Canine-assisted Interventions Research Articles

Observation of human-animal interaction for research (OHAIRE) behavior coding in a randomized control trial of children with attention-deficit hyperactivity disorder (ADHD) and a canine-assisted intervention.

Diagnosed in about 10% of children in the United States, attention-deficit hyperactivity disorder (ADHD) is characterized by symptoms including inattention, hyperactivity, and impulsivity. Traditional interventions, such as pharmacological and psychological interventions, are often used in conjunction with integrative health options, such as animal-assisted interventions. The objective of this manuscript is to report behavior coding findings from a randomized control trial of children with ADHD. As part of a larger randomized control trial focused on the efficacy of combining a canine-assisted intervention (live therapy dog or control stuffed dog) with cognitive behavioral therapy for children with ADHD, the current manuscript focuses on video-captured behavior observations (n = 35 children, approximately 322 minutes of data). Data were extracted and coded using the Observation of Human-Animal Interaction Research (OHAIRE) Coding System. Behavior codes are reported as summary scores for the following domains: animal social interaction and human social interaction (further separated into human-adult social interaction and human-peer social interaction). Repeated measures mixed models analyses were performed using SAS PROC GLIMMIX to evaluate group differences and change across the study period. There were no significant differences in how much children interacted with the live therapy dogs versus control stuffed dogs. With respect to human-to-human social interactions, children showed greater increases over time in human-directed social interactions in the presence of live therapy dogs compared to stuffed dogs (p = .020). Over the course of the 12-week intervention, children increased in interactions with both adults (p = .006) and their peers (p = .014); however, there were more increases over time in adult-directed social interactions in the live animal condition compared to the control stuffed animal condition (p < 0.0001). Findings suggest changes in social interaction when participating in this canine-assisted intervention, specifically greater increases in human-to-human social interactions over time when a live therapy dog is present compared to a control stuffed dog. Children appear to engage relatively equally with both live and stuffed dogs; however, the impact of animals on human socialization differs based on if a live animal is present. Future studies should consider incorporating behavior coding analysis into studies of canine-assisted interventions to identify how human-animal interactions may be moderators or mechanisms for psychosocial outcomes.

An exploratory randomised controlled trial comparing the effectiveness of different duration of canine-assisted interventions in higher education students

Abstract The aim of this study was to explore whether different durations of canine-assisted intervention (CAI) influenced the beneficial effects of CAI on anxiety, stress, depression, and the well-being of higher education (HE) students. Eighty-eight participants took part in an exploratory randomised control trial (RCT) and were assigned to the 2, 5, and 10-min CAI groups who interacted with a canine, or a control group who watched an unrelated slideshow. Pre- and post-intervention anxiety, stress, depression, and well-being levels were measured. Additionally, the type of interaction between humans and canines was recorded as well as participants’ views of the canines’ neoteny (juvenile features) to explore whether interaction activity and canine features have an impact on the beneficial positive effects of CAI. The results showed no differences in the duration of CAI in reducing anxiety, stress, and depression, meaning a 2-min CAI session was as effective as a 10-min session. The results also found individual intervention activities between humans and canines did not predict a reduction in anxiety, stress, depression, or an increase in general well-being. Additionally, a negative correlation was found between the cuteness of the canine and anxiety, and between the cuddliness of the canine and stress, although these results should be interpreted with caution due to high canine trait scores. Overall, this study used a CAI and control group to explore the differences between a single 2, 5, and 10-min CAI sessions in HE students and demonstrated a 2-min CAI session was as effective as a longer 10-min CAI session in supporting the mental health of HE students, by reducing anxiety, stress, and depression levels in the treatment group.

A mixed-methods examination of an on-campus canine-assisted intervention by gender: Women, men, and gender-diverse individuals’ self-reports of stress-reduction and well-being

Abstract On-campus canine-assisted interventions (CAIs) provide opportunities for college students to interact with therapy dog-handler teams and are considered a low-cost and low-barrier way for students to reduce their stress and bolster their well-being. Across studies, we see participant samples comprised predominantly of women participants. The aim of this study was to assess the effects of a 20-min CAI on the well-being of women ( n = 80), men ( n = 54), and gender-diverse ( n = 28; i.e., non-binary, genderfluid, and two-spirit) participants. Across all gender conditions, significant pre-to-post increases in well-being (i.e., campus connectedness, happiness, positive affect, or optimism) and decreases in ill-being (i.e., homesickness, loneliness, negative affect, anxiety, or stress) were found. Controlling for pre-test scores, there was no significant effect of gender on any of the well-being or ill-being. Findings corroborate previous research attesting to the efficacy of CAIs in enhancing the social and emotional well-being of students and suggest that CAIs are equally effective across participants of varied genders.

Unleashing compassionate care: canine-assisted intervention as a promising harm reduction approach to prisonization in Canada and its relevance to forensic psychiatry.

In recent years, there has been a global advancement in the offering of canine-assisted interventions (CAI) in prisons. However, these programs have focused primarily on the benefits to the dogs involved and not on the impact on the participants. The authors of this perspective study have been running a CAI program with therapy dogs, called PAWSitive Support, in a Canadian federal prison since 2016. Thoughts from the program facilitators and interviews with prison staff indicate that the program, and specifically the therapy dogs, provides a unique and integrated source of comfort, support, and love for participants. These benefits are consistent with those seen in CAI programs outside of prisons. Unique to the prison setting appears to be an improvement in participant-staff relations. The therapy dogs have helped participants to experience comfort and consequently express their emotions. This seems to contribute to their recognition of support within the prison system and specifically developing trust with staff. Additionally, the dogs have helped to create an experience of the feeling of love within the prison, interpreted as the feeling of being cared for, which is rare for this population. The authors suggest that the integration of a therapy dog intervention in prison could be a novel harm reduction strategy to address issues related to prisonization and associated mental health concerns, including substance use. This consideration can offer unique insight into the field of forensic psychiatry about providing compassionate care to patients.

Beyond Cuddling Canines: Exploring Students’ Perceptions of the Importance of Touch in an On-Campus Canine-Assisted Intervention

Despite the increasing popularity of canine-assisted interventions (CAIs) across a variety of contexts, there is a paucity of literature exploring participants’ perceptions of the mechanisms that contribute to the benefits reported by researchers. This study aimed to expand on the knowledge obtained by our Phase I findings and to better understand undergraduate participants’ ( N = 280) perceptions and experiences of direct, physical contact versus indirect, close contact with therapy dogs and spending time with therapy dog handlers alone. Participants’ responses revealed that direct contact with therapy dogs was more likely to elicit benefits in positive affect, including reducing stress and improving mood, than those in the indirect or handler-only groups. Conversely, spending time with the handlers only was more likely to elicit social benefits, such as feeling more connected and less homesick. These findings hold implications for post-secondary CAIs and for therapy dog programs.

An Experiential Approach to Canine-Assisted Learning in Corrections for Prisoners Who Use Substances.

Canine-assisted interventions are a promising approach to help address substance use and mental health issues in prisons. However, canine-assisted interventions in prisons have not been well explored in relation to experiential learning (EL) theory, despite canine-assisted interventions and EL aligning in many ways. In this article, we discuss a canine-assisted learning and wellness program guided by EL for prisoners with substance use issues in Western Canada. Letters written by participants to the dogs at the conclusion of the program suggest that such programming can help shift relational dynamics and the prison learning environment, benefit prisoners' thinking patterns and perspectives, and help prisoners generalize and apply key learnings to recovery from addiction and mental health challenges. Implications are discussed in relation to clinicians' practices, prisoners' health and wellness, and prison programming.

Visual Processing of the Faces of Humans and Dogs by Children with Autism Spectrum Disorder: An Eye-Tracking Study

ABSTRACT Recent studies indicate a positive correlation between canine-assisted interventions and social and communicative abilities in people with autism. These benefits could be due to more efficient processing of socially informative areas when dog faces are processed. Using an eye tracker, this study aimed to assess the visual processing of faces in 13 children with autism spectrum disorder (ASD) and 13 neurotypical (NT) children when gazing at the faces of humans and of dogs. We divided the faces into two categories. First, individual faces of adult humans, children, and dogs were used in a free-viewing paradigm, where the area of interest was the eyes. We recorded the total time spent gazing at the eyes (dwell time), latency to the first look, and continuous gaze time. Second, pairs of faces were presented at the same time in a pair paradigm, and preferences in terms of face position (left/right) and type (dog/human), and the number of transitions between faces, were measured. When presented with pairs of faces, ASD children gazed for longer at the dog’s face, regardless of its position, and showed a higher number of shifts between pictures when the face of a dog was present. However, the NT group did not discriminate between the two faces. The results for individual faces showed significant differences in how ASD children look at the eyes of faces rather than differences in the total duration of the gaze; they are faster in terms of their first gaze and exhibit a longer average fixation time when gazing at the eyes of dogs compared with those of humans. Both human and dog faces were processed atypically in children with ASD, who seemed to engage with dogs more rapidly and for extended periods. This suggests possible socio-communicative benefits of human–dog interactions for people with autism, from a visual processing point of view.

Does reading aloud to a dog improve children’s reading outcomes? An academic critique

Educators are increasingly seeking innovative interventions to improve children’s reading skills through enhancing their reading enjoyment, motivation, and frequency. One such approach is through canine-assisted reading interventions in schools, which involve children reading aloud to therapy dogs and their handlers. The popularity of this approach is growing, with the development and delivery of numerous programmes and organisations worldwide. Given increasing interest in canine-assisted reading programmes in schools, there is a need to subject these interventions to scientific scrutiny, to evaluate the extent to which they are grounded in psychological theory, determine their efficacy for improving reading outcomes, and inform their implementation. In this critique, an overview of the theoretical underpinnings of reading aloud to dogs is first presented. Intervention effects are explained in terms of attachment theory, attentional control theory, and self-determination theory. The current critique also includes the first systematic review examining the effects of school-based canine-assisted interventions, compared to control conditions, on children’s reading outcomes. Findings from nine controlled studies are discussed. Currently, there is mixed and limited evidence for the efficacy of school-based canine-assisted reading interventions, compared to control conditions, on children’s reading skills, attainment, and attitude. Implications for practice and intervention implementation are considered.

Canine-Assisted Interventions and the Relevance of Welfare Assessments for Human Health, and Transmission of Zoonosis: A Literature Review.

CAIs (canine-assisted interventions) include “canine-assisted therapy” in which a therapist sets client-oriented goals, 'canine-assisted activities' with recreational goals for clients, and 'canine-assisted education/learning' in which teachers or coaches create learning goals for students or clients. CAIs vary in nearly every way; their only common trait is the involvement of dogs to respond to human need. However, the benefits of involving dogs are highly dependent on the animal's health and behavior. A dog exhibiting negative behavior or an unwell dog might pose a risk, especially for CAI target groups, specifically individuals with immunosuppression, chronic illness, children, elderly, etc. Therefore, positive animal welfare as preventative medicine to avoid incidents or transmission of zoonosis is an attractive hypothesis, with implications for human and animal, health and well-being. This review aims to summarize the current published knowledge regarding different aspects of welfare in CAIs and to discuss their relevance in the light of health and safety in CAI participants. As method for this study, a literature search was conducted (2001–2022) using the Prisma method, describing issues of dog welfare as defined in the Welfare Quality® approach. This welfare assessment tool includes 4 categories related to behavior, health, management, and environment; it was, therefore, applicable to CAIs. Results indicate that dogs working in CAIs are required to cope with diverse variables that can jeopardize their welfare. In conclusion, we propose regular welfare assessments for dogs in CAIs, which would also protect the quality of the CAI sessions and the clients' safety and well-being.

Molecular Biomarkers of Adult Human and Dog Stress during Canine-Assisted Interventions: A Systematic Scoping Review

Simple SummaryInteractions between people and dogs may lower participants’ stress levels. However, this is a fairly new area of research and there has not been a review of what we know across studies. We examined the existing research and found that human–dog interactions consistently improve some indications of human stress levels and don’t seem to negatively affect dogs. However, we need to do more research to gain a better understanding of the impacts on people and dogs with a wider lens that looks at more markers of stress.Positive relationships, including those between humans and other animals, particularly dogs, may be a way to reduce stress in humans. However, research into this area is relatively new, and a comprehensive review of the impacts of these interactions on humans and dogs has not been conducted. A scoping review of the scientific literature was conducted to explore what is known about the impacts of canine-assisted interventions on molecular biomarkers (e.g., cortisol and oxytocin) and associated measures (e.g., heart rate and blood pressure) of human and canine stress. As reported across 27 identified studies, canine-assisted interventions have consistently been demonstrated to elicit positive changes in human stress markers, and typically do not cause negative impacts on the studied canine stress markers. However, results were inconsistent across measures of stress. For example, in humans, it was common for a study to show improvements to cortisol levels but no change to self-reported stress, or vice versa. Many of the reviewed studies also had significant methodological issues, such as not aligning the timing of sample collections to when the analyzed stress biomarkers could be expected to peak. More rigorous research should be conducted on the impacts of canine-assisted interventions on a wider range of stress biomarkers.

Therapy dogs, stress-reduction, and well-being within the detachment: Interviews with law-enforcement personnel

Abstract Despite the increasing popularity of canine-assisted interventions (CAIs) across a variety of contexts, and the demonstrated efficacy they have on stress reduction, there is a paucity of research exploring the implementation of such programs within the context of law enforcement. Policing is known to be an environment in which personnel experience elevated occupational stress. As stress can compromise the overall well-being of law-enforcement personnel and their ability to serve the public, it is important to understand how CAIs involving therapy dog visitation are experienced by the very individuals for whom they are intended to help. This qualitative study explored Royal Canadian Mounted Police (RCMP) members’ experiences of stress within a detachment and their perceptions of a CAI integrated within their workplace to support their well-being. Eight RCMP members (75% female, Mage = 49.21, SD = 6.12) from an urban RCMP detachment situated in the downtown core of a small city were interviewed. The interview focused on topics including members’ experiences of stress within the workplace, their perceptions of the effects of stress, resources and sources of support, and their experiences participating in a weekly CAI within their detachment. Results indicated that organizational stressors were identified more often than operational stressors; that members most commonly reported that stress rendered them more irritable and impacted their sleep, and that the most commonly reported coping mechanism and resource are exercise and medical services, respectively. In discussing the CAI, participants were overwhelmingly positive in their experiences of the program, and demonstrated support for having CAIs within the detachment setting. Discussion of the impact of the sessions demonstrated that participants found that the program served as a break from work, relieved their stress, improved their mood, and helped them to change perspectives. Participants also identified the role of the dogs within the program, which included their role as a social being. The findings from the current study contribute to better understanding of the lived experiences of stress within RCMP members and of CAIs within an applied setting.

The Importance of Client–Canine Contact in Canine-Assisted Interventions: A Randomized Controlled Trial

ABSTRACT Researchers have claimed that canine-assisted interventions (CAIs) contribute significantly to bolstering participants' wellbeing, yet the mechanisms within interactions have received little empirical attention. The aim of this study was to assess the impact of client–canine contact on wellbeing outcomes in a sample of 284 undergraduate college students (77% female; 21% male, 2% non-binary). Participants self-selected to participate and were randomly assigned to one of two canine interaction treatment conditions (touch or no touch) or to a handler-only condition with no therapy dog present. To assess self-reports of wellbeing, measures of flourishing, positive and negative affect, social connectedness, happiness, integration into the campus community, stress, homesickness, and loneliness were administered. Exploratory analyses were conducted to assess whether these wellbeing measures could be considered as measuring a unidimensional construct. This included both reliability analysis and exploratory factor analysis. Based on the results of these analyses we created a composite measure using participant scores on a latent factor. We then conducted the tests of the four hypotheses using these factor scores. Results indicate that participants across all conditions experienced enhanced wellbeing on several measures; however, only those in the direct contact condition reported significant improvements on all measures of wellbeing. Additionally, direct interactions with therapy dogs through touch elicited greater wellbeing benefits than did no touch/indirect interactions or interactions with only a dog handler. Similarly, analyses using scores on the wellbeing factor indicated significant improvement in wellbeing across all conditions (handler-only, d = 0.18, p = 0.041; indirect, d = 0.38, p < 0.001; direct, d = 0.78, p < 0.001), with more benefit when a dog was present (d = 0.20, p < 0.001), and the most benefit coming from physical contact with the dog (d = 0.13, p = 0.002). The findings hold implications for post-secondary wellbeing programs as well as the organization and delivery of CAIs.

Canine-Assisted Interventions in Hospitals: Best Practices for Maximizing Human and Canine Safety.

Canine-assisted interventions (CAI) are becoming more popular in hospital settings, representing a crucial intersection between animals, veterinary medicine, and society. However, standardized policies and procedures to minimize risk and maximize benefit to vulnerable humans and protect therapy dog welfare are lacking, posing a challenge to safe practice. Few intervention programs are evaluated to document efficacy compounding the potential risk. This paper presents a rationale for CAI in hospitals and describes the evidence, issues, and challenges to establishing and maintaining safe and effective programs for humans and animals. Recommendations are made for best practices based on the existing scientific evidence and a model program in place in a major medical center for 19 years. Scientific and practical implications are considered.

Up the leash: Exploring canine handlers’ perceptions of volunteering in canine-assisted interventions

ABSTRACT&#x0D; To date, research on canine-assisted interventions has focused on identifying the effects of spending time with therapy dogs on the well-being of participants and, to a lesser extent, exploring the effects of canine-assisted interventions on therapy dogs as a means of safeguarding canine welfare. Little empirical attention has focused on understanding the experience of volunteer canine handlers – agents at the heart of the success of canine-assisted interventions. The aim of this exploratory research was to first capture the voice of handlers to better understand their experience as volunteers and second to provide preliminary insights into their well-being. Sixty volunteer handlers with varying volunteer experience with a canine therapy program at a mid-size Canadian university responded to a series of open-ended prompts related to their volunteer work and completed a battery of well-being measures. Qualitative findings revealed that most participants identified social benefits to volunteering for themselves (64%) and for their dog (55%). The perceived impact on students (33%) and the ability to help university students (36%) were the most rewarding aspects of volunteering. Although drawn to volunteer by the program itself (36%), motivations to continue volunteering were predominantly associated with personal benefits of volunteering (44%). Most handlers reported no challenges associated with volunteering (73%) and qualified their dog as happy after sessions (71%). Participants commonly described good therapy dogs as relaxed, calm, and respectful (66%) and strong handlers as having good awareness of their dog (48%). Quantitative findings revealed volunteer handlers reported elevated levels of positive affect (p = &lt; 0.001, d = 1.19), greater satisfaction with life (p = &lt; 0.001, d = 0.85) and lower levels of avoidant attachment to their therapy dog (p = &lt; 0.001, d = -1.16) when compared to normative samples. Implications for the governing of on-campus programs and handler well-being are discussed.

Pups Assisting Wellness for Staff (P.A.W.S.): Evaluating the impact of canine-assisted interventions on critical care staff wellness.

Acute care settings can expose staff to job-related stressors. Pups Assisting Wellness for Staff (P.A.W.S.) has been designed as an innovative approach to support acute care staff in the emergency department and intensive care unit. Initially, P.A.W.S. was implemented as a Comfort Dog Pilot and then expanded into a Therapy Dog Model. The Therapy Dog Model incorporated learnings from the Comfort Dog Pilot to evaluate the impact of the following: more dogs, using certified therapy dogs, and visiting at different times of the day. Results throughout the project demonstrated a positive impact on staff morale, staff stress, overall and staff satisfaction, and a strong desire for the project to continue. As a result and with a collaborative effort between a multidisciplinary team, P.A.W.S. has now been operationalized as a permanent program to support staff in acute care.

Impact of canine-assisted interventions on the health and well-being of older people residing in long-term care: a mixed methods systematic review protocol.

The objective of this review is to synthesize and integrate the best available evidence on the impact of canine-assisted interventions on the health and well-being of older people residing in long-term care. Canine-assisted interventions are commonly used as an adjunct therapy to enhance health and well-being, and are often implemented in long-term care facilities. The number of studies undertaken in this area has increased substantially over the previous five years; therefore, an update of two previous systematic reviews is warranted. This review will consider older people who reside in long-term care facilities and who receive canine-assisted interventions. For the quantitative component, canine-assisted interventions will be compared to usual care, alternative therapeutic interventions, or no interventions, and outcomes will be grouped under the following headings: biological, psychological, and social. For the qualitative component, the experiences of older people receiving canine-assisted interventions, as well as the views of people directly or indirectly involved in delivering canine-assisted interventions, will be explored. Quantitative, qualitative, and mixed methods studies published from 2009 to the present will be considered. A search of 10 bibliographic databases and other resources for published and unpublished English language studies will be undertaken. Study selection, critical appraisal, data extraction, and data synthesis will be undertaken by two independent reviewers following the segregated JBI approach to mixed methods reviews. PROSPERO CRD42020161235.

Turning the Page for Spot: The Potential of Therapy Dogs to Support Reading Motivation Among Young Children

ABSTRACTThis study investigated whether dogs might facilitate a context conducive to reading for children when they are faced with a challenging reading passage. A within-subjects design was used to assess children’s motivation to read in two conditions: with a therapy dog and without a therapy dog. Seventeen children (8 girls; 9 boys) in Grades 1 to 3 (aged 6–8 years) and their parents participated in this study. Results of a multivariate repeated-measures ANOVA with two levels suggested that the presence of a therapy dog positively impacted children’s reading motivation and persistence when they were faced with the task of reading a challenging passage. Specifically, children confirmed feeling significantly more interested and more competent when reading in the presence (versus absence) of a therapy dog. Additionally, participants spent significantly more time reading in the presence of the therapy dog than when they read without the therapy dog present. To the best of our knowledge, this study is the first to use a within-subjects design to explore children’s reading motivation and reading persistence during a canine-assisted reading task. Moreover, as canine-assisted reading interventions assume that the reading context is one that may present a challenge, this research is unique because the reading passages were carefully selected and assigned to each participant to ensure that each child was provided with a challenging reading task. This research holds implications for the development of a gold-standard canine-assisted intervention for young struggling readers.

A Randomized Controlled Trial of Traditional Psychosocial and Canine-Assisted Interventions for Children with ADHD

Abstract This study provides findings on the final main outcomes from a randomized controlled trial of psychosocial intervention with and without canine assisted intervention (CAI) for children with Attention-Deficit/Hyperactivity Disorder (ADHD). Eighty-eight children, ages 7-9 with ADHD, combined subtype were randomly assigned to 12-week intervention groups (CAI or Non-CAI). Outcome measures were collected across multiple domains and time points. Main effects of group were revealed for total ADHD symptoms ( p &lt;.05), inattention ( p =.01) and social skills ( p =.04), indicating that the CAI group fared better than the non-CAI group. A significant interaction of group by time on ratings of problem behaviors ( p =.02) and social initiation ( p =.03), indicated the CAI group demonstrated a modest benefit over the non-CAI group in these domains. This manuscript describes the results and discusses the benefits and limitations of this intervention for children with ADHD.

Can Canine-Assisted Interventions Affect the Social Behaviours of Children on the Autism Spectrum? A Systematic Review

Autism spectrum disorder (ASD) is a neurodevelopmental condition impacting individuals’ social communication and interactions. Animal-assisted interventions (AAI) have been identified as practice modalities for children with ASD. A systematic review of the literature was completed identifying 13 articles addressing the impact AAI has on the social behaviours of children with ASD. Participant numbers were small with ages ranging from 3 to 18 years. Outcomes comprised verbal communication, non-verbal communication, identified desired and undesired behaviours. Findings suggested that AAI can have a positive impact on the social behaviours of children on the autism spectrum; however, studies were characterised by methodological weaknesses. More rigorous research methods are required to determine the effectiveness of AAI for children with ASD.

Methodological Considerations in Designing and Evaluating Animal-Assisted Interventions.

Simple SummaryThere is a growing literature on the benefits of companion animals to human mental and physical health. Despite the literature base, these benefits are not well understood, because of flawed methodologies. This paper draws upon four systematic reviews, focusing exclusively on the use of canine-assisted interventions for older people residing in long-term care. Two guides are offered for researchers, one for qualitative research, one for quantitative studies, in order to improve the empirical basis of knowledge. Research in the area of the human-animal bond and the potential benefits that derive from it can be better promoted with the use of uniform and rigorous methodological approaches.This paper presents a discussion of the literature on animal-assisted interventions and describes limitations surrounding current methodological quality. Benefits to human physical, psychological and social health cannot be empirically confirmed due to the methodological limitations of the existing body of research, and comparisons cannot validly be made across different studies. Without a solid research base animal-assisted interventions will not receive recognition and acceptance as a credible alternative health care treatment. The paper draws on the work of four systematic reviews conducted over April–May 2009, with no date restrictions, focusing exclusively on the use of canine-assisted interventions for older people residing in long-term care. The reviews revealed a lack of good quality studies. Although the literature base has grown in volume since its inception, it predominantly consists of anecdotal accounts and reports. Experimental studies undertaken are often flawed in aspects of design, conduct and reporting. There are few qualitative studies available leading to the inability to draw definitive conclusions. It is clear that due to the complexities associated with these interventions not all weaknesses can be eliminated. However, there are basic methodological weaknesses that can be addressed in future studies in the area. Checklists for quantitative and qualitative research designs to guide future research are offered to help address methodological rigour.