Exploring how therapeutic horse riding improves health outcomes using a realist framework

Abstract

Introduction

Evaluating how therapeutic horse riding improves health for children experiencing disability is made complex by a lack of clarity around mechanisms of treatment effect. This research develops an explanatory theory outlining how health outcomes may be optimised, by exploring what works for which riders, under what conditions and how.

Method

Within a realist research framework, we undertook three phases of study using a mix of qualitative and quantitative data collection and analysis approaches. Findings were then integrated into an overall evaluative account.

Results

Riders with a range of impairments (n = 32; aged 5 to 17 years), caregivers (n = 29) and therapeutic horse riding providers (n = 16) participated. Three key mechanisms of intervention effect are proposed: (1) therapeutic horse riding facilitates development of a rider’s self-concept through opportunities for accessible, meaningful participation; (2) the context in which therapeutic horse riding is provided promotes a focus on riders’ capacities and strengths and (3) therapeutic horse riding provides opportunities for a broad range of learning experiences.

Conclusion

Therapeutic horse riding provides opportunities for meaningful occupational participation for children experiencing disability. Ensuring that the physical and ideological context in which therapeutic horse riding is provided focuses on a rider’s capacities and strengths will enhance self-concept development and participation outcomes.

Keywords

Therapeutic horse riding disabled children occupational participation self-concept treatment effectiveness rehabilitation occupational therapy

Introduction

Therapeutic horse riding (THR) is accessed worldwide by children and young people who experience disability. However, it is often not clear why and how observed benefits from THR might have occurred (Heffernan, 2017). Frequently, claims are made within published literature about purported processes that lead to changes in health outcomes as a result of THR, without empirical data being provided to support these claims.

Literature review

Treatment theories underling THR

THR is one of a number of treatment approaches that sit under the broader category of equine-assisted interventions (EAI). Other types of EAI include hippotherapy, equine facilitated psychotherapy and equine-assisted learning. A wide range of treatment theories have been proposed to support these different types of EAI. Currently, these treatment theories are largely unsubstantiated. Nonetheless, within literature focused on either primarily physical or psychosocial outcomes, some theoretical themes are evident.

Physical outcomes

Within EAIs that focus on physical outcomes (for example hippotherapy and THR), attention has been given to the horse’s movement as providing the key intervention effect. It is proposed that a horse’s movement provides neuromotor stimulation, allowing riders to practise normal movement responses while also providing complex sensorimotor stimulation, thereby contributing to their developing sensory integration and spatial awareness (see, for example, Meregillano, 2004). Debuse et al. (2009) developed a conceptual framework explaining how hippotherapy constitutes an effective motor learning opportunity, postulating that physical and psychological effects of hippotherapy were due to neuro-motor, sensorimotor and psycho-motor inputs leading to neuroplastic changes within riders.

Psychosocial outcomes

No unifying theory has been presented explaining why horses might improve psychosocial outcomes. However, Kendall et al. (2014) suggested that three potential hypotheses emerge from the literature. First, the psychological benefits of EAIs are unrelated to the horse. For example, these factors may be due to the EAI being provided in a non-medical setting (providing a connection with nature). Second, it is possible that the horse provides a particularly positive context, thereby promoting the likelihood of psychological gains, which may be derived from other sources (for example, the horse may allow for a sense of normality for people experiencing disability, or the warmth and rhythmic movement provided by the horse may promote a relaxing context, which may have a calming effect on the rider). Third, the horse itself may have specific therapeutic qualities that bring about unique changes not otherwise likely to occur. In this way, the horse is viewed as being a catalyst that brings about changes such as trust, control and mastery, emotional expression and sensory integration.

Changes outside riding sessions

Within these proposed treatment theories there has been a focus on the specific benefits of horses within EAI sessions, while gains in person-centred, participatory-based outcomes and the mechanism of their effect have been researched less often (Heffernan, 2017). Specifically, there has been limited attention to how EAIs may contribute to changes in the rider’s occupational participation within their home, school and community contexts. Evaluating how effective THR is at improving health outcomes for children who experience disability is therefore made complex by a lack of clarity about which health outcomes can be optimised, key intervention ingredients and mechanisms of treatment effect.

Health outcomes

Contemporary conceptualisations of health emphasise holistic, positive development occurring via transactions between person and environment, that are influenced by the person's interests, valued activities, social interactions, opportunities and life experiences (Palisano et al., 2017). Health, therefore, pertains to a person’s participation within important social and occupational roles, and to the achievement of valued life goals. Interventions aimed at optimising health involve a process of learning to live well with impairments in the context of one’s environment, and health-optimising interventions aim to assist people to participate fully in personally valued occupational activities and roles, rather than solely focus on ‘fixing’ them (Gibson et al., 2009: 1446). As such, the experiential outcomes of THR assume greater relevance.

Evaluating the effectiveness of complex interventions

It is difficult to rigorously evaluate the effectiveness of health-optimising interventions with experimental group research designs when used in isolation (Shannon-Baker, 2016). Interventions aimed at improving health outcomes are often complex social processes with many potential active ingredients, typically delivered in uncontrolled, context-rich settings, and responded to differently by different people (Salter and Kothari, 2014). Mechanisms leading to improved outcomes as a result of interventions are often not simple, linear or deterministic (Wong et al., 2012). While effectiveness studies of interventions delivered in carefully controlled settings provide stronger evidence of linear causation, difficulties can occur when translating findings from these studies to ‘real world’ clinical practice where complexity is a certainty (McEvoy and Richards, 2006). Evaluating the effectiveness of interventions aimed at improving health, therefore, requires the use of a range of methods to explore salient contextual factors, which may account for variations in both programme delivery and outcomes for individuals participating in interventions to a greater extent than has historically been seen. That is, instead of only asking, ‘does it work?’ there is a need also to ask, ‘what works for who, in which contexts, to what extent and how?’ (Salter and Kothari, 2014).

Research aim

This research aimed to develop explanatory theory outlining how THR optimises the health outcomes of children and young people who experience disability. Specific consideration was given to what outcomes were valued most by riders and their caregivers, the influence of the context in which THR is provided, possible mechanisms of intervention effect, and variation in outcomes seen within and between riders. Mechanisms of effect represent how intervention resources (that is, THR activities and the context within which THR is provided) are received, interpreted and acted upon by riders to produce an outcome or pattern of outcomes (Salter and Kothari, 2014).

Methods

Design

A critical realist stance was adopted as the philosophical basis for this research (McEvoy and Richards, 2006). We conducted a mixed-methods study in three phases, culminating in an analytical synthesis in which findings from all three phases were integrated into one overall evaluative account. Phase 1 explored the context in which THR was delivered and outcomes that were valued by riders, while Phase 2 explored possible mechanisms that could account for changes in health outcomes in riders (Martin et al., 2017). Phase 3 measured in whom, and to what extent, changes in health outcomes were demonstrated in 12 riders (Martin et al., 2019). In this paper, we synthesise findings from all three phases and interpret these within an integrated evaluation of THR intervention effectiveness, with all phases equally accounting for evaluative claims. The University of Otago Human Ethics Committee (Health) provided ethical approval for all phases of this research [H14/075; H16/033]. Riders gave assent to be involved in the study, and adult participants (including riders/caregivers) provided written informed consent.

Description of THR intervention

This research took place in one urban New Zealand Riding for the Disabled Association (NZRDA) centre, where riders attend THR sessions once per week during school term times, for 1 year. THR sessions typically last for 1 hour and include activities both on and off the horse. One trained NZRDA coach, supported by trained volunteers acting in ‘horse-lead’ and ‘side-walker’ roles, facilitate a group of approximately six riders to complete a range of horse-related tasks. Tasks include horse care (such as grooming the horse and tacking up), riding skills (such as starting, stopping, using reins to direct the horse and trotting) and activities while on the horse (such as posting objects into boxes, throwing and catching a ball, or jousting). Most of the sessions were provided in a large covered arena, with riders often being given the opportunity to be part of an outdoor ‘trek’ around the agricultural park in which the arena is situated. Each rider’s session activities were individualised by the coach (in consultation with therapy and educational providers as appropriate) to address goals established at the start of the THR intervention. A Template for Intervention Description and Replication (TIdieR) checklist, included in the online supplementary material, provides more details of THR intervention characteristics.

Overview of research phase methods

There were three phases of data collection and analysis contributing to explanatory theory development (see Figure 1).

Figure 1.

Overview of research data collection and analysis contributing to the development of an explanatory theory about how THR works to optimise health outcomes. Phase 2 and 3 results are reported in Martin et al. (2017) and Martin et al. (2019).

Phase 1

In this phase, we explored the intervention components of THR provided by NZRDA, the context in which THR is delivered, and health outcomes prioritised by various stakeholders, but particularly riders. Specific attention was given to understanding similarities and differences in key stakeholder views of the value of THR. As such, this study contributed to determining key outcomes to be measured within Phase 3 (Martin et al., 2019). We collated results from two data sources – (a) existing service documents and (b) interviews and focus groups – using two distinct analytical methods. First, we used directed-content analysis (Hsieh and Shannon, 2005) to explore perspectives of various stakeholders as expressed in existing service-initiated documentation (unsolicited informal rider and caregiver testimonials (n = 11); feedback surveys routinely collected as part of NZRDA processes (n = 19); goal forms written by THR coaches for each rider (n = 60); training materials used across the wider NZRDA organisation). Second, we used thematic analysis (Braun and Clarke, 2013) to explore the experiences of 36 stakeholders via data collected from focus groups with their peers, or from semi-structured interviews: 13 riders, 10 caregivers and 13 THR intervention providers (five coaches, one physiotherapist, one horse-care staff member and six RDA volunteers working in side-walker or horse-lead roles). The four focus groups (incorporating 19 of the 36 participants) ranged from 50 to 105 minutes. Throughout the recruitment period, it became evident that some riders and their caregivers were unable to attend a focus group either due to the rider’s inability to cope with this environment or due to scheduling constraints. Therefore, we arranged semi-structured interviews (n = 9 interviews, incorporating 17 of 36 participants) for most riders and caregivers. These interviews ranged from 23 to 70 minutes long. Further details for this research phase can be found elsewhere (Martin, 2018).

Phase 2

This phase used grounded theory methods (Charmaz, 2014) to develop a conceptual model (Figure 2) explaining how THR might contribute to changed outcomes in riders. We collected and analysed data from interviews with 38 participants (16 riders aged 6–15 years plus 19 parents or caregivers, two education providers and one physiotherapist) and field notes written by the primary researcher (RM) from participant-observation during 22 THR sessions (Figure 1). Through these data sources, we explored stakeholders’ expectations, experiences and perceptions of change resulting from THR for children experiencing disability. How THR context influenced the processes by which THR produced an outcome was also explored further within this phase. This study is reported in full elsewhere (Martin et al., 2017).

Figure 2.

Model showing how involvement in therapeutic horse riding contributed to changes in health outcomes for riders (taken from Martin et al. (2017); reproduced with permission from Taylor & Francis).

Phase 3

A randomised multiple-baseline single-case experimental design (SCED) (Kratochwill et al., 2013) was used to examine whether a relationship could be demonstrated between the introduction of THR and changes in riders’ (n = 12) balance, activities of daily living, participation, social responsiveness and health-related quality of life (Figure 1). Health outcomes were repeatedly measured before and during 20 weeks of THR. Within this phase, we sought to evaluate who responded (and who did not respond) to THR under which conditions, based on the individual characteristics of riders. Systematic comparison of level, trend and variability of data from each case between baseline and intervention phases permitted determination of the presence or absence of any treatment effect for that case, thereby systematically specifying conditions under which THR was or was not effective for the cases being considered. This study is reported in full elsewhere (Martin et al., 2019).

Synthesis: method for developing an overall evaluative account

Within a realist framework (de Souza, 2013), findings of all three phases were synthesised and interpreted to develop an explanatory theory regarding how THR may contribute to the optimisation of health outcomes. Within this synthesis, the focus of this paper, all three phases mutually informed each other and contributed to the final account. Specifically, we used context–mechanism–outcome (CMO) configurations as a heuristic device to support explanations for how THR might work (de Souza, 2013).

The lead investigator (RM) conducted the initial synthesis of the data from each research phase. Using iterative and cyclical approaches to analysis, relationships between and within findings from each phase were explored with increasingly higher levels of conceptualisation. Manual diagramming was used to triangulate findings identified within different research phases, integrating evidence that contributed (or not) to interpretations and explanations within emerging CMO configurations (de Souza, 2013). Therefore, CMO configurations were used as an analytic template, with phase findings and specific cases being compared (by using a comparative approach looking for convergence and divergence of findings) to test hypothesised relationships between context, mechanisms and outcomes. ‘If-then’ statements (statements of the assumed context and mechanism (‘if’) and outcome (‘then’)) were constructed to summarise the key CMO configurations. To enhance reflexive practice and the trustworthiness of findings, the principal investigators (RM, FG and WL) had regular team discussions throughout this analytic process to discuss, contest and compare developing CMO configurations. The theory has also been consolidated by presenting findings in THR provider forums (for example national NZRDA training days and therapist training sessions), thereby contributing to the relevance, rigour, plausibility and conceptual refinement of the proposed theory (Emmel et al., 2018: 140).

Results

Participants

Throughout all phases of the research, we collected data from 32 riders, 29 caregivers, 13 THR providers and three educational or therapy providers (Figure 1). Riders were aged 5–17 years and had a wide range of functional, social and communicative abilities reflective of the range of people who typically access THR, with diagnoses including cerebral palsy, autism spectrum disorder, epilepsy, metabolic conditions, dyspraxia, bone disorders, chromosomal disorders, selective mutism, transverse myelitis, traumatic brain injury and global developmental delay. Ten (31%) of the child-riders were accessing THR for the first time, with no prior involvement in other EAIs. Further information regarding the demographic characteristics of participants can be found in the reporting of phases 2 and 3 ( Martin et al., 2017, 2019).

Overall evaluative account

Explanatory theory was developed outlining how health outcomes prioritised by riders could be optimised within THR delivery. Synthesised findings suggest that THR is a participation-focused intervention that addresses home, school or leisure roles for children experiencing disability. Riders experience THR as a context that promotes their capacities and strengths, and THR provides opportunities for a broad range of learning experiences with the child as an active agent within the intervention (see Figure 2). All three CMO configurations are interrelated, and though they are separated for the sake of discussion, in reality they interact with one another in complex ways. Within this section, an overall evaluative account will first be presented, then each of the key CMO configurations will be discussed in relation to literature, along with implications for THR delivery. An infographic has been developed to communicate this work with stakeholders (Figure 3), and a comic developed for children and young people who access THR. Both of these figures can be accessed via OURArchive (http://hdl.handle.net/10523/9019).

Figure 3.

Infographic outlining the key research findings, including key mechanisms of effect contributing to changes in health outcomes. Reproduced from OURArchive (http://hdl.handle.net/10523/9019).

What works for which riders, in what contexts, to what extent and how?

THR has broad applicability to a wide range of children experiencing disability with diverse diagnoses and levels of impairments – with no a priori patterns of child demographic characteristics linked with outcomes (which riders). THR is accessible to children with a range of physical, social or behavioural challenges, and provides a context in which riders experience an emphasis on their capacities and strengths rather than their deficits and impairments (which contexts). Riders and caregivers prioritised leisure and social participation outcomes in Phase 1, and changes in occupational participation into settings beyond THR as proposed by the Phase 2 model (Martin et al., 2017) were observed in Phase 3 (Martin et al., 2019). Occupational participation outcomes showed the most consistent change across participants within the Phase 3 single-case experimental design study (COPM performance score ES = 1.20, 95% CI (.82, 1.63); COPM satisfaction score ES = 1.11, 95% CI (.73, 1.55)). However, within the data collection period of Phase 3, only two participants demonstrated a clinically meaningful change in self-identified participation goals once baseline phase trends were taken into account (to what extent). Mechanisms by which THR appears to exert its treatment effect include riders’ experiences of meaningful participation; an expanded range of life experiences; an emphasis on capacities and strengths; learning to move, succeed, connect and adapt; and the rider’s role as an active agent within the process of learning (how). It is proposed that the THR therapeutic landscape experienced by riders allowed them to participate within an expanding range of life experiences, and therefore provided an increased repertoire of opportunities to view themselves in new and more positive ways. These opportunities for growth and development appeared to contribute to the ongoing development of self-concept; and led to the translation a new and emerging view of self, as moving, succeeding, connecting and adapting people, into other home, school and community contexts (how).

CMO configuration overview and discussion

Each of the three CMO configurations will now be discussed in more depth and in relation to existing literature. Supplementary materials online contain examples of data supporting the development of CMO configurations, as well as a case study illustrating their relevance to one rider.

Participation in an accessible activity

If children and young people who experience disability are involved in THR as an accessible activity [C] then this will lead to the development of riders’ self-concept by providing increased opportunities to view themselves in more positive ways [M] and will contribute to improved social participation outcomes, often reported as happening in other home, school and community settings [O].

THR was viewed as being accessible for children and young people with a wide range of impairments, providing for an increased activity repertoire and therefore increased opportunities to develop and practise skills. Riders and caregivers referenced a lack of accessible leisure activity options compared to their non-disabled peers, and findings suggested that riders and caregivers prioritised THR as expanding children’s opportunities for social participation. When reporting THR benefits in Phase 1, riders and caregivers subjectively prioritised participation outcome over outcomes within the impairment and activity domains of the International Classification of Disability, Functioning and Health (ICF) (World Health Organization, 2001). Results from Phase 3 (Martin et al., 2019) also demonstrated that changes in COPM scores, linked to the ICF participation domain, more consistently demonstrated a change in response to the delivery of the THR intervention (COPM performance score ES = 1.20, 95% CI (.82, 1.63); COPM satisfaction score ES =1.11, 95% CI (.73, 1.55)). Taken together, findings from both qualitative and quantitative data across all three phases of this research suggest that for riders and their caregivers, THR offers a positive participatory experience. Notably, participation was expanded beyond the immediate THR horse riding experience for riders to other domains of life, including participation in activities embedded in the home, school and other community settings.

Nevertheless, findings from Phase 1 also suggested that there is ongoing tension between THR being viewed as a discrete intervention, while concurrently being seen a leisure activity to participate within. Phase 1 findings indicate that THR providers tended to attribute more value to outcomes related to body structures and function – particularly noted in content analysis of THR goals within Phase 1. THR providers emphasised that THR was more than ‘just pony rides’ and were concerned that THR not be conceptualised as a leisure activity. While the potentially dual functions of THR pose challenges in categorising THR, the inherent pleasure and benefit of participation in THR as a leisure activity emerged as a significant element in its treatment effect.

Viewing THR as a leisure activity that can enhance social and occupational participation and therefore health outcomes for children experiencing disability could be given more priority by THR providers, consistent with international trends in rehabilitation and disability. Participation is considered to be a fundamental rehabilitation outcome (Hammel et al., 2008; Palisano et al., 2012) and as such THR very directly achieves this. Participation in leisure activities plays a pivotal role in facilitating children who experience disability to develop and explore their social, emotional, intellectual and physical potential and to grow as individuals (Dahan-Oliel et al., 2012; Majnemer et al., 2015; Shikako-Thomas et al., 2014). Through participating in meaningful leisure activities, children acquire skills and competency (Dahan-Oliel et al., 2012). Indeed, participation in leisure has been identified as a key domain that health professionals should target when working with children who experience disability (Janssens et al., 2014; Shikako-Thomas et al., 2014).

Appreciating the inherent pleasure and value of participating in THR, and the findings of this research, support the influence this mechanism of effect may have on health outcomes. Riders’ experiences of fun, humour and acceptance contributed to the ‘feel’ of the THR landscape. However, for riders the experience of pleasure not only facilitated engagement within THR; it also contributed to the meaning ascribed to the experience and to the creation of meaningful and enjoyable participation. It has been suggested that if an activity is going to be experienced as engaging over time, it should be enjoyable and the child’s choice (King et al., 2014; Nyquist et al., 2016; Rosenbaum and Gorter, 2012). Riders in this research valued sensory experiences and sensory stimulation (for example being outside, feeling the wind on their faces), being engaged in riskier physical activities and the sensation of ‘freedom’. For some riders, THR was viewed as a fun way of doing therapy. It was clear that riders’ enjoyment was a key mechanism impacting on the achievement, or not, of outcomes. While success was important for riders (as shown in Phase 2; Martin et al., 2017), opportunities to participate were enjoyable for their own sake. While being able to demonstrate competency through new skill development was a source of enjoyment for some riders, the ‘doing’ (participation) and the ‘achieving’ (gaining skills) were not synonymous, and both appear critical.

THR as an activity that can enhance participation – both in-session participation and improved occupational participation in other contexts – should be given more priority within THR delivery. Increased opportunities for riders to view themselves in more positive ways as a key mechanism of effect within THR and findings draws attention to how meaningful participation in THR can promote improvements in health outcomes. Findings also challenge a predominant focus in published THR literature on horse movement, and the connection developed between horse and rider, as being the two fundamental processes by which health outcome change occurs.

Promotion of capacities and strengths

If riders experience the THR physical and ideological space as being niche, novel, fun, challenging, risky, safe, individualised and normalising [C] then riders will perceive that their capacities and strengths are focused on, rather than their difficulties [M], and this will contribute to positive development of their self-concept, facilitating an emerging view of self as someone with skills and abilities [O].

For participants, THR was conceptualised as riders being embedded within an immersive physical, social and ideological (for example, including attitudes, policies and processes) landscape that they experienced as being niche, novel, fun, challenging, risky and yet safe, individualised and normalising. When viewed in this way, THR contributed to the achievement of health and wellbeing outcomes for riders by facilitating their emerging sense of self, through a focus on rider strengths and capacities, rather than their impairments and difficulties. Findings suggest that opportunities for growth and development within THR appeared to contribute to the ongoing development of self-concept and led to the translation of a new and emerging view of self, as a moving, succeeding, connecting and adapting person, into other home, school and community contexts.

How child-riders experienced the THR context appeared to play a crucial role in the mechanisms by which THR produced a change in health outcomes. Phase 1 and 2 findings suggest that characteristics of the THR therapeutic landscape contributed to a facilitative and engaging environment for riders, promoting their emerging sense of self, rather than merely the acquisition of skills (Martin et al., 2017). Participating meaningfully within the THR landscape allowed riders to flourish and blossom. Therefore, the context contributed to rider engagement in the activity, but also the meaning that riders derived from the experience – shaping and reinforcing riders’ values and contributing to the development of rider competence and the growth of self-concept. The ways in which THR was delivered encouraged riders to perceive themselves in more inclusive, healthy, functional and capacity-oriented ways. Instead of focusing on disease and dysfunction, the very physical, social and ideological context in which THR was delivered appeared to promote a focus on capacity and strengths.

Riders experienced the THR landscape as being developmentally supportive as it gave them opportunities and experiences allowing them to grow and develop in ways that mirrored their non-disabled peers. Riders’ participation in THR, viewed as a typical childhood activity and setting, contributed to the development of their sense of competence, belonging and self-understanding. This finding also links to recent attention within rehabilitation literature on the subjective experience of consumers of rehabilitation interventions and how meaning is derived from participating in activity settings (King et al., 2013; Rosenbaum and Gorter, 2012).

The horse played a central role in the THR landscape experience, providing ways for riders to experience movement, success, connection and adaption. However, riders experienced the horse in different ways. For some, the horse was a key intervention ingredient because of the relationship that riders developed with them. For other riders, however, the horse merely provided a means for them to participate, with some riders seeming to prioritise social connections with THR providers over a relationship with the horse. Riders within Phase 1 and Phase 2 of this study primarily referenced horses as contributing to their engagement in the activity and the enjoyment they got from the activity (Martin et al., 2017). Prior research has indicated that animals provide ways to facilitate meaningful activities (Gorman, 2017), with animals providing a sense of purpose within the activity. For riders, the horse appeared to provide a therapeutic modality in a way that was inherently more engaging than solely human facilitation and may be a key mechanism of treatment effect.

Self-concept development

THR supported riders to gain confidence and to flourish, thereby facilitating their lifelong process of becoming (Rosenbaum and Gorter, 2012). These opportunities for growth and development appeared to contribute to the development of self-concept. Self-concept can be defined as an evaluation of oneself and one’s capabilities (von der Luft et al., 2008) and is constructed and developed by individuals through their interaction with others, with their environment and through their reflections on these interactions. Self-concept promotes social functioning, independence and a higher quality of life in children experiencing disability (Russo et al., 2008). Some theorists have suggested that the development of self-concept in children occurs best in the context of achievement (Gibson et al., 2009; Ylvisaker and Feeney, 2002), with participatory activities appearing to contribute to the development of children’s confidence, competence, sense of achievement and capacity (Rosenbaum and Gorter, 2012). It has been suggested that positive and optimistic intervention contexts are needed to allow children to focus on their strengths since ‘success in most domains of life has more to do with how effectively people understand their strengths and needs, and how strategically they use their capacities and abilities to achieve their goals, rather than with the abilities themselves’ (Ylvisaker and Feeney, 2002: 54). Since the trajectory of human development is negatively impacted in children who experience disability, including the development of self-concept, experiences such as THR that counter this trend warrant attention.

Riders as active agents

If riders are allowed opportunities to practice agency in THR sessions, rather than passive participation [C], then this will optimise opportunities for learning [M] and will contribute to the development of self-concept regarding how they move, what they perceive themselves as being good at, who they connect with and how well they cope with change in settings other than THR [O].

Riders learning to move, succeed, connect and adapt in the THR landscape are fundamental mechanisms proposed by Phase 2 findings (Martin et al., 2017). While this research has identified these mechanisms as being present, they did occur variably between participants. Therefore, ongoing attention needs to be given to enhancing the activation of these mechanisms, through individualising THR to engender the experiences of moving, succeeding, connecting and adapting. Learning was facilitated by THR providers and occurred best when riders could act as active agents within the process of learning, rather than as passive recipients of tasks and activities instigated and controlled by THR providers.

Learning is a complex, dynamic and interactive process whereby knowledge is created through the transformation of experience (Kolb, 2015). The experiences of participants in this research suggest that learning experiences were optimised when riders could make decisions to influence events within THR sessions, were actively engaged in THR sessions and were given enough autonomy within the tasks that they were able to recognise the achievement of tasks as being a result of their efforts. Facilitating children to be active agents of their learning is accepted widely as optimising learning conditions in educational and child development theory (Bransford et al., 2004: 12). Self-determination theory (SDT) (Ryan and Deci, 2000) is a macro-theory of motivation, suggesting that learning is enhanced when the therapist or teacher attends to a child’s need for autonomy, relatedness and competence: the three basic psychological needs according to SDT. From an SDT perspective, it is argued that these three experiential requirements enable children to become engaged, active participants in treatment interventions. SDT also postulates that therapies will be more effective when they support children’s inner motivation and resources for change by supporting feelings of choice, connection and competency, since such a focus will promote a more satisfying and productive therapeutic alliance (Poulsen et al., 2015). Findings from Phase 2 (Martin et al., 2017) are consistent with these propositions of SDT.

The therapeutic relationship between rider and THR providers was a key mechanism promoting changes in health outcomes in riders and played an important role in facilitating learning experiences for riders. A fundamental characteristic of THR is that it has the potential to allow children to develop a sense of control over their environment. For example, findings from this research suggest that the ability of riders to learn to control the horse provided an experience of mastery and a sense of control. However, findings also indicated that how THR tasks and activities were facilitated by THR providers determined ways that riders could engage as active agents within sessions. Riders’ relationships and interactions with RDA providers were perceived as impacting significantly on riders’ learning opportunities, and particularly the ability of the child to be an active agent within THR. Therefore, RDA providers and their interactions with riders are considered to play an essential role in optimising outcomes.

Within THR, the establishment of an effective therapeutic relationship between THR providers and riders emerged as a key ingredient and fundamental transaction within THR intervention. Conversely, training documentation and perspectives of THR providers suggest a tendency to privilege technical knowledge and skills (for example horse management skills, risk minimisation and safe handling skills) over skills and strategies for facilitating therapeutic relationships within the delivery of THR. The therapeutic relationship is increasingly accepted as being a crucial potentiating factor in the success of rehabilitation interventions (Graham et al., 2009; Hall, 2010; King et al., 2019). We therefore suggest legitimising the value of therapeutic relationships in the development, resourcing, training and delivery of THR.

Implications for practice

Findings from this study can inform THR programme development, provider training, rider outcome assessment and ongoing programme evaluation. THR providers may draw from findings to critically appraise how they deliver THR and match rider and caregiver priorities.

A lack of clarity around THR benefits and the processes by which health outcomes are improved has implications on how THR is delivered. The development of explanatory theory for understanding mechanisms of change in health outcomes, and particularly social and occupational participation for child-riders, suggests a need for greater clarity in terminology and language within THR training and operational procedures, operationalising broader understandings of health within THR provision, considering THR session availability, focusing on therapeutic relationships developed between THR providers and riders within sessions, and giving more attention to how riders can take a more active role within THR sessions so that their learning is optimised.

Research implications

The explanatory theory proposed has application in guiding future research into THR effectiveness and has drawn attention to the range of outcomes that should be measured. Future research could seek to identify contextual conditions that increase rider engagement with THR. This could include exploring the complex ways that the individual rider and environment interact to produce a context meaningful for people who experience disability. While this research has identified the rider’s role as an active agent within the process of learning as an important mechanism of effect, it remains unclear which specific strategies and conditions heighten engagement for riders. It would also be interesting to examine additional ways that the inclusion of a horse within the intervention may alter the nature of the therapeutic relationship between riders and THR providers. The relative importance of interactions with THR providers versus the connection with the horse, and how these differences may account for different outcomes, also warrants further analysis.

Limitations

It is acknowledged that the theory arising from this work only offers a partial representation of reality. While three CMO configurations have formed the basis of the explanatory propositions, we are not inferring that these are simplistic and linear causal processes. Instead, the plurality and contingency of causation are acknowledged. Methods used within this research are also not able to provide information about the strength of association of relationships between various mechanisms of effect and outcomes. Differentiation between the relative importance of different processes for riders with different demographic characteristics (such as age, diagnosis or gender) is not addressed within the proposed theory. The potential impact of ‘learning to move, succeed, connect and adapt’ on those riders with varying levels of self-awareness or learning difficulties is unclear. It is also unclear whether increasing attention to occupational participation outcomes within THR, for example in goal-setting, would enhance the translation of skills to a non-THR context, and if this would result in further gains in occupational participation. Findings from this research are also not able to provide information about the dosage (including frequency and length) of THR required to observe changes in health outcomes, or specifically explore riders’ responses to participating in THR within a group situation. Therefore, at this point, we are presenting a programme theory that still needs further refinement.

Findings from this research are limited by data only being collected in one NZRDA Centre. There is a wide range of THR interventions provided internationally, with disparate differences between the foci of different types of interventions. However, congruent with realist research methods that aim to develop portable theory, this work has developed theory that can be used both nationally and internationally in THR delivery. In this way, this work has developed an evaluative account that provides explanatory adequacy, rather than producing a universal scientific ‘proof’ that can be generalised to other populations and contexts.

Conclusion

THR is a participation-focused intervention that addresses home, school or leisure roles. As an accessible activity for children who experience disability, THR promotes improvements in health outcomes through a focus on their capacities and strengths, opportunities for learning and the development of their self-concept. The development of explanatory theory around mechanisms of THR treatment effect adds to scientific knowledge about various processes, which may contribute to improved health outcomes for riders across the spectrum of EAIs, as well as within other paediatric-directed health interventions. Findings suggest there is a need to shift from focusing primarily on what is delivered to riders within THR sessions, to giving increased attention to the experiences of riders within the THR space – including how riders attach meaning to these experiences and how they perceive themselves as a result.

Key findings

Therapeutic horse riding (THR) provides opportunities for social and occupational participation for disabled children.

THR facilitates self-concept development because it focuses on a rider’s capacities and strengths.

Participation outcomes are optimised when riders can take an active role within THR sessions.

What the study has added

This study has provided more clarity around mechanisms of THR treatment effect by proposing an explanatory theory outlining how participation outcomes may be optimised for children experiencing disability.

Supplemental Material

Supplemental material for Exploring how therapeutic horse riding improves health outcomes using a realist framework

Supplemental Material for Exploring how therapeutic horse riding improves health outcomes using a realist framework by Rachelle A Martin, Fiona P Graham, William MM Levack, William J Taylor and Lois J Surgenor in British Journal of Occupational Therapy

Footnotes

Acknowledgements

The authors would like to thank all participants who gave their time to contribute to this study.

Research ethics

The University of Otago Human Ethics Committee (Health) provided ethical approval for all phases of this research [H14/075, 2014; H16/033, 2016].

Consent

All adults provided written informed consent, and all child-riders gave assent, to participate in the study.

Declaration of conflicting interests

The authors confirm that there is no conflict of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was funded by New Zealand Riding for the Disabled Association Inc. Scholarship was administered through the University of Otago. NZRDA did not influence the study results or preparation of this manuscript.

Contributorship

Rachelle Martin led the planning, design, conduct, analysis and reporting of this research. Fiona Graham, William Levack, Will Taylor and Lois Surgenor actively contributed to the development of the overall research design and analysis of the data for all study phases. Rachelle Martin wrote the first draft of this manuscript, with Fiona Graham and William Levack reviewing, editing and approving the final version.

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