Animal-Assisted Interactions for College Student Mental Health and a Conceptual Model of Practice: A Three-Paper Dissertation A Dissertation SUBMITTED TO THE FACULTY OF THE UNIVERSITY OF MINNESOTA BY Tanya Kathleen Bailey IN PARTIAL FULFILLMENT OF THE REQUIERMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY Adviser: Elizabeth Lightfoot, PhD August 21, 2021 © Copyright by Tanya Kathleen Bailey 2021 i    Acknowledgements Many hands make light work applied throughout my dissertation process and I extend my deepest gratitude to so many people who touched my life and helped me successfully accomplish this dissertation process. First, my committee members, Dr. Joe Merighi, Dr. Jessica Toft, and Dr. Elizabeth (Liz) Lightfoot with the School of Social Work, and Dr. Roni Evans with the Earl Bakken Center for Spirituality and Healing. The time and thoughtfulness you showed me helped me to think critically with my heart. Thank you, Liz, for being one of my first contacts with the PhD program, for supporting my work from the very beginning, and for doing “double duty” during such a difficult time. Second, to my colleagues at Boynton Health, I am deeply grateful for your advice and encouragement– especially when it got hard. I am beyond blessed to get to work with all of you each day doing something we are all so passionate about. And third, to the countless doctors, nurses, and staff who helped me travel through cancer, I would not be writing these words without your grace, compassion, and hope. My research would not have been possible without the hundreds of PAWS teams who have given so much of themselves since I started the program in 2013, and the thousands of students who have attended and shared their experiences with me. I am so thankful to all of you and you validated my study in ways that no statistics ever could. Speaking of statistics, I was fortunate to work with Rik Lamm who helped guide my analysis and served as a translator on many occasions. And for reading some of my initial drafts and chapters, thank ii    you Ellen, Holly, and Mary for sharing your wisdom and seeing so many parts of the elephant that were important perspectives to include. I recognize that while I am a first-generation college graduate, I hold an immense level of privilege as a white, heterosexual female born and raised in the United States. Furthermore, I have an incredible wealth of friends and family who truly care about and have always shown interest in my work. The deepest and widest influence throughout my life has been my mother, Siglinde Moore, who nurtured my curiosity and deep respect for the natural world and always made time to explore the world with me. Thank you mom and I love you very, very much. So many colleagues are woven into the fabric of my knowledge and expertise, and I am grateful for the time and instruction I have had with each one of them. Where I have come to be as a practitioner was shaped by every experience I have had with animals and the environment including Missy, Maude, Ginger, Penny, Rocky, Daisy, Crystal, Sophie, Ruby, and Toby. Most significantly, Torie, Woodstock, and Viola are relationships of my heart that remain present in my life and with whom I will forever remain deeply connected. Above all, my husband Peter Bailey has been my biggest fan during this journey and even during my cancer, never wavered from sharing my dream that someday, I would finally get to the end of this scholarly chapter so as to begin the next. I know there were many days when being my partner wasn’t easy – especially when I was analyzing my data – and you will never know how the depths of your love and selfless encouragement kept me going. You remain my iii    rock and beacon of love and I can never thank you enough for who you are in my life. Finally, my dissertation is in memoriam of Dr. Helen Q. Kivnick, my advisor, teacher, mentor, and friend. Helen came to watch me work with horses early in my studies and despite not being all that enthusiastic about animals, her infectious curiosity about my passion and course of study spoke volumes about who she was as a person and the deep care and commitment she gave to everything she did throughout her life. Thank you Helen for always reminding me to stay vitally involved no matter the circumstances. iv    Dedication To Peter – you are my heart, my Truelove, my lobster. I love you. v    The animals are more ancient than us. They were here for millennia before humans surfaced on the earth. Animals are our ancient brothers and sisters. They enjoy a seamless presence–a lyrical unity with the earth. Animals live outside in the wind, in the waters, in the mountains, and in the clay. The knowing of the earth is in them. The Zen-like silence and thereness of the landscape is mirrored in the silence and solitude of animals. Animals know nothing of Freud, Jesus, Buddha, Wall Street, the Pentagon, or the Vatican. They live outside the politics of human intention. Somehow they already inhabit the eternal. The Celtic mind recognized the ancient belonging and knowing of the animal world. The dignity, beauty, and wisdom of the animal world was not diminished by any false hierarchy or human arrogance. -- John O'Donohue, in Anam Cara: A Book of Celtic Wisdom   vi    Abstract People have long found comfort and support by interacting and sharing their lives with animals, and from this interest has led to a specific modality in human healthcare called Animal-Assisted Interactions (AAI). One application of AAI in higher education has gained much attention in the past 10 years. University campuses are a setting where suicide is the second leading cause of death and where college student mental health is in crisis. However, a robust understanding of the development, implementation, and impact of these programs in relation to these immense challenges remains vastly understudied. The purpose of this dissertation is to explore campus-based AAI programs for college student mental health, and as a three-paper manuscript, the information is presented in a progressive fashion. In the first paper, I describe a scoping review study in which I map the literature on campus-based AAI programs for college student mental health. In the second paper, I present the findings from a repeated, six-year cross-sectional study for academic years 2014/15 through 2019/20 using a secondary analysis of existing data from a campus-based AAI program. In the third paper I define a conceptual model of practice that I developed called the PACE—Practitioner, Animal, Client, and Environment—Model for AAI to frame the way AAI programs are established and applied. The implications presented from this study can inform future practice, education, policy, and research in the fields of social work, college student development, and AAI. vii    Table of Contents Acknowledgements i  Dedication ivv  Epigraph v Abstract vi  Table of Contents vii  List of Tables xiiii  List of Figures xiv Chapter 1: Introduction 1 Literature Review 3 College Students 3 The State of Today’s College Students 3 College Student Mental Health 6 Animal-Assisted Interactions 8 Humans Historical Connection to Animals 9 Current State of Therapeutic Interactions with Animals 14 AAI Programs with College Students 15 The Origins of My Research 16 Overview of the Three Papers 18 Paper One 18 Summary 18 Research Questions 19 viii    Analysis and Results 19 Paper Two 20 Summary 20 Research Questions 21 Analysis and Results 21 Paper Three 23 Summary 23 Objectives 23 Summary 24 References 27 Chapter 2: Paper One 39 Introduction 40 Literature Review 41 College Students and Stress 41 College Student Mental Health 43 Animal-Assisted Interactions 45 Scoping Review Study 48 Methods 48 Study Design 48 Protocol 49 Research Questions 50 Eligibility Criteria 50 ix    Evidence Sources and Search Strategy 52 Evidence Selection 55 Data Charting 55 Data Synthesis 56 Results 84 Information Sources 84 Characteristics of the Included Papers 86 Discussion 90 Limitations 95 Conclusions 97 References 99 References: Scoping Review Articles 113 Chapter 3: Paper Two 119 Introduction 120 Cross-Sectional Study 125 Methods 125 Study Design 125 Measures 126 Procedure 128 Data Analysis 129 Results 130 Discussion and Implications 153 x    Limitations 160 Conclusions 163 References 165 Appendix A: Sample Survey Questionnaire 173 Appendix B: Graphs of Attendance for Duration and Frequency of Visit 183 Chapter 4: Paper Three 187 Introduction 188 Background 190 Animal-Assisted Interactions 190 Conceptual Model of Practice 192 Overview of the PACE Model for AAI 195 PACE Model Components 197 Practitioner 197 Animal 199 Client 201 Environment 202 Reciprocal Interactions 204 Quality of Competence 207 Summary 213 References 216 Chapter 5: Conclusions 227 xi    Major Findings 227 Commonalities 231 Limitations 233 Implications 235 Social Work Practice 237 Social Policy 240 Research 241 Education 243 Future Directions 245 Summary 249 References 252  xii    List of Tables Paper One Table 1 – Scoping Review Search Terms and Locations Table 2 – Summary of Studies Included in a Scoping Review of AAI for College Student Mental Health Table 3 - Synthesis of Studies in a Scoping Review of AAI for College Student Mental Health Paper Two Table 1 – Distribution of College Students per Academic Year by Gender, International Student Status, Age, and Academic Status by Number and Percentages Table 2 – Number of Visits and Duration of Visits (in Minutes) Reported by College Students per Academic Year Table 3 – Survey Question Responses per Academic Year by Number and Percentages Table 4 – College Students' Scores on the PSS-10 by Gender and International Status (0-13=Low Stress; 14-26=Moderate Stress; 27-40=High Stress) Table 5 – Number of Adverse Life Experiences Selected by College Students 53 57 78 132 134 135 138 139 xiii    Table 6 - Logistic Regression Analysis for Duration, Gender, International Status, PSS-10-High, ALE_Have, and Reason_Stress on Students Saying Attending the AAI Program Helped Them Manage Their Stress Paper Three Table 1 – The Quality of Competence (QOC) Rubric for AAI Assessment 141 211 xiv    List of Figures Paper One Figure 1 – PRISMA Flow Diagram for the Scoping Review Process Paper Three Figure 1 – The PACE Model for Animal-Assisted Interactions (AAI) Figures 2-4 – Examples of Reciprocal Relationships in the PACE Model for Animal-Assisted Interactions (AAI) Figure 5 – Example of Combined Reciprocal Relationships in the PACE Model for Animal-Assisted Interactions (AAI) Figure 6 – The Quality of Competence Gauge in the PACE Model for Animal-Assisted Interactions (AAI) 85 190 205 207 209 1 Chapter One: Introduction People have long found comfort and support by interacting and sharing their lives with animals, yet only in the later part of the 20th century did human healthcare providers, researchers, and educators start to recognize that these interactions were deeply therapeutic for the body, mind, and soul. One of the most recognized moments of animals impacting mental health occurred during the 1960’s. It is the story of psychologist Boris Levinson and his dog named Jingles. Levinson is credited with first using the term Pet Therapy in his seminal text Pet-Oriented Child Psychotherapy (Levinson, 1969). After several unsuccessful therapy sessions between Dr. Levinson and a client, Jingles entered the room and as a result of this unplanned interaction, the client started to engage with the dog and with the psychologist (Levinson, 1969). Levinson’s writings and professional presentations set into motion a conversation about the relational exchange between humans and animals that, 50 years later, continues to evolve and remains relevant across the entire planet. The discipline known as Anthrozoology helped develop and define what is commonly known as the Human-Animal Bond (HAB) or Human-Animal Interactions (HAI) and out of these foundational structures grew a professional modality called Animal-Assisted Interactions (AAI) (Hosey & Melfi, 2018). I define AAI as an active partnership with human practitioners and specially selected animals, both have received training, and together as a team provide the purposeful delivery of direct and measurable therapeutic and educational 2 services for human learning and well-being (A. H. Fine, 2019). Similar terms with slightly different definitions found in the literature are Animal-Assisted Therapy (AAT), Animal-Assisted Activities (AAA), and Animal-Assisted Education (AAE). When specifically focusing on mental health, the literature shows that AAI programs and services have demonstrated a limited yet positive impact on stress, depression, schizophrenia, anxiety, chemical addictions, and sense of belonging (Maujean et al., 2015; Nimer & Lundhal, 2007). One application of AAI in higher education has gained much attention in the past 10 years. As of a 2015 census, there were 925 campus-based AAI programs across a variety of colleges and universities in the United States (Crossman & Kazdin, 2015). Among a number of ways to reduce stress, it is logical to surmise that if animals bring joy and positive engagement when they are our pets, then perhaps some of these same animals could provide stressed-out college students with a moment of respite, fun, and decompression, especially during midterm and final exams. The enthusiastic support garnered by consumer demand, public acceptance, and media hype has left an impression that feeling better can simply be solved with a “pet Rx” (A. H. Fine & Ferrell, 2021; Serpell et al., 2017). However, a robust understanding of if, how, and to what extent these programs are effective remains vastly understudied (Herzog, 2015). The purpose of this dissertation is to explore campus-based AAI programs for college student mental health, and as a three-paper manuscript, the information is presented in a progressive fashion. In Paper One, I describe a 3 scoping review study that I conducted to map the literature on campus-based AAI programs and college student mental health. This paper provides an organized way to create a current state of what is known about how research has investigated the topic and what gaps exist to help direct future studies. In Paper Two, I present the findings from a repeated cross-sectional study conducted for six academic years (2014/15 to 2019/20) using a secondary analysis of existing data from a campus-based AAI program. The setting for this study was a program I developed in 2013 and continue to direct as of the time of writing this dissertation, and the main outcome was if or to what extent attending this program helped students manage their stress. In Paper Three, I define a conceptual model of practice I developed called the Practitioner, Animal, Client, and Environment (PACE) Model (Bailey, 2015) to frame how AAI programs are established and implemented. The final chapter of this dissertation presents a summary of the major findings, limitations, and recommendations for how this knowledge can inform future practice, policy, research, and education in the fields of social work, college student development, and AAI. Literature Review The following literature review provides a summary of the three main concepts in this dissertation–college students, college student mental health, and AAI–and is expanded in more detail within each of the three papers. College Students The State of Today’s College Students 4 Today’s college students face a myriad of experiences and adjustments while also navigating the comprehensiveness and rigor of academia. It is quite common for students to struggle with most aspects of this new phase of development and question just about everything–Who am I? What do I want to become? How am I going to succeed?–because this is a period of increased independence and when one’s productivity becomes heavily intertwined with who one is socially and emotionally (Blanco et al., 2008; Hefner & Eisenberg, 2009). Furthermore, compared to previous decades, more students struggle with their overall health and well-being. Data show that physical safety, food and housing insecurity, and paying for college are three main stressors for many college students (Lederer et al., 2021). Likewise, many do not meet national nutrition and physical activity guidelines, and they may engage in riskier behaviors while they test out and acquire healthy life skills (Eisenberg et al., 2019; Lederer & Oswalt, 2017). College student health was officially recognized in 1859 with the establishment of the first health center at Amherst College, but unlike today, clergy or faculty were the main sources of emotional support (Welch, 1982). Only as recently as the later part of the 20th century did college student mental health receive attention as a separate practice and research agenda (Shapiro et al., 2019). Furthermore, not until the 1990s did a public health lens begin to shape additional university-based mental health services through outreach, health education, health promotion, and informal peer support (Kraft, 2010). Authors 5 Lederer and Oswalt (2017) argue that common misperceptions regarding college students–that they are privileged, healthier than the rest of society, and that higher education is not responsible for focusing on their well-being–are inaccurate and partially responsible for why so little is known about overall college student health. This lack of fully understanding the college student experience is significant when college campuses essentially function as distinct communities within society. As of 2019, the overall undergraduate college enrollment for individuals between the ages of 18 and 24 in the United States was 41%, or 16.6 million students (Hussar et al., 2020). Furthermore, 5.5% of the total student body included close to 1.1 million international students (Hanson, 2021). From this massive group of people, a range of 25% to 50% live in campus housing (American College Health Association (ACHA), 2020; Bill and Melinda Gates Foundation, 2020) which helps to create small neighborhoods outfitted with amenities like restaurants, shops, places of worship, and commercial buildings. Furthermore, what is considered a “traditional” versus “nontraditional” student is slowly evaporating as today’s college students are becoming more diverse. Data show that 62% of college students are working at least part-time, 44% are people of color, 42% live at or below the poverty line, 38% are receiving financial aid, 34% are first-generation students, and 26% are parents (Bill and Melinda Gates Foundation, 2020; Higher Learning Advocates, 2018). Attending college provides access to a wide range of disease prevention 6 and treatment options—one of the greatest international public health interventions of the 21st century—and as a core component embedded in the mission of higher education, helps to also support overall societal health (Hernández-Torrano et al., 2020; Lederer & Oswalt, 2017). More than 100 years ago, the American Student Health Association was formed, later renamed the American College Health Association (ACHA), and provided early recognition that college student health was a unique discipline apart from overall population health (Christmas, 1995). Being a college student is not just an extension of late adolescence or the beginnings of adulthood, and health sciences now considers this age bracket of 18 to 24 a distinct developmental stage deserving its own inquiry and strategic services, processes, and interventions (Lederer & Oswalt, 2017). Indeed, one result from this shift in mindset is a ten-fold increase in publications during the past 15 years addressing college student mental health and which parallels the growing concern of the role and impact universities may have on the full spectrum of student well-being (Hernández-Torrano et al., 2020). College Student Mental Health While awkward social adjustments and feelings of homesickness are still prominent factors in the college experience, the current state of college students’ mental health is dire. Statistics show that after accidents, suicide is the second leading cause of college student death across all types of postsecondary institutions in the United States while it is the tenth leading cause of death in the general population (Drapeau & McIntosh, 2020).The Healthy Minds Study of 7 2020 reported that close to two out of every five students were diagnosed with a lifetime mental health disorder (Eisenberg et al., 2020). Furthermore, comparing this report to its 2007 edition demonstrates that there is an overall trend of rising rates of depression (17% to 28%) and anxiety (7% to 31%), the two most frequently reported mental health conditions for today’s college students (Eisenberg et al., 2013, 2020). Campus medical and counseling centers are also seeing a rise in overall cases and complex psychological challenges (Acharya et al., 2018) that far surpasses what many colleges can adequately address in the way of prevention, intervention, and treatment (LeViness et al., 2019). Throughout the past 20 years, the degree of comorbid college student mental health issues has come to include schizophrenia, bipolar disorder, eating disorders, self-injury, post- traumatic stress disorder (PTSD), and psychosis (Gallagher & Taylor, 2014; Pedrelli et al., 2015). Furthermore, trauma from the COVID-19 pandemic has compounded the stress and disparities many students were already experiencing. More than 60% of students reported that trying to access mental health care became more difficult once many colleges and universities essentially shut down all in-person operations in March of 2020 (Healthy Minds Network & ACHA, 2020). Given that 75% of mental illness disorders will manifest by age 24 (Pedrelli et al., 2015), higher education must bring a heightened sensitivity to mental health prevention and provide interventions for a college study body that on average remains between the ages of 18 and 24. 8 The literature demonstrates that college students’ mental health has reached crisis proportions, resulting in severe impacts on academic retention and success (Kognito, 2017; Tinto, 2017). In a survey conducted by the National Alliance of Mental Illness (Gruttadaro & Crudo, 2012), 65% of students who dropped out of college during a five-year timeframe reported that the reason was due to their poor mental health, yet half of these individuals had never accessed supportive services. When one is struggling emotionally, it is less than ideal for the overall health of a college campus to have counseling center waiting lists, session limits, and extensive delays in-between appointments. Scholars have called for expanding, enhancing, and innovating current approaches to support student health and academic services (Lederer et al., 2021). In response, many colleges and universities are exploring how bringing animals to campus might be one way of exposing students to a therapeutic activity that is engaging, fun, and helps to normalize mental health support and care. Animal-Assisted Interactions More than 50 year ago, psychologist Boris Levinson’s 1969 foundational publication, Pet-Oriented Child Psychotherapy, helped develop our current understanding of how animals can provide a myriad of social, emotional, cognitive, physical, and spiritual benefits to humans (Levinson, 1969). Far from exhaustive, what follows are some historical moments when humans engaged with and appreciated animals far beyond the realms of hunting and husbandry. This section concludes with an overview of the current state of the AAI field and 9 its developing role to support college student mental health. Human’s Historical Connections to Animals There is no debate that animals and humans have shared their lives with one another for millennia. Archeological excavations have discovered animal petroglyphs, animal mummification or skeletons next to human remains, and animals depicted in cave paintings. In the sixth century BCE, the Greeks dedicated a shrine to Asclepius, the god of medicine, and kept his associated familiar, the dog, on temple grounds. Known as cynotherapy, use of a dog’s tongue was believed to cure a variety of illnesses, and the temple became a pilgrimage to those in need of healing (Zebroski, 2016). One of the earliest accounts of humans interacting with animals for mental well-being dates to the ninth century in Gheel, Belgium. Individuals deemed as “handicapped” were cared for on farms, not institutions, where they worked with and learned about the daily living needs of farm animals (Duval, 1860). After visiting Gheel, famous geographer Jules Duval stated, "In this atmosphere, open in every sense, the affinities which draw man and animal together develop, and it is on the top rank of the scale of affections, far from lacking influence on the condition of certain patients….Is there any doubt that these simple and childlike pleasures take away sorrows, and can even help to re-establish the harmony of soul and body?” (Duval, 1860, p. 91-92). The satirical term funny farm is a reference to how some psychiatric and long- 10 term care facilities, like the one in Gheel, were working farm programs where residents could contribute to and remain engaged with the surrounding community. Ironically, up until the Age of Enlightenment in the 18th century, the mentally insane were commonly treated like wild animals, institutionalized, kept in chains, and subjected to inhumane interventions such as bloodletting, physical abuse, and starvation (Gerard, 1997). However, physician Philippe Pinel (1745- 1826) advocated that insanity was a unique emotional and social sickness worthy of medical care (Boyd, 2008). This small shift in conventional wisdom influenced William Tuke (1732-1822), a Quaker in England. In 1792, Tuke opened The Retreat in York, England and included a wide variety of animal- and nature- based programs for people with mental illness (A. H. Fine, 2019). “Each of the court areas at the Retreat contained a number of small animals, including rabbits and poultry, so that the patients might learn self-control by caring for creatures dependent on them” (Bustad, 1980, p. 117). The Retreat pioneered the use of moral treatment–treating patients with kindness and acceptance–and was instrumental in conveying that all sentient beings should be cared for humanely (Borthwick et al., 2001; Bustad, 1980). Animal-assisted programs slowly evolved and found application in other health services and settings. Florence Nightingale (1859) wrote that animals were helpful for the chronically ill. She once noted that when an “invalid” was asked about his care that included a nurse and a dog, the patient preferred the 11 dog because, “Above all, it did not talk” (Nightingale, 1859, p. 147). A few years later in 1867, care for people with epilepsy began on a farm at Bethel (now the Epilepsy Center Bethel) in Bielfield, Germany. Since the inception of this facility, animals have remained a significant component of residents’ daily lives. Similar to The Retreat, staff believed “That using pets to help people is natural, just common sense, and accept it as an appropriate and reasonable way of life” (Bustad, 1980, p. 118). In the United States, it is inconclusive as to when animals joined the health care system. Some texts cite 1919 when Secretary of the Interior Franklin K. Lane suggested that dogs could be an important therapeutic support for psychiatric patients at St. Elizabeth’s Hospital in Washington, D.C. (Robinson, 1995). Lane observed the healing connection WWI soldiers experienced with dogs and stated, “Lonesome boys in France found their dogs a great comfort and men with shell shock recover their balance sometimes by getting close to a dog with his limited mind but his unequalled capacity for affection” (Robinson, 1995, p. 57). Other 1940s documents list when WWII airmen experienced physical rehabilitation and support for battle fatigue by working with animals (dogs, horses, and farm animals) on a farm at the Army Air Force Convalescent Center in Pawling, NY (Bustad, 1980). By the mid-20th century, animals and plants were common components in healthcare settings such as at the University Hospital in Ann Arbor, Michigan where children hospitalized with chronic illnesses like polio received welcomed distractions from their lengthy stays by interacting with and 12 caring for a wide variety of animals (Cosgrove, n.d.). The idea that an animal could be instrumental in mental health sessions received initial consideration in the writings of Carl Jung with his description of animal ancestors as part of the collective unconscious (Jung, 1969) and Sigmund Freud with his female Chow dog Jofi. Freud wrote about the assessment benefits he experienced when Jofi accompanied him into sessions with clients and in particular, when these clients were children or adolescents (Coren, 2002). Jofi would emerge from her usual spot under Freud’s desk and move closer to a client that exhibited very depressed symptoms or move farther away from clients who presented as highly anxious (Coren, 2002). One predominant theory in the AAI field is Biophilia, a term psychoanalyst Erich Fromm first introduced in The Heart of Man: Its Genius for Good and Evil (Fromm, 1964) that was also later popularized by Harvard biologist E. O. Wilson as an instinctive bond between human beings and other living systems (Wilson, 1984). Wilson expanded on Erik Erikson’s (Erikson & Erikson, 1997) and Abraham Maslow’s (Maslow, 1962) theories of human development to imply that humans are hard-wired for connection and engagement with the natural world including animals and other living organisms (Wilson, 1993). To divorce ourselves from our environment is to invite a significant threat to human well- being. Furthermore, the field of self-psychology posits that “it is essential to the wellbeing of a person or self to have nourishing selfobject responsiveness throughout life, whether it comes from a person, animal, experience, object, or 13 idea” (Brown, 2004, p. 72). In the late 1960s, child psychologist Boris Levinson introduced animals into modern mental health practice. Similar to Freud, Levinson’s dog Jingles would often accompany him to his therapy sessions with clients. After several unsuccessful therapy sessions, Levinson witnessed a client finally engage when Jingles entered the therapy room (Levinson, 1969). Although Levinson judiciously documented his evolving method of working with a dog in psychotherapy, he was criticized by many colleagues for such a “preposterous technique” until his 1972 survey revealed that more than one-third of New York psychotherapists included animals in their practice (Levinson, 1972). In 1969 and 1977 respectively, the North American Riding for the Handicapped Association (now PATH Int’l–the Professional Association of Therapeutic Horsemanship International, 2021) and the Delta Foundation (now Pet Partners, 2021) were formed and began to establish standards, best practices, terminology, and evaluation for human-animal programs in the United States. Furthermore, the terms Animal-Assisted Therapy (AAT) and Animal- Assisted Activities (AAA) were operationalized with the 1996 publication, The Standards of Practice for Animal-Assisted Activities and Therapy (Delta Society, 1996), and thereby helped create common language towards the practice of including animals in human healthcare and education. The literature demonstrates that many compatible terms such as pet therapy and dog therapy have been used to describe the extent of human-animal programs, especially as 14 these programs have expanded in the past four decades. As discussed earlier, I use the term Animal-Assisted Interactions (AAI) throughout this dissertation. Current State of Therapeutic Interactions with Animals AAI programs and services can be found in a wide variety of settings with a numerous variety of domestic animal species to support a range of human biopsychosocial conditions. During the 1960s and 1970s, AAI was focused on populations with health challenges and the elderly; these programs were and continue to be part of activity rosters in many hospitals and eldercare facilities across the United States (Hines, 2003). As the field has continued to progress, AAI can be found in schools, libraries, physical and occupational therapy clinics, trauma recovery units, courthouses, residential treatment facilities, disaster recovery zones, airports, prisons, individual or group therapy programs, and college campuses. The most common species in AAI programs are dogs and equines and in general, domestic and farm animals such as cats, birds, guinea pigs, rabbits, llamas, sheep, goats, and pigs are also involved to a lesser extent (Pet Partners, 2021). In a review of the literature, significant anecdotal reports and short-term observations have helped propel AAI into elevated and somewhat unfounded spheres of efficacy (A. H. Fine & Ferrell, 2021). AAI is associated with diverse human biopsychosocial benefits such as reduced depression, loneliness, stress, and anxiety (Souter & Miller, 2007), increased communication and problem- solving skills (Hanselman, 2001), motivation to exercise (Johnson & Meadows, 15 2010), improved literacy and comprehension (Le Roux et al., 2014), and improved well-being (Bivens et al., 2007). One strength in the AAI research literature is with studies that measure the physiological outcomes of AAI such as increased or decreased cortisol, oxytocin, and alpha amylase. Such protocols have become a recognized way to demonstrate AAI’s effectiveness (Beetz et al., 2012; Pendry et al., 2019; Pendry & Vandagriff, 2019) because these tests use advanced technology and are standardized tools that measure natural science phenomenon (Kilbourne et al., 2018). AAI Programs with College Students For most youth and young adults, a relationship with animals, especially a pet, proves to be a significant source of emotional and social support (Crawford et al., 2006; Hart, 2000; Serpell, 2000). According to a biennial census, more than 60% percent of all households in the United States own a pet–dog, cat, horse, bird, fish, or specialty/exotic (American Pet Products Association, 2019). Pets are commonly considered family members by 95% of U.S. households (Shannon-Missal, 2015), a relationship described in terms of kinship (Charles, 2014). When an individual leaves home for college, many important connections and relationships with family and friends change. Leaving behind the close connectivity with a beloved pet is often more difficult than saying good-bye to other established relationships (Rodgers & Tennison, 2009). However, postsecondary scholarship tends to overlook the significance of this human- animal bond for college student well-being. 16 When a student has a strong attachment to a pet or animals in general, it stands to reason they may feel enough motivation to attend a campus-based AAI program for a break from academic pressures and to relax and have fun. Animals are often seen as non-judgmental and accepting of others regardless of a person’s behavior or how they present in general (Aydin et al., 2012), and their presence can “socially lubricate” exchanges between strangers so as to invite more person-to-person engagement (Bossard, 1944; Messent, 1983). Furthermore, these human-animal experiences may help fulfill a connection void just as adeptly as an interaction or relationship with another human being (Sable, 2012; Wood et al., 2015). Although observation of or time with the animal are likely incentives for why students attend these campus-based AAI sessions, participants share this unique experience with other human participants which leads to rapport-building and the development of community (Hoffman et al., 2005). By observing, engaging with, and talking about the animals as a group, these campus-based AAI programs also bring the added benefit of nurturing touch, one factor that recent scholarship has reported helps support college students’ mental health (Pendry et al., 2020). The Origins of My Research This dissertation examines the current state and outcomes of AAI programs for college student mental health, and offers ways to conceptualize how these programs operate. I used the formal years of my PhD studies to complete this dissertation research; however, my knowledge and understanding 17 of mental health and AAI is grounded in close to 30 years of experience as a social worker who has included and partnered with animals throughout my entire career. My interest in the relationship between humans and animals started before I can really remember as animals of all kinds and their environmental surroundings have been integral figures of influence in my life. I have learned and continue to learn so many life lessons about love, spirituality, heartbreak, and healing because of my experiences with animals. My privilege of having a childhood that allowed this spark to grow inside of me has remained a through line across my entire personal and professional life. When I started my PhD studies in 2013, I developed and continue to direct a weekly campus-based AAI program for college student mental health at a large, Midwestern university of over 50,000 students, and this program was the setting for the study reported in Paper Two. I wore multiple hats for this research as I developed it, collected it, analyzed it, and also participated in it as a practitioner with my registered therapy chickens. Moreover, my experience with this campus-based AAI program provided me with the unique opportunity to have an insider perspective because I attended almost every session. I witnessed countless students demonstrate many positive emotional states when they interacted with the AAI teams, and several of them also shared verbal and written feedback as to the important–and sometimes life-saving–impact the program had in their lives. I acknowledge these dual roles create significant bias and threats to the validity and reliability of this study, and I make no assumptions that the 18 results can be generalized to other college student populations. As a provider of AAI programs and services, I have a deep sense of knowing that AAI is effective and healing for so many people who struggle socially and psychologically; however, the explorer in me strives to remain open and curious as to what is known and unknown—and especially to what we think is known about AAI. In the years that I have been directing a campus-based AAI program, I have observed a surge in public enthusiasm to connect animals with college students. While scientific inquiry into the outcomes of campus-based AAI programs is growing, there remains a significant amount of empirical as well as practical knowledge that is unknown (A. H. Fine & Ferrell, 2021). The following section provides an overview of the three papers in my dissertation including what research questions or objectives guided each paper’s development. Each paper provides new and comprehensive information and adds to the growing body of translational research for the fields of social work, college student mental health, and AAI. Overview of the Three Papers Paper One Summary Paper One is a scoping review that surveyed and summarized the existing peer-reviewed or dissertation literature on campus-based AAI programs for college student mental health. In the last 10 years, public opinion has grown in support of AAI programs and services to help support college student mental 19 health; however, there is no examination of what is currently known about these programs and their outcomes. A scoping review is about “knowledge synthesis” and is often a precursor to a systematic review of a topic. When a body of literature and research is evolving so that its extent, breadth, and depth of understanding is unclear, or when concepts and strategies in this literature lack consistency and structure, a scoping review helps to produce an overview or map of what is known (Arksey & O’Malley, 2005; Munn et al., 2018; Peters et al., 2015). This scoping review followed the Joanna Briggs Institute (JBI) manual for conducting scoping reviews (Peters et al., 2020) and used the 22-item checklist set forth by the Preferred Reporting Items for Systematic reviews and Meta- Analyses extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018). Research Questions The following research questions guided this study: 1. What existing evidence has been reported on campus-based AAI programs for college student mental health? 2. How much of this evidence reported on college student stress and the resulting outcomes? 3. What other mental health outcomes were reported in this evidence? Analysis and Results I used an empirical structure to identify, screen, and select 37 articles that were eligible for this scoping review on campus-based AAI programs for college student mental health. All articles were published since 2003 and the majority 20 were from the United States. Study designs included 18 randomized controlled trials, 14 quasi-experimental, and five mixed methods. Eleven of the articles also included some type of open-ended questions to elicit additional qualitative data. Generally, these studies enrolled 100 individuals or fewer, included only dogs, and offered a single, one-time session which lasted between 15 and 60 minutes. I coded 44 individual mental health conditions that were further grouped into cognitive, physiological, psychological, or social quality of life domains. The two most frequently recorded outcomes were stress/perceived stress followed by anxiety which mirrors the college health literature showing that these same two conditions are leading concerns for today’s college students (Eisenberg et al., 2019). Furthermore, 75% of the studies in this scoping review showed an improved directional change for at least one mental health outcome and this finding is consistent with the same results from other AAI research in other settings and with other populations. Paper Two Summary Paper Two is a repeated, six-year (2014/15 to 2019/20) cross-sectional study of secondary analysis of existing data from a campus-based AAI program located on a large, Midwestern university campus. This study explored the correlation between dose of attendance at a campus-based AAI program and students’ perception that this helped them manage their stress. The design of this study was observational and I used a purposive convenience sample to 21 gather the same information about exposures and outcomes experienced by the same identified population–college students–over various points in time, thereby creating six different samples. A structured 30-item questionnaire that included the 10-item Perceived Stress Scale (PSS-10) (Cohen & Williamson, 1988) was administered once at the end of each of the six academic years to a different group of students who were members of the overall campus body. The University of Minnesota’s Institutional Review Board (IRB) and Institutional Animal Care and Use Committee (IACUC) approved this study. Research Questions The following research questions guided the study in Paper Two: 1. What were the demographic and mental health features among the students who attended a campus-based AAI program over the six years of this study? 2. What, if any, factors were associated with a student’s perception that attending a campus-based AAI program helped them manage their stress? 3. Did students’ attendance at a campus-based AAI program–both in length of time and frequency of visits–impact their perception that the program helped with stress management? Analysis and Results Subsequent analysis resulted in a total sample size of 3,255 individuals who were predominantly female, from the United States, 19 to 20 years of age, 22 and undergraduate students. Logistic regression examined the prevalence of an outcome–perceived stress management–and measured the correlation between that outcome and an exposure (a student’s dose of attendance at an AAI program) which included time spent and the number of visits. Odds ratios were used to assess factors that may have been associated with a student’s perception that attending a campus-based AAI program helped them manage their stress, and included gender, international student status, reported level of stress, adverse life experiences, and reasons for attending the program. The results demonstrate that for five out of six years, duration—number of visits and length of time—and selecting their reason for attending (because I thought it would help me relieve stress) were associated with higher odds of a student stating that the AAI program helped them manage their stress than for a student who did not share these factors. For three of the study’s six years, a student who identified as gender other had had lower odds of stating that the AAI program helped them manage their stress compared to those who identified as female. Similarly, for one of the six years, students who scored in the high stress range on the PSS-10 also had lower odds of stating that attending the AAI program helped them manage their stress compared to students who scored in the low or moderate stress ranges. A student’s age, identification as male, international student status, and adverse life experiences were not statistically significant in this study. 23 Paper Three Summary Finally, Paper Three defines a conceptual model of practice I developed called the PACE (Practitioner, Animal, Client, and Environment) Model for AAI (Bailey, 2015). I often use a phrase, In the simplicity is the power, when I talk about AAI with other people. AAI can appear to be as basic as humans and animals coming together in a facilitated fashion, yet when this outer layer is pulled away, what is revealed is much deeper and complex. In the PACE Model, there are four distinct factors that are present in every single AAI session–the practitioner, the animal, the client, and the environment–and it is in their interplay that the power to impart such profound and effective results for human health and well-being is created. Objectives Paper Three is a product of my experience as a practitioner, researcher, and educator in the fields of AAI and college student mental health. The PACE Model is a synthesis of how I relate with and think about AAI on a practical as well as philosophical level and was guided by the following objectives: 1. To provide a conceptual model of practice to help advance the understanding of the intricacies found in AAI programs. 2. To contribute to and address a gap in AAI by presenting a conceptual model of practice that gives consistent parameters and 24 definitions through which all beings in the AAI field can have constructive collaborations with each other. Using the PACE Model helps to instill an overt mindfulness and recognition that AAI is not a one-way activity whereby an animal gives and a person receives. Practitioners have an ethical and moral responsibility to respect and honor all living entities in an AAI session and to continuously evaluate the well-being of the two that cannot speak human words–the animals and the environment. A simple change in semantics and eliminating the word use when explaining AAI, (e.g., one does not use a dog in AAI and instead works with or partners with a dog), becomes another powerful reminder that all living beings have a right to their independence and to have that right recognized. Developing and fortifying AAI programs and services with integrity requires effort, planning, monitoring, and reflection to ensure that the needs of human beings do not overshadow the capacity for the animal and the environment to engage in a safe and therapeutic manner for all involved. Summary This dissertation establishes that the practice and research of campus- based AAI programs for college student mental health is a 21st century occurrence. The papers within this body of work use three different methods, and each paper delivers a new and critical lens on the important role animals can have in our lives. The scoping review in Paper One provides a better understanding of the current state of college-based AAI programs for student 25 mental health. The cross-sectional study in Paper Two adds to the small body of research that has reported improved mental health outcomes, especially perceived stress levels, for college students who have attended campus-based AAI programs. And the interpretive conceptual model of practice called PACE in Paper Three illustrates that the importance of assessing an AAI experience is complex because it requires measuring multiple living entities who and that are constantly evolving at every single moment in that session. The intersectionality of these three papers helps to strengthen best practices for the way AAI programs are conceived, implemented, and evaluated. Students will continue to struggle with the stress inherent in attending college and as current trends indicate, may face a mental health crisis. A student’s universal well-being, which includes mental health, is inextricably linked to one’s academic success with resulting consequences that are absorbed by the entire academic community in the short term, and by broader society in the long term. As of a 2015 census, there were 925 campus-based AAI programs across a variety of colleges and universities in the United States. In light of the many health promotion services vying for the same limited resources, continued rigorous inquiry of AAI programs to support college student mental health and well-being is imperative. The challenge of measuring AAI outcomes is to try and overlay methods used in the natural sciences for a phenomenon that is dependent on behaviors of multiple living systems such as the practitioner, client, animal, and environment 26 (Weick, 1987) and which create interactional complexities that are the hallmarks of AAI. Furthermore, the connection humans have for and with animals is often a highly emotional experience and can confound the ability to evaluate with impartiality the questions of if, how, to what extent, and why AAI makes a difference in someone’s life. This means that mental health outcomes which are less defined and use measurement techniques not fully adopted across all bodies of human healthcare practice and research can be criticized for having less rigor and importance in the overall understanding of a condition. The nature of what constitutes reality in AAI is a continued tension between qualitative stories and humanistic experiences of success with what is known and can be empirically measured, all unfolding within a larger context of what remains open for debate pending additional study and evaluation (A. H. Fine, 2019; Gray et al., 2009). This dissertation is one step towards increasing the scrutiny that AAI programs must meet ethical and moral obligations for all living entities involved in these sessions including the practitioners, clients, animals, and environments. With such a limited body of literature describing this burgeoning application of AAI for an equally escalating outcome of college student mental health, now is the ideal time to create standardization in definitions, procedures, and measurements so as to continue to evaluate and establish the fidelity of this intervention. 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Routledge. 39 Chapter Two Paper One A Scoping Review of Campus-Based Animal-Assisted Interactions Programs for College Student Mental Health 40 Introduction Of the thousands of mental health programs offered on college campuses, during the last 10 years Animal-Assisted Interactions (AAI) has grown in public opinion and frequency as a way to help mitigate student stress and support well- being (Aiken & Cadmus, 2011; Bell, 2013; Pendry & Vandagriff, 2019). AAI is active partnership with human practitioners and specially selected animals, both have received training, and together as a team provide the purposeful delivery of direct and measurable therapeutic and educational services for human learning and well-being (Fine, 2019). The idea that animals can help support human well- being is not a new concept. Accounts of individuals with disabilities living on a farm in Gheel, Belgium who cared for the animals as a way to contribute to and stay engaged with the surrounding community were documented as far back as the ninth century (Duval, 1860). Animal-assisted services have continued to evolve and diversify. Today, they are found in a wide variety of settings such as eldercare facilities, hospitals, prisons, libraries, trauma centers, airports, and college campuses. When an individual leaves home for college, important bonds with family and friends change. Students have reported that leaving their pets to attend college is more difficult than saying good-bye to the important people in their lives (Rodgers & Tennison, 2009), and postsecondary scholarship tends to overlook the significance of this bond for college students. When applied to the college setting, AAI invites students to take a break from academic pressures, 41 relax, and have fun. Participants gain aspects of stress reduction and social support by being with the animals, their handlers, and other students who can relate to the mutually challenging experience of being in college. The animals in an AAI program can also represent a transitional object for students separated from their own pets, and help evoke comfort and positive emotions tied to home and to having animals in one’s life (Wünderlich et al., 2021). Public perception and mainstream media have helped perpetuate the impression that these campus-based AAI programs are an efficient, high-impact, low-cost way to relieve college students’ stress (Fine & Ferrell, 2021; Serpell et al., 2017). Despite the increased provision of bringing animals to campus, there is no published scoping or systematic review of the emerging literature about campus-based AAI programs for college student mental health. This study aims to provide a current state of understanding about the diversity of campus-based AAI programs for college student mental health so as to inform and strengthen AAI programming overall and help guide additional research. Literature Review College Students and Stress College campuses across the United States function as distinct communities and as of the fall 2019, 41% of young adults or 16.6 million people between the ages of 18 and 24 were enrolled as undergraduates in a two- or four-year postsecondary institution (Hussar et al., 2020). Today’s college students continue to trend female (58%) and as a group, students who identified 42 as Black, Hispanic, and Asian/Pacific Islander, American Indian/Alaska Native, and of two or more races increased from 16% of the collegiate population in 1976 to 45% in 2018 (Stolzenberg et al., 2020; U.S. Department of Education, National Center for Education Statistics, 2019). Enrollment has also increased for students who are older (between the ages of 25 to 34), are military veterans, have dependent children, live below the poverty line, or work at least one part- time job (Gault et al., 2014; Hussar et al., 2020). Attending college represents a significant development stage for many young adults and in addition to opportunities for discovery and growth, brings an onslaught of new experiences amid an unfamiliar environment that many college students find overwhelming. As a world unto its own, college is a time of developing new relationships, finding a sense of belonging, experiencing romantic and deep connections with others, and establishing an identity as an independent person away from parental and guardian oversight. Factor in having to adjust to the rigors of time management and academic expectations as well as the high propensity for poor sleep hygiene and erratic eating patterns, and today’s college students are primed to struggle with immense and unavoidable stress. The ability to manage stress in a productive and appropriate manner is a skill that challenges many students. The Fall 2019 National College Health Assessment surveyed 41,140 students from 67 colleges and found that 76% of respondents reported experiencing moderate or high stress within the last 12 43 months, and that stress and anxiety were the top two issues that negatively impacted their academic performance (American College Health Association (ACHA), 2020). While some level of stress is considered appropriate because it provides energy and motivation, psychological strain is the most common form of college student stress (Ragsdale et al., 2011) and can put a student at a heightened risk of a mental health crisis (Kessler et al., 2007; Xiao et al., 2017). College Student Mental Health Data from the World Health Organization (WHO) show approximately half of all Americans will experience mental illness such as depression or anxiety in their lifetime (Kessler et al., 2007), and 75% of these disorders will occur by age 24 (Kessler et al., 2005). Furthermore, research shows that people who struggle emotionally take an average of 11 years until they initially seek treatment (Hunt & Eisenberg, 2010). These statistics are significant because they involve the age range of the majority of people enrolled in college and can mean that students’ risk of experiencing a decline in their mental health will go untreated, resulting in a dire impact on their college experience and across their lifespan (Hunt et al., 2015). Nationwide, mental health is the number one public health concern for today’s institutions of higher learning (Eells et al., 2012). Comparing undergraduate students from 2007 to 2020, mental illness as a category of student disabilities in the United States has grown in frequency, complexity, and severity (Gallagher & Taylor, 2014; Lipson et al., 2018). Rates of depression rose 44 from 17% to 28% and anxiety increased from seven percent to 31% during the same timespan (Eisenberg et al., 2013, 2020). As a point of comparison, in 2017 the rate of depression for adults aged 18 to 24 in the general population was 13% (National Institute of Mental Health, 2019). After accidents, suicide is the second leading cause of college student death (Drapeau & McIntosh, 2020), and students have a 41% lifetime prevalence of being diagnosed with at least one mental disorder (Eisenberg et al., 2020). These rising rates in mental illness are also impacting campus counseling centers where the number of visits doubled between 2007 and 2017 (from 19% to 34%) (Lipson et al., 2018), and in addition to depression and anxiety, the centers are treating difficult, comorbid issues that now include schizophrenia, bipolar disorder, eating disorders, self-injury, post-traumatic stress disorder (PTSD), and psychosis (Pedrelli et al., 2015; Reetz et al., 2014; Xiao et al., 2017). However, college students often do not recognize the severity of their emotional struggles and compared to other adults—those between the ages of 18 and 24—are the least likely group to seek help when they experience mental health concerns (Substance Abuse and Mental Health Services Administration (SAMHSA), 2020). Many students remain afraid of the stigma associated with mental illness (Gruttadaro & Crudo, 2012), are unaware of available services (Grasgreen, 2012), and believe their condition is “normal” so that seeking help would use resources–time, student fees, personnel–better allocated to someone else (Kognito, 2015). 45 As college student mental health needs continue to increase, intensify, and become multi-layered, the college experience is a significant opportunity to impact millions of people during their primary years of bio-psychological development. However, the literature on this unique population tends to focus on pathology versus intervention (Hernández-Torrano et al., 2020), and considering that stress is one of the most frequent conditions examined in United States society, there is a nominal knowledge of how college students as a population experience, perceive, and manage their stress (Robotham & Julian, 2006). This gap hinders a comprehensive understanding of how and in what ways the colleges and universities of tomorrow can meet the needs that their dynamic campus communities of increasing student body diversity experience (Bransberger et al., 2020). The following section reviews Animal-Assisted Interactions, one intervention helping college students manage their stress. Animal-Assisted Interactions In general and among diverse groups of individuals, AAI programs are associated with human health benefits such as reduced depression, loneliness, stress, and anxiety (Jones et al., 2019; Kamioka et al., 2014; Souter & Miller, 2007), increased communication and problem-solving skills (Hanselman, 2001), motivation to exercise (Johnson & Meadows, 2010), improved literacy and comprehension (Le Roux et al., 2014), and improved well-being (Bivens et al., 2007). Animals are often seen as “non-judgmental” and accepting of others (Aydin et al., 2012), and can provide “unconditional positive regard” (Bryant, 46 2008; Jung, 1969; McCulloch, 1982). The presence of an animal can “socially lubricate” the somewhat awkward or polite exchange between strangers, and can invite more person-to-person connection and belonging (Bossard, 1944; Messent, 1983). Often cited as the seminal reason for AAI programming is E. O. Wilson’s concept of Biophilia, “the innate tendency to focus on life and lifelike processes” (Wilson, 1984, p. 1). Wilson’s Biophilia Hypothesis helps explain how humans possess a physical, emotional, spiritual, cognitive, and social connection to other living beings, such as animals, and proposes that our continued disconnection from the natural world is a fundamental cause of human suffering (Kellert & Wilson, 1993). More recently, the concept of One Health, One Welfare has also brought attention to the many benefits from human-animal interactions and complements the Biophilia Hypothesis. One Health, One Welfare is a multi- disciplinary approach to the overall health of the planet that focuses on the interdependence between humans, animals, and the environment (Chalmers & Dell, 2015). Providing AAI on a large scale such as via programming at a university exemplifies how a therapeutic connection between humans and animals can impact the health of the environment–the campus–and build the collective welfare for all beings involved. AAI is not a homogenous modality, as it encompasses a wide range of experiences typically thought to enhance human well-being through interactions with a variety of animals (Hediger et al., 2019). A person who has received some 47 level of instruction, be it clinical or vocational, may work with an animal, usually their own pet, in a professional or volunteer capacity. Ideally, these animals have also participated in specialized training to work with other people, are at least six to 12 months of age depending on the species, have received a health and parasite screening from a veterinarian, and are domestic or farm animals such as dogs, cats, birds, equines, and rabbits (Pet Partners, 2021). In the majority of cases, the human participant and this animal have also passed a skill and aptitude test by an independent evaluator so that together, they are registered as a therapy animal team with a reputable national therapy animal organization such as Pet Partners (Pet Partners, 2021). The idea that an animal could be instrumental for one’s mental health received initial consideration in the writings of Sigmund Freud and Carl Jung and was later propelled into modern mental health practice by child psychologist Boris Levinson with his 1962 article, The Dog as “Co-Therapist”, and his 1969 foundational publication, Pet-Oriented Child Psychotherapy (Coren, 2002). Organizations like Pet Partners (formerly the Delta Society), the Professional Association of Therapeutic Horsemanship International (PATH Int'l) and the International Association of Human-Animal Interaction Organizations (IAHAIO, n.d.) have also been instrumental in defining the terms and establishing best practices for human-animal programs across the world. The most recent national census in 2015 found that 925 United States colleges or universities had some type of AAI or visiting-animal program to help 48 students deal with stress (Crossman & Kazdin, 2015). These programs are typically defined by one or two stress-buster events during midterms and final examinations and include a broad range of delivery approaches from sessions provided by registered therapy animal teams, usually dogs, to those conducted with staff pets or Humane Society animals. Highly popular and well-attended, these campus-based animal programs bring pleasure, enjoyment, and comfort to many people. Often perceived as effective and efficient, AAI is a modality increasingly utilized as a way to support a diverse array of college student mental health issues. However, this enthusiasm for connecting students with animals must be accompanied by an equal level of rigorous inquiry that provides evidence for how and why interaction with animals should be considered in addition to the many other ways of supporting student well-being (Fine & Ferrell, 2021; McCardle et al., 2011; Serpell et al., 2017). Therefore, the objective of this study was to present a scoping review that examined and summarized existing peer-reviewed or dissertation literature about campus-based AAI programs for college student mental health. Scoping Review Study Methods Study Design This scoping review followed the Joanna Briggs Institute (JBI) manual for conducting scoping reviews (Peters et al., 2020) and used the 22-item checklist 49 set forth by the Preferred Reporting Items for Systematic reviews and Meta- Analyses extension for Scoping Reviews (PRISMA-ScR) (Tricco et al., 2018). A scoping review examines, summarizes, and produces an overview or map of what is known about a topic or concept (Arksey & O’Malley, 2005), and this mapping follows an organized and essential process to maintain methodological and reporting quality (Levac et al., 2010; Tricco et al., 2018). Often a precursor for a systematic review, a scoping review may be used when a topic’s body of literature and research is evolving and thus the extent, breadth, and depth of understanding is unclear, or when concepts and strategies in its literature lack consistency and structure (Arksey & O’Malley, 2005; Munn et al., 2018; Peters et al., 2015). The objective of a scoping review is knowledge synthesis (Colquhoun et al., 2014), rather than analyzing the quality of study results or to make policy and practice recommendations. Furthermore, exploring the current state of information and research which, as in the case of AAI programs for college student mental health, can then help guide further reviews and identify research limitations and gaps. Protocol I developed an a priori protocol to give structure to the decisions that guided the scoping review process. I followed the methodology proposed by JBI (Peters et al., 2020) for this protocol which allows for refinement as content is gathered and further understanding of a concept is gained. The nine steps of a scoping review framework are: (1) selecting a title that clearly identifies the topic 50 of the study and lists it as a scoping review, (2) writing a comprehensive introduction, (3) listing the research objectives and questions, (4) developing and aligning the eligibility criteria with the objectives and questions, (5) describing the search strategy, (6) selecting the evidence, (7) charting the data, (8) synthesizing the data, and (9) summarizing and reporting the results (Peters et al., 2020). Research Questions The following research questions that guided this scoping review: 1. What existing evidence has been reported on campus-based AAI programs for college student mental health? 2. How much of this evidence reported on college student stress and the resulting outcomes? 3. What other mental health outcomes were reported in this evidence? Eligibility Criteria I used the PCC model (participants, concept, and context) to develop and use eligibility, inclusion, and exclusion criteria to screen the results of my search. In contrast to other search criteria such as PICO (population, intervention, comparator, outcome), PCC allows for a broader inclusion of information in order to create a scoping review’s wide-ranging map of a topic (Peters et al., 2015). Participants. Manuscripts that described studies involving participants enrolled in some form of post-secondary learning throughout the world and participating in AAIs with a live animal were considered for this scoping review. No limits were placed on student age, status (e.g., full-time or part-time), living 51 situation (e.g., commuting or living on or near campus), or higher education type (e.g., public, private, for-profit, vocational, or community college). The animals in the study could not be immature (e.g., puppies or chicks), had to be identified as therapy animals in some fashion (e.g., registered with Pet Partners or Alliance of Therapy Dogs), and had to be a domestic or farm animals. Concept. Studies that examined any form of a campus-based AAI program intended to impact college student mental health were considered for this review. While stress management was the specific outcome of interest, only a handful of articles identified stress as the sole concept of study. Therefore, this protocol was revised to include a broader focus on mental health or well-being in an effort to capture a more diverse and extensive sample. There was no limit to the format, frequency, or duration of these AAI experiences. Finally, research studies that did not include registered AAI teams were excluded from this literature review because I believe it is professionally and operationally important to uphold the standards of practice developed in 1996 by the Delta Society (now called Pet Partners). Context. Articles that listed any context describing a post-secondary education setting throughout the world were included in this review. Other. This literature search was not limited to a specific date range of publication, and because this body of literature was very small, dissertations were included with articles from peer reviewed journals that reported an empirical 52 study. Finally, I excluded studies if their full articles were unavailable or written in a language where no translation to English was readily available. Evidence Sources and Search Strategy In consultation with a library specialist at the University of Minnesota, Scott Marsalis, I used an iterative, three-step process to conduct my literature search (Peters et al., 2020) that followed the Peer Review of Electronic Search Strategies (PRESS) 2015 Evidence-Based Checklist (McGowan et al., 2016). First, I focused on three groups of subject headings and keywords to guide this search: AAI (e.g., animal-assisted therapy, human-pet bonding, dog therapy), college students (e.g., campus, higher education, emerging adult, student health services), and mental health (e.g., depression, psychological stress, anxiety, loneliness, well-being, mental health services). I used Academic Search Premier (EBSCOhost) and PsychINFO (Ovid) to pilot this search strategy, and the retrieved papers were searched for free text in the title, abstract, subject headings, and index terms in order to assess if other related concepts appropriate for each topic were missing. Second, I revised and adapted this search strategy for Web of Science and conducted a new search in 20 databases listed at the bottom of Table 1, where the final search strategy for Academic Search Premier (EBSCOhost) can be found. And third, literature saturation was ensured by reviewing the references of included studies, grey literature using Google Scholar, and related AAI websites, reviews, and summaries. I accessed 53 the databases from the libraries of University of Minnesota, and my search included all languages and all journal publications up to October 25, 2020. Table 1 Scoping Review Search Terms and Locations Subject Headings Terms Used in Databases Population–College Students: Campus; College(s); Education, professional; Emerging adult; Higher education; Post-secondary; Student health services; Students; Universities; Young adult Concept–Animal- Assisted Interactions: Animal assisted activity(ies); Animal assisted interaction(s); Animal assisted intervention(s); Animal assisted therapy; Animal therapy; Bonding; Canine therapy; Dog therapy; Human- animal bond(s); Human animal relationship(s); Human-pet; Equine- assisted therapy universit* or college* or post-secondary or postsecondary or campus* or professional or university education or college education or post-secondary education or postsecondary education or campus education or higher education or professional education or university involvement or college involvement or post-secondary involvement or postsecondary involvement or campus involvement or professional involvement or university undergraduate* or college undergraduate* or post-secondary undergraduate* or postsecondary undergraduate* or campus undergraduate* or professional undergraduate* or university student* or college student* or post-secondary student* or postsecondary student* or campus student* or professional student* or university participation or college participation or post-secondary participation or postsecondary participation or campus participation or professional participation or emerging adult* or young adult* or graduate student* or international student* or law student* or medical student* or seminarian* or seminarian student* or transfer student* or vocational school student* or health promotion or student health service* animal visit* OR animal psychotherap* OR canine psychotherap* OR dog psychotherap* OR horse psychotherap* OR equine psychotherap* OR pet psychotherap* OR animal-assisted psychotherap* OR canine-facilitated psychotherap* OR dog-facilitated psychotherap* OR horse-assisted psychotherapy* or equine-assisted psychotherapy* or pet-assisted psychotherapy* or animal-facilitated psychotherap* OR canine-facilitated psychotherap* OR dog-facilitated psychotherap* OR horse-facilitated psychotherap* OR equine-facilitated psychotherap* OR pet-facilitated psychotherap* OR pet psychotherapy* or human-animal psychotherap* OR human-pet psychotherap* OR animal bond* OR animal-assisted bond* OR canine-assisted bond* OR dog-assisted bond* OR equine-assisted bond* OR pet-assisted bond* or animal-facilitated bond* OR canine-facilitated bond* OR dog-facilitated bond* OR equine-facilitated bond* OR pet-facilitated bond* or human-animal bond* OR human-pet bond* OR animal intervention* OR canine intervention* OR dog intervention* OR horse intervention* OR equine intervention* OR pet intervention OR human-animal intervention* OR human- pet intervention* OR animal interaction* OR canine interaction* OR dog interaction* OR horse interaction* OR equine interaction* OR pet interaction* OR human-animal interaction* OR human-pet interaction* OR animal-assisted intervention* OR canine-assisted intervention* OR dog-assisted intervention* OR horse-assisted intervention* OR equine-assisted intervention* OR pet- assisted intervention* or animal-assisted interaction* OR canine-assisted interaction* OR dog-assisted interaction* OR horse-assisted interaction* OR equine-assisted interaction* OR pet-assisted interaction OR dog-facilitated interaction* OR canine-facilitated interaction* OR animal-facilitated interaction* 54 OR equine-facilitated interaction* OR horse-facilitated interaction* OR pet- facilitated interaction* OR dog-facilitated intervention* OR canine-facilitated intervention* OR animal-facilitated intervention* OR equine-facilitated intervention* OR horse-facilitated intervention* OR pet-facilitated intervention* or animal relationship* OR canine relationship* OR dog relationship* OR cat relationship* OR horse relationship* OR equine relationship* OR pet relationship* OR human-animal relationship* OR human-pet relationship* OR animal-assisted relationship* OR canine-assisted relationship* OR dog- assisted relationship* OR cat-assisted relationship* OR horse-assisted relationship* OR equine-assisted relationship* OR pet-assisted relationship* OR human-animal relationship* OR human-pet relationship* OR dog-facilitated relationship* OR canine-facilitated relationship* OR animal-facilitated relationship* OR equine-facilitated relationship* OR horse-facilitated relationship* OR pet-facilitated relationship* OR animal therap* OR canine therap* OR dog therap* OR cat therap* OR horse therap* OR equine therap* OR pet therap* OR human-animal therap* OR human-pet therap* OR animal- assisted therap* OR canine-assisted therap* OR dog-assisted therap* OR cat- assisted therap* OR horse-assisted therap* OR equine-assisted therap* OR pet-assisted therap* OR dog-facilitated therap* OR canine-facilitated therap* OR animal-facilitated therap* OR equine-facilitated therap* OR horse-facilitated therap* OR pet-facilitated therap* OR animal activit* OR canine activit* OR dog activit* OR cat activit* OR horse activit* OR equine activit* OR pet activit* OR human-animal activit* OR human-pet activit* OR animal-assisted activit* OR canine-assisted activit* OR dog-assisted activit* OR cat-assisted activit* OR horse-assisted activit* OR equine-assisted activit* OR pet-assisted activit* OR dog-facilitated activit* OR canine-facilitated activit* OR animal-facilitated activit* OR equine-facilitated activit* OR horse-facilitated activit* OR pet-facilitated activit* OR animal education* OR human-animal education* OR human-pet education* OR animal-assisted education* OR canine-assisted education* OR dog-assisted education* OR cat-assisted education* OR horse-assisted education* OR equine-assisted education* OR pet-assisted education* OR dog-facilitated education* OR canine-facilitated education* OR animal- facilitated education* OR equine-facilitated education* OR horse-facilitated education* OR pet-facilitated education* OR animal visit* OR canine visit* OR dog visit* OR pet visit* OR animal-assisted visit* OR canine-assisted visit* OR dog-assisted visit* OR cat-assisted visit* OR horse-assisted visit* OR equine- assisted education* OR pet-assisted education* OR dog-facilitated visit* OR canine-facilitated visit* OR animal-facilitated visit* OR equine-facilitated visit* OR horse-facilitated visit* OR pet-facilitated visit* OR animal program* OR canine program* OR dog program* OR cat program* OR horse program* OR equine program* OR pet program* OR animal-assisted program* OR canine- assisted program* OR dog-assisted program* OR cat-assisted program* OR horse-assisted program* OR equine-assisted program* OR pet-assisted program* OR dog-facilitated program* OR canine-facilitated program* OR animal-facilitated program* OR equine-facilitated program* OR horse-facilitated program* OR pet-facilitated program* Outcome measures– Mental Health: Anxiety; Anxiety disorder; Counseling; Depression; Depressive disorder; Distress; Health promotion; Loneliness; Mental disorders; Mental mental health or mental health service* or psychological distress or mental disorder* or counseling or stress* or psychological stress* or mental healing or psychotic disorder* or depress* or anxiet* or lonel* or depressive disorder* or anxiety disorder* or social isolation or mood* or distress or mental illness* or psychiatric illness* or psychology or therap* or wellbeing or well-being or wellness or stress reduction or stress management or stress prevention or stress relief or mental health support or emotional support or mental distress or mental stress* 55 healing; Mental health; Mental health services; Mental illness; Mood; Psychiatric illness; Psychological distress; Psychology; Psychotic disorders; Social isolation; Stress, psychological; Therapy; Wellbeing; Well-being; Wellness Databases Searched EBSCOhost: Academic Search Premier; Alt HealthWatch; Business Source Premier; CINAHL Plus with Full Text; EBSCO MegaFILE; Education Source; ERIC; Health Source - Consumer Edition; Health Source: Nursing/ Academic Edition; Library & Information Science Source; Professional Development Collection; Science Reference Center; SPORTDiscus with Full Text; Wildlife & Ecology Studies Worldwide; OpenDissertations Ovid: CAB Abstracts – Daily; MEDLINE(R) – Daily, Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Without revisions; PsychINFO – Archives Web of Science Evidence Selection I reviewed all studies produced from this search on the eligibility, inclusion, and exclusion criteria in my protocol. These publications were screened by title, keywords, abstract, and then full text to select potentially relevant articles for inclusion in this scoping review. As the sole reviewer of my literature search results, I acknowledge a variance to the PRISMA-ScR requirements for a team approach to conducting a scoping review study (Levac et al., 2010; Peters et al., 2020). The bias of this scoping review may be a limitation in the replication of this study by other investigators. Data Charting I used Excel 2016 to develop a data-charting table a priori as shown in 56 Table 2, and this was revised as needed to extract relevant details from the 37 articles in this scoping review. This charting process helped answer my research questions regarding what is known about campus-based AAI programs for college student mental health, and what mental health outcomes—specifically stress—were reported in these studies. The following data was included in my chart: author(s) and year of publication; title; journal or dissertation; number of participants; institution, city, state, and country of the lead author; study aim(s); study design; intervention timing (e.g., once or weekly for six weeks) and intervention duration (e.g., 15 minutes or a range of 45 to 60 minutes); animal species and census; outcome(s) measured; and key findings. Intervention and participant type were not catalogued as only articles that used AAI as the intervention for college student participants were included. Data Synthesis As with the literature search and charting, data synthesis was an iterative process that provided an opportunity to refine all the content into a cohesive and orderly report. First, the data in Table 2 was organized into three main categories as shown in Table 3: article demographics, methodology, and results. Article demographics included year published, location of the lead author, and if the paper was an empirical study or a dissertation. Methodology included study design, participants, and intervention. The subcategory of participants was divided into human and animal, and the subcategory of intervention was divided into timing and duration. And finally, results included the outcomes measured Author and Year Published Title Journal or Dissertation Participants (N ) and Location Anderson (2018) The effect of animal-assisted therapy on nursing student anxiety. Dissertation 90 University of Kansas Lawrence, KS USA Barker, Barker, McCain, and Schubert (2016) A randomized cross-over exploratory study of the effect of visiting therapy dogs on college student stress before final exams. Anthrozoös 78 Virginia Commonwealth University Richmond, VA USA Barker, Barker, Randolph, McCain, and Schubert (2017) The effect of a canine-assisted activity on college student perceptions of family supports and current stressors. Anthrozoös 74 Virginia Commonwealth University Richmond, VA USA Binfet (2017) The effects of group-administered canine therapy on university students’ wellbeing: A randomized controlled trial. Anthrozoös 163 University of British Columbia Vancouver, British Columbia Canada Binfet and Passmore (2016) Hounds and homesickness: The effects of an animal-assisted therapeutic intervention for first-year university students. Anthrozoös #1 - 86 #2 - 44 #3 - 17 University of British Columbia Kelowna, British Columbia Canada Table 2 Summary of Studies Included in a Scoping Review of AAI for College Student Mental Health (n = 37. NOTE: 6 studies are multiple for a total of 45) 57 Study Aims Study Design Intervention Duration and Timing This study investigated college students' anxiety levels before and after attending an AAI program. Mixed methods 1 day 35-45 min This study investigated college students’ perceived stress and physiological stress before and after attending an AAI program. Randomized controlled study 1 day 15 min This study investigated college students' perception of family supports and current stressors before and after attending an AAI program. Secondary data analysis of a randomized controlled study 1 day 15 min This study investigated college students' perceived stress, homesickness, and connection to campus before and after attending an AAI program. Randomized controlled study 1 day 20 min This study investigated college students' well- being before and after attending an AAI program. Mixed methods #1 - 8 days, weekly, 45 min #2 - 8 days, weekly, 45 min #3 - 1 day, length of time not given 58 Animal Species and Census Outcomes Measured Study Results Dog 8 1. Anxiety Anxiety decreased. Dog 10 1. Perceived stress 2. Physiological stress -sVAS -SnGF Perceived stress and physiological stress decreased. Dog 10 1. Perceived family supports No change in perceived family supports. Dog 14 1. Connection to campus 2. Homesickness 3. Perceived stress Connection to campus increased; homesickness and perceived stress decreased. #1 - Dog, 12 #2 - Dog, 20 #3 - n/a 1. Connection to campus 2. Homesickness 3. Satisfaction with life Connection to campus and satisfaction with life increased; homesickness decreased. 59 Binfet, Passmore, Cebry, Struik, and McKay (2018) Reducing university students’ stress through a drop-in canine-therapy program. Journal of Mental Health 1960 University of British Columbia Kelowna, British Columbia Canada Binfet, Trotman, Henstock, and Silas (2016) Reducing the affective filter: Using canine assisted therapy to support international university students' English language development. BC TEAL Journal 7 University of British Columbia Kelowna, British Columbia Canada Camaioni (2013) Creating social connections in higher education: Insights from the campus canines program at the University of Pittsburgh. Dissertation 270 University of Pittsburgh Pittsburgh, PA USA Chakales, Locklear, and Wharton (2020) Medicine and horsemanship: The effects of equine-assisted activities and therapies on stress and depression in medical students. Cureus 28 University of Central Florida Orlando, FL USA Crossman, Kazdin, and Knudson (2015) Brief unstructured interaction with a dog reduces distress. Anthrozoös 67 Yale University New Haven, CT USA Crump and Derting (2015) Effects of pet therapy on the psychological and physiological stress levels of first-year female undergraduates. North American Journal of Psychology #1 - 27 #2 - 61 Murray State University Murray, KY USA 60 This study investigated college students' perceived stress before and after attending an AAI program, and if length of time at an AAI program was a moderator. Quasi-experimental design 19 days 90 min This study investigated international college students' perceptions of their English language development and stress before and after attending an AAI program. Mixed methods 5 days, weekly 90 min This study created a description of an AAI program through exploring the relationships college students created by attending the AAI program. Mixed methods 13 days, weekly 60 min This study investigated college students’ stress and depression before and after attending an AAI program. Quasi-experimental design 7 days 3-4 hours This study investigated college students' perceived anxiety and mood before and after attending an AAI program. Randomized controlled study 1 day 7-10 min This study investigated college students’ perceived psychological and physiological stress before and after attending an AAI program. Randomized controlled study #1 - 1 day, 15 min #2 - 1 day, 30 min 61 Dog 15-17 1. Perceived stress Perceived stress decreased. Dog 14 1. Language development 2. Perceived stress Language development increased and perceived stress decreased. Dog 22 1. Social relationships Social relationships increased. Horse Unknown total 1. Depression 2. Perceived stress 3. Stress frequency 4. Stress severity Depression, perceived stress, stress frequency, and stress severity decreased. Dog 1 1. Anxiety 2. Mood -Positive mood -Negative mood Anxiety and negative mood decreased; positive mood increased. #1 - Dog, 9 #2 - Dog, 7 #1 1. Perceived stress 2. Physiological stress - BP - HR #2 1. Perceived stress 2. Physiological stress - Cortisol Perceived stress decreased, all forms of physiological stress decreased. 62 Delgado, Toukonen, and Wheeler (2018) Effect of canine play interventions as a stress reduction strategy in college students. Nurse Educator 48 Cleveland State University Cleveland, OH USA Dell et al. (2015) PAWSing student stress: A pilot evaluation study of the St. John Ambulance Therapy Dog Program on three university campuses in Canada. Canadian Journal of Counselling and Psychotherapy 403 University of Saskatchewan Saskatoon, Saskatchewan Canada Dhooper (2003) Animal-assisted therapy: The effects of the presence of a trained therapy dog on group anxiety management training. Dissertation 11 University of South Dakota Vermillion, SD USA Dluzynski (2017) A quantitative assessment of test anxiety and human-animal interaction in college students. Dissertation 56 Michigan School of Professional Psychology Farmington Hills, MI USA Engel (2011) An animal-assisted intervention with college students with Asperger's syndrome. Dissertation 4 Alfred University Alfred, NY USA 63 This study investigated college students’ perceived stress and physiological stress before and after attending an AAI program. Quasi-experimental design 1 day 15 min This study investigated college students’ experience of love and support after attending an AAI program. Quasi-experimental design #1 - 3 days, site 1 - 6 days, site 2 - 2 days, site 3 Up to 60 min each site This study investigated college students’ perceived anxiety before and after attending an AAI program. Randomized controlled study 6 days, weekly 60-90 min This study investigated college students’ physiological stress and exam performance before and after attending an exam session with an AAI dog present. Randomized controlled study 1 day Unclear, approx. 30 min This study investigated the effectiveness of an AAI program for college students with Asperger's syndrome. Quasi-experimental design 6 days, weekly 30 min 64 Dog 5 1. Mood - Negative mood 2. Perceived stress 3. Physiological stress - BP - Cortisol - HR Negative mood, perceived stress, and all forms of physiological stress decreased. Dog Unclear 1. Love 2. Support Love and support increased. Dog 1 1. Anxiety Anxiety decreased. Dog 1 1. Physiological stress - HR 2. Task completion Physiological stress and task completion showed no change. Dog 1 1. Positive and negative behaviors specific to Asperger's syndrome Positive and negative behaviors specific to Asperger's syndrome showed no change. 65 Fiocco and Hunse (2017) The buffer effect of therapy dog exposure on stress reactivity in undergraduate students. International Journal of Environmental Research and Public Health 61 Ryerson University Toronto, Ontario Canada Gebhart et al. (2018) Distraction-focused interventions on examination stress in nursing students: Effects on psychological stress and biomarker levels. A randomized controlled trial. Distraction and Animation Stress #1 - 72 #2 - 72 FHG - Zentrum für Gesundheitsberufe Innsbruck Austria Grajfoner, Harte, Potter, and McGuigan (2017) The effect of dog-assisted intervention on student well-being, mood, and anxiety. International Journal of Environmental Research and Public Health 132 Heriot Watt University Edinburgh Scotland Hall (2018) Nursing campus therapy dog: A pilot study. Teaching and Learning in Nursing 77 Amarillo College Amarillo, TX USA House, Neal, and Backels (2018) A doggone way to reduce stress: An animal assisted intervention with college students. College Student Journal 235 Millersville University Millersville, PA USA Jarolmen and Patel (2018) The effects of animal-assisted activities on college students before and after a final exam. Journal of Creativity in Mental Health 86 Kean University Union, NJ USA 66 This study investigated college students' physiological responses before and after attending an AAI program. Randomized controlled study 1 day 10 min This study investigated college students' exam stress before and after three types of distraction- focused interventions (AAI program was included). Randomized controlled study #1 - 4 days 45-60 min #2 - 4 days 45-60 min This study investigated college students’ well- being, mood, and anxiety before and after attending an AAI program. Randomized controlled study 1 day 20 min This study investigated college students' perception of anxiety and depression before and after attending an AAI program. Randomized controlled study 16 weeks, at least 2 days/week AAI team was available for 7 hours/day This study investigated college students' perceived personal benefits after attending an AAI program. Quasi-experimental design 3 days 5 hours This study investigated college students’ physiological stress before and after attending an AAI program. Quasi-experimental design 1 day 15 min 67 Dog 10 1. Mood - Negative mood - Positive mood 2. Perceived stress 3. Pet attitude 4. Physiological stress Negative mood and physiological stress decreased; positive mood increased; and perceived stress and pet attitude showed no change. #1 - Dog, 4 #2 - Dog, 4 1. Anxiety 2. Perceived stress 3. Physiological stress - Cortisol - IgA On a non-exam day, anxiety, perceived stress, and cortisol decreased; IgA increased. On exam day, anxiety and perceived stress showed no change; cortisol decreased; and IgA increased. Dog 7-12 1. Anxiety 2. Mood 3. Well-being Anxiety decreased; mood and well-being increased. Dog 1 1. Anxiety 2. Depression Anxiety decreased and there was no change in depression. Dog Unclear 1. Awareness of counseling services 2. Homesickness 3. Perceived stress 4. Perceptions of counseling staff Awareness of counseling services and perceptions of counseling staff increased; homesickness and perceived stress decreased. Dog 11 1. Physiological stress - BP Physiological stress decreased. 68 Krause-Parello, Tychowski, Gonzalez, and Boyd (2012) Human-canine interaction: Exploring stress indicator response patterns of salivary cortisol and immunoglobulin A. Research and Theory for Nursing Practice: An International Journal 33 Kean University Union, NJ USA McArthur and Syrnyk (2018) On-campus animal-assisted therapy events: Post-secondary students' reactions and mood. Society & Animals #1 - 80 #2 - 38 St. Mary's University Calgary, Alberta Canada Morgan (2017) Stress management for college students: An experiential multi- modal approach. Journal of Creativity in Mental Health 42 Richard Bland College Petersburg, VA USA Muckle and Lasikiewicz (2018) An exploration of the benefits of animal-assisted activities in undergraduate students in Singapore. Asian Journal of Social Psychology 75 James Cook University Singapore Pendry, Carr, Gee, and Vandagriff (2020) Randomized trial examining effects of animal assisted intervention and stress related symptoms on college students' learning and study skills. International Journal of Environmental Research and Public Health 309 Washington State University Pullman, WA USA Pendry, Kuzara, and Gee (2019) Evaluation of undergraduate students' responsiveness to a 4- week university-based animal- assisted stress prevention program. International Journal of Environmental Research and Public Health 228 Washington State University Pullman, WA USA 69 This study investigated college students' salivary cortisol and immunoglobulin A (IgA) before and after attending an AAI program. Quasi-experimental design 1 day 20 min The study investigated college students’ mood before and after attending an AAI program. Quasi-experimental design #1 - 1 day, 90 min #2 - 1 day, 90 min This study investigated college students' perceived stress before and after a multi-modal approach (AAI program was included). Quasi-experimental design 3 days, weekly 45 min This study investigated college students’ perceived well-being and physiological stress before and after attending an AAI program. Quasi-experimental design 1 day 60 min This study investigated college students' learning and study strategies before and after attending an AAI program. Randomized controlled study 4 days, weekly 60 min This study investigated college students' responsiveness before and after attending an AAI program. Mixed methods 4 days, weekly 40 min 70 Dog 1 1. Physiological stress - Cortisol - IgA Cortisol decreased and IgA increased. #1 - Dog, 6 #2 - Dog, 6 1. Mood 2. Program satisfaction Mood and program satisfaction increased. Horse 5 1. Perceived stress Perceived stress decreased. Dog 15 1. Anxiety 2. Perceived stress 3. Physiological stress - BP 4. Self-esteem Anxiety and physiological stress decreased, self- esteem increased, and a change in perceived stress was not given. Dog 27 1. Learning and study strategies Learning and study strategies increased. Dog 26 1. Behavioral change re. stress mgmt. 2. Enjoyment 3. Recommend program 4. Usefulness Behavioral change regarding stress management, enjoyment, likelihood of recommending the program, and finding the program useful increased. 71 Polheber and Matchock (2014) The presence of a dog attenuates cortisol and heart rate in the Trier Social Stress Test compared to human friends. Journal of Behavioral Medicine 48 Pennsylvania State University Centre County, PA USA Robino et al. (2020) College student mental health in an animal-assisted intervention program: A preliminary study. Journal of Creativity in Mental Health 38 Nova Southeastern University Fort Lauderdale, FL USA Stewart, Dispenza, Parker, Chang, and Cunnien (2014) A pilot study assessing the effectiveness of an animal-assisted outreach program. Journal of Creativity in Mental Health 55 Idaho State University Pocatello, ID USA Thew (2017) The effect of interaction with a therapy dog on college student stress levels as measured by physiological indicators. Dissertation 67 Washington State University Pullman, WA USA Trammell (2017) The effect of therapy dogs on exam stress and memory. Anthrozoös #1 - 127 #2 - 44 #3 - 56 Pepperdine University Malibu, CA USA Trammell (2019) Therapy dogs improve student affect but not memory. Anthrozoös 44 Pepperdine University Malibu, CA USA 72 This study investigated college students’ physiological stress before and after attending a session with a social stressor that included an AAI dog present versus a human friend. Randomized controlled study 1 day 60 min This study investigated college students' short- term emotional state and quality of the human–animal interaction before and after attending an AAI program. Quasi-experimental design 2 days 60 min This study investigated college students' perceived anxiety and loneliness before and after attending an AAI program. Quasi-experimental design Unclear, twice a month for one quarter 2 hours This study investigated college students' physiological stress before and after attending an AAI program. Randomized controlled study 1 day Unclear, approx. 60 min This study investigated college students' perception of stress and exam scores before and after attending an AAI program. Randomized controlled study #1 - 1 day, 15 min #2 - 1 day, 15 min #3 - 1 day, 15 min This study investigated college students' affect and memory retention before and after attending an AAI program. Randomized controlled study 2 days Unclear, no less than 10 min 73 Dog 1 1. Physiological stress - Cortisol - HR Physiological stress decreased. Dog, 2 Bird, 1 Rabbit, 1 1. Human-animal interaction quality 2. Mood - Negative mood - Positive mood 3. Time at the intervention Negative mood decreased and positive mood increased. The quality of the human-animal interaction and time spent at the intervention had no impact on negative or positive mood. Dog 1 1. Anxiety 2. Loneliness Anxiety and loneliness decreased. Dog 10 1. Physiological stress - BP * Diastolic * Systolic - Skin temperature There was no change in physiological stress. #1: Dog, 7-12 #2: Dog, 6 #3: Dog, 5 1. Exam scores 2. Perceived stress Exam scores increased in one study and showed no change in two studies; perceived stress decreased in two studies and showed no change in one study. Dog 2 1. Cognition and memory 2. Mood 3. Perceived stress 4. Psychological arousal Cognition and memory showed no change; mood increased; and perceived stress and psychological arousal decreased. 74 Ward-Griffin et al. (2018) Petting away pre-exam stress: The effect of therapy dog sessions on student well-being. Stress and Health #1 - 246 #2 - 246 University of British Columbia Vancouver, British Columbia Canada Williams el al. (2018) An animal-assisted intervention's influence on graduate students' stress and anxiety prior to an examination. Open Access Library Journal 39 Belmont University Nashville, TN USA Wood, Ohlsen, Thompson, Hulin, and Knowles (2018) The feasibility of brief dog-assisted therapy on university students stress levels: The PAwS study. Journal of Mental Health 127 The University of Sheffield Sheffield England 75 This study investigated college students’ perceived well-being before and after attending an AAI session. Randomized controlled study 1 day 90 min This study investigated college students’ anxiety and physiological stress before and after attending an AAI program. Randomized controlled study 1 day 15 min This study investigated college students’ perceived stress and physiological stress (BP) before and after attending an AAI program, and if length of time at an AAI program was a moderator. Quasi-experimental design 1 day 15 min 76 #1 - Dog, 7-12 #2 - n/a 1. Energy 2. Happiness 3. Mood - Negative mood - Positive mood 4. Perceived stress 5. Satisfaction with life 6. Social support (2 POINTS IN TIME: - I = immediately after intervention - F = follow-up period after intervention) Immediately after the intervention, energy and happiness increased and perceived stress decreased. Dog 4 1. Anxiety 2. Physiological stress - BP - HR Anxiety decreased and physiological stress showed no change. Dog 1-2 1. Anxiety 2. Physiological stress - BP Anxiety and physiological stress decreased. 77 2020 3 Austria 1 31 Mixed methods 5 2019 2 Canada 8 Qualitative 0 2018 12 England 1 Dissertation 6 Quasi- 2017 8 Scotland 1 experimental 14 2016 3 Singapore 1 Randomized 2015 3 USA 25 controlled trial 18 2014 2 Studies with 2013 1 open-ended 2012 1 questions out 2011 1 of total 37 2010-04 0 studies 11 2003 1 Table 3 Synthesis of Studies in a Scoping Review of AAI for College Student Mental Health Article Demographics Methodology Year Published and Frequency Location of Lead Author and Frequency Empirical Paper or Dissertation and Frequency Study Design and Frequency Empirical article 78 2 Bird* One day only 26 7-10 min 1 7 N= 1 1 10 min 1 11 15 min 10 17 Dog (35 papers) Multiple days 10 20 min 3 27 N =1 8 30 min 2 28 N =1 to 2 1 35-40 min 1 33 N =2 2 Weekly 10 40 min 1 38 N =4 3 45 min 3 38 N =5 2 45-60 min 2 39 N =6 3 Not given 1 60 min 9 42 N =7 1 60-90 min 1 44 N =7 to 12 3 90 min 5 44 N =8 1 120 min 1 44 N =9 1 3-4 hours 1 48 N =10 4 5 hours 1 48 N =11 1 7 hours 1 55 N =12 1 Not given 4 56 N =14 2 56 N =15 1 61 N =15 to 17 1 61 N =20 1 67 N =22 1 67 N =26 1 72 N =27 1 72 N =unclear 2 74 N =n/a 2 75 43 Methodology Participant N Per Study (45 individual studies total) **One study had three locations with different amounts of days. Animal Species, N Per Study, and Frequency (45 individual studies total) Intervention Timing and Frequency (47 individual studies total)** Intervention Duration and Frequency (47 individual studies total)** (23 were effective in causing change) (9 were effective in causing change) (9 were effective in causing change) **One study had three locations with different amounts of days. 79 Increased No change Decreased Awareness of counseling services 1 1 Behavioral change 1 1 Behaviors specific to Asperger's syndrome 1 1 Cognitive recognition 1 1 Exam scores 3 1 2 Language development 1 1 Learning and study strategies 1 1 Perceptions of counseling staff 1 1 Pet attitude 1 1 Program recommendation 1 1 Program satisfaction 2 2 Program usefulness 1 1 Task completion (math) 1 1 Total Cognitive 16 10 6 0 Physiological stress -BP 8 4 4 -Cortisol 6 1 5 -HR 5 3 2 -IgA 3 2 1 -sNGF 1 1 -sVAS 1 1 -skin sweat (EDA 1 1 - skin temp 1 1 Total Physiological 26 2 10 14 Outcome Changes and Frequency Results Outcomes Measured and Frequency Cognitive (13 individual codes) Physiological (8 individual codes) 80 Of the 37 studies, six had multiple studies for a total of 45 studies when examining participant N for each study; and animal species, N for each study, and frequency. One study also had multiple locations for a total of 47 studies when examining intervention timing and frequency, and intervention duration and frequency. 81 77 78 Horse (2 papers) 80 N =5 1 86 N =unclear 1 86 2 90 Rabbit* 127 N =1 1 127 132 163 228 235 246 246 270 309 403 1960 *Bird and rabbit were part of the same study that also included a dog. 82 Anxiety 11 1 10 Depression 2 1 1 Energy 1 1 Enjoyment 1 1 Happiness 2 1 1 Homesickness 4 4 Loneliness 1 1 Love 1 1 Mood/affect - NOS 4 4 - Negative 5 5 - Positive 4 3 1 Perceived stress (1 was not given) 20 3 16 Psychological arousal 1 1 Satisfaction with life 3 2 1 Self-esteem 1 1 Stress frequency 1 1 Stress severity 1 1 Well-being 1 1 Total Psychological 64 15 8 40 Connection to campus 3 3 Family supports 1 1 Social relationships 1 1 Social support 1 1 Support 1 1 Total Social 7 6 1 0 Psychological (18 individual codes) Social (5 individual codes) 83 83 Anxiety 11 1 10 Depression 2 1 1 Energy 1 1 Enjoyment 1 1 Happiness 2 1 1 Homesickness 4 4 Loneliness 1 1 Love 1 1 Mood/affect - NOS 4 4 - Negative 5 5 - Positive 4 3 1 Perceived stress (1 was not given) 20 3 16 Psychological arousal 1 1 Satisfaction with life 3 2 1 Self-esteem 1 1 Stress frequency 1 1 Stress severity 1 1 Well-being 1 1 Total Psychological 64 15 8 40 Connection to campus 3 3 Family supports 1 1 Social relationships 1 1 Social support 1 1 Support 1 1 Total Social 7 6 1 0 Psychological (18 individual codes) Social (5 individual codes) and the outcome changes. Next, I synthesized the mental health outcomes among four quality of life domains–cognitive, physiological, psychological, or social–that I adapted from the World Health Organization’s quality of life model (World Health Organization (WHO), 2012). I recorded the findings for each outcome in each domain as increased, no change, or decreased. Finally, I used 84 a numerical analysis to present frequency patterns which are described in the results section. Results Information Sources Once I completed the literature search, I examined and screened the results in four steps based on the PRISMA-ScR protocol for a scoping review process (Moher et al., 2009) and illustrated in Figure 1. Potential articles were combined into an Excel spreadsheet and duplicates were removed. Article titles and keywords were screened against the eligibility criteria, and I read the full texts of the remaining articles. I identified 37 articles reporting 45 individual studies that were eligible for this scoping review. Among those excluded in the group of 67 articles, four are worth mentioning because of their strong relationship to this study. The first one is the 1994 seminal work by Folse, Minder, Aycock, and Santana (Folse et al., 1994) because it is cited in the majority of articles on AAI. While the authors reported that “animal-assisted therapy” was a worthwhile option to treat college students who self-reported depression in a group format within a mental health clinic, the two dogs that participated in the study were a puppy and an adult dog with no mention of specific training or testing for AAI work. Two articles were authored by Pendry and colleagues (Pendry, Vandagriff, et al., 2019; Pendry & Vandagriff, 2019) and both included cats and dogs as participants in their campus-based animal program. However, these animals came from a local humane society 85 Figure 1 PRISMA Flow Diagram for the Scoping Review Process A full list of reasons for excluding records can be obtained from the author. Id en tif ic at io n Sc re en in g El ig ib ilit y In cl ud ed Full-text articles excluded, with reasons (n = 30)  Not AAI – 12  No intervention – 9  Not mental health – 3  Not a dissertation – 3  Not college student – 2  Not available – 1 Articles included (n = 37*) Full-text articles assessed for eligibility (n = 67) Records after duplicates removed (n = 1195) Additional records identified through other sources (n = 206) Records identified through database searching (n = 1190) Records excluded (n = 1128) Records screened (n = 1195) 86 shelter and did not have specific training, testing, or paired with a human partner to provide these AAI programs. The fourth article examined the impact of mindfulness training on college students’ ability to manage stress, and an AAI dog acted as a control (Shearer et al., 2016). Because this study focused on the outcomes produced through mindfulness training and not an AAI program, it did not meet the inclusion criteria used for this review. Characteristics of the Included Papers Article Demographics. As shown in Table 3, the literature in this scoping review on campus-based AAI programs for college student mental health does not precede the 21st century as all 37 studies were published since 2003. From 2017 to 2020, this research has proportionally grown a sizable amount as in this timeframe, 25 (68%) of the 37 articles were published. Furthermore, this body of information is dominated by researchers in the United States and Canada publishing 25 and eight articles respectively. The remaining four articles were from Austria, England, Scotland, and Singapore. The sources for this study were empirical articles (n=31) and dissertations (n=6). Methodology. All included articles used a quantitative study design: n=18 were randomized controlled trials, n=14 were quasi-experimental, and n=5 were mixed methods. Overall, 11 studies also included some type of open-ended questions to elicit additional qualitative data. When examining the participant section of the methodology category, there were a total of 45 individual studies because six articles included multiple studies. The range of human participants 87 was n=4 to n=1960, and close to 75% of all studies had a participant range of n=100 or fewer. Dogs were the most frequent animal in these 45 studies (n=43) and one of those studies with dogs also included one rabbit and one bird. The remaining two of the 45 studies included horses. The range of animal participants was n=1 to n=27 and the most frequent choice among all the studies was one dog (n=8). For the remaining sections of the methodology category, a total of 47 individual studies are described because one study operated at three different sites with varied amounts of days and durations for those three study sites. The included studies reported a variety of timing options: n=26 were offered only once; n=10 were offered multiple days, either during the same week or spread out over weeks; n=10 were offered weekly; and n=1 was not given. The duration of the AAI interventions in this scoping review ranged from seven minutes to seven hours, and the two most frequent session lengths were 15 minutes (n=10) and 60 minutes (n=9). Results. There were 37 papers included in this scoping review and from the reported results, n=44 individual mental health outcomes or codes were assigned to one of four quality of life domains: cognitive, physiological, psychological, or social. Combined, these mental health outcomes were cited 113 times as shown in Table 3, and the most frequently recorded outcome was stress/perceived stress (frequency=20). Overall, these studies showed an improved directional change in the mental health outcomes measured in college 88 students who attended AAI programming. At least one of the 44 outcomes improved in 33 papers or explained another way, 85 of the 113 frequencies (75%) improved; at least one outcome did not change in 14 papers (25 of the 113 frequencies, or 22%); one paper reported that two outcomes worsened (2%); and one paper did not report on one outcome (1%). Cognitive (n=13, frequency=16). There were 13 cognitive outcomes identified in the studies that examined students’ responses to an AAI program, and there was an improved directional change in the frequencies 63% of the time. I define a cognitive outcome as one that requires thought processes such as the creation of attitudes, ideas, or perceptions and academic skills such as language and test taking. The outcome exam scores was the most frequent result listed in this scoping review and one frequency had a positive increase while the other two reported no change. Two studies measured students’ satisfaction with the AAI program and both reported increased satisfaction. The remaining 11 cognitive outcomes showed mixed results as four did not change and seven improved. Physiological (n=8, frequency=26). There were eight physiological outcomes identified in the studies that examined students’ responses to an AAI program and there was an improved directional change in the frequencies 62% of the time. The outcomes blood pressure (BP), cortisol, and heart rate (HR) comprised nearly 75% of the frequencies associated with the physical markers of stress assessed in this scoping review. The ratio of frequency results–no change 89 to decrease (meaning improvement)–was mixed for these three outcomes and had a total split of 8:11: BP was split 4:4; cortisol was split 1:5; and HR was split 3:2. Immunoglobulin A (IgA) was measured three times and one frequency showed no change and the other two frequencies showed an improved change. The remaining four physiological outcomes were recorded once and one reported no change while the other three frequencies showed improved results. Psychological (n=18, frequency=64, one outcome=not reported). There were 18 psychological outcomes identified in the studies that examined students’ responses to an AAI program and there was an improved directional change in the frequencies 86% of the time. Close to 70% of the frequencies associated with the psychological markers of stress included perceived stress (frequency=20), mood (frequency=13), and anxiety (frequency=11). For perceived stress, 16 frequencies reported an improvement, three reported no change, and one was not given. Three mood outcomes were totaled for an overall mood outcome and 12 frequencies reported an improvement and one reported no change. For anxiety, 10 frequencies reported an improvement and one study reported no change. Of the remaining 13 psychological outcomes, only homesickness, satisfaction with life, depression, and happiness were cited more than once. For homesickness, all four frequencies reported an improvement. The ratios of frequency results–no change to improvement–were mixed for the other three outcomes: satisfaction with life was split 2:1; depression was split 1:1; and 90 happiness was split 1:1. Among the final nine outcomes within the psychological category, all reported an improved directional change. Social (n = 5, frequency = 7). There were five social outcomes identified in the studies that examined students’ responses to an AAI program and there was an improved directional change in the frequencies 86% of the time. The social outcome connection to campus was the most frequent result at three, and all improved. The frequency of the four remaining social outcomes of family support, social relationships, social support, and support were each cited once, family support reported no change and the other three reported an improvement. Qualitative Findings. Finally, the qualitative results to the open-ended questions established the following themes: students attended AAI sessions because of the dogs; AAI sessions produced feelings of “home”, stress relief, enjoyment, relaxation, happiness, and belongingness to a community; AAI sessions facilitated interactions and communication with other students; students were in favor of AAI sessions continuing on a regular basis; the interaction with the dogs was the most helpful program aspect; and students were more likely to use a counseling center because of the AAI program. Student responses also demonstrated that attending an AAI program did not increase involvement in other campus programs or foster continued contact with others on campus. Discussion This is the first scoping review of its kind to explore campus-based AAI programs for college student mental health and for the purpose of identifying 91 gaps in the AAI practice and research knowledge. An empirical structure was used to identify, select, and explore findings from 37 articles. The data from this review show a broad range of mental health outcomes in the cognitive, physiological, psychological, and social quality of life domains. The research suggests that a reduction in outcomes such as stress, anxiety, homesickness, blood pressure, and cortisol as well as a positive increase in mood and connection to campus resulted from students attending campus-based AAI programs. That the most frequent mental health outcome studied was perceived stress, followed by anxiety, directly parallels some of the most prevalent and presenting concerns noted at college counseling centers across the United States (Eisenberg et al., 2019). This study demonstrated that AAI for college student mental health is an emerging interest in mental health research, practice, and education as all 37 studies were published since 2003, and 25 (68%) studies were published from 2017 to 2020. Furthermore, institutions in the United States (68%) and Canada (22%) dominate this research. Excluding the six dissertations, 31 articles that reported on an intervention for college student mental health are minor when compared to the entire body of college student development literature. Furthermore, the limited number of studies in this review is in stark contrast to the fact that there are more than 925 colleges or universities in the United States that provide some type of campus-based AAI program (Crossman & Kazdin, 2015). This further exemplifies the criticism that while conceptual and anecdotal 92 support for AAI remains high, there is also a lack of high-quality reports analyzing the effectiveness of AAI programs on college students’ mental health (Haggerty & Mueller, 2017; Pendry & Vandagriff, 2019). This imbalance of what is known about AAI and what is being practiced across college campuses clearly warrants further investigation and conversation. This review identified 22 randomized controlled trials reported in 18 articles, and two trials included a control group that engaged in another type of therapeutic interaction (e.g., connection with a friend) (Polheber & Matchock, 2014), and mandala painting and music therapy (Gebhart et al., 2020). It is important to increase the validity and reliability of studies by comparing them alongside other types of therapeutic interventions in an effort to differentiate what components are critical for AAI success (Herzog, 2015; Serpell et al., 2017). Further, no study in this review included reasons for study withdrawal, non- participation, or undesirable results (e.g., allergies, animal bites/scratches, or worsening of symptoms the study was intended to improve) which are just as important as a study’s compliance in order to deepen and create a well-rounded understanding of AAI (Herzog, 2015). Eleven studies in this review used some form of open-ended questions, and no study has yet to be published that solely takes a qualitative approach to better understand the depth and compliment the breadth of this small body of research. Authors Hall (2018) and Pendry et al. (2018) who study campus-based animal programs have called for qualitative 93 research to examine how these programs bring value to the college student experience. These AAI programs were most frequently offered once (n=26) for 15 minutes (n=10) and with one dog (n=8). One study did not report the program’s frequency of sessions, and for the programs that offered one session, 23 were effective in causing statistically significant change. Of the ten programs that offered multiple days of sessions held over a range of timeframes, nine reported change, and of the 10 programs that offered weekly sessions for varying lengths of duration, nine also showed change. Seven studies in this scoping review provided follow-up results with a range of outcomes. No change was found at two weeks (Binfet, 2017) or at six weeks (Pendry, Kuzara, et al., 2019); at 10 hours post-AAI intervention, negative mood, and perceived stress decreased while social support increased (Ward-Griffin et al., 2018); at six weeks, academic skills remained high for students who were at risk of academic failure (Pendry et al., 2020); and “days after” and at three months, participants favorably recalled the AAI program and reported that it was helpful in their stress management (Anderson, 2018; Dell et al., 2015). Examination of the length of time spent at an AAI program, the number of visits, and long-term effects reveals important dose- response gaps in the literature. Dogs were the predominant species involved in this research which likely stems from the general societal emphasis on training dogs for therapeutic work and the ease and accessibility dogs provide when traveling to program sites. The 94 heterogeneity in the numbers of dogs that participated in these AAI intervention studies, or the ratio of participants to animals did not demonstrate any statistically significant trends regarding the outcomes. However, the inherent nature of an AAI program is framed as an animal being partnered with a human to form a team. Thousands of these teams exist in the world, and each one is unique because of human and animal differences making it impossible to have one constant, independent variable to compare to other variables. Did a change in behavior or emotion occur because of a small white poodle or because of a large brown mixed-breed dog? Did perceived stress for one study participant decrease because they felt really supported by the person working with the poodle, while perceived stress for another participant increased because they felt the handler with the brown dog was aloof or awkward in how they engaged with the student? Furthermore, only three other animal species were a part of this scoping review: one bird, one rabbit, and an unspecified number of horses. No study in this review provided an explanation for the species that was part of each study, and there exists an opportunity to examine the impact of non-canine animals in AAI programming, especially in light of a diverse college student body where members may object to dogs based on cultural beliefs, allergies, and phobias or fears (Hanif, 2015; Herzog, 2019; Lawson, n.d.). Finally, this scoping review not only illuminated the current state of what is known about AAI programs for college student mental health but also presented some threats to designing and implementing further research in this area. First, 95 the overall field of AAI suffers from a lack of clarity as to what types of human- animal interactions constitutes or qualifies as AAI rather than a common encounter with an animal. Second, there are no standardized and agreed-upon requirements for each of the AAI components of animal, practitioner, and environment such as training, testing, oversight, and features (e.g., space size, animal species, and the ratio of participants to animals). Ideally, to become an AAI team, a human and trained animal must pass an evaluation administered by a person who has also received specific training and testing to administer these exams. While there are national and international organizations working to develop these standards and best practices such as the American Veterinary Medical Association (AVMA, 2021) and the International Association of Human- Animal Interaction Organizations (IAHAIO, 2018), there is no method to oversee or mandate that AAI programs follow these protocols. And third, because a researcher sets inclusion and exclusion criteria for their study, they may select a way or ways of defining AAI that does not effectively translate to others in the AAI field (Fine & Ferrell, 2021). One result would be the research of one campus- based AAI program examining very different program components than another research study. Limitations As is the case for all studies, this scoping review has some limitations that must be considered when reviewing the findings. First, this scoping review was open to selection and assessment bias because I hold more than 25 years of 96 experience as an educator, practitioner, and researcher in AAI, and for the past 10 years, I have been conducting a campus-based AAI program for college student mental health. I relied heavily on my eligibility criteria and used it as a rubric against which I screened and selected the articles in this study. Second, while I included studies across all institutions of higher education, I limited my analysis to monolingual, English-language publications. Differences in terminology and definitions of key concepts indicates that some studies might have been missed during the search process that could have added to my final description and findings (O’Brien et al., 2016). I attempted to address this limitation by applying a wide variety of search terms and databases to detect as many studies as possible. Third, while the rigor of this body of empirical information includes randomized controlled trials (RCTs) in addition to quasi- experimental designs, the small number of articles identified in this scoping review makes it difficult to issue strong recommendations about AAI programs for college mental health. As the results’ quality are only as representative of that data upon which they are based, publication bias and unpublished manuscripts may have hindered a more balanced understanding of AAI programs for college student mental health (Arksey & O’Malley, 2005). And finally, because scoping reviews examine all available data on a topic, they also typically do not answer a direct research question or hypothesis such as, Do students who attend a campus-based AAI program demonstrate improved mental health? However, the use of scoping review methods developed by JBI and the 22-item checklist set 97 forth by PRISMA-ScR provide an empirical framework and impetus for further research on AAI for college student mental health. Conclusions The key findings from the 37 articles in this scoping review demonstrated a broad range of mental health benefits in the cognitive, physiological, psychological, and social quality of life domains for students who attended a campus-based AAI program. Overall, 75% of the mental health outcomes improved, 22% showed no change, 2% got worse, and 1% was not reported. A reduction in stress was the most frequently recorded outcome followed by a reduction in anxiety. The most common format for the AAI sessions in this study consisted of one event where students engaged with one dog for 15 minutes. The study of campus-based AAI programs for college student mental health is a 21st century endeavor dominated by researchers in the United States. To date, all studies that examined these programs were quantitative, 18 articles were randomized controlled studies, and 11 included open-ended questions. Two of the RCTs used a comparable control group who engaged in wellness activities that complimented the integrative nature of AAI. The need for rigorous, well-designed, and openly reported studies on AAI programs for college student mental health is clear and is an important research agenda within the extensive body of post-secondary literature. College students will continue to experience stress and universities will continue to seek out the most effective and evidence-based ways to provide support and healing for their 98 respective campus communities. AAI programs are efficient because they are well-attended and economical because the majority of AAI teams volunteer their time. Furthermore, the question of efficacy is becoming clearer as the findings in this scoping review demonstrate consistency with results from other AAI research in other settings and with other populations–that AAI programs and services may contribute to mental health outcomes by decreasing negative emotions and improving positive emotions. The importance of the knowledge gained from this scoping review is considered high because it is the first to present the current state of the research about AAI programs for college student mental health–a crisis that is unlikely to decrease in the wake of COVID-19. If institutions of higher learning were unable to adequately address students’ needs before the pandemic, they now face this challenge with even fewer resources. E. O Wilson wisely asked, “What service (do animal species bring) to the human spirit?” (Kellert & Wilson, 1993, p. 37). 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Wood, E., Ohlsen, S., Thompson, J., Hulin, J., & Knowles, L. (2018). The feasibility of brief dog-assisted therapy on university students stress levels: The PAwS study. Journal of Mental Health, 27(3), 263–268. EBSCO MegaFILE. 119 Chapter Three Paper Two A Repeated Cross-Sectional Study of a Campus-Based Animal-Assisted Interactions Program on College Student Stress Management 120 Introduction Throughout history, animals have given humans enjoyment, respite, and encouragement, and over the past 50 years in the United States, interest in the practices and study of these human-animal experiences has grown (Fine, 2019). The literature demonstrates that interactions with animals can enhance a wide continuum of biopsychosocial human conditions and most recently, their presence became instrumental in people’s lives during the COVID-19 pandemic (Nieforth & O’Haire, 2020). Considering the isolation, stress, and physical disconnection felt by so many people during the pandemic, connections with animals have been shown to reduce loneliness (Black, 2012), provide social support (Barker et al., 2018; Mueller & Hunter, 2019), and buffer the effects of stress and traumatic experiences (Beetz et al., 2019; O’Haire et al., 2015). Animals’ significance for human mental health care was first illuminated through Dr. Boris Levinson’s 1969 foundational publication, Pet-Oriented Child Psychotherapy. He recounted that after several unsuccessful therapy sessions with a client, a breakthrough in their engagement occurred when Levinson’s dog, Jingles, entered the therapy room (Levinson, 1969). Around this same decade, researchers tracking heart attack survivorship included pet ownership as a variable in their survey. To their surprise, participants in the study who had a pet were significantly more likely to be alive one year post-heart attack than those who did not have a pet (Friedmann et al., 1980). 121 Some of these experiences with animals have been formalized into a modality called Animal-Assisted Interactions (AAI) whereby the animals involved are often referred to as therapy animals. Dogs are the most common animal species in most AAI services, and cats, rabbits, birds, horses, guinea pigs, and llamas are also prevalent in these programs (Pet Partners, 2021). Ideally, these animals and their human partners have completed extensive training, testing, and review—usually through an independent evaluator versed in animal behavior and therapy animal activities—and together, form a team to support human well- being (Fine, 2019). While a number of studies show that AAI can enhance the mental health of multiple populations in various settings, for college student mental health, AAI is a recent programmatic and research interest that is gaining momentum (Stewart et al., 2014). A 2015 survey counted 925 college-based AAI programs across the United States (Crossman & Kazdin, 2015), and simply showing images or video of the exuberance on students’ faces during their time with these animals has allowed the media to propel these programs into popular culture. Empirically, a much smaller quantity of information exists about these programs’ methods and effectiveness. In the first scoping review to explore AAI programs for college student mental health (Bailey, in progress), none of the 37 studies that met the review criteria were published before 2003. Despite the overall paucity of literature examining AAI programs for college student mental health, this scoping review demonstrated that stress/perceived stress was the most frequent outcome 122 measured, and 75% of all measured mental health outcomes improved (Bailey, in progress). Mental health is now the leading public health concern on college campuses across the United States, and after accidents, suicide is the leading cause of student death (Drapeau & McIntosh, 2020). Two recent studies that examined the prevalence of college student mental illness and the utilization rates of on-campus mental health services from 2007 to 2018 demonstrated a marked increase in the severity of mental health problems, and the frequency of using mental health services on campus rose from 19% to 34% (Lipson et al., 2018). The second study demonstrated that the significant decline in college student mental health is independent of trends in student demographics, pre- existing conditions, unhealthy lifestyle choices tied to technology, or earlier access to mental health assessment and treatment (Duffy et al., 2019). What were once historical presentations for less complicated developmental issues at campus counseling centers have now given way to college students who are more anxious, more depressed, and committing more intentional self-harm than ten years ago. One consistent factor linked to college student mental health and reported by numerous college surveys is the adverse effects of stress. Stress is one of the most researched concepts of the past 100 years, and while the construct of stress is a complex variable to investigate, medical researchers estimate that stress promotes between 75% to 90% of all illnesses (American Psychological 123 Association, 2017). A certain level of stress is fundamental because it provides motivation to take risks, be persistent, innovate, and accomplish life endeavors. However, if adequate resources are unavailable or a person is unsuccessful in enacting a functional and healthy form of coping, the negative effects of stress can become chronic and have significant and lasting detrimental effects on one’s mental health 20 years into the future (Chiang et al., 2018). Along with the problematic trend of increased college student stress (ongoing for decades), research demonstrates that high rates of stress are significantly linked to lower grade point averages (Eisenberg et al., 2009), higher dropout rates up to 86% even when, on average, one in every three students never finishes college (Breslau et al., 2008; Collins & Mowbray, 2005; Kognito, 2017), risk of violence and crime (Pettitt et al., 2013), substance abuse and addiction (Slutske, 2005), chronic disease (Prince et al., 2007), and poverty (Loprest & Maag, 2007). In a 2019 survey conducted by the American College Health Association (ACHA), three out of every four students (76%) reported higher-than-average stress within the last 30 days and over one-fourth (27%) rated their stress as “tremendous”. In the past 12 months, 38% of surveyed students identified stress as a factor in poor class performance or a delay in progress towards graduation (ACHA, 2020). Throughout the last 50 years, universities have devoted significant attention to developing comprehensive plans to address the lowest mental health rates for college students in over 50 years (Stolzenberg et al., 2020). In addition 124 to traditional forms of support such as counseling and psychiatry, some colleges are teaching mental health first aid techniques to faculty and staff, psychologists are being embedded into athletic departments, and health promotion departments are developing innovative prevention services like sobriety and recovery groups, health advocate programs, and fun stress-buster events to reach students who may underestimate the severity of their struggles (University of Minnesota, 2018). Because connections with animals are such a natural and enjoyable experience for so many people, adding a campus-based AAI program may be a uniquely effective way to introduce mental health services while continuing to dismantle the stigma around students asking for help (Yanos et al., 2014). This manuscript aims to explore the correlation between dose of attendance at a campus-based AAI program and students’ perception that this activity helped them manage their stress. The AAI program in this study was designed using a public health model for human well-being and not as a mental health intervention to replace clinical counseling and psychiatry. The study used a repeated cross-sectional method comprised of six years of secondary analysis of existing data, and was guided by the following research questions: 1. What were the demographic and mental health features among the students who attended a campus-based AAI program over the six years of this study? 125 2. What, if any, factors were associated with a student’s perception that attending a campus-based AAI program helped them manage their stress? 3. Did students’ attendance at a campus-based AAI program–both in length of time and frequency of visits–impacted their perception that the program helped them manage their stress? Cross-Sectional Study Methods Study Design I undertook a repeated cross-sectional study for six academic years (2014/15 to 2019/20) using a secondary analysis of existing data from a campus- based AAI program located at a large, Midwestern university with over 50,000 students in the United States. The original purpose of the survey used for this study was to gather year-end data for program performance measurement and evaluation. The design of this study was observational and gathered the same information about exposures and outcomes experienced by a convenience sample of the same identified population–college students–over different points in time, thereby creating six different samples (Wang & Cheng, 2020). Subsequent secondary analysis examined the prevalence of an outcome (perceived stress management) and explored the correlation between that outcome and the exposure, which was defined as dose of attendance at a campus-based AAI program. 126 Measures A structured 30-item questionnaire shown in Appendix A was administered by the director of research at this university’s health center using Qualtrics software, version XM (Qualtrics, 2020). The questionnaire was sent once at the end of each of the six academic years to a different group of students who were members of the overall campus body. The survey asked participants to self- report their age (under 19, 19-20, 21-24, 25-34, or 35+), gender (female, male, or other), international student status (yes, no, or not applicable), status on campus (student, staff, faculty, or other), and year in school (first, second, third, fourth, fifth and beyond, or graduate student). Students recorded the number of visits they made to the AAI program on a scale of 1 time to 10 or more times and how long they stayed on a scale from 1 minute to 120 minutes. Students were asked to respond to the following statement: “I believe the (name of the AAI program) program helped me manage my stress” on a Likert scale from 1 (strongly agree) to 5 (strongly disagree). This dependent variable of “destress” was dichotomized into a 1 for scale values 1 or 2 and a 0 for scale values 3, 4, or 5 (years 2015 through 2017 did not have a middle value of neither agree nor disagree). Students were also asked: “What is the reason you decided to attend a (name of the AAI program) session?” and they could select all that applied from a list of 10 options. One option stated I thought it might help me relieve stress and was dichotomized into a 1 for “reason-stress” if selected or a 0 if not selected. 127 The Adverse Life Experiences (ALE) item, a checklist adapted from the College Student Health Survey administered by the University of Minnesota (Lust, 2021), gathered how much hardship a student was exposed to during the previous 12 months. Participants could select all that applied from a series of 20 items as well as supply additional self-written experiences under other. The ALE score was dichotomized into “ALE-have” if a student selected at least one item on the checklist and “ALE-none” if no items were selected. Students’ perceived stress was assessed using the 10-question Perceived Stress Scale (PSS-10) (Cohen & Williamson, 1988). The PSS-10 is a validated tool that measures the degree to which one perceives various parts of one’s life as overwhelming, uncontrollable, or unpredictable over the past month, and is structured in a non-specific, context-free fashion that does not focus on specific life experiences (Denovan et al., 2019). For example, one question from the PSS-10 asked: “In the last month, how often have you felt nervous or stressed?” Items were rated using a 5-point Likert scale (0=never, 1=almost never, 2=sometimes, 3=often, 4=very often), four questions were reverse coded, and responses were summed consistent with instructions for scoring the PSS-10. Based on a 40-point scale, scores between 0 and 13 indicated low stress, 14 to 26 equaled moderate stress, and 27 to 40 qualified as having experienced high stress. For analysis, perceived stress was dichotomized into “PSS-high” (score of 27 and higher) and “PSS-not high” (score of 26 and lower). 128 Procedure The University of Minnesota’s Institutional Review Board (#1409S53383, 10-14-2014) approved this study for human subjects and all participants provided informed consent prior to taking the survey. This study was also approved by University of Minnesota’s Institutional Animal Care and Use Committee (#1402- 31350A, 01-26-2015) for animal subjects. The species types involved in this study included dogs, cats, rabbits, miniature horses, guinea pigs, fancy rats, and chickens. All animals involved in this study were recruited from the community and were registered therapy animals with one of four national organizations: Pet Partners, Therapy Dogs International, Alliance of Therapy Dogs, or Intermountain Therapy Animals. All animals were privately owned by a human member of the registered team and were acquired at the discretion of their owners from sources including shelters and breeders. Every Monday through Thursday during the academic year, AAI sessions were consistently held at various locations and times on the university’s campus (e.g., Monday sessions were always held at the recreation center from noon to 2:00 pm in room MP7 on the fourth floor). Each location averaged a different number of participants (e.g., 60 people on Mondays and 110 people on Wednesdays); therefore, a range of four to 10 teams from a roster of approximately 120 delivered these AAI sessions. Each session was two hours in length and participants could attend as many sessions as they wanted, including 129 multiple times each week, and remain for as long as they wanted at each session. When participants arrived at the program, they were invited to be a part of the study and asked to provide an email address where they could be contacted at the end of the academic year. Approximately two weeks before the start of spring semester finals (mid-April), participants received an email with an electronic link to access an informational website that described the study, assessed inclusion and exclusion criteria, and required consent to complete or opt out of the study. After consent was secured, individuals were directed to the online survey which took less than 15 minutes to complete. Participants included in this study met inclusion criteria identifying them as being 18 years of age or older; able to provide consent; and currently enrolled as a full- or part-time student. Exclusion criteria included allergies or fears/phobias of animals, and identification as a staff, faculty, or other non-student individual, (e.g., a campus visitor). Lifestyle practices that prohibited interacting with dogs, (e.g., cultural or religious customs), were not part of the exclusion criteria because individuals were not required to physically touch any of the animals. A random drawing for one of 10 $20 gift cards was offered as an incentive for participation in each annual survey. Data Analysis Descriptive statistics of frequencies, percentages, means, and standard deviations were calculated for socio-demographic items and the dependent and 130 independent variables in order to detect any outliers, non-normality, missing data, and coding errors. Logistic regression analysis determined the odds ratio (OR) and confidence intervals (95% CIs), and the level of statistical significance established was p <.05. The collected data were analyzed using RStudio Server Pro (RStudio Team, 2019). Results Participants Descriptive statistics for the study are shown in Table 1. A total of 12,884 surveys were sent and 4,149 individuals (response rate of 32.20%) completed the survey. After assessing eligibility criteria and missing data, the total sample available for analysis was 3,255 individuals. As listed in Table 1, participants were predominantly female (79.26%), from the United States (92.96%), 19 to 20 years of age (42.34%), and were undergraduate students (80.61%). The distributions of participants across the years of the study were: first year (n=791), second year (n=399), third year (n=537), fourth year (n=284), fifth year (n=709), and sixth year (n=535). In Table 2, the mean number of visits was 3.55 (SD 2.73) and the mean number of minutes spent at the program totaled 31.40 (SD 20.68). In Table 3, when asked “What is the reason you decided to attend the AAI program?” 2,577 (79.17%) people selected because “I thought it might help me relieve stress”. Students’ perception of program effectiveness was high, as 2,850 (87.72%) people strongly agreed or agreed that they believed the AAI program helped 131 them manage their stress. And 2,684 (82.48%) people rated the program an 8, 9 or 10—the excellent range—on a 10-point Likert scale. Perceived Stress For one PSS-10 question listed in Table 3, a total of 2,301 (70.82%) students responded with fairly often or often to the question, “In the last month, how often have you felt nervous and ‘stressed’?” The mean total PSS-10 score for all six years was 19.54 (SD 6.01, Cronbach’s alpha=.87), which falls into the moderate stress (14-26) range of PSS-10 shown in Table 4. The gender differences found in this sample indicated that students who identified as gender other reported higher levels of perceived stress (M=23.45, SD=5.18) than females (M=19.76, SD=5.87) and males (M=17.85, SD=6.30), though all were still in the moderate range. International students reported virtually the same levels of perceived stress (M=19.43, SD=5.76) as domestic students (M=19.55, SD=6.03). Adverse Life Experiences Overall, 2,482 (76.25% of) students reported having at least one ALE in the past 12 months, and the mean ALE was 2.04 (SD 1.91) as shown in Table 5. Three of these ALEs are highlighted in Table 3. First, diagnosed with a mental illness in the past year was selected by 594 (18.25% of) students. Second, 521 (34.10%) students selected receiving treatment for mental health in the past year—an option only available for years four through six. And third, attempted (n =791) % (n =399) % (n =537) % (n =284) % Gender Female 638 80.66% 325 81.45% 431 80.26% 204 71.83% Male 135 17.07% 63 15.79% 90 16.76% 68 23.94% Other 18 2.28% 11 2.76% 16 2.98% 12 4.23% Trans 8 1.01% 0.00% 0.00% 0.00% Prefer 11 1.39% 0.00% 0.00% 0.00% GQ 0.00% 0.00% 0.00% 0.00% Trans_Male 0.00% 0.00% 0.00% 0.00% Trans_Female 0.00% 0.00% 0.00% 0.00% TOTAL 791 100.00% 399 100.00% 537 100.00% 284 100.00% 40 5.06% 24 6.02% 42 7.82% 31 10.92% Under19 33 11.62% 19-20 126 44.37% 21-24 76 26.76% 25-34 44 15.49% 35+ 5 1.76% TOTAL 284 100.00% Academic Year 1st year 353 44.63% 62 15.54% 171 31.84% 101 35.56% 2nd year 118 14.92% 140 35.09% 106 19.74% 41 14.44% 3rd year 98 12.39% 71 17.79% 81 15.08% 43 15.14% 4th year 90 11.38% 50 12.53% 59 10.99% 33 11.62% 5th year 17 2.15% 9 2.26% 13 2.42% 5 1.76% Graduate 115 14.54% 67 16.79% 107 19.93% 61 21.48% TOTAL 791 100.00% 399 100.00% 537 100.00% 284 100.00% (question was not asked this year) (question was not asked this year) 2014-15 2015-16 2016-17 2017-18 Table 1 Distribution of College Students Per Academic Year by Gender, International Student Status, Age, and Academic Status by Number and Percentages (question was not asked this year) Age (n=3255) International Student Study total 132 (n =709) % (n =535) % (n =3255) % 557 78.56% 424 79.40% 2579 79.26% 127 17.91% 89 16.67% 572 17.58% 25 3.53% 21 3.93% 103 3.17% 0.00% 0.00% 8 0.25% 0.00% 0.00% 11 0.34% 0.00% 0.00% 0 0.00% 0.00% 0.00% 0 0.00% 0.00% 0.00% 0 0.00% 709 100.00% 534 100.00% 3254 100.00% 45 6.35% 47 8.79% 229 7.04% 112 15.80% 72 13.46% 217 14.20% 281 39.63% 240 44.86% 647 42.34% 201 28.35% 130 24.30% 407 26.64% 106 14.95% 88 16.45% 238 15.58% 9 1.27% 5 0.93% 19 1.24% 709 100.00% 535 100.00% 1528 100.00% 276 38.93% 212 39.63% 1175 36.10% 97 13.68% 83 15.51% 585 17.97% 89 12.55% 65 12.15% 447 13.73% 78 11.00% 47 8.79% 357 10.97% 9 1.27% 7 1.31% 60 1.84% 160 22.57% 121 22.62% 631 19.39% 709 100.00% 535 100.00% 3255 100.00% 2019-20 TOTAL All Years2018-19 133 134 2014-15 (n =791) 2015-16 (n =399) 2016-17 (n =537) 2017-18 (n =284) 2018-19 (n =709) 2019-20 (n =535) TOTAL All Years (n =3255) 3.10 (2.52) <2.93-3.28> 3.14 (2.52) <2.89-3.38> 3.67 (2.76) <3.44-3.91> 4.42 (3.28) <4.03-4.81> 3.84 (2.75) <3.64-4.05> 3.55 (2.64) <3.33-3.78> 3.55 (2.73) <3.46-3.64> 33.12 (20.60) <31.67-34.57> 32.52 (21.20) <30.41-34.63> 30.06 (19.42) <28.42-31.71> 34.57 (24.60) <31.68-37.46> 29.75 (20.87) <28.21-31.28> 29.93 (18.73) <28.34-31.52> 31.40 (20.68) <30.68-32.11> Mean total (standard deviation) Duration of Visits Number of Visits Table 2 Number of Visits and Duration of Visits (in Minutes) Reported by College Students per Academic Year (n =791) % 611 77.24% Diagnosed with a mental illness 125 15.80% Received treatment for mental health Attempted suicide 14 1.77% Never 4 0.51% Almost never 35 4.44% Sometimes 205 26.02% Fairly often 315 39.97% Very often 229 29.06% 788 100.00% 1 Strongly agree/ Strongly agree 213 26.93% 2 Agree/ Somewhat agree 520 65.74% 733 92.67% 3 (not asked years 1-3)/ Neither agree or disagree 4 Disagree/ Somewhat disagree 53 6.70% 5 Strongly disagree/ Strongly disagree 5 0.63% 58 7.33% TOTAL 791 100.0% 1 0 0.00% 2 0 0.00% 3 3 0.38% 4 4 0.51% 7 5 25 3.16% 6 23 2.91% 7 97 12.26% 145 8 160 20.23% 9 164 20.73% 10 315 39.82% 639 TOTAL All Ratings 791 2014-15Study total Table 3 Survey Question Responses Per Academic Year by Number and Percentages ALE questions: What is the reason you decided to attend PAWS: "I thought it might help me relieve stress." didn't ask this year TOTAL Rating 1-4 TOTAL Rating 5-7 TOTAL Rating 8-10 "Overall, how would you rate the PAWS program?" (only students, n =3255 ) TOTAL TOTAL Combined 1 and 2 TOTAL Combined 4 and 5; or 3, 4, and 5 Please respond to the following statement: "I believe PAWS helped me manage my stress." *This was a 4-point scale for years 2015-2017, and a 5- point scale for years 2018-2020. PSS-10 question: 135 (n =399) % (n =537) % (n =284) % 302 75.69% 433 80.63% 245 86.27% 66 16.54% 117 21.79% 56 19.72% 105 36.97% 7 1.75% 7 1.30% 1 0.35% 1 0.25% 2 0.37% 0 0.00% 15 3.77% 15 2.79% 8 2.82% 98 24.62% 134 24.95% 63 22.18% 164 41.21% 208 38.73% 117 41.20% 120 30.15% 178 33.15% 96 33.80% 398 100.00% 537 100.00% 284 100.00% 101 25.38% 159 29.72% 113 39.79% 268 67.34% 332 62.06% 130 45.77% 369 92.71% 491 91.78% 243 85.56% 28 9.86% 26 6.53% 35 6.54% 8 2.82% 3 0.75% 9 1.68% 5 1.76% 29 7.29% 44 8.22% 41 14.44% 398 100.0% 535 100.0% 284 100.0% 1 0.25% 1 0.19% 0 0.00% 0 0.00% 1 0.19% 0 0.00% 1 0.25% 1 0.19% 2 0.70% 3 0.75% 7 1.31% 0 0.00% 5 10 2 14 3.51% 10 1.87% 5 1.76% 16 4.01% 25 4.66% 3 1.06% 50 12.53% 54 10.07% 27 9.51% 80 89 35 92 23.06% 92 17.16% 50 17.61% 72 18.05% 106 19.78% 48 16.90% 150 37.59% 239 44.59% 149 52.46% 314 437 247 399 536 284 2015-16 2016-17 2017-18 didn't ask this yeardidn't ask this year 136 (n =709) % (n =535) % (n =3255) % 590 83.22% 396 74.02% 2577 79.17% 122 17.21% 108 20.19% 594 18.25% 225 31.73% 191 35.70% 521 34.10% 12 1.69% 10 1.87% 51 1.57% 1 0.14% 3 0.56% 11 0.34% 20 2.82% 16 3.00% 109 3.35% 168 23.73% 160 29.96% 828 25.48% 304 42.94% 228 42.70% 1336 41.12% 215 30.37% 127 23.78% 965 29.70% 708 100.00% 534 100.00% 3249 100.00% 221 31.26% 162 30.34% 969 29.82% 363 51.34% 268 50.19% 1881 57.89% 584 82.60% 430 80.52% 2850 87.72% 85 12.02% 79 14.79% 192 5.91% 28 3.96% 16 3.00% 166 5.11% 10 1.41% 9 1.69% 41 1.26% 123 17.40% 104 19.48% 399 12.28% 707 100.0% 534 100.0% 3249 100.00% 1 0.14% 0 0.00% 3 0.09% 0 0.00% 0 0.00% 1 0.03% 3 0.42% 1 0.19% 11 0.34% 4 0.56% 7 1.31% 25 0.77% 8 8 40 1.23% 8 1.13% 7 1.31% 69 2.12% 22 3.10% 20 3.74% 109 3.35% 70 9.87% 54 10.09% 352 10.82% 100 81 530 16.29% 117 16.50% 80 14.95% 591 18.16% 117 16.50% 110 20.56% 617 18.96% 367 51.76% 256 47.85% 1476 45.36% 601 446 2684 82.48% 709 535 3254 100.00% 2019-202018-19 TOTAL All Years 137 138 Table 4 College Students' Scores on the PSS-10 by Gender and International Status (0-13=Low Stress; 14-26=Moderate Stress; 27-40=High Stress) PSS-10 (n=3255 ) 2014-15 (n=791) 2015-16 (n=399) 2016-17 (n=537) 2017-18 (n=284) 2018-19 (n=709) 2019-20 (n=535) TOTAL All Years (n=3255) Female Mean 19.03 19.21 20.15 20.02 19.75 20.95 19.76 95% CI 18.60-19.46 18.65-19.77 19.65-20.65 19.33-20.71 19.33-20.17 20.46-21.44 19.54-19.99 Median 19 19 20 20 20 21 20 Std. Deviation 6.10 5.72 5.87 5.90 5.68 5.75 5.87 Male Mean 16.90 17.21 17.65 19.03 18.34 18.99 17.85 95% CI 16.46-17.34 16.61-17.81 17.10-18.20 18.32-19.74 17.86-18.82 18.46-19.52 17.33-18.37 Median 17 17 17 19 18 19 18 Std. Deviation 6.29 6.13 6.47 6.08 6.50 6.23 6.30 Gender: Other Mean 24.54 23.67 26.92 21.40 22.77 24.41 23.45 95% CI 24.24-24.84 23.02-24.32 26.44-27.40 20.72-22.08 22.47-23.07 24.04-24.78 22.42-24.47 Median 24 23 27.5 21.5 23 24 23 Std. Deviation 4.25 6.59 5.66 5.82 4.13 4.39 5.18 International Mean 17.78 18.70 19.43 19.84 19.84 20.41 19.43 Total 95% CI 17.37-18.19 18.18-19.22 18.87-19.99 19.20-20.48 19.46-20.22 19.92-20.90 18.67-20.19 Median 17 18 21 21 20 21 20 Std. Deviation 5.92 5.26 6.60 5.50 5.12 5.80 5.76 Domestic Mean 18.77 19.04 19.82 19.85 19.53 20.74 19.55 Total 95% CI 18.33-19.22 18.43-19.64 19.29-20.36 19.10-20.59 19.08-19.98 20.22-21.27 19.34-19.77 Median 19 19 20 20 20 21 20 Std. Deviation 6.17 5.93 6.05 6.00 5.9 5.85 6.03 All Mean 18.73 19.02 19.79 19.85 19.55 20.71 19.54 95% CI 18.30-19.16 18.44-19.60 19.28-20.31 19.16-20.54 19.12-19.98 20.21-21.21 19.34-19.75 Median 19 19 20 20 20 21 20 Std. Deviation 6.16 5.89 6.09 5.93 5.85 5.84 6.01 Cronbach's α 0.88 0.87 0.88 0.86 0.86 0.84 0.87 139 2014-15 (n =791) 2015-16 (n =399) 2016-17 (n=537) 2017-18 (n =284) 2018-19 (n =709) 2019-20 (n=535) TOTAL All Years (n =3255) 1480 797 991 689 1527 1170 6654 593 (75%) 308 (77%) 394 (73%) 233 (82%) 543 (77%) 411 (77%) 2482 (76%) Mean 1.87 2.00 1.85 2.43 2.15 2.19 2.04 95% CI 1.74-2.00 1.81-2.19 1.70-2.00 2.20-2.66 2.01-2.30 2.02-2.35 1.98-2.11 Median 1 2 2 2 2 2 2 Std. Deviation 1.83 1.89 1.76 2.01 2.01 1.93 1.91 ALE (n=3255 ) Total ALEs Total with at least 1 ALE Table 5 Number of Adverse Life Experiences Selected by College Students 140 suicide in the past year (51 students, 1.57%) was not included in the final analysis as overall total numbers were too small for statistical significance. Logistic Regression Table 6 shows the results of logistic regression measuring the correlation between the exposure of dose attendance and the outcome of college students’ perceptions that the AAI program helped them manage their stress. A total of 68 (2.09% of) participants were excluded from regression analysis because of missing data. For this study, the OR represents the odds that given specific baseline variables, college students said attending the AAI program helped them manage their stress compared to other college students who did not experience these same variables. As shown in the graphs in Appendix B, the longer amount of time spent at the AAI program and the greater the number of visits were both associated with higher odds that the person said that the AAI program helped them manage their stress. This effect was statistically significant for five out of the six years. The following example demonstrates the odds for a visit that lasted 10 minutes and a visit that lasted approximately 30 minutes (the average overall length of time students spent at the AAI program) for 2015 as shown in Table 6. The odds that a person who attended for 10 minutes would select that the AAI program helped them manage their stress was 1.38 times higher, and the odds that a person who attended for 30 minutes would select that the AAI helped them manage their stress was 2.61 times higher than someone who did not select this option. Estimates (SE) Odds Ratio P-Value LOW HIGH INTERCEPT 0.270 0.008 0.032 0.012 1 1.030 1.008 1.058 10 1.377 1.083 1.751 20 1.896 1.174 3.065 30 2.612 1.271 5.366 (mean per year) 33.12 2.886 1.303 6.390 40 3.597 1.377 9.393 50 4.953 1.492 16.445 60 6.821 1.616 28.789 70 9.393 1.751 50.400 80 12.936 1.896 88.235 90 17.814 2.054 154.470 100 24.533 2.226 270.426 110 33.784 2.411 473.428 120 46.525 2.612 828.818 Number of visits 0.398 0.001 0.123 1 1.489 1.164 1.904 2 2.217 0.611 3.626 3 3.300 0.478 6.903 4 4.914 0.374 13.144 5 7.316 0.292 25.028 6 10.892 0.229 47.656 7 16.216 0.179 90.740 8 24.143 0.140 172.777 9 35.945 0.109 328.981 10+ 53.517 0.085 626.407 Table 6 Logistic Regression Analysis for Duration, Gender, International Status, PSS- 10-High, ALE_have, and Reason_Stress on Students Saying Attending the AAI Program Helped Them Manage Their Stress Duration (in minutes) Variables Year 2014-15 (n =791; 23 eliminated due to missingness) 95% Confidence Intervals (CI) 141 Estimates (SE) Odds Ratio (OR) P-Value LOW HIGH 0.218 0.009 0.052 0.020 1.054 1.012 1.096 1.682 1.127 2.509 2.829 1.271 6.297 4.759 1.433 15.800 32.52 5.425 1.477 19.922 8.004 1.616 39.646 13.464 1.822 99.484 22.646 2.054 249.635 38.092 2.316 626.407 64.072 2.612 1571.837 107.770 2.945 3944.194 181.272 3.320 9897.129 304.905 3.743 24834.771 512.859 4.221 62317.652 0.402 0.025 0.180 1.495 1.043 2.143 2.234 1.088 4.591 3.340 1.134 9.836 4.993 1.183 21.073 7.463 1.234 45.150 11.156 1.287 96.737 16.676 1.342 207.265 24.928 1.399 444.078 37.263 1.459 951.462 55.701 1.522 2038.562 (n =399; 13 eliminated due to missingness) Year 2015-16 95% Confidence Intervals (CI) 142 Estimates (SE) Odds Ratio P-Value LOW HIGH 0.369 0.001 0.047 0.014 1.048 1.019 1.078 1.600 1.209 2.117 2.560 1.462 4.482 4.096 1.768 9.488 30.06 4.108 1.770 9.531 6.554 2.138 20.086 10.486 2.586 42.521 16.777 3.127 90.017 26.843 3.781 190.566 42.948 4.572 403.429 68.717 5.529 854.059 109.947 6.686 1808.042 175.915 8.085 3827.626 281.463 9.777 8103.084 0.242 0.020 0.104 1.274 1.035 1.568 1.623 1.070 2.460 2.067 1.107 3.857 2.633 1.146 6.050 3.353 1.185 9.488 4.272 1.226 14.880 5.441 1.269 23.336 6.931 1.313 36.598 8.829 1.358 57.397 11.246 1.405 90.017 95% Confidence Intervals (CI) Year 2016-17 (n =537; 6 eliminated due to missingness) 143 Estimates (SE) Odds Ratio P-Value LOW HIGH -0.234 0.019 0.124 (0.012) 34.57 0.014 0.844 (0.073) 95% Confidence Intervals (CI) Year 2017-18 (n =284; 10 eliminated due to missingness) 144 Estimates (SE) Odds Ratio P-Value LOW HIGH -0.658 0.019 0.013 0.008 1.020 1.003 1.036 1.209 1.030 1.419 1.462 1.062 2.014 1.768 1.094 2.858 29.75 1.760 1.093 2.833 2.138 1.127 4.055 2.586 1.162 5.755 3.127 1.197 8.166 3.781 1.234 11.588 4.572 1.271 16.445 5.529 1.310 23.336 6.686 1.350 33.115 8.085 1.391 46.993 9.777 1.433 66.686 0.219 0.000 0.057 1.245 1.111 1.395 1.550 1.234 1.946 1.929 1.370 2.716 2.401 1.522 3.789 2.989 1.690 5.286 3.721 1.878 7.374 4.632 2.085 10.288 5.766 2.316 14.354 7.178 2.573 20.025 8.935 2.858 27.938 95% Confidence Intervals (CI) Year 2018-19 (n =709; 8 eliminated due to missingness) 145 Estimates (SE) Odds Ratio P-Value LOW HIGH 0.094 0.016 0.035 0.008 1.016 1.000 1.033 1.174 1.000 1.377 1.377 1.000 1.896 1.616 1.000 2.612 29.93 1.614 1.000 2.606 1.896 1.000 3.597 2.226 1.000 4.953 2.612 1.000 6.821 3.065 1.000 9.393 3.597 1.000 12.936 4.221 1.000 17.814 4.953 1.000 24.533 5.812 1.000 33.784 6.821 1.000 46.525 0.136 0.015 0.056 1.146 1.024 1.281 1.313 1.049 1.642 1.504 1.075 2.104 1.723 1.101 2.697 1.974 1.127 3.456 2.261 1.155 4.428 2.591 1.183 5.675 2.968 1.212 7.272 3.401 1.241 9.318 3.896 1.271 11.941 95% Confidence Intervals (CI) Year 2019-20 (n =535; 8 eliminated due to missingness) 146 Variables Estimates (SE) Odds Ratio P-Value LOW HIGH INTERCEPT 0.270 Gender Male 0.461 (0.438) 1.585 0.712 4.060 0.293 Gender Other -0.971 (1.106) 0.379 0.061 7.354 0.380 International -0.748 (0.553) 0.473 0.170 1.549 0.176 -0.476 (0.420) 0.621 0.281 1.485 0.257 ALE have -0.145 (0.346) 0.865 0.426 1.671 0.675 Reason_Stress 0.993 (0.308) 2.699 1.475 4.957 0.001 Year 2014-15 (n =791; 23 eliminated due to missingness) PSS-10 high (score 27-40) 95% Confidence Intervals (CI) 147 Estimates (SE) Odds Ratio (OR) P-Value LOW HIGH 0.218 0.787 (0.768) 2.197 0.599 1.422+01 0.305 14.114 (1154.028) 1352009.577 0.000 5.245+129 0.990 0.589 (1.097) 1.803 0.306 3.485+01 0.591 -0.579 (0.562) 0.560 0.197 1.859+00 0.303 -0.448 (0.534) 0.639 0.201 1.699+00 0.402 0.594 (0.434) 1.812 0.759 4.226+00 0.171 Year 2015-16 (n =399; 13 eliminated due to missingness) 95% Confidence Intervals (CI) 148 Estimates (SE) Odds Ratio P-Value LOW HIGH 0.369 0.268 (0.463) 1.308 0.556 3.493 0.562 -0.073 (1.133) 0.929 0.141 18.613 0.948 -0.414 (0.522) 0.661 0.252 2.001 0.427 -1.096 (0.423) 0.334 0.146 0.795 0.011 -0.368 (0.403) 0.692 0.302 1.483 0.361 0.963 (0.366) 2.618 1.265 5.361 0.009 95% Confidence Intervals (CI) (n =537; 6 eliminated due to missingness) Year 2016-17 149 Estimates (SE) Odds Ratio P-Value LOW HIGH -0.234 -0.467 (0.422) 0.627 0.278 1.468 0.268 -1.786 (0.696) 0.168 0.044 0.714 0.010 -0.143 (0.544) 0.866 0.313 2.702 0.792 1.253 (0.776) 3.500 0.940 22.913 0.106 0.732 (0.419) 2.078 0.897 4.678 0.081 1.157 (0.456) 3.181 1.274 7.690 0.011 95% Confidence Intervals (CI) (n =284; 10 eliminated due to missingness) Year 2017-18 150 Estimates (SE) Odds Ratio P-Value LOW HIGH -0.658 0.173 (0.293) 1.189 0.681 2.160 0.555 -1.324 (0.503) 0.266 0.100 0.739 0.009 0.904 (0.557) 2.469 0.922 8.644 0.105 -0.090 (0.294) 0.914 0.521 1.660 0.760 0.029 (0.254) 1.030 0.619 1.682 0.908 1.244 (0.239) 3.469 2.169 5.541 0.000 95% Confidence Intervals (CI) Year 2018-19 (n =709; 8 eliminated due to missingness) 151 Estimates (SE) Odds Ratio P-Value LOW HIGH 0.094 -0.252 (0.307) 0.777 0.432 1.447 0.412 -1.350 (0.539) 0.259 0.091 0.776 0.015 -0.523 (0.374) 0.593 0.289 1.262 0.162 -0.160 (0.306) 0.852 0.474 1.582 0.601 -0.105 (0.281) 0.901 0.512 1.545 0.709 1.067 (0.243) 2.907 1.805 4.681 0.000 95% Confidence Intervals (CI) Year 2019-20 (n =535; 8 eliminated due to missingness) 152 153 For the following five of six years, a student who selected that they attended the AAI program because I thought it might help me relieve stress had higher odds of reporting that the AAI program helped them manage their stress than a student who did not select relieving stress as a reason for attending: 2015 (OR=2.70, 95% CI=1.48-4.96, p=.00), 2017 (OR=2.62, 95% CI=1.27-5.36, p=.01); 2018 (OR=3.18, 95% CI=1.27-7.69, p=.01); 2019 (OR=3.47, 95% CI=2.17-5.54, p=.00); and 2020 (OR=2.91, 95% CI=1.81-4.68, p=.00). A student who identified as gender other had lower odds, compared to someone who identified as female, of reporting that the AAI program helped them manage their stress for the following three years: 2018 (OR=0.17, 95% CI=0.04-0.71, p=.01); 2019 (OR=0.27, 95% CI=0.10-0.74, p=.01); and 2020 (OR=0.26, 95% CI=0.09-0.78, p=.02). There was no statistical significance for individuals who identified as male. Similarly, for 2017, a student who scored high on the PSS-10 evaluation had lower odds of reporting that the AAI program helped them manage their stress compared to someone who did not score high on the PPS-10 (OR=0.33, 95% CI=0.15-0.80, p=.01). Finally, the result with a p– value of .08 for a student who scored with at least one ALE in 2018 is approaching statistical significance and future studies should explore this further. Discussion and Implications The overall aim of this study was to examine a secondary analysis of existing data from the six-year period of a college-based AAI program addressing student mental health and to explore the correlation between dose of attendance 154 at a campus-based AAI program and students’ perception that their doseage helped them manage their stress. For the first research question regarding the demographics and mental health features of those who participated, students were predominantly female, from the United States, 19 to 20 years of age, and undergraduate students. These demographics are similar to another campus- based AAI program at a large university that was conducted over the course of three semesters (Binfet et al., 2018). As a group, for “perceived stress”, these students scored in the middle of the mid-range on the PSS-10 scale. Those who identified as gender other scored the highest on the PSS-10, followed by females and then males, which is representative of the literature reporting decreased mental health for LGBTQIA college students (Blanco et al., 2008; Dunbar et al., 2017). International students scored lower on the PSS-10 than domestic students but being an international student was not statistically significant regarding the outcome of reporting that the AAI program helped them manage their stress. Close to seven out of every 10 students who attended this campus-based AAI program selected being nervous and stressed fairly often or very often in the past month. This result is consistent with a national Fall 2019 study that found 76% of students reported experiencing moderate or severe stress within the last 12 months (American College Health Association, 2020). Furthermore in this study, nearly eight out of every 10 students selected at least one ALE over the course of the past year and this included two out of every 10 students who were 155 diagnosed with a mental illness, and a little more than three out of every 10 students who received treatment for their mental health. For every 100 students, close to 16 had attempted suicide in the past 12 months. In comparing this study’s statistics with national trends, the ALE checklist is not a standardized tool so it cannot be equated to other reports. However this study’s results aligned with national rates of the collegiate student body that show 41% are diagnosed with a mental illness (Eisenberg et al., 2020), 34% seek mental health services on campus (Lipson et al., 2018), and one percent (1%) attempt suicide (Eisenberg et al., 2020). The second research question asked if there were any conditions associated with a student’s perception that attending a campus-based AAI program helped them relieve stress; five factors showed statistical significance. First, students who selected I thought it might help me relieve stress as a reason they attended the AAI program had higher odds of reporting that attending the AAI program helped them manage their stress for five of the six years compared to students who did not select this reason. One reason for this connection may be that intentionality determines outcomes so that one is guided to explain an event—that an AAI program helped manage stress–based on an individual’s actions around that event: The reason I attended the AAI program is because I thought it would help me relieve stress (Malle et al., 2014; Wu et al., 2018). Another reason for this odds outcome could be that because “stress” was 156 contained in the name of the AAI program, students were predisposed to their own stress management. Two other factors associated with a student’s perception that attending a campus-based AAI program helped them relieve stress were gender and their score on the PSS-10. For three of the six years, there were lower odds that a student who identified as gender other to report the AAI program helped them manage their stress compared to students who identified as female, and the factor of male was not statistically significant. For one of the six years, there were also lower odds for students to report attending the AAI program helped them manage their stress if they scored high on the PSS-10 compared to students who scored in the low or moderate stress ranges. An explanation for these lower odds could be based in these students’ presenting mental health conditions when they attended. As referenced earlier, students who identify as gender other suffer decreased mental health compared to their male and female peers (Blanco et al., 2008). While certainly therapeutic, the AAI program in this study was designed using a public health model for human well-being and not as a mental health intervention to replace clinical counseling and psychiatry. Further studies are needed to explore campus-based AAI programs that also use a public health framework in addition to AAI programs that could be incorporated into college students’ mental health treatment plans. The third research question is connected to the fourth and fifth factors in Question Two. For five of the six years, higher durations–increased number of 157 visits and length of time–were associated with higher odds that the person reported attending a campus-based AAI program helped them relieve stress. Having no statistical significance for 2018 (visit quantity and duration) may have been caused by a lack of power due to that year’s smaller sample size. The results of this study provide important implications for practitioners and administrators of campus-based AAI programs. First, consistent with other research (Bailey, in progress), this study adds to the limited but growing body of research that suggests a positive association between college students who attend a campus-based AAI program and improved mental health, particularly regarding stress management. Second, these results also add to the knowledge of AAI for mental health in general. To my knowledge, this is the first multi-year study to examine mental health outcomes, especially stress and stress management, associated with a college-based, weekly AAI program offered throughout the academic year. Second, this study found that the odds a student reported attending the AAI program helped them manage their stress were higher if they attended the program more frequently or for longer durations. These results suggest that ongoing, multiple-session AAI programs may be more favorable for students’ ability to manage their stress than single-session events such as what is commonly offered during midterm and final exams (Crossman & Kazdin, 2015). Furthermore, these results also suggest longer lengths of time spent participating 158 in an AAI program may be more beneficial overall; additional studies are needed to support these findings. There are no defined best practices when it comes to determining an optimal dose-response for a mental health intervention like AAI. Recognized by many scholars, this critical gap in the field calls for further investigation (Binfet, 2017; Crossman et al., 2015; Robino et al., 2021; Ward-Griffin et al., 2018). Previous work exploring AAI programs for college student mental health found positive outcomes for a range of durations from attending once for seven to 20 minutes (Binfet, 2017; Crossman et al., 2015; Fiocco & Hunse, 2017), attending more than 10 sessions for 60 to 90 minutes each (Binfet et al., 2018; Camaioni, 2013), or twice a month for three months and staying up to 120 minutes (Stewart et al., 2014). However, the notably small number of follow-up studies on students who attended AAI programs have been inconclusive. Their results have ranged from no change after two weeks (Binfet, 2017), effects that were strong post- session and became small after 10 hours (Ward-Griffin et al., 2018), and changes that were statistically significant for decreased negative mood and perceived stress, and increased social support (Wood et al., 2018). In a scoping review of campus-based AAI programs (Bailey, in progress), more than half of the 47 studies were offered only once and 40% of these studies lasted 30 minutes or less in duration. The average length of time a student remained at the AAI program in this study was just more than 30 minutes and the average number of visits was four (3.55 rounded up). These results are 159 consistent with other studies of campus-based AAI programs where the featured program did not set predetermined time limits, and students participated in a session for an average of 26 to 35 minutes (Binfet et al., 2018; Robino et al., 2021). Furthermore, while the number of studies in this scoping review were small, those that were held for multiple days or across multiple weeks created positive change in mental health outcomes at a higher rate compared to studies that were held only once. Finally, in light of the important role of the animal in the success of these AAI programs, there is a developing recognition that their welfare is often unchecked at best and dismissed at worst (Fine & Ferrell, 2021). This study was approved by IACUC and is one example of how future researchers can add an additional layer of ethical oversight to their studies. All animals in AAI programs must be recognized for their sentience and in doing so, afforded the respect, dignity, and care they deserve as co-practitioners and not discussed in terms of being used or a tool in the process. There can be a natural tendency to try and balance the mental health needs of thousands of college students with AAI programs that last for several hours with too few AAI teams and allow students to pet the animals as if they were in a production line rather than a therapeutic environment. Practitioners and administrators of campus-based AAI programs cannot forget that the animal in AAI is these programs’ greatest precious resource. Without a healthy, well-trained, and engaged animal, none of these AAI programs could be part of initiatives to support college student mental health. 160 Limitations The findings from this study should be considered in light of some limitations. First, sampling error impacts the cross-sectional estimates. The study did not use a representative sample that was randomly selected from the total population of college students at this university. The students who attended this campus-based AAI program and then also agreed to be part of this study likely had variable response rates to this study’s questions compared to students who did not attend. For example, if participants attended the program because they liked animals or because targeted marketing made students more aware that the program helped to support stress management, then these preferences caused selection bias. Furthermore, the low response rate of 32% impacts the results’ accuracy and does not allow for generalizability to the total college student population as well as the population’s sub-groups. The end of an academic year is when college students tend to concentrate their energies on coursework so they might have ignored the invitation and prompts to complete the study’s survey, thus contributing to the low response rate. This timing also likely introduced information bias since students tend to find the end of any semester a highly stressful period so they may have scored higher on this survey’s questions regarding stress. Second, while a cross-sectional study allows measurement of multiple variables at the same time, several important factors were omitted that limit a full snapshot of the participants of this program. The independence of all 161 observations could not be determined as there may have been some individuals who attended across multiple years of this study. Demographics such as race, ethnicity, age, and residency in the United States were not included. For example, there may have been higher attendance rates by students whose hometowns were further from campus due to them experiencing higher levels of isolation or homesickness. Furthermore, other mental health conditions that have high prevalence in the college community such as eating disorders, attention- deficit/hyperactivity disorder (ADHD), addictions, phobias, and post-traumatic stress disorder (PTSD) were not assessed in this study (Auerbach et al., 2016). Stress does not occur in a vacuum and comparing students across various categories is a finding that would help inform and target programming on college campuses. Third, because this study examined a single moment in time with no pre- test, the results do not allow for a cause-and-effect relationship between college students’ attendance at a campus-based AAI program and their reported ability to manage their stress. Furthermore, these results cannot be used to examine individual change, analyze behavior over a period of time, or establish long-term trends. It is unknown if the observed stress management rates apply beyond this study’s maximum of 10 visits and 120 minutes; therefore, longitudinal data are needed to more accurately assess the impact of attendance on perceived stress as well as the impact of covariates such as gender, international student status, age, and race. 162 Fourth, the measures used in this study impacted the ability to assess the effectiveness of this campus-based AAI program. The PSS-10 and the ALE checklist provided preliminary information about the incidents of stress and mental health struggles for the population in this study; however the ALE checklist has not been validated. As discussed earlier, a survey at the end of the year likely garnered higher stress responses on the PSS-10, and this instrument was not issued as a pre-assessment or tied to any specific attendance rates or durations. While students may have rated this campus-based AAI program high in regards to it helping them manage their stress, the results of this study cannot substantiate these individual perceptions. Further exploration using methods with strong psychometric properties are needed in addition to use of the PSS-10. Fifth, this study did not define the degree to which various components in an AAI session impacted the outcomes. In a review of the literature (Bailey, in progress), one study suggested that interacting with a dog or a dog and its human handler during an AAI session produced statistically significant positive outcomes whereas spending time with the handler alone did not (Grajfoner et al., 2017). In another study, interacting with the dogs in a college-based AAI program produced a statistically significant decrease in cortisol levels as well as for a second control group that observed these animal interactions while waiting for their turn to participate (Pendry & Vandagriff, 2019). The dynamic of AAI programs is complex to be sure, and how to tease apart and measure the 163 multiple and most prevalent influencing factors in an AAI session has yet to be established. Additional limitations of this study include it being based on self-report, and its overrepresentation of participants who identified as female and first-year students. Stress is felt across all college years and it is critical to explore why other college student populations such as those who identify as male are not accessing campus-based AAI programs at the same rate as their female peers. And because students were asked to reflect on their experiences for an entire academic year, the accuracy of how long and how often they attended the AAI program may be limited. Conclusions These findings, along with existing research, provide further evidence for promoting campus-based AAI programs among the college population, a group with consistently high rates of stress, depression, and anxiety. And while college health surveys continue to demonstrate that students underutilize mental health resources partially due to stigma, these AAI programs may help break down barriers and normalize the conversation around mental health, appeal to students who are highly stressed and treatment-avoidant, and expose more people to preventative mental health promotion activities. Subsequently, post-secondary institutions should consider how AAI programs can help expand a campus culture that openly and equitably acknowledges the daily stressors inherent to attending college. Through an unassuming environment that is inviting and relaxing, 164    campus-based AAI programs can help buffer the effects of stress and provide college students another resource in their arsenal of mental health supports. 165    References American College Health Association. (2020). American College Health Association National College Health Assessment: Fall 2019 reference group data. 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Psychiatric Rehabilitation Journal, 38. 173    Appendix A Sample Survey Questionnaire 174    CONSENT FORM Welcome! You are invited to be in a research study about health and health- related behaviors at the University of ____ and the relationship to the ____ program. You were selected as a possible participant because you volunteered your email address during a ____ program session. This study is being conducted by: Tanya Bailey, MSW, LICSW, University ____ Animal-Assisted Interactions Program Coordinator and ____, Principal Investigator (PI). To participate, read the "Survey Details" section below and then check the consent box at the bottom of this page. Please print a copy of this page for your records. The University of ____ is the sponsor of this survey. For more information about the University of ____ participation in this survey or the survey itself, contact survey administrator ____ Director of Research, University of ____ at (email address) or (office phone number). For technical concerns please also contact ____. SURVEY DETAILS The University of ____ is interested in finding out more about health and health- related behaviors among those who participated in the ____ program. This page describes the purpose and methodology of the survey. If you need more information before you agree to participate, please contact ____ at the email address or phone number listed above. WHAT IS THE PURPOSE OF THIS SURVEY? This survey provides ____ program staff with information about the health and well-being of its students and evaluation of the ____ program. This information helps to develop programs based on data. WHAT DO I NEED TO DO? Read this information and check the consent box at the bottom of this page to participate in the survey. You must be at least 18 years of age to participate, not have any severe allergies to animal fur, and have a valid ____ email address. The survey should take approximately 15 minutes. After you have completed the survey you will be asked to provide your contact information. Your contact information will only be used for the purpose of entering you into the prize drawing. WHAT ARE MY RISKS AND BENEFITS? This survey has the likelihood of the risk that some of the questions about how you feel may provide a low level of annoyance or discomfort. There are no direct benefits to participation in the study. 175    WHAT IS THE COMPENSATION? Those who complete the survey by ____ will be entered into a drawing for a $20 Amazon gift card. Ten participants will win one of these gift cards. The chances of winning the $20 gift card is approximately 1 in 40. All winners will be notified by ____. Although you are not required to complete the survey, you must complete the survey in order to be eligible for the prizes. WHO’S GOING TO SEE MY ANSWERS? The survey contains no information that can identify you. Your responses will be totally anonymous. Only summary statistics will be used in reports pertaining to this study. No individual data will be reported. Research records will be stored securely and only researchers will have access to the records. Study data will be encrypted according to current University policy for protection of confidentiality. Choose a private place to take the survey, as some of the questions are personal. For example: “Have you experienced any of the following in the past 12 months? Attempted suicide, excessive credit card debt, being put on academic probation.” VOLUNTARY NATURE OF STUDY Taking this survey is totally voluntary. It is acceptable to start the survey and then withdraw if you need or want to. Your decision to participate will not affect your current or future relationship with the University ____ and will in no way affect your ability to participate in the ____ program. You are free to complete all, some, or none of the questions on the survey. CONTACTS AND QUESTIONS The researchers conducting this study are Tanya Bailey, MSW, LICSW, and ____. If after completing the survey you have found some of the questions to be stressful or disturbing and would like to discuss this with a qualified professional, please feel free to contact Tanya Bailey, ____ Program Coordinator, at (office phone number) or (email address). For concerns or questions about your rights as a subject, contact: Research Subjects’ Advocate Line, (address and phone number). Thank you in advance for your participation. The results of this survey will help us provide better services for college students! Statement of Consent:  Yes, I have read the above description and I agree to participate in the study.  No, I do not want to participate in this study. 176    Thanks for completing our survey. Your responses will help us determine future directions for ____. At the end of the survey you will be invited to enter a drawing for one of ten $20 Amazon gift certificates. Your information will only be used for the purpose of the drawing. Q1 Where did you attend the University of ____ ____ program?  East  Other campus  West  Recreation center  Combination of Locations Q2 What is the reason you decided to attend a __ session? (Check all that apply)  I miss my pet at home  I thought it might help me relieve stress  My friend(s) wanted to come  I wanted to meet other people  I thought it might be fun  I like dogs and other animals  I wanted to see the Therapy Chicken  I was already at the clinic for care and decided to just stop in  I was already in the building holding ____ and decided to come  Other reason Q3 Which animals did you interact with? (Check all that apply)  Dog  Chicken  Cat  Rabbit  Horse  Guinea Pig  None (Please share why you did not interact with an animal) ____ Q4 How did you find out about ____? (Check all that apply)  Internet  Email  Flyer/Poster  Friend  School newspaper (6)  Other ____ 177    Q5 Typically how long do you stay at ____? 0 10 20 30 40 50 60 70 80 90 100110120 Number of minutes () Q6 How many times have you attended ____ since it began this school year? ▼ 1 times (1) ... 10 or more times (10) Q7-Q8 We are conducting a focus group regarding the performance of the ____ program. Would you be willing to be part of this focus group, if you are, please provide your email contact. If you would prefer to not participate just click on "Next Page" button. Q9 While at ____ , have you: (Check all that apply)  Collected one of the animal trading cards?  Followed ____ on Twitter?  Hugged an animal?  Taken a picture with you and an animal?  Tweeted a picture of an animal?  Met someone new who has become a friend?  None of the above Q10 Do you have a pet? (Check all that apply)  Yes, I have a pet in my current living situation  Yes, I have a pet that someone else is currently taking care of  I use to have a pet but the pet died, so currently I do not have a pet  I use to have a pet but I had to give it away, so currently I do not have a pet  No, I have never had a pet Q11 Have you experienced any of the following in the past 12 months? (Check all that apply)  Getting married  Failing a class  Serious physical illness of someone close to you  Death of someone close to you  Diagnosed with a serious illness  Diagnosed with a mental illness 178     Spouse/partner conflict (not including marriage)  Termination of a personal relationship  Attempted suicide  Put on academic probation  Excessive credit card debt  Excessive debt other than credit card  Arrested  Fired or laid off from a job  Roommate/housemate conflict  Parental conflict  Lack of healthcare coverage  Issues related to sexual orientation  Bankruptcy  Received treatment for a mental health problem  Other ____  Not applicable-none of the above happened to me Q12 In the last month, how often have you been upset because of something that happened unexpectedly?  Never  Almost never  Sometimes  Fairly often  Very often Q13 In the last month, how often have you felt you were unable to control the important things in your life?  Never  Almost never  Sometimes  Fairly often  Very often Q14 In the last month, how often have you felt nervous and "stressed"?  Never  Almost never  Sometimes  Fairly often  Very often 179    Q15 In the last month, how often have you felt confident about your ability to handle your personal problems?  Never  Almost never  Sometimes  Fairly often  Very often Q16 In the last month, how often have you felt that things were going your way?  Never  Almost never  Sometimes  Fairly often  Very often Q17 In the last month, how often have you found that you could not cope with all the things that you had to do?  Never  Almost never  Sometimes  Fairly often  Very often Q18 In the last month, how often have you been able to control irritations in your life?  Never  Almost never  Sometimes  Fairly often  Very often Q19 In the last month, how often have you felt that you were on top of things?  Never  Almost never  Sometimes  Fairly often  Very often 180    Q20 In the last month, how often have you been angered because of things that were outside of your control?  Never  Almost never  Sometimes  Fairly often  Very often Q21 In the last month, how often have you felt difficulties were piling up so high that you could not overcome them?  Never  Almost never  Sometimes  Fairly often  Very often Q22 Please respond to the following statement: "I believe ____ helped me manage my stress".  Strongly agree  Somewhat agree  Neither agree nor disagree  Somewhat disagree  Strongly disagree Q23 Rate the ____ program Poor 1 2 3 4 5 6 7 8 9 Excellent 10 Q24 Do you have any suggestions on ways of improving the ____ program? Q25 What is the most important thing you have gotten out of attending ____? Q26 I am (year in school) Q27 How old are you?  Under 19 years  19-20 years  21-24 years  25-34 years  35 or more years of age 181    Q28 Are you an international student?  Yes  No  Not applicable, I am not a student Q29 Current residence during the school year  Residence Hall  Sorority/Fraternity House  Off-campus housing (apartment/house)  Parent's home or other relative  Other ___ Q30 Gender (Check all that apply)  Male  Female  Transgender/Genderqueer  I prefer the following ____ Q31 Would you like to participate in the drawing for an Amazon gift card?  Yes  No Q32 Thank you for taking the survey. If as a result of taking this survey you are experiencing any distress the following are resources available to you: Crisis Information Crisis / Urgent Consultation is available on campus, Monday-Friday, 8:00-4:30. No appointment is needed to speak with a counselor for an urgent need. If you are in a life-threatening emergency, call 911, Or for 24-hour phone counseling, call Crisis Connection 1-HOPE: (612) 301-4673 Essential Numbers ____ Mental Health Clinic (phone number) University Counseling & Consulting Services (phone number) Disability Resource Center (phone number) International Student and Scholar Services (ISSS) (phone number) (Sexual assault) Center (phone number) Behavioral Consultation Team (phone number) 182    Q33 You indicated you would like to participate in the drawing please provide you contact information. Winner will be notified by email. Thank you.  First name  Last name  Email address 183    Appendix B Graphs of Attendance for Duration and Frequency of Visit 2015 2016 184  185    2018 2017 2020 2019 186  187    Chapter Four Paper Three The PACE Model for Animal-Assisted Interactions: A Conceptual Model of Practice 188    Introduction There is no debate that animals and humans have shared their lives with one another for millennia, and over time, some animals have become part of purposeful, facilitated, and active human health experiences. One of the earliest accounts of animals supporting human well-being dates to the ninth century in Gheel, Belgium. Individuals deemed as “handicapped” were cared for on farms, not institutions. They worked with and learned about crops and the daily living needs of livestock so as to contribute to and stay engaged with the surrounding community (Duval, 1860). In 1792, William Tuke opened The Retreat in York, England and included a wide variety of animal- and nature-based programs for people with mental illness (Fine, 2019), and in 1859, Florence Nightingale wrote that animals were helpful for the chronically ill. Nearly a decade later in 1867, people with epilepsy received care on a farm at Bethel (now the Epilepsy Center Bethel) in Bielfield, Germany where animals continue to be a significant component of residents’ daily lives (Endermann, 2010). Over the course of past five decades, continued professional interest in human-animal interactions has helped develop terminology, theoretical frameworks, scope of practice, and research agendas in this field of study (Hines, 2003). From this growth, one specific modality has taken on an established presence in human healthcare programs and services: Animal- Assisted Interactions. I define AAI as an active partnership with human practitioners and specially selected animals, both have received training, and 189    together as a team provide the purposeful delivery of direct and measurable therapeutic and educational services for human learning and well-being (Fine, 2019). The literature contains a diverse list of theories to understand and explain the complexities of AAI including attachment theory (Julius et al., 2012; Zilcha- Mano et al., 2011), cognitive theory (Geist, 2011), social support theory (McConnell et al., 2011; McNicholas & Collis, 2000), and the Biophilia Hypothesis (Wilson, 1984). With the growth of this integrative human health modality, practitioners, educators, researchers, and scholars have also had to grapple with a lack of mutual consensus as to what constitutes an AAI experience. Similar to the parable of the blind men who feel different parts of an elephant and respectively think they are touching a snake, a tree trunk, or a wall, AAI can mean having a one-time or multiple-session encounter with a dog, horse, rabbit, or cat for physical, emotional, social, or cognitive outcomes. However, this breadth also means there is opportunity to innovate how the profession can generate inclusivity through and for the practice of AAI. To that end, the purpose of this paper is to present a conceptual model of practice I developed called the Practitioner, Animal, Client, and Environment (PACE) Model and depicted in Figure 1 to help frame the way AAI programs are designed and implemented. Unless cited, terminology used to describe the many attributes of this model are ones that I have developed, and the PACE Model is applicable across all manner and types of AAI services. 190    Background Animal-Assisted Interactions For many people, a relationship with animals, especially one’s pet, proves to be an empirically- and anecdotally-reported source of support (Crawford et al., 2006; Hart, 2000; Serpell, 2000). According to a biennial census, approximately 60% of all households in the United States own a pet–dog, cat, horse, bird, fish, or specialty/exotic (American Pet Products Association, 2019). Pets are Figure 1 The PACE Model for Animal-Assisted Interactions (AAI) 191    commonly considered family members by 95% of U.S. households (Shannon- Missal, 2015), and this affiliation is often described as a kinship which indicates the strong and significant connection shared between humans and animals (Charles, 2014). Credited as social lubricants (Bossard, 1944), animals provide opportunities for people to meet each other, form friendships, share experiences, and create a sense of belonging (Blazina et al., 2011; Wood et al., 2015). AAI, once a program primarily offered in eldercare facilities and hospitals, has continued to evolve and diversify. To date, AAI programs and services occur in a wide variety of settings including prisons, libraries, trauma centers, airports, and college campuses (Nimer & Lundhal, 2007). AAI is also implemented with numerous animal species a range of bio-psychosocial circumstances such as hippotherapy and cerebral palsy (Mutoh et al., 2018), dolphin therapy and autism spectrum disorders (Marino & Lilienfeld, 2021), fish in aquariums and dementia (Edwards & Beck, 2013), and dogs and post-traumatic stress disorder (PTSD) (Beetz et al., 2012). Furthermore, systematic reviews show limited support for the benefits from AAI for people who have conditions such as depression, schizophrenia, and chemical addictions (Kamioka et al., 2014), cognitive decline and behavioral symptoms from dementia (Charry-Sánchez et al., 2018), and children with autism (Maujean et al., 2015) and physical challenges related to balance and gross motor function (Stergiou et al., 2017). AAI’s growth in popularity and expansion as a modality, especially in the fields of health care and education, is apparent despite lacking a robust body of 192    empirical support (Rodriguez et al., 2018; Serpell et al., 2017). On the one hand, a 2018 survey with 300 mental health practitioners revealed that 91.7% perceived AAI as a valid modality and more than half were interested in practitioner and program training (Hartwig & Smelser, 2018). In contrast, scholars recognize that existing research contains limitations such as constructs with inconsistent definitions, assessment tools that lack reliability and validity, and unrefined results (Herzog, 2015). The current state of AAI sits at a unique junction. It can be argued that the most important direction must provide further study on the impact and outcomes of these programs. However, without full understanding of the processes and mechanisms that drive the implementation of AAI sessions, the field ignores another course and opportunity to clarify what, how, and to what extent various factors interact and collaborate to generate optimal learning and healing. Therefore, the purpose of this paper is to present a conceptual model of practice for AAI, called the PACE Model, as a way to examine the mechanisms and help explain the outcomes such as those reported in the literature (McCardle et al., 2011). Conceptual Model A conceptual model is a frame of reference that helps clarify or guide learning and knowledge, and can be considered a physical representation of various components or broad phenomenon and the causal pathways in which they relate to each other (Delcambre et al., 2018). For the purposes of this paper, I consider a conceptual model to identify what factors will affect an outcome, 193    detail the mechanisms that help explain how and why an intervention works, and be informed by relevant theory (Dalkin et al., 2015). While mechanisms are classified as moderators and mediators, this specificity is not included in my model as I chose to focus on the components and their reciprocal relationships with each other. Using a conceptual model also assists with optimizing an intervention because each concept can be independently examined, all interactions can be assessed, and the optimal combination to produce the highest possible outcomes can be selected (Collins, 2018). A review of the literature provides no clear evidence that the field of AAI has selected an existing conceptual model or critically evaluated the applicability of any conceptual models in comparable fields (Fine, 2019). Furthermore, the field of AAI has not clearly specified what mechanisms in programming and services definitively contribute to and support human well-being (López-Cepero, 2020; Shen et al., 2018).The importance of having a conceptual model of practice in AAI is demonstrated by exploring the recent surge in campus-based AAI programs for college student mental health. Similar to how the overall field of AAI continues to rapidly evolve, campus- based AAI programs as a whole do not follow an established course of implementation and based on a recent scoping review (Bailey, in progress), remain highly variable in numerous ways. First, some programs are facilitated by college staff or community volunteers, both of whom may or may not have training in some associated discipline such as health promotion or mental health. 194    Second, while it is commonly perceived that these programs work with animals trained and registered as therapy animals, such standards are not always the case. Some animals may be less than a year of age which means they have received minimal formalized training. Animals may come directly from an animal shelter and are only assessed for their friendliness and general willingness to engage with people, or animals may include exotic species so as to run a greater risk of zoonotic disease (Lefebvre et al., 2008). Third, some AAI sessions are open to all students while others specifically target students to support their mental health outcomes (Grajfoner et al., 2017). Fourth, AAI sessions can range in frequency from operating only during finals and midterms (House et al., 2018) to occurring weekly or monthly throughout the academic year (Bailey, 2020; Stewart et al., 2014). And fifth, AAI is naturally a spatially diverse modality; it can be practiced via an intimate, one-to-one interaction in a small space (Engel, 2011) or occur in large open areas that provide accessibility to all students (Camaioni, 2013). This example of diversified AAI programming for such a niche area as college student mental health is also indicative of the variability in AAI programs and services across the world. The practice of AAI can almost seem like speaking or living out another language depending on the audience because working with a horse and a group of teenagers differs profoundly in program planning, application, and appearance than a person visiting an eldercare facility with a rabbit. However, some essential components and mechanisms in the 195    practice of AAI are identical in the two preceding sessions with the horses and rabbit. These components make up the PACE Model and are discussed in more detail in the next section. Overview of the PACE Model for AAI The PACE Model for AAI is a conceptual model of practice that defines four essential components—practitioner, animal, client, and environment—that exist and are consistent in every AAI session. Not yet tested, this model is meant to be applied in pursuit of a comprehensive and encompassing framework of practice that overtly and equitably represents the living experience every practitioner, animal, client, and environment produces at AAI sessions. It draws on the underpinnings of person-in-environment (PIE) theory, developed by one of social work’s founders, Mary Ellen Richmond (“A Holistic View of Social Work,” 2019), and Bronfenbrenner’s (1977) socio-ecological systems theory. These theories emphasize an ecosystem where humans and the environment have a bi-directional relationship, and it is in the exchange with these multifaceted and constantly changing surroundings that one develops their thoughts, feelings, and behaviors. While I recognize that AAI outcomes focus on influencing change in human well-being, I strongly believe that a significant strength of this modality– which is identified in the PACE Model–is the inclusion of environment. The objective of the PACE Model is to provide what authors Britt and Chen (2013) call “the clear display of complexity” that is AAI. The model directs the reader to what is often understood as inherent, albeit often unconsciously, in 196    AAI programs and services and creates a more informed awareness for program planning, implementation, and assessment (Soulliere et al., 2001). And expressing the PACE Model in a three-dimensional form demonstrates how these factors are independent, yet interrelated, regardless of program structure or personnel experience. Finally, the dynamic intersectionality of all four components is not random, and in response to various contexts, they form a network of reciprocal relationships that ultimately influence outcomes and set the pace for AAI sessions (Collins, 2018). Given the gap in the literature coupled with the increased societal promotion of involving animals in so many facets of one’s life, it is crucial to use a conceptual structure to help advance understanding of the intricacies found in AAI programs. The PACE Model enables practitioners, scholars, and researchers to identify and develop a deeper understanding of AAI programs’ key mechanisms, ones that distinguish this modality from other human well-being experiences (Soulliere et al., 2001). This model provides a research framework for the critical analysis and optimization of AAI outcomes, and it has potential use as a performance measurement tool that helps direct the complex tasks required throughout all aspects and phases of AAI program design. Finally, AAI practitioners can also use this model as a holistic guide to assess program rigor, goals and objectives, risk management, and precautions and contraindications (Britt & Chen, 2013). 197    As a licensed clinical social worker and educator with more than 25 years of experience in the AAI field, I have collaborated with and learned from clients, students, animals, and colleagues as I carefully considered what critical concepts are part of the broad application of AAI. The PACE Model took shape while I was instructing college graduate-level AAI courses, and students in these classes— as well as other AAI practitioners—have provided feedback to help me apply further refinements. Through this model, I intend to bring together factors that provide the beginnings of a structure that furthers theory development, and to encourage rigorous examination of the mechanisms used in AAI programs on par with those applied to empirical outcomes. PACE Model Components I maintain two primary tenets as essential guides when using this model: (1) all beings involved in AAI are autonomous and have an inherent right to be treated with dignity and respect, and (2) the dynamic interplay that happens during an AAI session produces an alchemy greater than the sum of the four components on their own. In this section, I describe each of the four PACE components and the reciprocal interactions they produce in AAI programming. Practitioner The first component in the PACE Model is the practitioner who is the identified individual responsible for the delivery of AAI services. This person may or may not work with an animal depending on the level of program oversight and supervision required to manage the needs of the identified client, animal, and 198    environment in an AAI session. Individuals providing AAI sessions may also include more than one person from more than one professional discipline, such as a psychologist and a physical therapist (Koukourikos et al., 2019). All support staff are also included in this category as they add additional structure to overall program implementation. A practitioner who delivers AAI services should work within the scope of their profession and also possess advanced skills and training such as the example in Table 1 to demonstrate their competence for working with such a complex modality (Fine, 2019). Many programs feature a human-animal team approach in which one person works with an animal, usually their own, or two people work together with an animal such as in many equine programs (Stern & Chur-Hansen, 2019). Often overlooked in the AAI literature, by partnering with one’s own pet and sharing considerable familiarity with each other (e.g., this animal lives with the practitioner), the ethical concern of a dual relationship in a therapeutic setting is introduced. It is a delicate process of assessment and management for a practitioner to intellectually and psychologically separate from the personal relationship they have with their animal and establish boundaries in a working environment where they must determine that this animal has requisite skills to match a session’s goals and objectives (Boland-Prom & Anderson, 2005). Of primary consideration for any AAI program is if the outcomes are beneficial for all beings involved. Only recently has the AAI field explicitly 199    acknowledged and included in codes of training and practice the importance of an animal’s welfare when engaged in these programs (Fine & Ferrell, 2021; Howie, 2015). No longer is it appropriate to say, “I use a horse in my work with children” or “I use a dog to help counsel people with addictions issues.” Instead, practitioners are encouraged to work with or partner with the animal in the same way they would with a human co-therapist and not use the animal as an inanimate tool. For AAI programs that serve a large group of people, multiple practitioners may work together and either be partnered with their individual, assigned animals or engage with a group of animals such as a herd of horses to simultaneously provide interactions to several people. In the case of a campus-based AAI program, the practitioner is also responsible for upholding the values and objectives of this large group program, always advocating for the health and safety of all beings while balancing program quality with quantity. The varying environments for each session, both in terms of physical locations and natural conditions, coupled with the kaleidoscope of students who may range from frequent to first-time attendees, can increase the factor of variability at each program session to infinity. Other terms for practitioner include provider, therapist, teacher, instructor, educator, and facilitator. Animal The second component in the PACE Model is the animal and can be one individual or several animals working together. Based on best practices in the 200    field of AAI (Pet Partners, 2021), this animal is ideally a domestic species no less than six months of age for animals like rabbits, guinea pigs, and fancy rats, and at least one year of age for dogs, cats, equines, birds, etc. Animals that are directly involved in AAI sessions should have a natural temperament suited to a program’s goals, objectives, and setting (Butler, 2013). For example, a cat that remains calm and seeks out interactions when introduced to a group of people is a potential candidate to work in a large, heavily attended campus-based AAI program. Another cat that tends to stay close to one person may be better suited for a less complex setting like individual therapy sessions. To prepare them for the multifaceted work in AAI programs and services, animals also need specific training beyond basic obedience (Butler, 2013) and should receive some level of assessment as to their skills and aptitude for working with people through national organizations such as the Alliance of Therapy Dogs (2017) or Pet Partners (2021). Occasionally, animals that are not identified or trained become part of AAI sessions and are considered ad hoc program animals. When taking in the larger milieu of a session, these ad hoc program animals could include songbirds, squirrels, or another dog going for a walk with a student on campus. Adding ad hoc animals often occurs when AAI programs take place outdoors or in settings where multiple other animals already reside, like a horse barn or dog training center (Bokkers, 2006). While these additional animals are not the intended program animal for AAI sessions, they can have minimal to very significant 201    influence on the other three components of the PACE Model. A chicken working outdoors during an AAI session will be attuned to its surroundings in a much more vigilant way than one working indoors or a less dynamic environment and may therefore be less present in its interaction with people than if the session was held in a covered space that provided protection from predators (Fischer & Milburn, 2019). Client The client is the third component in the PACE Model and is the identified and intended recipient of an AAI service. All sessions start and end with the client in mind, and better rapport with the client leads to better outcomes (American Psychological Association, 2019). If the goal of a campus-based AAI program is to address college student mental health, then the “client” could reasonably include all students on campus or it could mean a specific roster of students who are receiving mental health services focused on conditions such as anxiety, depression, or disordered eating (Binfet, 2017; Engel, 2011; Pendry et al., 2020). The feedback loops that result any time there is interaction between two or more components serve to create meaning and inform future transactions (e.g., “Was that a pleasant and empowering experience I was to repeat or a traumatic and destructive experience I want to avoid?”), and there may be some clients who are inappropriate for AAI programs and services. Just because a person might view or experience interactions with animals as enjoyable does not always mean those experiences will be therapeutic or help to accomplish specific 202    treatment goals. Some common precautions and counter-indications for AAI include a person’s physical ability (e.g., whether they are they ambulatory or able to move around safely with staff support); their sensitivity to allergens such as fur, dander, and pollen; and their mental status such that they are not actively psychotic, violent, or have phobias and fears about animals (Fine, 2019). Thorough preparation on the part of the client as a consumer and by the practitioner who is responsible and ultimately liable is just as critical as the selection and training of an animal to help ensure that AAI sessions are effective as well as safe for all involved. As with the animal component of the model, the client includes all people present in an AAI session who are not program staff or support personnel. Simply put, each person present at an AAI session, whether active or passive during a session’s interaction, has a sphere of relational influence on a program’s operations and must be considered integral to the process (Arnold et al., 2012; Kivlighan III & Narvaez, 2020). Other terms for the client are participant, student, group, family, and individual. Environment The fourth component in the PACE Model is the environment and is defined as the identified location where the AAI program occurs; it includes the greater milieu of one’s “everyday geographies” that are natural, created, and negotiated (Mossabir et al., 2021). The environment can be the most complex and often overlooked factor in the PACE Model due to common assumption that 203    AAI sessions that take place in commercial buildings or spaces are more focused, predictable, and less impacted by natural elements compared to those that occur in outdoor capacities such as barns or farmyards. Regardless of whether or not an AAI program’s activities are sheltered from the elements, the physical surroundings invoke all the senses and can have a major impact on how a session progresses (Guite et al., 2006). For example, the environment of programs that occur inside can include such factors as room temperature, floor surfaces that may pose a slipping hazard, lighting that is too bright or dim, the scent of hand sanitizer or cleaning supplies that have left a residue on tables and chairs, loud or unpredictable noises and sounds, and spatial set-up which could constrict interactions or result in a lack of accessibility for all participants. Furthermore, natural weather patterns are influential regardless of session location as evidenced by many dogs that display fearful behaviors like shaking or vocalizing when there is a loud thunderstorm. The PACE Model encapsulates what makes AAI programs and services unique–a practitioner, an animal, and a client come together in a shared environ- ment to accomplish a human health or well-being objective. However, each of these four components brings a wide range of attributes and distinguishing features that when combined, creates a fifth concept called Reciprocal Interaction. In this next section, I add some metaphorical movement to the PACE Model given that the intersectionality of these four components creates outcomes that are multi-dimensional and greater than the sum of each part. 204    Reciprocal Interaction Conceptual models help to visually identify the key or most important feature of an area of interest or phenomenon, especially one comprised of many subtleties like AAI where a component’s presentation and meaning are constantly evolving (Britt & Chen, 2013). Furthermore, conceptual models also help define the causal nature of relationships between and among concepts (Soulliere et al., 2001). In addition to the individual merits of each PACE component and how they uniquely behave and evolve at every session, the term Reciprocal Interaction describes the process and results created when the four components converge and form a separate yet similarly changing unit (Eriksson et al., 2018). Because the components have relationships that operate with and independent of one another that may modify over time, a constant give-and-take occurs throughout an AAI session to find balance. For example, a registered therapy rabbit will have a relationship divergent from that with a student who attends an AAI program once versus with another student who comes every week, regularly sits on the floor, and engages with the rabbit. The reciprocity between each of the four components is represented by the bars shown in Figure 1. Adapted from Mostwin’s Family Life Space Drawing (1980), these bars are dynamic and reflect the strength or health (narrow or wide) of each connection as well as the familiarity (close or distant) between them. In Figure 2, the bar connecting the animal with the practitioner is wide and short. This human-animal team may be one that has worked solidly and 205    successfully together for many years, has a strong relationship (wide bar) and knows each other well (short bar). In Figure 3, this same short bar could signify that the practitioner is well-versed in working with a particular species, but because this individual animal is a fairly new partner in AAI programming and their relationship is still forming, the bar is narrower. Another example in Figure 4 shows a thin and long bar between the animal and the client. This could indicate that the client is not yet socially or emotionally connected to this animal (narrow bar) and may be new to receiving AAI services, so the whole context of participating in therapy this way is unfamiliar (long bar). Figures 2 - 4 Examples of Reciprocal Relationships in the PACE Model for Animal- Assisted Interactions (AAI) 206    Including reciprocal interactions in the PACE Model is a specific way to demonstrate how the four components interact and also provides a way to consider the mechanisms that impact AAI outcomes. As shown in the hypothetical configuration in Figure 5, the PACE Model becomes transformed each time these four components come together and helps emphasize the organic nature of AAI sessions. Using socio-ecological theory, each component represents a context that is impacted biologically, socially, and culturally (Eriksson et al., 2018), and because these four components interact individually yet collectively with one another, their varying relationships create outcomes that are multi-dimensional and greater than the sum of each part. Much like baking bread, the finesse of planning, combining the four PACE components, and conducting AAI programs is both an art and a science (Van den Brink et al., 2019). A recipe may call for combining different amounts of ingredients and although there is an exact measurement of how much water to use, an intuitive baker also knows when bread dough they are making requires more or less liquid to be successful. Similarly, the therapeutic and skilled use of self (Harris & White, 2013) prompts an AAI practitioner to thoughtfully examine the strengths and weaknesses that each program element could bring to a session–known as Quality of Competence–and then plan what permutations of the model are most appropriate to maintain safety, ensure animal welfare, and effectively address therapeutic goals and objectives (Soulliere et al., 2001). 207    Quality of Competence Each PACE Model component brings a level of skill, aptitude, and capability to an AAI session that I define as Quality of Competence (QOC). The QOC is dependent on context and individuality and involves quantitative attributes like one’s age, animal breed, species, and facility layout as well as qualitative elements like experience, formal education or training, and a person’s mental health status or cognitive ability. As with the recognition of four main components comprising every AAI session, this consideration of each component’s aptitude for program engagement is generally a process that happens innately. An experienced clinician knows to conduct a mental health Figure 5 Example of Combined Reciprocal Relationships in the PACE Model for Animal- Assisted Interactions (AAI) 208    status exam (Forrest & Shortridge, 2020) each time they meet with their client, yet using a similar process to assess their animal partner and an AAI session’s environment may not be at the fore of that day’s program planning. When using this model and considering the reciprocal interactions of a session, the goal is to create balance by recognizing the shortcomings and strengths of each component. Where one component may have less skill or ability (low QOC), the other three can be examined for higher levels of skill or ability (medium and high QOCs) so that shortcomings in one area of a session can be compensated for and balanced by strengths in other areas. Equality is not a goal of balance (Evans, 2020). Instead, the model endeavors for equity, stability, and congruence in AAI sessions. Furthermore, the PACE Model provides ways of evaluating program components so that objectivity is added to an otherwise very experiential process (Van den Brink et al., 2019). The PACE Model in Figure 6 illustrates the QOC by using a gauge or meter with a “minus” end and a “plus” end. The greater the competence each component brings to the AAI session, the higher that component is listed on the gauge. This gauge does not assign meaning to a component’s QOC (e.g., a bad animal or a good practitioner) and is only one way of attributing a quantifying marker to a living entity at one moment in time. For example, a car can have a full tank of gas (high QOC) or be almost empty (low QOC) and the car will still run so long as gas is present in the tank. Similarly, a young dog that has recently started working in AAI programs will have a lower QOC when compared to a dog 209    that has been coming to campus for four years. While the older dog knows the ropes a bit more than the younger one, the QOC for both will continue to evolve as they age and gather more experience. Another tool to conduct a PACE Model assessment is demonstrated in Table 1’s QOC rubric. As shown in the hypothetical example in Figure 5, a Figure 6 The Quality of Competence Gauge in the PACE Model for Animal-Assisted Interactions (AAI) 210    component’s QOC can increase or decrease during a session, and as one connection changes, the entire model constantly evolves. That same rabbit visiting with a student could be calm and have a high QOC one moment and then quickly experience a low QOC because the sound of a slamming door has startled it (Gewirtz & Radke, 2016; nidirect, 2015). The QOC rubric uses the first three stages of Howell’s Conscious Competence Learning Model (Howell, 1986)–unconscious incompetence, conscious incompetence, and conscious competence, and as depicted in Table 1, moves from low to high competence. I do not include Howell’s fourth stage, unconscious competence, because I believe the practitioner must maintain active and purposeful attention during a session. Considering that the three other components in the model have an ability to function at a high level of independence, these dynamics require constant monitoring to assess and reassess the total interplay of the experience and this cannot be left to an unconscious, albeit competent, practitioner. For example, conducting an AAI session on a very hot day could result in an environment with a low enough QOC that the other three components do not have a combined QOC high enough to create balance. Instead, if the environment can be changed to help increase the session’s QOC, (e.g., relocated to an indoor facility with air conditioning), it can now complement the QOCs of the other three components. In another example, a standard poodle that is a registered therapy dog demonstrates much trepidation when walking on   211    Table 1 The Quality of Competence (QOC) Rubric for AAI Assessment 212    slick or polished surfaces. While the dog has been working in AAI programming for more than five years, its QOC increases or decreases depending on the location (environment) of each session. The handler may not be able to provide enough of their own QOC to appropriately support their canine partner because this standard poodle weighs 70 pounds and is too heavy to carry over a long length of tiled flooring. Therefore, the handler could decide to only work with their dog at facility environments that have anti-skid concrete or carpeted floors. This decision would help the handler and the dog maintain high QOCs and thereby contribute to the safety of the session. The handler is not distracted and worried about where the dog is walking and the dog maintains its confidence and ease while moving about the AAI session. Furthermore, because the practitioner and animal have high QOCs in this instance, the environment or the client could have lower QOCs and still produce an AAI session that demonstrates high standards of practice. The PACE Model provides a tangible way to assess the practical development and facilitation of each AAI session by considering every component’s QOC and, subsequently, the reciprocal relationships that are possible once all four components converge. If a practitioner has yet to established proficiency in a human health or educational condition, working in a predictable and calm setting with an animal partner they know well is one strategy that would help them balance their current low QOC and contribute to an intended outcome that benefits their client. The model also strives for a holistic 213    and broad perspective of AAI practice by overtly naming the four essential components present in every AAI session and contextualizing them in relation to socio-ecological theories and current empirical literature (Eriksson et al., 2018; Fine, 2019). Furthermore, the model illustrates that the importance of assessing an AAI experience is complex because it requires measuring multiple living entities who and that are constantly evolving at every moment of that session. In this way, individual components are simultaneously emphasized alongside contextual factors as to their independence yet dependence on one another in every AAI session. The PACE Model therefore offers a universal tool that may help explain and determine the mechanisms that promote ethical and effective AAI outcomes. Summary The fundamental purpose of this paper was to present a conceptual model of practice for AAI called the PACE Model–practitioner, animal, client, and environment–and provide practitioners and administrators with an exercise in awareness or conscious competence for the design, implementation, and practice of AAI sessions. While I continue to make refinements to the PACE Model based on my experiences, reviewing the literature, numerous consultations with colleagues, and feedback from students, there is no current research evidence that supports this model’s application and effectiveness in AAI. Important next steps for this model are to develop and conduct rigorous research designs, provide scrutiny and testing of this model in the real world of AAI practice, and determine how useful this model is for practitioners. 214    Future studies are also needed to examine the validity of the four main components in this model as well as test the applicability and conformity of the overall model with numerous AAI programs and services (Britt & Chen, 2013; Soulliere et al., 2001). Scholars have called for directed attention at intervention fidelity, a substantial shortcoming in the extant literature, but this cannot be adequately accomplished without also clearly identifying and operationalizing the key mechanisms of change that support or hinder outcomes. The four components of this model need further definition especially in regards to how the QOC levels are categorized for each factor. Those in the fields of AAI as well as other complementary disciplines in human health, (e.g., social work, public health, physical therapy, education, and psychology), and animal health (e.g., veterinary medicine, animal welfare, and animal behavior) are particularly suited to evaluate this model because each can provide perspective from multiple and varied points of practice. Presentation of the PACE Model contributes to and addresses a gap of collaboration and consensus in the AAI field. Simplifying a complex system by naming the four concepts that are critical to any AAI session–the practitioner, the animal, the client, and the environment–helps foster shared principles, language, and behavior among people who develop, implement, or evaluate AAI programs and services (Delcambre et al., 2018). Identifying a way for all AAI methods to come together under one common understanding ultimately adds integrity, accountability, and efficacy to all facets of the field. 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Attachment & Human Development, 13(6), 541–561. 227 Chapter Five: Conclusion This three-paper dissertation examines a human health modality called Animal-Assisted Interactions (AAI) for college student mental health and in doing so, expands on and contributes to a small and rapidly developing area of multidisciplinary practice and research. The fundamental reason for this study is the importance of health for the practitioners and personnel who are invested in college student well-being; the current and potential individuals who are college students; the animals who help provide these AAI programs; and the campus environment. A secondary reason for this study is structural knowledge of how a larger perspective on campus-based AAI programs coupled with a conceptual model of practice can generate greater cohesion and understanding among all who care about and are involved in the field of AAI. The three papers that comprise this dissertation employ three unique vantage points that, to my knowledge, provide new information previously unreported in the literature. In this concluding chapter, I summarize each paper and explore how their intersectionality converges to form a more comprehensive lens to elucidate the complexity of providing ethical and effective AAI program and services. I discuss the limitations of each paper, and finally, I propose the implications this study provides for AAI and college student development through social work practice, policy, research, and education. Major Findings Paper One presents a scoping review, namely the first one to examine 228 and summarize existing peer-reviewed or dissertation literature about campus- based AAI programs specifically addressing college student mental health. The results identified 37 papers that were all published since 2003, demonstrating that campus-based AAI programs are an emerging intervention to support college student mental health. Furthermore, the United States and Canada lead this research initiative to examine AAI programming for collegiate mental health. As to the logistics, the most frequent way these campus-based programs were offered was a one-time, single-session of 15-minute duration with one dog, the predominant species in this body of research. Overall, the studies in this scoping review showed an improved directional change in the mental health outcomes measured in college students who attended AAI programming. This scoping review identified 44 individual mental health outcomes in the cognitive, physiological, psychological, or social quality of life domains; and combined, these mental health outcomes were cited 113 times. There were 18 randomized controlled trials, 14 were quasi-experimental, and five were mixed methods. While 11 studies included some type of open-ended questions, as of yet, no published study has solely taken a qualitative approach. Among the results, 75% of the mental health outcomes improved, 22% showed no change, 2% got worse, and 1% was not reported. The most frequently recorded outcome was stress/perceived stress followed by anxiety, and these findings are among some of the most prevalent and presenting concerns 229 experienced and documented at college counseling centers across the United States (Eisenberg et al., 2020). Paper Two explores the correlation between dose of attendance at a campus-based AAI program and college students' perception that said programming helped them manage their stress. The study uses a repeated cross-sectional, six-year study of secondary analysis of existing data. The sample included a total of 3,255 individuals who were predominantly female, from the United States, 19 to 20 years of age, and undergraduate students. On average, students came to the AAI program four times and participated for 31.4 minutes per session. Across all six years, students scored 19.54, the moderate stress range on the PSS-10 (Perceived Stress Scale-10), (Cohen & Williamson, 1988), and more than seven out of 10 students fairly often or often felt nervous or stressed in the past month. Close to eight out of 10 students reported at least one adverse life experience (ALE) in the past year, and the average was two, on a checklist adapted from the College Student Health Survey at the University of Minnesota (Lust, 2021). Included in these ALEs, approximately one-fifth of the group was diagnosed with a mental illness and more than one-third received mental health treatment. Close to eight out of 10 participants selected “I thought it might help me relieve stress” when responding to why they attended the AAI program, and nine out of 10 students rated the program highly effective at helping them manage their stress. Using logistic regression, the results showed that overall and independent 230 of one another, the odds were higher that a student reported the AAI program helped them manage their stress if they attended more often, stayed longer, and selected that they attended because they thought it would help relieve stress versus students who did not identify having these factors. For three of the six years, compared to those who identified their gender as female, students who identified as gender other had lower odds to report the AAI program helped them manage their stress; these lower odds were also present for students who scored high on the PSS-10 compared to those who scored in the medium or low ranges for one out of the six years. There was no statistical significance if a student identified as male, international, or had an ALE in the past 12 months. Paper Three presents a conceptual model of practice I developed for AAI called the PACE Model (Practitioner, Animal, Client, and Environment) which identifies and makes overtly conscious the four key components that help frame how AAI programs are developed and implemented. The model also examines the mechanisms of change to help explain the outcomes from these AAI programs and which are reported in the literature. The scoping review in Paper One and a review of the literature provide no clear evidence that the field of AAI has selected an existing conceptual model or critically evaluated the applicability of any other conceptual models in comparable fields (Fine, 2019). Furthermore, the field of AAI has not clearly specified what mechanisms in programming and services contribute to and support human well-being (López-Cepero, 2020; Shen et al., 2018). To that end, this paper offers a three-dimensional model and 231 assessment rubric to help practitioners, scholars, and researchers identify and gain a deeper understanding of AAI programming’s key design features. The PACE Model illustrates that through the interplay of its four components, ever-evolving reciprocal interactions are created that impact AAI outcomes. Assessing an AAI experience is complex because it requires measuring multiple living entities who and that uniquely behave and evolve at every single moment in that session. In addition, the skill, ability, and current state of each component translates to a Quality of Competence (QOC) measurement. Where one component may have less skill or ability (low QOC), the other three can be examined for higher levels of skill or ability (medium and high QOCs) so that shortcomings in one area can be balanced by strengths in other areas. This QOC produces an assessment of the stability each individual component brings to an AAI session and also an overall perspective of how these four components play out in one experience when they are combined. Consequently, the PACE Model creates a model of practice that provides a way for all AAI methods to come together under one common understanding so that integrity and consensus may be fostered as to how to practice AAI ethically, humanely, and effectively. Commonalities While these three papers utilized different perspectives, the results from this dissertation are important contributions to a small but growing research and practice agenda that focuses on AAI programs and services for mental health. 232 Taken together, their findings offer a more robust understanding of this topic’s context and demonstrate the critical need for continued scholarly investigation in two ways. First, the findings from the first two studies are aligned with the overall literature, suggesting an association between improved student mental health outcomes and attending an AAI program. More specifically, these findings are focused on stress and college students, a unique group that are steadily demonstrating increasing and more complex mental health challenges (Crossman & Kazdin, 2015; Eisenberg et al., 2007, 2020). Examining stress as an outcome of campus-based AAI programs is especially relevant due to the fact that on a Fall 2019 survey, 76% of students reported experiencing “moderate” or “high” stress within the last 12 months; and overall, stress and anxiety were the top two issues that negatively impacted students’ academic performance (American College Health Association (ACHA), 2020). Second, despite these positive results, each paper helps reinforce that campus-based AAI programs as a mental health intervention remain in an infant phase of critical understanding. As of a 2015 census, there were 925 campus- based AAI programs across the United States (Crossman & Kazdin, 2015) compared to the scoping review in Paper One that showed since 2003, only 37 empirical studies that examine these programs have been published. The rapid expansion of AAI programs on college campuses has greatly outpaced the evaluation of their effectiveness for college student mental health. Findings from this dissertation affirm that AAI programs and services are highly complex, 233 extremely varied, and lack an overall conceptual model of practice. In order to further understand this modality, a process to measure program fidelity, dose- response outcomes, and—perhaps most importantly—the health impacts on AAI animals are critical gaps that require attention. Limitations While this dissertation presents many new findings and contributes to current AAI literature, it is not without its limitations. First, the findings reported in the scoping review of Paper One were only derived from English-language publications. The wide variability in AAI terminology or definitions of key concepts means that some studies might have been missed during the search process (O’Brien et al., 2016). Second, bias may have been introduced by not having access to unpublished manuscripts that would have added to the overall map of the AAI field. Third, my lengthy professional experience and practice in the AAI field may have also added bias to the overall results. And finally, scoping studies do not tend to assess the quality of included studies or answer a specific research question and therefore, do not typically make specific recommendations based on findings. Second, the findings from the cross-sectional study in Paper Two are impacted by sampling error as they are based on a convenience sample of college students taken at the end of each academic year and who were predominantly female and in their first year of studies. This sample has a low response rate and was not randomly selected which likely resulted in variable 234 response rates to this study’s questions. Therefore, such a convenience sample limits the generalizability and establishment of a cause-and-effect relationship between students’ attendance at a campus-based AAI program and their resulting ability to manage their stress. The methods used for this study included self-report and non-standardized measurement tools that omitted some important demographic information. It is not possible to assess the effectiveness of this AAI program across the broader collegiate population or subgroups because factors such as race, ethnicity, age, and residency in the United States were not listed on the survey. And while this study covered six years of data, the study questionnaire was issued once at the end of each academic year. Thus, it cannot be used to examine individual change, analyze behavior over a period of time, or establish long-term trends. Finally, this study did not tease apart the impact that each component (e.g., the animal, the handler, the environment) of an AAI session may have had on resulting stress management. Paper Three also notes that no research evidence supports the application and effectiveness of the PACE Model for AAI practice. First, it is critical to create a robust understanding of the four components–practitioner, animal, client, and environment–in the PACE Model and the mechanisms that help explain what, if any, variations create noteworthy changes to the plan, facilitation, or outcome of an AAI session (Dalkin et al., 2015; Soulliere et al., 2001). For example, if instead of practicing with one horse, five horses are added to an AAI treatment plan, then more staff are also needed to manage a larger 235 group of interactions. An assessment of this session would gauge if and how a client’s one-to-one connection with the practitioner and horse changes in light of this new, multi-layered experience with other beings. Second, examining and testing this model in the real world of AAI, specifically sessions with diverse practitioners working with different animal species for a variety of client outcomes in a multitude of environments, is a foundational next step to determine the validity of this model for the field (Britt & Chen, 2013). And finally, using a socio- ecological framework for the concepts of reciprocal relationship and quality of competence must also be tested to determine their level of conformity to theory and allow adjustments in how they are defined. Implications Historically, the lives of animals and humans have been intertwined from time immemorial and because of these bonds, it is difficult to separate out care for humans without also acknowledging the same concern for animals. Notably, American Humane, the first national humane organization founded in 1877, began with a mission centered on animal welfare and then added child safety and protection in 1878 (American Humane, 2021). American Humane recognized that the two most vulnerable populations in US society–animals and children–had no source of advocacy and support for their collective well-being. Furthermore, forms of oppression or prejudice such as racism or sexism are inextricably linked to the same underlying psychological patterns of violence and injustice towards animals (Everett et al., 2019; Horta, 2010). 236 More recently, when Hurricane Katrina struck in 2005, many people would not abandon their homes or seek shelter because this meant leaving their animals behind, and refusal to do so ultimately cost many lives (Edmonds & Cutter, 2008). This tragedy marshaled the creation and passage of the 2006 PETS Act; FEMA funding distribution to states is now dependent on including animals in emergency plans (American Veterinary Medical Association, 2021). Finally, a more extreme example of the human-animal bond is the term “Link”, which is associated with the propensity of abuse to be multi-dimensional insomuch as animal abuse is a risk factor for child abuse and vice versa (Arkow, n.d.). Many domestic violence cases have a clearly established pattern in which animals (pets) are abused first and used as pawns by the human perpetrator for control over other people (Girardi & Pozzulo, 2012). This human-animal bond is so important and powerful that in both examples, people will not leave danger if it means their pets could suffer or die. Given that these historical and modern examples illustrate the interconnection between humans and animals, the field of social work has largely ignored the relevance of these relationships. In The Biophilia Hypothesis, Harvard biologist E. O. Wilson posits that humans are deeply connected to animals and nature (1993). From an evolutionary perspective, this bond with animals was just as critical for survival as human connections (Wilson, 1984). He goes on to suggest that dis-ease is invited in the literal and figural sense of the word as people become “divorced” from their natural surroundings (Wilson, 237 1984). Social work has largely missed that “environment” in aspects such as environmental racism or community-based practice also includes animals and the natural world (Norton, 2009). Knowledge gained from this research is considered of high importance given that the findings are so unique. This study is the first to present an overview of the current state of campus-based AAI programs for college student mental health, the results of a multi-year study of one such program, and a conceptual model of practice to help guide the ethical and effective implementation of these programs. By examining what, if any, role campus- based AAI programs play for college student mental health, this study also contributes to the fields of social work, college student development, and AAI. In the following section, I discuss how this study can be viewed through the lens of social work’s core values (National Association of Social Workers (NASW), 2021) and demonstrate the significant implications for social work practice, policy, research, and education. Social Work Practice Social work’s guiding philosophical and ethical framework is called Person-in-Environment (PIE), a holistic approach that seeks to understand the whole person in a social environment in which they live and function (NASW), 2021). One fundamental principal for all social workers is to uphold the inherent dignity and worth of all people they serve, and to advocate for their well-being in light of the complex and broader ecosystems that exist on micro, mezzo, and 238 macro levels (NASW, 2021). However, this world is not solely a world of inter- human relationships. When a vast number of people create vital and meaningful bonds and interactions with animals, social work must include these other sentient beings and the natural world as part of that social realm in order to acknowledge the totality of the human condition. Because the findings of this dissertation and the presentation of the PACE Model suggest that AAI can be an effective health promotion initiative addressing college student mental health, social workers based on college campuses or who work with college student populations can include AAI as a viable therapeutic intervention. First, Paper One suggests that students who attended on-campus AAI programs experienced increased positive mental health outcomes. Furthermore, Paper Two proposes that the odds for students to state that attending an AAI program helped them manage their stress increased if they came more often, participated longer, and also selected on the survey that they attended because they thought it would help relieve stress. Also worth noting, students struggling with anxiety, stress, depression, and loneliness, may be unaware or unsure of how to access their campus’s multiple supportive mental health services. The implications of these two studies can help direct social workers to make a “referral” or take the step to add attending an AAI session to student treatment plans. Second, colleges and universities may want to consider offering AAI programs and services on a consistent basis because of the results from Paper 239 Two that duration–number of visits and length of time for each visit–were associated with higher odds that the student reported attending a campus-based AAI program helped them relieve stress. Currently, the trend on most college campuses is to provide AAI programming just once or twice during such times as midterm and final examination weeks. For all the time and planning required to develop and implement a campus-based AAI program, the return on this effort is likely higher for programming with longer and more frequent sessions. Social workers can also utilize the findings in this dissertation as a professional source of support for including animals in other aspects of their practice. Starting with a biopsychosocial assessment at the beginning of individual therapy sessions, questions about a student’s exposure to pets and animals are just as critical as those that deal with parental support, chemical use, and academic progress. Histories that reveal the presence of one or more animals in a student’s life should be explored in an effort to assess possible neglect, abuse, or trauma that may have involved the animal and either directly or indirectly, the student (Arkow, 2013). AAI could also become part of a social worker’s direct practice. The PACE Model provides structure and overtly names critical factors that social works can use during the processes of training and evaluation of their animal for eventual AAI work with students. For the macro social worker, recognizing and honoring the significance of animals in many people’s lives is also a form of social justice (Irvine, 2007). Many individuals consider their pet to be a “family member” and describe these animals 240 as “kin” (Charles, 2014), yet many college students have experienced a disproportionate level of injustice and racism whereby sharing their lives with animals has not been possible. This study provides social workers with the essential information and rationale to intervene and become an advocate for adding campus-based AAI programs as an additional support for college student mental health. In this way, AAI programs are an opportunity to address a social justice deficit for those students who have never or rarely had the means or privilege to experience or interact with a pet (Irvine, 2007). Using a socio- ecological framework also helps to affirm the interconnection, interdependence, and holistic efforts towards well-being for all in an environment or community, including its people, plants, and animals (Broom & Johnson, 2019; Chalmers & Dell, 2015). Social Policy Access is one prominent area of social policy impacted by this study. It is highly unlikely that every college student who wants to attend an AAI program on their campus would or will be able to make that happen. However, if future studies continue exhibit positive mental health outcomes and more importantly, they can be tied to a particular dose-response, then policies will need to address and provide equitable ways for students to benefit from these interactions. Some colleges or universities may decide that students are allowed to bring their pets to live with them on campus. Others may work to increase the scope and reach of their AAI programs. Depending on their location, a campus could also offer a 241 community-based amenity of a dog park, dog boarding, or dog-walking services which would bring a wide variety of dogs into casual contact with students but without the need for high-level planning or oversight. Other schools may create a feature whereby groups of smaller animals remain on campus and students engage with them through passive observation (i.e., fish tanks or aviaries) or facilitated, hands-on activities similar to the current, campus-based AAI sessions. Research Social work research strives to be timely, relatable, and transferable to practice so that a body of evidence helps inform what interventions a social worker may use with clients (Teater, 2017). The novelty of AAI programs bodes well in that continued research will explore this topic, especially in light of the “cute animal effect” coupled with the current state of mental health crisis across post-secondary institutions in the United States (Eisenberg et al., 2020). Yet despite the extensive use of AAI services intended to impact a wide variety of outcomes for so many types of populations, a considerable gap remains in the social work literature regarding the human-animal bond’s relevance in so many people’s lives. One challenge for future research on AAI is the field’s lack of protocols for practice–what does it mean to provide an AAI session?–so establishing effective and relevant translational studies can be difficult (Fine & Ferrell, 2021; Serpell et al., 2017). As the rigor of scholarly works intensifies, a far-reaching opportunity exists to establish lockstep intervention fidelity that can be added to future AAI research methods and outcomes. This is particularly 242 imperative when the AAI field also uses many overlapping terms to describe similar but distinctive concepts (Fine, 2019; McCardle et al., 2011). A second implication of this study for social work research is that the PACE Model emphasizes a holistic, socio-ecological lens which aligns with the knowledge generated through social work practice (Besthorn & Canda, 2002; Green & McDermott, 2010). The AAI modality has the option to work with so many animal species, practice in a broad spectrum of settings, and address a myriad of bio-psychosocial outcomes. Clearly, to design and implement a research study on AAI that will yield statistically significant results is not an endeavor that can be conducted without considerable resources and expertise. The PACE Model helps to address the extensive diversity throughout the AAI field as it also creates a united, grounding framework for practice and for research. Another implication of this study for future research involves the critical gap in understanding the impact of this work on the animals that are involved. Social workers understand and value a socio-ecological and PIE perspective which means their advocacy, respect, and care are extended to all entities in an AAI program, not just college students (Eriksson et al., 2018; Norton, 2009). Again, social workers are particularly situated to take on this challenging research endeavor partly due to the profession’s adherence to a code of ethics that is sensitive to vulnerable populations (NASW, 2021). Animals in AAI programs are vulnerable if for no other reason than their human partner decides 243 when and where they will provide their services. And aside from dogs, additional studies with AAI programs that include other species such as cats, rabbits, and birds are also vital in order to provide a culturally-competent scope of this work. Thoroughly examining an animal’s constantly evolving and reciprocal interactions is as critical to the success and integrity of AAI sessions as the practitioner’s competence, the environmental conditions, and the client’s experiences. And finally, there is a notable absence of research on campus-based AAI programs that included follow-up studies. The scoping review in Paper One identified seven studies that provided follow-up results with varied results, length of time until follow-up, and method of follow-up. The study featured in Paper Two potentially included students who may have attended the AAI program once or multiple times and then reported at the end of the academic year that they were able to manage their stress because of their participation. However, there is no way to tease apart all the participants and determine these factors. Education In 1977, the first academic center to examine human-animal interactions was established in the School of Veterinary Medicine at the University of Pennsylvania, followed by the University of Minnesota in 1981 in its School of Public Health (O’Haire et al., 2018). Within the field of social work, in 2005 Denver University became the first school of social work to include AAI as part of their Master’s curriculum. In 2002, the University of Tennessee-Knoxville developed what is now called veterinary social work–a specific form of social 244 work connected to veterinarian services and includes functions such as grief counseling for clients who face the death of their animal and trauma support for veterinarian providers, a group of professionals who face a high rate of suicide (Jackson, 2013). Furthermore, the American Psychological Association (APA), (Human-Animal Interactions Ethics Workgroup, 2020) and the American Counseling Association (ACA), (Stewart et al., 2016) have established professional guidelines of AAI practice. However, within social work curriculum, it is unknown how widely the human-animal bond is discussed as an essential concept in human development or the role that AAI could have as a function within social work practice. Future research could map the state of human-animal material in social work programs to better understand if and how this topic is addressed. As with all therapeutic practices, foundational theories and concepts create a framework through which one learns the more intricate details of practice and application. Upholding and maintaining one’s scope of practice is also a critical, ethical standard within the overall discipline of human healthcare and learning these competencies and becoming a skilled practitioner does not happen without education and training. Social workers are guided in their approach by the recognition that people engage with, impact, and are products of the micro, meso, and macro systems in which they live (Bronfenbrenner, 1977; Norton, 2009), and learning this PIE perspective is a current educational mandate for all accredited schools of social work (Council on Social Work 245 Education (CSWE), 2015). To the same extent that they learn about what risk factors, buffers, and evidence-based interventions are important across the human lifespan, social workers must learn about the importance of the human- animal bond throughout the social work curriculum for the purpose of cultivating appreciation and enacting advocacy for campus-based AAI programs. This dissertation also addresses a social worker’s core value of competence as working with an animal partner in a therapeutic or educational context is another layer of experience that differs from learning co-facilitation or group process skills (NASW, 2016). Grounded in a strengths-based approach to delivery of care, social workers are ideally suited to administer as well as participate in campus-based AAI programs. However, research on training in the method of AAI remains a gap in the field because clearly defined skills that can be evaluated to determine one’s competency have yet to be established. Instead, practitioners in AAI tend to gain hands-on learning through community-based courses, online materials, or working with a mentor (Fine, 2019). The social work profession has an obligation to extend the social work curriculum and offer advanced training in AAI applications so as to support this influential and advancing field of practice. Future Directions Future studies on campus-based AAI programs are needed because of their ability to impact such a broad group of people at a critical phase in their development. This study serves as an acknowledgment that for some college 246 students, their animal is a significant source of psychosocial support and to leave this pet to attend college may be a source of distress. This deeper understanding of the human-animal bond helps establish various contexts in which feelings of sadness and grief can be normalized and students are encouraged to openly share and express thoughts and feelings about their pets. Additionally, the death of a pet is often a person’s first experience with the loss of an intimate relationship and feelings of extreme sadness (King & Werner, 2011). If this loss or impending death occurs when a student is at college, support and recognition for these feelings are just as vital to a student’s grief process as if a parent or sibling passed away (Besthorn & Canda, 2002). However, the research on this topic remains in its infancy despite a 2015 census that identified 925 campus-based services on college campuses across the United States (Crossman & Kazdin, 2015). What limits a comprehensive understanding of AAI in general, and for college students specifically, is a lack of standardization in terminology, methodology, human-animal team training, and intervention protocols that clearly identify intervention mechanisms of change and outcomes. Furthermore, rigorous studies using randomized controlled trials are needed to isolate intervention dosage and effect size, and emphasizing diverse human and animal study populations are critical to address the applicability of AAI for marginalized communities. In conjunction with public health promotion campaigns on college campuses that address smoking cessation, food and housing insecurity, and sexual assault, continued research to 247 demonstrate the efficacy of campus-based AAI programs is an appropriate and worthwhile agenda in the field of social work. The three papers in this dissertation provide a logical roadmap continuing my scholarship in the fields of AAI, social work, and college student development. Through the use of a scoping review, Paper One has established what is known about the small but rapidly growing body of empirical literature on college-based AAI programs for student mental health. Interestingly, since this review ended in October of 2020, three new studies have been published on this topic. The next step to expand understanding is to conduct a systematic review of methodological rigor, data quality, and intervention protocols so that continued use of campus-based AAI programs are informed by the latest evidence available. This review could explore answers to such questions as: What was the quality of the randomized controlled studies?; What were the dose-responses based on program attendance duration and frequency?; or What are the mechanisms that help explain how and why an AAI intervention works? Programmatically and in an effort to address intervention rigor, another review question could address the types of training and evaluation each AAI team completed prior to participating in the study. Finally, examining the dose- response based on animal species is a serious gap in the field; however, too few studies have been published to date that have included other animals in addition to dogs. 248 To fortify the rigor of the study in Paper Two, a second step to explore is if and how attending an AAI program helps to positively impact college student mental health outcomes. First, a retrospective pretest-posttest (RPP) design would be used for students who attend an AAI session for the first time. It would ask three or four questions regarding perceived stress or other mental health outcomes (Little et al., 2020). Throughout the academic year, all participants would also sign in and out using their ID cards as an efficient way of gathering comprehensive demographics and dosage–duration and number of visits. Effect sizes would be established, statistically valid instruments would be used, and survey questions would be carefully and clearly developed to limit cultural bias. Participants would not be surveyed at the end of an academic semester when there is a higher likelihood of increased stress. Instead, a representative sample of the overall student body would be randomly selected from those enrolled in the study and after they attended five times and then 10 times, sent a second survey measuring the intended outcomes of this specific campus-based AAI program. Another method to improve on this dissertation is to create a randomized controlled trial with appropriate control groups. This next study would conduct a pre/post assessment using standardized measurements to test the interaction effect on stress management and other mental health conditions such as depression and anxiety. A third step for future research is to examine students’ lived experiences in relation to their participation in an AAI program, especially the delivery of these 249 programs from a culturally-informed perspective. This project will add a qualitative study to the current literature as well as explore how these AAI programs may help contribute to a student’s sense of belonging and resilience against stress. The PACE Model for AAI may be useful for developing these next research studies by determining the factors that help create and impact AAI outcomes. Finally, applying the PACE Model to AAI practice and testing these results across multiple types of programs is another avenue for future research. Such a project would refine the conceptualization of each of the four components for improved clarity and understanding of how the model is structured and used. Furthermore, the assessment rubric that is presented in Paper Three warrants further testing so as to build out the sets of skills into levels of competencies. This endeavor would also help address intervention rigor, a gap in the field that recognizes there are no consistent ways of training or assessing practitioners and their animal partners for AAI programs and services. Summary This is the first study to present information about campus-based AAI programs and services through a scoping review and multi-year, cross-sectional analysis of 3,255 participants, and then propose a conceptual model for AAI practice to further define the complexity and non-linearity of this work. Overall, the findings from this dissertation suggest that college students experience positive mental health outcomes by attending AAI programs. While the small 250 body of literature shows these benefits can occur with one dog for 15 minutes, Paper Two of this dissertation reveals that the odds of a student stating that attending the AAI program helped them manage their stress were higher for those who attended AAI sessions more frequently and stayed for longer durations during those sessions. And while these results are a much needed contribution to the fields of AAI, college student mental health, and social work, substantial gaps remain which can help to inspire continued and critical examination of AAI as a method to support human health and well-being This dissertation also sought to highlight the complexity of AAI programs and services. It therefore echoes the charge that more attention is needed to understand the role and the experience of the animal in AAI. Using a socio- ecological framework, the PACE Model for AAI overtly demonstrates that the four main components in an AAI session share a reciprocal dynamic that is greater than the sum of the parts. The significance of such interrelationality serves to challenge the status quo that humans are the sole consumers or directors of AAI. In this way, animals are respected as unique, sentient beings in AAI programs and services and not as “tools” that are discounted or underappreciated in the name and service of human well-being. Furthermore, the PACE Model invites new ways of knowing and recognizes that the health and welfare of all in a society, including animals, must be a part of conversations, campaigns, and initiatives addressing any form of human or environmental injustice. 251 Experiencing the COVID-19 pandemic, coupled with the traumatic social, political, economic, and racial reckoning has revealed there is much to learn about what motivates humans to behave in ways that foster community and connection or alienation and discontent. The potential for AAI to be a bright spot during such recent and ongoing upheaval is significant. However, college budgets vary in their capacity for personnel to implement the myriad of established, as well as trendy, college health programs. Based on a 2015 report that showed more than 925 colleges or universities in the United States provided some type of campus-based AAI program, many students now have the option of spending time with an animal as a way to help relieve stress and support their mental health. And as the field of AAI continues to improve its research rigor and capacity and better conceptualize the mechanisms and practice of AAI, the evidence will determine if, how, and why AAI should be considered in addition to the many other ways of supporting student well-being. Investing in fully understanding the impact campus-based AAI programs may have for hundreds of thousands of college students at risk of a mental health crisis is a worthy and timely endeavor; it speaks to the interconnections of what makes AAI unique: the practitioners, the animals, the clients, and the environment. 252 References American College Health Association (ACHA). (2020). 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