26(2): 237- 252.  https://doi.org/10.2752/175303713X13636846944286

10. Wesenberg S, Mueller C, Nestmann F, Holthoff-Detto V. Effects of an animal-assisted intervention on social behaviour, emotions, and behavioural and psychological symptoms in nursing home residents with dementia. Psychogeriatr. 2019;19(3): 193-288. doi:10.1111/psyg.12385