P ERSON , STIMULI , AND ENVIRONMENTAL ATTRIBUTES THAT INFLUENCE ENGAGEMENT

In the engagement model by Cohen-Mansfield et al. (2009a), important personal attributes are cognitive function, demographic characteristics, general level of activity, and interest. Stimulus attributes represents human aspects, social versus non-social, and live versus not alive, and

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environmental attributes are described as surroundings, such as time, place, number of people around, and the manner of stimulus presentation. In an animal-assisted intervention with a dog, all of these aspects will influence the participants’ interaction with the dog and its handler.

Interaction between stimulus and environment is highly relevant in animal-assisted interventions, since responsiveness to modelling is an important factor. Another important factor is person-stimulus interactions, such as participants’ preference for dogs, see Figure 8 (Cohen-Mansfield et al., 2009a).

Figure 8. The Comprehensive Process Model of Engagement (Cohen-Mansfield et al., 2009).

In Paper 4, we report that participants with severe dementia were found to spend less time looking at the dog activity and to sleep more during the sessions than those with mild or moderate dementia. Home-dwelling persons with dementia showed more behaviours such as smiling or laughing towards the dog, were engaged in more conversation, and slept less during the sessions than persons with dementia living in a nursing home. This finding might be related to the lower degree of cognitive loss and less use of medications in the home-dwelling population. This would be in line with the study by Cohen-Mansfield et al. (2009b), who analysed

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the impact of participants’ attributes and found that higher cognitive function positively affected engagement in terms of duration, attention, attitude, and refusal towards the stimulus (Cohen-Mansfield et al., 2009b). However, Cohen-(Cohen-Mansfield et al. did not find any correlation between the number of psychotropic medications and engagement (Cohen-Mansfield et al., 2009b).

Demographic characteristics are assessed in all four papers in this thesis, especially in Paper 1.

Significantly more persons with dementia in nursing homes had severe dementia, but even when stratified by the degree of dementia, persons with moderate dementia living in nursing homes had significantly more use of walking aids, less social contact, lower levels of moderate activity, and a higher use of psychotropic medication. These results provide important information, which is essential when an intervention is to be implemented. In order to provide the best intervention, health care workers need to gain as much knowledge as possible about the persons in their care (Cohen-Mansfield et al., 2009a). This knowledge includes demographic data, past and present interests, and psychological and physiological challenges, as well as the reason for implementing an intervention, which could be either to decrease boredom, loneliness, and problematic behaviour or to increase positive affect and improve physical impairments, to mention a few examples.

Participants with a past interest in pets have been found to have a longer duration of engagement in their interactions with a dog and participants who reported that they currently enjoyed dogs paid a significantly higher attention towards the dog in interactions with a dog (Cohen-Mansfield et al., 2010c). The high amount of attention paid towards the dog activity and the overall long duration of engagement seen in both places of residence reported in Paper 4 was probably affected by the fact that in the study reported in Paper 1 we found that the majority of nursing home residents and home-dwelling participants enjoyed contact with animals.

With regard to stimulus attributes, the social qualities of the dog might influence the level of participants’ engagement (Cohen-Mansfield et al., 2010f; Marx et al., 2010), since social stimuli have been found to create significantly more engagement among persons with dementia than non-social stimuli, and participants have been found significantly more attentive and with significantly more positive attitude towards a social stimulus than to a non-social stimulus

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(Cohen-Mansfield et al., 2011; Cohen-Mansfield et al., 2010f). The high degree of participants’

involvement, as well as indications of them having a positive attitude (frequent smiles and laughter) reported in Paper 4 implies that the intervention both created engagement among the participants and had a positive affect on them. Also, the dog’s size and/or breed influences the amount of engagement towards it (Marx et al., 2010). In our study, we deliberately used different dogs of different sizes and breeds. We examined possible differences between the different nursing home units, and found no significant differences. It therefore seems that in terms of breed or personality individual dogs did not influence the amount of engagement. Although the dogs were of different breeds, they were rather homogenous in the sense that they shared preferred traits and had received the same training. This was also the case for the handlers, who were all female, had similar background, and had received the same training and education. In an animal-assisted activity, the dog serves as an adjunct to the therapist/dog handler. The dog’s handler should therefore be considered as part of the stimulus attributes, but also part of environmental attributes, as a central component in modelling the intervention.

A very important environmental factor in the study was the group design and modelling of the intervention. In group activities, the group represents a secure environment that contributes to experiences of strength, inspiration, and joy (Sundsteigen et al., 2009). The number of participants in each group in our study varied between three and seven. Including dog handler and a health care worker, the number of people present in the room varied between five and nine. Attention to the engagement stimulus has been previous found significantly higher when there are between four and nine people in the room, as opposed to fewer than four or greater than nine (Cohen-Mansfield et al., 2010d). The intervention modelling was done by the dog handlers. The dog handlers were required to follow the standardized intervention protocol (Appendix 1), but were free to facilitate the session for the maximum benefit for the individual participant. The intervention modelling, such as in which way the dog is presented and the guidance provided to the participant on how to interact with the dog, is very important in animal-assisted activities. Modelling appropriate behaviour has been found to increase the duration of engagement significantly, and to create a significantly more positive attitude among persons with dementia when interacting with a stimulus (Cohen-Mansfield et al., 2010d). Other important

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environmental attributes in the study were time and place. The sessions were conducted in the same room every time and therefore the location became familiar to the participants.

Predictability was also ensured by always holding sessions on the same weekdays and within a certain time span, between 12:00 and 13:30. Time of the day affects participants’ level of engagement, since both the duration of engagement and the span of attention to the stimulus are shorter during the morning (10:00–12:00) than in the afternoon (Cohen-Mansfield et al., 2010d).