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Complementary Therapies in Clinical Practice 42 (2021) 101298Available online 24 December 20201744-3881/© 2020 Elsevier Ltd. All rights reserved.Pawsitive Connections: The role of Pet Support Programs and pets onthe elderlyStephanie Cryer, Claire Henderson-Wilson, Justin Lawson *Deakin University, 221 Burwood Hwy, Burwood, Victoria, 3125, AustraliaA R T I C L E I N F OKeywords:ElderlySocial isolationPetsAttachmentA B S T R A C TObjectives: This study describes the experiences of Pet Support Program clients in Melbourne, Australia and howthe programs reduce the social isolation of the elderly. The study also describes the role of pets and associatedhealth benefits of pet ownership.Method: The qualitative description study comprised of two phases: a secondary data analysis of interviews with14 PSP clients, and key informant interviews with four PSP providers.Results: The interviews were thematically analysed which resulted in three interconnected themes: Attachment,Support and Social Isolation. Social isolation was reduced by the PSP through access to social support groups, aswell as the provision of a regular visitor who provides meaningful conversation and companionship.Conclusion: These results align with literature on pet ownership and Attachment Theory. The results also offer aninsight into how PSPs allow the elderly to maintain pet ownership and age in place, thus enhancing their healthand well-being.1. Background1.1. The health of elderly AustraliansAustralia’s elderly population generally experiences good health andyet displays similar rates of social isolation and loneliness as otherdeveloped countries [1]. Elderly Australians, in urban areas such asMelbourne, present with the highest rates of social isolation compared torural areas, which negatively impacts their physical health [2–6].The negative health outcomes of loneliness, perceived isolation andsocial disconnectedness can result in poor immune health [5], mortalityand morbidity, physiological ageing, and higher risk of obesity [7],increased systolic blood pressure and cardiovascular disease [8] as wellas poorer mental health outcomes, such as increased levels of stress [5,7], higher rates of depression [9], impaired cognitive functioning [7],dementia [7], and anxiety [5,7]. Not only is improving the socialisolation and loneliness of the elderly important in improving theirhealth and wellbeing, it is important in reducing the strain on thehealthcare system and aged care facilities, and in allowing the elderly toage in place [2,10].1.2. Pets and the elderlyPet ownership is linked to lower social isolation, loneliness andimproved physical activity and physical health [11–17]. Mental healthbenefits associated with pet ownership include improved psychologicaland social wellbeing, a sense of responsibility, boosted morale, feelingsof safety and security, and less depression [15,18,19].Studies indicate that pets play important roles in the lives of theirowners and in alleviating social isolation/disconnection and lonelinessas they act as ice-breakers and catalysts for conversation [13,16,20], abuffer in stressful situations [21], and promote increased physical activity [11,15].Furthermore, the elderly are particularly responsive to AnimalAssisted Interventions (‘any intervention that intentionally includes orincorporates animals as a part of a therapeutic or ameliorative process ormilieu’), and Animal Assisted Therapy (which is a type of goal drivenintervention that involves animals as a fundamental point for personalised treatment of a human client) [22–24]. However, most of thesestudies exclude independently living elderly, and how this populationcan benefit from Pet Support Programs (PSPs) (affordable or free,community-based programs that offer services such as dog walking,* Corresponding author.E-mail addresses: stephanie.louise96@hotmail.com (S. Cryer), claire.henderson-wilson@deakin.edu.au (C. Henderson-Wilson), justin.lawson@deakin.edu.au(J. Lawson).Contents lists available at ScienceDirectComplementary Therapies in Clinical Practicejournal homepage: http://www.elsevier.com/locate/ctcphttps://doi.org/10.1016/j.ctcp.2020.101298Received 20 June 2020; Received in revised form 20 October 2020; Accepted 14 December 2020Complementary Therapies in Clinical Practice 42 (2021) 1012982litter tray cleaning or grooming to pet owners who need assistance) orhow pets improve the health and quality of life of the elderly [10,22–29]. The literature indicates that these interventions improve qualityof life, depressive symptoms, cognitive functioning, perceived energylevel, and overall mood; and decrease pain, tension, anxiety and fatigue[24,26].The majority of research on how pets influence the health of theelderly is confined to institutions, mainly nursing homes, so researchingPSPs and how they impact independently living elderly people is novel.In 2015, only 5.2% of the elderly in Australia lived in institutions while26.8% of the 94.8% living in households lived alone [30]. Determiningwhether PSPs enhance the ability of the elderly to keep their pets andlive independently is crucial; evidence highlights that the elderly arewilling to put their pet’s health before their own with significant consequences [10,31], therefore the use of PSPs could mitigate these impacts. This study aimed to describe the experiences of people over 65who utilise PSPs in Melbourne, Australia.2. Materials and methodsResearch questions to address the above aim were:– How do PSP recipients experience improved social connectednesswith other people via their involvement in the program?– How does interaction with PSPs and/or pets impact on socialisolation?– How do PSP recipients describe the role of their pet in their life?2.1. Research methodology and designA Qualitative Description approach was applied; this is used to understand a particular phenomenon or the perspectives of those involved,and when time and resources are limited [32,33]. Qualitative Description was deemed appropriate as it is generally used when only adescription of a phenomenon is desired, which is what the study aimedto do [33]. As this study falls into a very specific category, QualitativeDescription allowed for a small sample of interviews to be conducted sothe researchers could explore the experiences of people participating inPSPs and gain an insight into their perspectives. It also allowed for ananalysis that enabled the researchers to stay close to the data anddescribed the impact of PSPs on the elderly and whether they improvedtheir social connectedness and social isolation accurately [33].This study involved two stages of analyses. Firstly, a secondary dataanalysis of interviews, which were conducted previously with a formerresearcher, with PSP clients was undertaken. From the findings of theseinterviews, Key Informant interviews with PSP providers took placewhich were then analysed using Thematic Analysis to enable an organisation of themes and a description of the data in rich detail [47]. Thestudy obtained ethics approval from the authors’ university ethicscommittee and complied with The Code of Ethics of the World MedicalAssociation (Declaration of Helsinki) and the Australian Code for theResponsible Conduct of Research 2007 (updated 2018).2.2. ParticipantsA convenience sample was employed in this study; a sample of thefirst eligible participants available until the quota was met [36,37].Fourteen people aged over 65 years who use a PSP in Melbourne,excluding those not living independently, had severe cognitive impairment or were unable to read and converse in English, were invited toparticipate in the study. This sample size was deemed adequate, as thepopulation size itself is small with similar studies having sample sizesranging from eight to twenty-two, and was sufficient to reach datasaturation [36–42]. The participants in this study were all Caucasian,aged 65–90 (average age 81) and mainly female, with only twoparticipants being male. Most participants (11) were dog owners, withthree participants being cat owners.Two PSPs in Melbourne acted as gatekeepers and mailed flyers topotential participants who were offered a small financial token ofappreciation at the conclusion of their interview. Participants were sentinformation about the study that they could consider before agreeing totake part. Informed consent was obtained from all participants.To take part in a PSP, recipients approached the program provider toexpress interest in being selected to participate and then were screened.Once they passed the screening process, they were matched with avolunteer depending on factors such as personality, location and availability. A meeting was facilitated by the PSP providers between potentialrecipients and volunteers to confirm the matching. The volunteers andrecipients then decided on parameters including: how often the volunteer will visit and for how long, whether it was a short term or anongoing arrangement, as well as whether a participant had one ormultiple volunteers dependent on availability and needs. A small annualfee (A$30) was charged for participants by the PSP providers.The Key Informants consisted of a convenience sample of four PSPproviders in Melbourne: one volunteer support officer, one CEO and twoprogram co-ordinators, who were able to offer a range of perspectives,given their differing roles. The Key Informants were recruited via apromotional email or phone call inviting them to partake in the study.This size was deemed sufficient as these interviews were only a follow upto the initial interviews and conducted to find out whether PSP providers voiced similar opinions to the PSP recipients.2.3. Data collection and analysisAll 18 interviews were semi-structured, lasting between 30 and 60minutes, recorded and transcribed for coding, with additional field notesbeing taken [43]. Interviews with PSP participants were conducted intheir home whereas interviews with Key Informants were conducted attheir PSP facility. Reference was made to a topic list, to ensure consistency in the experience of the interview process. By asking participantssimilar questions, this allowed for patterns to emerge during the codingprocedure.The topic list included questions such as: “How long have you beeninvolved?”, “Can you describe the program, the screening and allocationprocess?”, “What are the roles in the program, protocols and procedures?” as well as inquiring about the relationships between participant/volunteer and participant/pet, program and mental/physical health,experiences with the PSP, and whether the PSP is viewed more than aservice.Thematic Analysis, a common Qualitative Description method fordata analysis, was conducted in both analyses stages (for the analysis of14 program participants and four program providers) [44]. It is a flexible tool to provide rich and detailed explanations for findings and allows identification, analysis and reporting of themes [44,45]. Thematicanalyses allows for both inductive and deductive approaches [44,46].The theoretical flexibility of Thematic Analysis allowed this analysis tobe conducted under the constructivist paradigm, a philosophicalapproach suggesting that people can construct their own understandingand knowledge of the world through their experiences [44,46,47].Secondary Data Analysis involved the analysis of data that hadalready been collected for the study in order to use alternative strategiesthat were not a part of the primary analysis [48]. Although qualitativeSecondary Data Analysis has been criticised, a qualitative SecondaryData Analysis was appropriate for this study. Even though qualitativeresearch includes collecting and interpreting subjective data influencedby social or cultural truths at the time of data collection and whenre-analysed, social or cultural norms may have changed, the data usedfor this study was only two years old and was collected to answer verysimilar research questions. Due to the data being relatively recent andrelevant, it was decided that a qualitative Secondary Data Analysis wasappropriate as the chance of using inappropriate analysis strategies andS. Cryer et al.Complementary Therapies in Clinical Practice 42 (2021) 1012983misinterpreting the data were minimised.Transcripts and notes were entered into NVivo and codes weregenerated using the software. Several potential themes were thendeveloped from these codes, which were revised. The Thematic Analysisof the PSP provider interviews followed a very similar process.To enhance rigour an analysis ledger was kept, detailing all stepstaken during the analysis process which allowed each of the three researchers to determine potential errors in the analysis process. The researchers corroborated in regards to the initial codes and potentialthemes that were developed, in that they undertook separate crosschecking of codes and themes, then discussed their findings, andcollated the codes and themes to develop the final codes and themes[49].3. TheoryThis study was guided by elements of Attachment Theory which hasbeen suggested to provide, ‘an empirically supported framework forexplaining how close relationships contribute to emotion regulation,mental health, and psychological growth’ [34]. In this study, Attachment Theory refers to the proposition that people differ in their degree ofattachments to pets along the dimensions of attachment anxiety andavoidance and these differences can influence pet-related cognitions,emotions, and behavior [34]. This notion is related to the termHuman-Animal Bond which is known as the ‘mutually beneficial anddynamic relationship between people and other animals that is influenced by behaviours that are essential to health and wellbeing of both’[35].The strong attachment elderly people have with their pets helps toexplain how close relationships influence the regulation of emotions,mental health and psychological growth [34]. Attachment Theory discusses the ways in which available attachment figures are supportiveand nurture a ‘sense of attachment security and internal working modelsthat are positive and optimistic’ and how unavailable or rejectingattachment figures cause an individual’s sense of security to becomeundermined as well as forming negative working models, which canresult in attachment-related anxiety and avoidance [34]. As attachmentto pets is considered a coping tool and lowers feelings of depression andisolation, it is important for the elderly to have access to PSPs [12]. Dataanalysis conducted in this project was informed by Attachment Theory;questions asked were heavily influenced by attachment, whether thatwas to the participant’s pet or volunteer, and different aspects ofAttachment Theory.4. Results and discussionAfter the data analyses were completed, three main themes emergedfrom the data. These themes were ‘Attachment’ (the attachment between pet and owner, as well as client and volunteer), ‘Support’ (accessto social support groups, as well as the provision of a regular visitor whoprovides meaningful conversation and companionship) and ‘SocialIsolation’ (the benefits of the PSP to the client, such as reducing loneliness and social isolation).4.1. AttachmentAs mentioned earlier, Attachment Theory explores how close relationships impact on how we regulate our emotions, our mental healthand how we grow psychologically [34]. The theory also discusses howattachment figures provide a safe haven and sense of security [34].The results of this exploratory study indicate that pets benefit thesocial and mental health of their owners, with these benefits possiblybeing due to attachment [10,20,31,50,51]. Pets can assist in improvingpeople’s mental health through acting as a buffer in stressful situations[35], which was evidenced when Client Four expressed that:I don’t think I would be here, if it wasn’t for him. I don’t think I couldlive. I am going to be teary; I don’t think I could live through the lastyear, without him.Attachments to pets are similar to that of a human, such as a familymember or friend [12], with clients considering their pets a familymember; a phenomenon also discussed by Key Informants. ClientFourteen stated:And I think all animals, if you have an animal, you got to treat themlike one of the family.Attachment was considered, by both the client and Key Informantinterviewees, to lower feelings of depression and loneliness with themajority of clients discussing how they would not be able to live withouthaving a pet and their unwillingness to be separated from their pet.As an example, Key Informant One detailed their experience:I can’t tell you how many times I heard an older person say the onlyreason I get up in the morning is because I know I have to feed mydog. That’s all about living isn’t it, keeping that person alive and well… Really important, like I said before about not wanting to get out ofbed in the morning, but knowing they have to feed their dog.Clients indicated that they also develop an attachment to their volunteers, who are seen as friends or extended family by most and evenconfidants by some. Key Informants also discussed this type of relationship, with Key Informant Two saying:I think sometimes with our volunteers, clients sometimes see them aspart of their family too, there’s that and it mightn’t be that thevolunteer feels that way, but the clients feel that way. They becomefriends with them and they become another part of their integratedfamily.Key Informants stated, however, that this relationship can blur thelines of responsibility due to the more informal nature of volunteering inpeople’s homes, which is a much more casual and personal setting. KeyInformants stressed the importance of ensuring that boundaries are setand that these boundaries are clearly outlined for the volunteers duringtheir training to ensure they remember why they are at the client’shome. The protocol was discussed by Key Informant Three:It’s not laid out, it’s not in written form … but in the interview stagesfor the volunteer, a new volunteer, they’re made aware of boundaries and we do put training into boundaries … So I talk to themabout what’s acceptable and what isn’t. When we go out to do theinitial meet and greet, those sort of things are reinforced, you knownot letting the dog off the lead, please don’t embarrass the newvolunteer by inviting them to family outings or giving them presentsbecause you know those sort of things are not allowed.Pets also provide owners with feelings of safety and act as a form ofsecurity [17,19], elements of Attachment Theory first coined by Bowlbyand highlighted in Zilcha-Mano et al. [34]. Several clients discussed howtheir pets will act as a guard or watch dog of sorts. Client Thirteenmentioned:But she does let me know when there is somebody around. She’s a bitof a guard dog in that respect but … or better still a watch dog. Sheknows what’s going on around her and she’ll let me know.4.2. SupportThe elderly rely on physical supports, such as PSPs and familymembers, to maintain independence and keep their pets healthy (i.e.dog walking or changing the litter tray). They also rely on emotionalsupport from other people, such as having someone to talk/vent to, visitsto look forward to, someone to keep them company as they live alone,S. Cryer et al.Complementary Therapies in Clinical Practice 42 (2021) 1012984and a purpose to get up in the morning.The elderly look to support, such as PSP, in order to keep their petwith them at home, with research finding that community dwellingelderly who do not have access to social networks or community basedpet supports are forced to pay for expensive commercial services [2,31].Key Informants discussed how PSPs fill these gaps, as PSPs can provideassistance in looking after pets, which is crucial as some elderly areunwilling to ask family for help and feel like they are a burden. Furtherto this, clients discussed their appreciation for the help of their volunteers, as evidenced during the interview with Client Fourteen:I find it very hard even to sweep. Because as even if I pick up a dustpan, I am shaking so much it just comes out. So it’s a real blessing tohave someone to come in to clean the litter tray each week.PSPs not only reduce social isolation and loneliness throughproviding clients with someone to talk to, they are also a welfareassessment, as some clients may go for a long time without seeinganyone and their volunteer can check that their health is not deteriorating. Key Informant Two described this situation:The volunteer went to the person’s house and the person had had afall, so the pet walker isn’t just going and walking a dog, they’reactually a welfare check, also our check for health deterioration, andwe know with older people that a little bit of a health issue can reallyprogress quite quickly. So from one week to the next, if a volunteergoes there and notices they might have a memory problem or itmight just be they’re not looking well, they can flag that with us. Wecan then contact next of kin, we can contact other services as well.Flagging health conditions is important as the elderly willingly puttheir pet’s health first, which could be reduced or eliminated throughthe use of PSPs [10,31]. It also promotes ageing in place and puts lessstrain on the health system as their condition will not be as severe as itwould if there was no volunteer checking up on them. As the PSP assiststhe elderly to look after their pet, they are able to keep the pet at homefor longer, which is important as the elderly can regard their relationship with their pet as a crucial source to their wellbeing [10], and thathaving to give up their pet is unthinkable to clients so they want toensure the health of their pet. Client Two commented that:I don’t function well without a dog, so it [pet ownership] is evenmore important to me now.All Key Informants said they would recommend the PSP to a friend orrelative and clients only had positive things to say about the PSP, such asthe health benefits for them and their pet, as well as being grateful fortheir volunteer. Key Informant One mentioned that:It’s a win-win all round program. Like, first of all the client’s going tohave their dog looked after, or get a bit of help looking after theirdog, and their dog’s going to be a happier dog because it’s gettingwalked and socialised, the dog’s got an extra person in its life andmost dogs can’t get enough people in their lives.4.3. Social isolationPSPs are important as rates of social isolation are likely to increase asthe population ages [2]. It is not only important due to a lack of sense ofcommunity, but also important for people who struggle to leave theirhomes and have families who are too busy to visit regularly. Some clients did discuss having family or friends who would help out, howeverthis was not generally on a regular basis, and many stated that they didnot get to see their family much, mainly due to them being grown upwith their own families.PSPs connect these socially isolated people with others, enablingthem to connect with the community. For example, Key Informant Onediscussed:[T]he clients look forward to the visit and to say hello to someone,might be the only person they see all week, and also once they’reconnected with us and in the pet companion program, if we canidentify isolation, we can get them involved in some of our socialsupport groups or our friendly visiting program … there are quite afew people on the program that just don’t have any family aroundthem at all … They are very isolated people.The importance of pets in reducing social isolation and facilitatingpeople’s social wellbeing and interactions [10,20,31,50,51], was discussed by some clients, for example by Client Eleven:Up at the park there are a lot of people who walk their dogs, thenumber of people that I know through their dog, don’t know theirnames, know the dog’s name, don’t know the people’s name. Um, Ithink we are in the same boat. But yes, a dog will always sparkconversation I think from other dog lovers.Key Informant Four stated:[W]e’ve been able to provide them with opportunities to cometogether outside of their home, so in some ways it has widened theirnetwork and it’s connected them with potentially other clients thatare experiencing similar issues and similar lifestyles to themselves soI think that helps them not to feel as isolated and as alone.Key Informants stressed the importance of PSPs being a holisticservice that ensures clients are not socially isolated and also trying toidentify gaps in services that they may be able to refer participants to,such as social support groups or cleaners. PSPs allow clients to be moresocially connected and develop close relationships and this is particularly important for the population in this study as the elderly livingindependently in urban areas are the most socially isolated people inAustralia [2].5. ConclusionThrough the use of the PSP, the elderly are able to stay at homelonger and age in place as they are able to improve their quality of lifeand health, and lessen their social isolations. By being able to stay athome, the elderly are also able to keep their independence and live theirlife autonomously.This study ascertained that recipients of PSPs experience improvedsocial connectedness through their involvement in the program due tohaving someone from the community, their volunteer, coming to visitthem every week. The study also found that interaction with PSPs andpets positively impacts the social isolation of participants as participantsare able to keep their pet at home for companionship and comfort, aswell as providing them with access to social support groups and a regular visitor in the form of their volunteer to talk to every week and forgea friendship. The study was also able to describe the role of pets in thelives of PSP recipients, with pets being described as a family member, afriend, company and someone to talk to by participants. Pets were alsodescribed as providing a sense of responsibility, and purpose, as well asfeelings of safety and security.The study explored the concept of Attachment Theory, with KeyInformants and participants describing the attachments between participants and their volunteers, with participants not only formingfriendships with their volunteers, but also confiding in them. Theattachment of the participant to their pet was also explored, with participants considering their pets as a family member or friend whocreated a sense of responsibility and safety. The attachment of pets totheir owners was also discussed, with pets being described as showingaffection and being protective of their owners, as well as being happy tosee their owner return home.Australian literature is small and does not necessarily correlate withinternational literature in regards to pet ownership and health. Thefindings of this study, however, suggest that pet ownership has mentalS. Cryer et al.Complementary Therapies in Clinical Practice 42 (2021) 1012985and physical health benefits, and has the ability to lower the risk ofsocial isolation.Exploring the health benefits of PSPs is a unique topic when it comesto the literature, nationally and internationally. Hence this study provides a first glance at how PSPs are able to assist the elderly to live longerand have a higher quality of life with their pets. This is important, aswhile the benefits of pet ownership is promoted throughout extensiveliterature, the importance of PSPs is lacking.Qualitative Description, Convenience Sampling, and Secondary DataAnalysis were potential limitations to this study; however, QualitativeDescription allowed the research questions to be addressed as it provided a description of the experiences of PSP clients and providers [33,52]. Convenience Sampling was limiting as it involves the first eligibleparticipants [36,37], however it was appropriate for this study as thepopulation was small and geographically local [37]. Secondary data wasa limitation due to a lack of control over the questions asked in the initialinterviews [53]; however the Secondary Data Analysis still provided richdata that was able to guide Key Informant interviews [48,53]. Strengthsof the study include the enhancement of credibility due to the additionof key informant interviews and ensuring the study was heavily enrichedin theoretical underpinnings and the literature [49]. Despite the limitations, there is scope for further research in this field and the potentialfor the program to expand to other vulnerable populations also warrantsfurther investigation. As people age and relationships change significantly over that duration, the companionship afforded by pets andvolunteers can be a critically important factor in ensuring the stability oftheir health and wellbeing.Statement of fundingThis research did not receive any specific grant from fundingagencies in the public, commercial, or not-for-profit sectors.Declaration of competing interestNone.AcknowledgementsThe authors would like to thank Monique Valencia who conductedthe interviews with Pet Support Program recipients as well as the studyparticipants for their contributions to the interviews.References[1] Australian Bureau of Statistics, 2071.0 – Census of Population and Housing:Reflecting Australia – Stories from the Census, 2016, 2017 retrieved 27 April 2018from, http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2071.0~2016~Main%20Features~Ageing%20Population14 ˜ .[2] A. Beer, D. Faulkner, J. Law, G. Lewin, A. Tinker, L. Buys, R. Bentley, A. Watt,S. McKechnie, S. Chessman, Regional variation in social isolation amongst olderAustralians, Regional Studies, Regional Science 3 (1) (2016) 170–184, https://doi.org/10.1080/21681376.2016.1144481.[3] E.Y. Cornwell, L.J. Waite, Social disconnectedness, perceived isolation, and healthamong older adults, J. Health Soc. Behav. 50 (1) (2009) 31–48.[4] O. Hazer, A.A. Boylu, The examination of the factors affecting the feeling ofloneliness of the elderly, Procedia – Social and Behavioral Sciences 9 (2010)2083–2089, https://doi.org/10.1016/j.sbspro.2010.12.450.[5] L.M. Jaremka, C.P. Fagundes, J. Peng, J.M. Bennett, R. Glaser, W.B. Malarkey, J.K. Kiecolt-Glaser, Loneliness promotes inflammation during acute stress, Psychol.Sci. 24 (7) (2013) 1089–1097, https://doi.org/10.1177/0956797612464059.[6] D. Unalan, S. Gocer, M. Basturk, H. Baydur, A. Ozturk, Coincidence of low socialsupport and high depressive score on quality of life in elderly, European GeriatricMedicine 6 (4) (2015) 319–324, https://doi.org/10.1016/j.eurger.2015.02.009.[7] L.C. Hawkley, J.T. Cacioppo, Loneliness matters: a theoretical and empirical reviewof consequences and mechanisms, Ann. Behav. Med. 40 (2) (2010) 218–227,https://doi.org/10.1007/s12160-010-9210-8.[8] L.C. Hawkley, C.M. Masi, J.D. Berry, J.T. Cacioppo, Loneliness is a unique predictorof age-related differences in systolic blood pressure, Psychol. Aging (1) (2006) 152.[9] L.M. Jaremka, C.P. Fagundes, R. Glaser, J.M. Bennett, W.B. Malarkey, J.K. KiecoltGlaser, Loneliness predicts pain, depression, and fatigue: understanding the role ofimmune dysregulation, Psychoneuroendocrinology 38 (8) (2013) 1310–1317,https://doi.org/10.1016/j.psyneuen.2012.11.016.[10] A.M. Toohey, J.A. Hewson, C.L. Adams, M.J. Rock, When ’places’ include pets:broadening the scope of relational approaches to promoting aging-in-place,J. Sociol. Soc. Welfare 3 (2017) 119.[11] Z. Feng, C. Dibben, M.D. Witham, P.T. Donnan, T. Vadiveloo, F. Sniehotta, I.K. Crombie, M.E.T. McMurdo, Dog ownership and physical activity in later life: across-sectional observational study, Prev. Med. 66 (2014) 101–106, https://doi.org/10.1016/j.ypmed.2014.06.004.[12] C.A. Krause-Parello, Pet ownership and older women: the relationships amongloneliness, pet attachment support, human social support, and depressed mood,Geriatr. Nurs. 3 (2012) 194.[13] D.M. Robins, C.R. Sanders, S.E. Cahill, Dogs and their people: pet-facilitatedinteraction in a public setting, J. Contemp. Ethnogr. 1 (1991) 3.[14] A. Shibata, K. Oka, S. Inoue, H. Christian, Y. Kitabatake, T. Shimomitsu, Physicalactivity of Japanese older adults who own and walk dogs, Am. J. Prev. Med. 43 (4)(2012) 429–433, https://doi.org/10.1016/j.amepre.2012.06.019.[15] M.N. White, A.C. King, J.F. Sallis, T.L. Conway, K.L. Cain, J. Kerr, L. Frank, B.E. Saelens, Caregiving, transport-related, and demographic correlates of sedentarybehavior in older adults: the senior neighborhood quality of life study, J. AgingHealth 28 (5) (2016) 812–833, https://doi.org/10.1177/0898264315611668.[16] L. Wood, K. Martin, H. Christian, A. Nathan, C. Lauritsen, S. Houghton, I. Kawachi,S. McCune, The pet factor – companion animals as a conduit for getting to knowpeople, friendship formation and social support, PloS One 4 (2015), https://doi.org/10.1371/journal.pone.0122085.[17] L.J. Wood, B. Giles-Corti, M.K. Bulsara, D.A. Bosch, More than a furry companion:the ripple effect of companion animals on neighborhood interactions and sense ofcommunity, Soc. Anim. 15 (1) (2007) 43–56, https://doi.org/10.1163/156853007X169333.[18] C.K. Cheung, P.K. Kam, Conditions for pets to prevent depression in older adults,Aging Ment. Health (2017) 1–7, https://doi.org/10.1080/13607863.2017.1385723.[19] R. Erickson, Companion animals and the elderly, Geriatr. Nurs. 6 (2) (1985) 92–96,https://doi.org/10.1016/S0197-4572(85)80006-9.[20] N.M.D. Antonacopoulos, T.A. Pychyl, An examination of the potential role of petownership, human social support and pet attachment in the psychological health ofindividuals living alone, Anthrozoos ¨ 1 (2010) 37.[21] P. Raina, D. Waltner-Toews, B. Bonnett, C. Woodward, T. Abernathy, Influence ofcompanion animals on the physical and psychological health of older people: ananalysis of a one-year longitudinal study, J. Am. Geriatr. Soc. 47 (3) (1999) 323,https://doi.org/10.1111/j.1532-5415.1999.tb02996.x.[22] R.A. Johnson, S.J.O. Johannes, R.L. Meadows, Animal-assisted interventionsresearch: issues and answers, West. J. Nurs. Res. 4 (2002) 422.[23] H. Kamioka, S. Okada, K. Tsutani, H. Park, H. Okuizumi, S. Handa, T. Oshio, S.-J. Park, J. Kitayuguchi, T. Abe, T. Honda, Y. Mutoh, Effectiveness of animalassisted therapy: a systematic review of randomized controlled trials, Compl. Ther.Med. 22 (2) (2014) 371–390, https://doi.org/10.1016/j.ctim.2013.12.016.[24] A. Moretti, R. De Ronchi, V. Bernabei, L. Marchetti, B. Ferrari, C. Forlani,F. Negretti, C. Sacchetti, A.R. Atti, Pet therapy in elderly patients with mentalillness, Psychogeriatrics 11 (2) (2011) 125–129, https://doi.org/10.1111/j.1479-8301.2010.00329.x.[25] B. Berget, S. Grepperud, Animal-Assisted Interventions for psychiatric patients:beliefs in treatment effects among practitioners, European Journal of IntegrativeMedicine 3 (2) (2011) e91–e96, https://doi.org/10.1016/j.eujim.2011.03.001.[26] A.B. Coakley, E.K. Mahoney, Creating a therapeutic and healing environment witha pet therapy program, Compl. Ther. Clin. Pract. 15 (3) (2009) 141–146, https://doi.org/10.1016/j.ctcp.2009.05.004.[27] P. Crowley-Robinson, D.C. Fenwick, J.K. Blackshaw, A long-term study of elderlypeople in nursing homes with visiting and resident dogs, Appl. Anim. Behav. Sci.47 (1) (1996) 137–148, https://doi.org/10.1016/0168-1591(95)01017-3.[28] A.L. Dookie, Perspectives of animal assisted activities on empowerment, selfesteem and communication with caregivers on elders in retirement homes, Act.Adapt. Aging 37 (3) (2013) 189–212, https://doi.org/10.1080/01924788.2013.816831.[29] Z. Vrbanac, I. Zeˇcevi´c, M. Ljubi´c, M. Beli´c, D. Stanin, N.B. Bottegaro, G. Jurki´c,B. Skrlin, ˇ L. Bedrica, D. Zubˇci´c, Animal assisted therapy and perception ofloneliness in geriatric nursing home residents, Coll. Antropol. 37 (3) (2013)973–976.[30] Australian Bureau of Statistics, 4430.0 – Disability, Ageing and Carers, Australia:Summary of Findings, 2015, 2016 retrieved, http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4430.0main+features302015. (Accessed 7 August 2018).[31] L. Fitzpatrick, Identifying the Need for Companion Animal Support for the Homeand Community Care Target Population, Real Animals Pets and People and theNational Ageing Research Institute, Melbourne, 2008.[32] C. Bradshaw, S. Atkinson, O. Doody, Employing a qualitative description approachin health care research, Global Qualitative Nursing Research 4 (2017) 1.[33] M.A. Neergaard, F. Olesen, R.S. Andersen, J. Sondergaard, Qualitative description– the poor cousin of health research? BMC Med. Res. Methodol. 9 (1) (2009) 52,https://doi.org/10.1186/1471-2288-9-52.[34] S. Zilcha-Mano, M. Mikulincer, P.R. Shaver, Pets as safe havens and secure bases:the moderating role of pet attachment orientations, J. Res. Pers. 46 (5) (2012)571–580.[35] A.H. Fine, S.J. Weaver, The human-animal bond and animal-assisted interventionin van den Bosch, in: W. Bird (Ed.), Oxford Textbook of Nature and Public Health:the Role of Nature in Improving the Health of a Population, Oxford UniversityPress, Oxford, 2018, pp. 132–138.S. Cryer et al.Complementary Therapies in Clinical Practice 42 (2021) 1012986[36] R. Endacott, M. Botti, Clinical research 3: sample selection, Intensive Crit. CareNurs. 21 (1) (2005) 51–55, https://doi.org/10.1016/j.iccn.2004.11.001.[37] O.C. Robinson, Sampling in interview-based qualitative research: a theoretical andpractical guide, Qual. Res. Psychol. 11 (1) (2014) 25–41, https://doi.org/10.1080/14780887.2013.801543.[38] D.M. Bohman, G. Borglin, Student exchange for nursing students: does it raisecultural awareness’? A descriptive, qualitative study, Nurse Educ. Pract. 14 (3)(2014) 259–264, https://doi.org/10.1016/j.nepr.2013.11.006.[39] D. Clement, M. Arvinen-Barrow, T. Fetty, Psychosocial responses during differentphases of sport-injury rehabilitation: a qualitative study, J. Athl. Train. 50 (1)(2014) 95–104, https://doi.org/10.4085/1062-6050-49.3.52.[40] J. Gibbins, R. Bhatia, K. Forbes, C.M. Reid, What do patients with advancedincurable cancer want from the management of their pain? A qualitative study,Palliat. Med. 28 (1) (2013) 71–78, https://doi.org/10.1177/0269216313486310.[41] A. Jewson, G. Lamaro, B.R. Crisp, L. Hanna, A. Taket, Service providers’experiences and needs in working with refugees in the Geelong region: aqualitative study, Aust. J. Prim. Health 21 (2) (2015) 233–238.[42] E. Learmonth, A. Taket, L. Hanna, Ways in which ‘community’ benefits frail olderwomen’s well-being: ‘we are much happier when we feel we belong’, Australas. J.Ageing 31 (1) (2012) 60–63, https://doi.org/10.1111/j.1741-6612.2011.00555.x.[43] B. DiCicco-Bloom, B.F. Crabtree, The qualitative research interview, Med. Educ. 40(4) (2006) 314–321, https://doi.org/10.1111/j.1365-2929.2006.02418.x.[44] M. Vaismoradi, H. Turunen, T. Bondas, Content analysis and thematic analysis:implications for conducting a qualitative descriptive study, Nurs. Health Sci. 15 (3)(2013) 398–405, https://doi.org/10.1111/nhs.12048.[45] J. Smith, J. Firth, Qualitative data analysis: the framework approach, Nurse Res. 18(2) (2011) 52–62.[46] J. Fereday, E. Muir-Cochrane, Demonstrating rigor using thematic analysis: ahybrid approach of inductive and deductive coding and theme development, Int. J.Qual. Methods 5 (1) (2006) 80–92.[47] V. Braun, V. Clarke, Using thematic analysis in psychology, Qual. Res. Psychol. 3(2) (2006) 77–101, https://doi.org/10.1191/1478088706qp063oa.[48] N. Ruggiano, T.E. Perry, Conducting secondary analysis of qualitative data: shouldwe, can we, and how? Qual. Soc. Work 18 (1) (2019) 81–97, https://doi.org/10.1177/1473325017700701.[49] E. Thomas, J.K. Magilvy, Qualitative rigor or research validity in qualitativeresearch, J. Spec. Pediatr. Nurs. (JSPN) 16 (2) (2011) 151–155, https://doi.org/10.1111/j.1744-6155.2011.00283.x.[50] O. Cusack, E. Smith, Pets and the Elderly: the Therapeutic Bond, Routledge,London, 2014.[51] J.S.J. Odendaal, Animal-assisted therapy; magic or medicine? J. Psychosom. Res.49 (4) (2000) 275–280, https://doi.org/10.1016/S0022-3999(00)00183-5.[52] J. Milne, K. Oberle, Enhancing rigor in qualitative description: a case study,J. Wound, Ostomy Cont. Nurs. 32 (6) (2005) 413–420, https://doi.org/10.1097/00152192-200511000-00014.[53] T.P. Vartanian, Secondary Data Analysis, Oxford University Press, New York, 2011.S. Cryer et al.