Stakeholders’ Perceptions and Experiences of Animal Assisted Interventions for People Living With Dementia: A Qualitative Evidence Synthesis Protocol

Abstract

Background: Dementia is a priority public health issue globally. Behavioral and psychological symptoms of dementia (BPSD) lead to low quality of life (QoL) for people living with dementia and can also cause distress amongst their caregivers. To date, the effectiveness of pharmacological treatments for dementia have had limited. Animal assisted intervention (AAI) has become a popular non-pharmacological therapy and psychosocial intervention, and can have positive effects on mood, social behavior, physical activity and QoL of people living with dementia. The factors influencing the delivery of AAI remain underexplored. The aim of this review is to synthesize qualitative research regarding stakeholders’ perceptions and experiences of AAI for people living with dementia in community settings. Methods: We will systematically search nine databases/platforms. Two reviewers will independently screen the titles, abstracts and full texts; the process will be reported following PRISMA guidance. Data from included studies will be extracted according to a specifically designed form. Three reviewers will independently appraise the methodological quality of studies using the Critical Appraisal Skills Program qualitative checklist. We will analyze data following thematic synthesis. GRADE-CERQual will be applied to assess confidence in the findings. The research team will engage in reflexivity throughout all review stages of process through regular meetings/discussions. A Public and Patient Involvement (PPI) contributor will be included to oversee and provide advice on the QES process. Discussion: AAI is a potentially valuable for improving mood and reducing BPSD for people living with dementia. However, the perceptions and experiences of stakeholders and factors influencing the implementation of AAI for people living with dementia are not clear. This qualitative evidence synthesis will significantly contribute to the evidence base. It will identify factors and recommendations for AAI guidance, and have clinical and social implications of improving the well-being of people living with dementia and their caregivers.

Keywords

dementia animal assisted therapy animal assisted intervention qualitative synthesis QES perception experience

Background

Dementia is a priority public health issue globally, with a rapidly increasing number of people living with dementia, expected to rise to 152 million by 2050 (Patterson, 2018). The World Health Organization (WHO) defines dementia as “an umbrella term for several diseases affecting memory, other cognitive abilities and behavior that interfere significantly with a person’s ability to maintain the activities of daily living” (WHO, 2017). More than 90% people diagnosed with dementia suffer Behavioral and Psychological Symptoms of Dementia (BPSD), including depression, anxiety, agitation, and aggression. BPSD leads impacts on people living with dementia, and it is the main cause of stress and distress for caregivers and negatively impacts on their well-being (Bessey & Walaszek, 2019; Tible et al., 2017). Thus, providing supports for people living with dementia and caregivers to improve their quality of life (QoL) and well-being is increasingly important (Barrière et al., 2021; WHO, 2017).

To date, pharmacological treatments for dementia have had limited effectiveness, are expensive, and are often accompanied by side effects (Jessop et al., 2017; Patterson, 2018). Non-pharmacological therapy has emerged as an essential, economical and alternative treatment to reduce BPSD and alleviate cognitive decline (Abraha et al., 2017; Kim et al., 2021; Leng et al., 2020). Studies have found that animal assisted intervention (AAI) is a popular type of non-pharmacological therapy (Leng et al., 2020) and psychosocial intervention (Barrière et al., 2021) which can have positive effects on physical, psychological, and social functioning of people living with dementia (Chang et al., 2021; Forget et al., 2021; Marks & McVilly, 2020; Yakimicki et al., 2019).

The International Association of Human-Animal Interaction Organizations (IAHAIO) defines AAI as “planned and goal-oriented psychosocial interventions aimed at improving the QoL for vulnerable populations like dementia by trained animals”. AAI include Animal Assisted Activity (AAA), Animal Assisted Therapy (AAT), Animal Assisted Education (AAE), and Animal Assisted Coaching/Counselling (AAC) (Barrière et al., 2021). AAI has been widely used in many domains such as mental health, psychiatric disorders, autism, trauma in different populations, with positive impact, especially on people living with dementia in recent years (Chen et al., 2022; Fine, 2019).

Recent systematic reviews have found that AAI has positive effects on mood, social behaviors, physical activity, QoL and cognitive impairment in people living with dementia, through activities with animals such as petting, grooming, training, drawing, and taking photos, to recall memories and enhance stimulations (Chang et al., 2021; Chen et al., 2022; Marks & McVilly, 2020; Yakimicki et al., 2019). Such human-animal interaction can stimulate motivation and positive feelings when people living with dementia interact with animals (Hu et al., 2018; Ritchie et al., 2021). Kim et al. conducted a neurological perspective analysis to interpret the mechanism of AAI, through sensory interactions with animals to improve emotional and social activities, thereby to counter Aβ deposition, tau hyperphosphorylation and neuroinflammation related to Alzheimer’s disease pathologies (Kim et al., 2021).

It should be noted however, that there is some conflicting evidence regarding AAI. A systematic review by (Lai et al., 2019) compared the efficacy of AAI among live animals, robotic animals and soft toys for people living with dementia. The authors concluded, with low-certainty evidence, that AAI can slightly reduce depression, and that there is no clear difference in QoL, cognitive function, physical activity in people living with dementia. The authors provided two main factors which reduce their level of certainty, the small number of studies and the way the studies were designed and implemented. Research on AAI for people living with dementia is primarily quantitative, and the qualitative studies that have been conducted have not been synthesized (Swall et al., 2017, 2019). The barriers and facilitators of delivering/implementing AAI remains to be further explored, and the risks of AAI need to be assessed, such as allergies, infections, bites, fear and parasites. (Lai et al., 2019; Zafra-Tanaka et al., 2019).

Overall, AAI is a potentially valuable for improving mood, QoL and reducing BPSD for people living with dementia. It is important to explore the perceptions, experiences and acceptance of AAI by stakeholders (including, but not limited to, people living with dementia and their family members, health care staff caring for people living with dementia and animal handlers). This would significantly contribute to the evidence base of AAI, guideline development, and clinical and social implications of improving the well-being of people living with dementia and their caregivers.

Objectives

The aim of this review is to synthesize stakeholders’ perceptions and experiences of AAI for people living with dementia in community settings. The specific objectives are to:

• Explore stakeholders’ perceptions and experiences of implementing AAI for people living with dementia.

• Identify the factors influencing the delivery of AAI for people living with dementia.

• Examine any differences in the above, by types of animals, settings, and stages of dementia.

• Develop recommendations to enhance the implementation, and potentially effectiveness of AAI for people living with dementia.

Methods

We have used EPOC’s Protocol and Review Template for Qualitative Evidence Synthesis to develop this protocol, which was registered on the International Prospective Register of Systematic Reviews (PROSPERO) database (CRD42023393938).

Criteria for Considering Studies for This Review

Types of Studies

Primary studies that use qualitative study designs such as ethnography, phenomenology, case studies, grounded theory studies, exploratory, action research and qualitative process evaluations will be included. Mixed method studies including qualitative data will be considered if it is possible to extract data collected using qualitative data collection and analysis methods. There will be no filters for publication date, language and country.

Topic of Interest

The SPICE (setting, perspective, intervention, comparison, evaluation) tool was used to develop the research question and to guide the search strategy (Booth, 2006).

We will include studies focusing on stakeholders’ experiences and perceptions of AAI for people living with dementia. In this review, we are adopting the IAHAIO (2018) definition of AAI as planned and goal-oriented psychosocial interventions by human-animal teams, including AAA, AAT, AAE and AAC. We will include face to face AAI only, with all types of live animals (e.g., dogs, cats, guinea pigs, horses, fish, birds, reptiles.), robotic pets and animal shaped soft toys will be excluded. Robotic and soft toy animals are alternatives to AAI, and an emerging field that needs more research, which is being explored by another research team within our institution (Koh et al., 2022). We are also interested in comparison of any differences observed among different animals, settings and stages of dementia.

We define stakeholders as “individuals or groups who are responsible for or affected by health- and healthcare-related decisions that can be informed by research evidence” (Concannon et al., 2012), including but not limited to people living with dementia and their family members, health care staff caring for people living with dementia and animal handlers. Health care staff may include physicians, nurses, therapists, social workers, psychologists, psychiatrists, and staff of nursing home/care center. Animal handlers include paid staff working in animal organizations and volunteers participating in AAI. There are no exclusion criteria (e.g., age, region, gender, education, religion) for health care staff. Studies which include people living with dementia at any age or stage, and their family members, will be included. We will include the studies that report on stakeholders’ perceptions and experiences of AAI for people living with dementia. Perceptions include attitudes, opinions, evaluations, beliefs, expectations, understanding, emotions, and physical sensations (Ryan et al., 2018).

We will include studies that examine AAI conducted in community settings, such as the community, nursing homes, care centers, day care, long-term care facilities, residential care homes, or rehabilitation centers. The majority of people with dementia are living in the community, 1/3 live in residential care facilities (Harrison et al., 2019). We will exclude studies conducted within hospital and home settings as different contexts.

Search Methods for Identification of Studies

Electronic Searches

We will systematically search the several following electronic databases from inception.

• Medline (Ovid)

• CINAHL (EBSCOhost)

• Embase (Ovid)

• Scopus

• Web of Science

• PsycINFO (EBSCOhost)

• AgeLine (EBSCOhost)

These databases cover a wide variety of literature from different disciplines, including nursing, medicine, health, social science, psychology and aging. See Appendix 1 for the Medline database search strategy, which we will adapt for other databases.

Grey Literature

We will conduct a grey literature search in the following sources to retrieve primary studies or PhD Dissertations & Theses which not in the databases listed above:

• ProQuest

• PsycEXTRA

Searching Other Resources

Finally, we will use reference and citation checking (forward and backward chaining), hand searching, and contact with related author to identify potential records (Booth, 2016).

Selection of Studies

Two review authors (DZ and QL) will independently assess the titles, abstracts and full text against the eligibility criteria by 2 phase screening. Firstly, titles and abstracts of the identified records will be screened. Secondly, potentially eligible full texts will be assessed. Disagreements between two reviewers will be discussed to resolve, or through a third reviewer (CH or MH) when required. We will contact the primary studies’ author for further information if necessary. Endnote 20 will be used for deduplicating, Covidence (Harrison et al., 2020) will be used for screening. The screening process and search results of selected studies will be reported in accordance with PRISMA flow diagram.

Language Translation

Google Translate will be initially used to assist in screening titles and abstracts, which are not published in English, as recommended by EPOC (Glenton et al., 2022). If the translation indicates inclusion, we will retrieve full text and ask members who are proficient in that language to translate.

Sampling of Studies

A large number of primary study data in a qualitative synthesis can threaten the depth and breadth of the evidence synthesis, but it also depends on the eligible studies we will identify. If it is necessary to sample from the eligible studies, a three-step sample frame for purposive sampling (Ames et al., 2019; Houghton et al., 2020) will be used to assess whether data richness is sufficient to answer the research question. Firstly, sampling studies settings across different income levels. Secondly, sampling studies score 3 or higher using data richness scale of 1–5 (see Appendix 2). Thirdly, sampling studies closely relevant to our research aims.

Data Extraction

Data extraction in this qualitative evidence synthesis will be conducted in two stages. At first, contextual and methodological information will be extracted using a specifically designed data extraction form relevant to our review objectives, including first author, year, purposes, research design, study setting, type of participant (people living with dementia, family members, health care staff, animal handlers), type of intervention, sample size, data collection and analysis methods, theory or models of the studies. Secondly, findings in the form of quotes from stakeholders about perceptions and experiences of AAI for people living with dementia in community settings, subthemes and themes identified by original authors and observational data will be extracted (Sandelowski & Barroso, 2002). We will use QSR NVivo to facilitate the systematic extraction and synthesis of findings, and aid rigor and transparency (Houghton et al., 2017).

Assessing the Methodological Limitations of Included Studies

Three review authors (DZ, MH, CH) will independently assess methodological limitations for included studies using Critical Appraisal Skills Program (CASP) qualitative checklist, which includes 10 questions containing four aspects “addressing rigor”, “research methods”, “relevance”, and “research integrity”. We will report our assessments results in a Methodological Limitations table. Disagreements will be resolved by discussion.

Data Management, Analysis and Synthesis

The search progress and strategy will be recorded in detail to enhance transparency and replicability. Search strategy will be saved in word format and upload to a OneDrive account of University of Galway. Search results will be inputted in Endnote 20 and be backed up on OneDrive. Covidence software will be used for screening and NVivo 2020 will be used for data management and analysis.

The RETREAT framework (Booth et al., 2018) will be adopted to guide the selection of the most suitable method in this QES following seven domains, including “review question”, “epistemology,” “timeframe,” “resources,” “expertise,” “purpose,” and “type of data”. After full consideration and comparison by the guidance of the RETREAT framework, “thematic synthesis” will be used as an appropriate method for data analysis in this evidence synthesis to present description and interpretation of stakeholders’ view and experiences of AAI (Noyes et al., 2018; Thomas & Harden, 2008). Thematic synthesis is a frequently used approach to synthesize the findings from multiple primary qualitative studies, and can be combined with quantitative results to generate more appropriate evidence to inform clinical practice (Stern et al., 2021).

Thematic synthesis is composed of three stages. Stage one: coding the text “line-by-line”, conduct a free line by line coding from primary studies; stage two: developing the “descriptive themes”, organize the generated free codes to create descriptive themes; stage three: forming the “analytical themes”, the reviewer will interpret and explain the findings beyond primary studies and combing with review question (Thomas & Harden, 2008). The lead reviewer (DZ) will conduct the analysis following above three steps and share with other reviewers for input. NVivo software will be used to enhance the transparency and rigor of analytical process (Houghton et al., 2017). Subgroup analysis will be considered to compare the impact of delivering AAI in different stages of dementia, using different types of animals, in different settings.

Assessing Our Confidence in the Review Findings

Three review authors (DZ, MH, CH) will use the “Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual)” approach to assess the confidence of each finding from this review; this will improve the confidence of findings and reduce the risks of over-simplistic use of results. GRADE-CERQual is method transparently assess the confidence of findings and support decision-making in guideline development and policy formulation. It includes four components: methodological limitations, coherence, adequacy of data, and relevance of data with rate as high, moderate or low confidence. All findings start as high confidence and will then be graded down if there are important concerns regarding any of the components.

Summary of Qualitative Findings table(s) and Evidence Profile(s)

Findings from the evidence synthesis and generated overall confidence in detailed description will be presented in an Evidence Profile and a Summary of Qualitative Findings table (SoQF) (Lewin et al., 2018).

Review Author Reflexivity

To ensure rigor within this review, the research team will engage in prospective and retrospective reflexivity throughout all stages of the process. We will consider how researcher subjectivity (briefs, background, value system, knowledge base) could influence each step of the research. We will follow culturally responsive framework (cultural self-awareness, knowledge of clients and developing skills) (Jegatheesan, 2015) to minimize the impact of cultural contexts and religious beliefs clouding our analysis. The team will meet regularly, and will document our discussions and decisions, including our reflexivity around these. A Public and Patient Involvement (PPI) member will be included to ensure the readability and usefulness of QES findings, and to oversee and provide advice on the research process.

This protocol and QES are supported by an experienced qualitative researcher (CH) as a co-convenor of Cochrane Qualitative Methods Implementation Methods Group (QMIG). The research team members have research background in geriatric nursing (CH, DZ), health promotion/health services research (MH) and health science (QL). CH, MH, DZ and QL have clinical, academic and/or personal experience working with people living with dementia. All of the members have experience of qualitative research, CH and MH are experienced in qualitative research (e.g., qualitative evidence synthesis, qualitative research methodology, etc.) and skilled in NVivo, Covidence and Endnote software, have published on this (Hennessy et al., 2018; Houghton et al., 2020, 2022). The review team has a positive attitude to the delivery of AAI for people living with dementia and are interested in exploring how it could be implemented more effectively. Research team members will maintain a mindful consideration and ongoing engagement in reflection to minimize the risk of author bias or skewing analysis. A reflexive journal will be used by DZ throughout the review process in which to record and reflect on review progress and decisions made.

Footnotes

Acknowledgments

We would like to thank China Scholarship Council (CSC) for supporting this research (Grant No. 202106370229). We also thank Rosie Dunne, James Hardiman Library, University of Galway, for her comments on the development and revision of our search strategy; and Qiuxia Li, School of Health Sciences, University of Galway, for her assistance on this review.

Author Contributions

This project is under supervision and administration by CH and MH. CH, MH and DZ formulated the research question and conceived the review. DZ, CH and MH designed the research methodology. DZ wrote the original draft; CH, MH and DZ critically reviewed, commented, revised and edited it.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: China Scholarship Council (CSC), Grant No. 202106370229.

ORCID iDs

Dou Zhang

Marita Hennessy

Catherine Houghton

Appendix 2. Data Richness Scale ( Ames et al.,2017;2019 ).

Score	Measure	Example
1	Very little qualitative data presented that relate to the synthesis objective. Those findings that are presented are fairly descriptive	A mixed-methods study using open-ended survey questions or a more detailed qualitative study where only part of the data relate to the synthesis objective
2	Some qualitative data presented that relate to the synthesis objective	A limited number of qualitative findings from a mixed-methods or qualitative study
3	A reasonable amount of qualitative data that relate to the synthesis objective	A typical qualitative research article in a health services journal
4	A good amount and depth of qualitative data that relate to the synthesis objective	A qualitative research article in a social sciences journal with more context and setting descriptions
5	A large amount and depth of qualitative data that relate in depth to the synthesis objective	A detailed ethnography or a published qualitative article with the same objectives as the synthesis

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