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Effect of Animal-Assisted Therapy (AAT) on Social Interaction and Quality of Life in Patients with Schizophrenia during the COVID-19 Pandemic: An Experimental Study

Open AccessPublished:January 12, 2023DOI:https://doi.org/10.1016/j.anr.2023.01.002

      Summary

      Purpose

      Most patients with schizophrenia exhibit low willingness to return to society because of negative social experiences. The COVID-19 pandemic led to severe social isolation for schizophrenia patients. However, animal-assisted therapy (AAT) can improve individuals' empathy, social functions, and quality of life. The study aimed to evaluate the effectiveness of AAT in improving social interactions and quality of life in patients with chronic schizophrenia during the COVID-19 pandemic.

      Methods

      An experimental study was conducted, with six institutions for psychiatric rehabilitation in Taiwan as the case institutions. Patients in these institutions were randomly allocated to the experimental group, which received 60 minutes of AAT once a week for 12 weeks, or the control group, which engaged in routine discussion groups and watched short films about animals. Comparisons between the two groups were made before and after the intervention on social function, social adaptive function, and quality of life. Data were collected before the intervention (T1), immediately after the intervention (T2), and 3 months after the intervention (T3).

      Results

      Comparison between groups showed that social functioning was significantly higher in the experimental group than in the control group at T2. However, there was no sign of improvement in social adaptive functions of the experimental group. The experimental group exhibited significantly higher quality of life than the control group at T2 and T3.

      Conclusions

      There was an impact of COVID-19 on the studied effects. AAT improved social functioning and quality of life in patients with chronic schizophrenia. The effect on quality of life lasted only up to 3 months after the intervention. AAT should be promoted for use as a community-based rehabilitation tool in patients with chronic schizophrenia.

      Trial registration

      Chinese Clinical Trial Registry, ChiCTR2200061715. https://www.chictr.org.cn.

      Keywords

      Introduction

      The restoration of patients suffering from psychiatric disorders to society has been a crucial topic given recent trends toward deinstitutionalization. Patients with psychiatric disorders who receive long-term institutional treatment may experience an impaired quality of life and face challenges in returning to and living in society [
      World Health Organization
      World health report.
      ]. The possession of beneficial social skills is crucial for patients with psychiatric disorders to return to a community and may improve their quality of life and increase their satisfaction with social support. However, during their return to society, patients with psychiatric disorders may be less willing to interact with others because of their previous experiences with stigmatization and ostracism [
      • Krupchanka D.
      • Chrtková D.
      • Vítková M.
      • Munzel D.
      • Čihařová M.
      • Růžičková T.
      • et al.
      Experience of stigma and discrimination in families of persons with schizophrenia in the Czech Republic.
      ,
      • Eigenhuis E.
      • Waumans R.C.
      • Muntingh A.D.T.
      • Westerman M.J.
      • van Meijel M.
      • Batelaan N.M.
      • et al.
      Facilitating factors and barriers in help-seeking behaviour in adolescents and young adults with depressive symptoms: a qualitative study.
      ]. In particular, patients with schizophrenia experience discrimination and misunderstanding most frequently. Patients who take medication regularly may still exhibit residual psychotic symptoms. When others do not understand their disease condition, they can easily misunderstand and become upset with the patients. The patients thus face setbacks in interpersonal relationships, experience distress, and feel a sense of worthlessness and helplessness [
      • Eigenhuis E.
      • Waumans R.C.
      • Muntingh A.D.T.
      • Westerman M.J.
      • van Meijel M.
      • Batelaan N.M.
      • et al.
      Facilitating factors and barriers in help-seeking behaviour in adolescents and young adults with depressive symptoms: a qualitative study.
      ]; these factors can lower their intention to engage in social interaction [
      • Guan Z.
      • Huang C.
      • Wiley J.A.
      • Sun M.
      • Bai X.
      • Tang S.
      Internalized stigma and its correlates among family caregivers of patients diagnosed with schizophrenia in Changsha, Hunan, China.
      ,
      • Rezayat F.
      • Mohammadi E.
      • Fallahi-khoshknab M.
      • Sharifi V.
      Experience and the meaning of stigma in patients with schizophrenia spectrum disorders and their families: a qualitative study.
      ]. When patients with schizophrenia exhibit increased levels of loneliness and social isolation, they are likely to develop illusions and delusions [
      • Michael J.
      • Park S.
      Anomalous bodily experiences and perceived social isolation in schizophrenia: an extension of the social deafferentation hypothesis.
      ]. Social isolation is not only a critical predictor of both positive and negative symptoms but also a risk factor for suicidal behavior and intention [
      • Bornheimer L.A.
      • Nguyen D.
      Suicide among individuals with schizophrenia: a risk factor model.
      ,
      • Khosravani V.
      • Mohammadzadeh A.
      • Oskouyi L.S.
      Early maladaptive schemas in patients with schizophrenia and non-patients with high and low schizotypal traits and their differences based on depression severity.
      ]. Since the outbreak of the COVID-19 pandemic in 2019, human interactions have decreased significantly, worsening the social isolation of schizophrenia patients. Ma et al. [
      • Ma J.
      • Hua T.
      • Zeng K.
      • Zhong B.
      • Wang G.
      • Liu X.
      Influence of social isolation caused by coronavirus disease 2019 (COVID-19) on the psychological characteristics of hospitalized schizophrenia patients: a case-control study.
      ] conducted a study on schizophrenia patients dwelling in psychiatric facilities and concluded that, after their close contact with COVID-19 patients, there was an obvious increase in social isolation compared to those who did not interact with COVID-19 patients, showing that COVID-19 leads to severe mental burden.
      To improve the social interaction skills of patients with schizophrenia, professionals in healthcare institutions should establish stable and positive therapeutic relationships with patients before initiating treatment. However, interpersonal relationships are subjective experiences, even for well-trained professionals; unconditional acceptance of a relationship with other people cannot be achieved easily. Relationships with animals, however, can mitigate this difficulty. The enthusiasm of dog could motivated and engaged participants and help improving participants' social interaction despite their age and diseases [
      • Pichot T.
      • Coulter M.
      Animal-assisted brief therapy: a solution-focused approach.
      ]. Animal-assisted therapy (AAT) involves the appropriate introduction of animals that satisfy certain criteria into healthcare scenarios with the guidance and assistance of professionals to achieve goal-oriented intervention measures [
      • Kruger K.A.
      • Serpell J.A.
      Animal-assisted interventions in mental health.
      ]. Animals show unconditional acceptance and companionship, thereby helping reduce depression and anxiety symptoms in older adults [
      • Holder T.R.N.
      • Gruen M.E.
      • Roberts D.L.
      • Somers T.
      • Bozkurt A.
      A systematic literature review of animal-assisted interventions in oncology (Part I): methods and results.
      ] and aiding teenagers in understanding their behavioral problems and increasing empathy [
      • Seivert N.P.
      • Cano A.
      • Casey R.J.
      • May D.K.
      • Johnson A.
      Animal assisted therapy for incarcerated youth: a randomized controlled trial.
      ]. Among studies concerning the use of AAT to help patients with psychiatric disorders, Calvo et al. [
      • Calvo P.
      • Fortuny J.R.
      • Guzmán S.
      • Macías C.
      • Bowen J.
      • García M.L.
      • et al.
      Animal assisted therapy (AAT) program as a useful adjunct to conventional psychosocial rehabilitation for patients with schizophrenia: results of a small-scale randomized controlled trial.
      ] conducted a randomized clinical trial to study the application of AAT to patients with schizophrenia. The results revealed that patients in the experimental group not only improved significantly in terms of both positive and negative symptoms but also exhibited fewer negative symptoms and problematic behaviors, such as social withdrawal after discharge from the hospital. Chang et al. [
      • Chang B.H.
      • Chang S.Y.
      • Yeh M.L.
      The healing process of chronic schizophrenic patients in animal-assisted therapy.
      ] conducted 24 weeks of AAT group activity for patients with schizophrenia and recorded the therapeutic process with respect to 20 patients. The content analysis results indicated that positive activity design and social interaction among participants created supportive group atmospheres, improved participants' willingness to challenge themselves, and increased their self-efficacy. These research results suggest that AAT can substantially improve the physical conditions, psychological status, and quality of life of patients with schizophrenia.
      To date, only a limited amount of research has been conducted concerning the application of AAT to patients with schizophrenia. In particular, the social interaction between patients with schizophrenia and other individuals has rarely been explored during the COVID-19 pandemic. Most relevant studies have focused on positive and negative symptoms, depression and anxiety, and quality of life. The objective of the present study was to explore the effectiveness of AAT with respect to improving the social interaction and quality of life of patients with chronic schizophrenia during the COVID-19 pandemic.

      Methods

      Research site and recruitment

      This longitudinal, single-blind experimental study mainly recruited participants from institutions for psychiatric rehabilitation in northern Taiwan. A small psychiatric rehabilitation institution generally has an average of 15–30 residents in Taiwan. This study needed to recruit 4–6 institutions. A lot-drawing method using Microsoft Excel was employed to provide a random selection of all institutions for participant recruitment. After approvals were obtained from six institutions by the selection list, coin tosses were used to assign an institution randomly to the experimental or control group, with three institutions per group. Participants of the control group and the experimental group were not in contact throughout the intervention, avoiding interference to the results. The intervention activities in both groups involved the participation of researchers, and animals were featured in the intervention activities of both groups. Participants and institution personnel were blinded to the grouping. Recruitment took place between January 29 and February 7, 2021. The researchers introduced and highlighted the benefits of the objectives and contents of the study to residents at the institutions' activity halls. Individuals who satisfied the inclusion criteria were recruited after signed consent forms were obtained.
      The researchers wanted to investigate the changes over time. Referencing Olsen et al. [
      • Olsen C.
      • Pendersen I.
      • Bergland A.
      • Enders-Slegers M.J.
      • Ihlebæk C.
      Effect of animal-assisted activity on balance and quality of life in home.
      ]'s research design. Data were collected before the intervention (T1), immediately after the intervention (T2), and 3 months after the intervention (T3).

      Inclusion and exclusion criteria for participant recruitment

      The inclusion criteria were as follows: patients diagnosed with schizophrenia according to the Diagnostic and Statistical Manual of Mental Disorders, 5th edition; patients who resided in the institution for psychiatric rehabilitation throughout the research period (at least 3 months); patients with ages between 20 and 65 years; and patients who were able to listen to, speak, and write Mandarin or Taiwanese. The exclusion criteria were patients with cognitive impairment, alcoholism, brain injury, mental retardation, personality disorders, or allergies to or fears of dogs.

      Sampling

      The study used G-power to calculate the sample size. Utilizing the work of Virués-Ortega et al. (2012) on the meta-analysis of AAT on elderly populations and patients with psychiatric disorders, outcome indicators including depression, anxiety, and behavior disturbances. The range of the effect size is 0.29–0.34 [
      • Virués-Ortegaa J.
      • Pastor-Barriusob R.
      • Castellotec J.M.
      • Poblaciónd A.
      • Pedro-Cuestae J.
      Effect of animal-assisted therapy on the psychological and functional status of elderly populations and patients with psychiatric disorders: a meta-analysis.
      ] and is small to medium ES [
      • Cohen J.
      Statistical power analysis for the behavioral sciences.
      ]. The criteria set by this study are rigorous, while ES was set at 0.25, with α being set at 0.05 and power at 0.8. Repeated-measures statistical tests were used at three time points. The total sample size was 86 participants. To account for possible withdrawals, this study recruited 90 patients. After the study has concluded, doing post hoc power analysis by G-power and we found that the calculating power is 81.9%.

      Research ethics

      This study was reviewed by the Institutional Review Board of National Yang Ming Chiao Tung University on January 29, 2021 (Approval no. YM1091XXF). Participants were informed that they could withdraw any time without affecting their rights. All personal data were coded for privacy protection. All data were used for research purposes only.

      Research instruments

      Demographics

      Demographic data included sex, age, education level, marital status, employment, religion, and age of diagnosis. The demographic data were used as control variables to understand the intervention effectiveness of AAT on residents' social interaction and quality of life.

      Mental health-social functioning scale (MHSFS)

      This study used the MHSFS developed by Song [
      • Song L.Y.
      The development and validation of a caregiver burden scale: a focus on practice applicability.
      ] to measure participants' social competence and abilities in daily life. The MHSFS comprises 36 items across 7 subdimensions, namely, social/withdrawal, interpersonal communication, independence-ability, independence-performance, entertainment, sociality, and occupation/employment. Each item is scored from 0 to 3, except for items in the “occupation/employment” subdimension. The total score ranges between 0 and 100. Higher scores indicate better social functioning. The MHSFS exhibited good internal consistency with respect to patients with psychiatric disorders; Cronbach's alpha coefficient of the overall dimension was 0.80. MHSFS can be filled by patients with psychiatric disorder or their caregivers [
      • Song L.Y.
      The development and validation of a caregiver burden scale: a focus on practice applicability.
      ], for this study to reach the same level of evaluative criteria, it would be filled by the regular institutional staff. The scale was completed by institutional staff who evaluated the social functioning of residents over the last 3 months.

      Social adaptive function scale (SAFS)

      This study used the SAFS developed by Li and Tsai [
      • Li S.M.
      • Tsai T.Y.
      The development of the social adaptive function scale.
      ] to measure participants' day-to-day living abilities, social functioning, and occupational abilities. SAFS is used by mental health workers to assess patients with psychiatric disorder's social life. The scale was completed by institutional staff. The SAFS contains 15 items and is scored on a 4-point (0 to 4) Likert scale. Higher scores indicate worse adaptive functions. Cronbach's alpha coefficients of each factor were 0.88 for day-to-day living abilities, 0.90 for social functioning, and 0.90 for occupational abilities. The internal consistency of the scale was 0.94.

      Taiwanese version of the world health organization quality of life brief version WHOQOL-BREF

      The WHOQOL-BREF, Taiwanese version [
      • Yao G.
      • Chung C.W.
      • Yu C.F.
      • Wang J.D.
      Development and applications of the WHOQOL-Taiwan version.
      ], the scale is measuring participants' subjective feelings toward their life quality, was completed by participants. This questionnaire consists of four dimensions: physical, psychological, social, and environmental. It contains 28 items, each of which is scored on a 5-point Likert scale. Higher scores indicate better quality of life. Cronbach's alpha coefficients of the dimensions ranged between 0.70 and 0.77. The overall Cronbach's alpha coefficient of the questionnaire was 0.91, suggesting good internal consistency [
      The WHOQOL-Taiwan Group
      Introduction to the development of the WHOQOL-Taiwan version.
      ].

      AAT program

      This study developed a 12-week AAT program, with one 60 min session of group activity per week. The program was designed considering the labor and economic cost and was also based on previous studies [
      • Chang B.H.
      • Chang S.Y.
      • Yeh M.L.
      The healing process of chronic schizophrenic patients in animal-assisted therapy.
      ]. The intervention program was implemented through support groups to help participants develop their skills in social interaction and emotional expression (Table 1). The expert validity of the intervention was determined by five nurses and social workers who had more than 3 years of experience providing clinical care in the Psychiatry Department and by two AAT experts. The scale-level content validity index was calculated to be 0.976, implying that the overall program demonstrated good content validity.
      Table 1Framework of the 12 Week Animal-Assisted Therapy Program.
      GoalProposal content
      Building relationshipWeek 0 Introducing the group
      • 1.
        Introduce the content of the group activity to the participants
      • 2.
        Finish the distribution and measurements of the pretest questionnaires
      Week 1 Meet the puppies
      • 1.
        Introduce the participants to each other and start building relationship
      • 2.
        Increase participants' willingness to continue engaging in these activities
      Week 2 Get to know the puppies—“touching”
      • 1.
        Guide the participants to try to get along with the service dogs
      • 2.
        Guide the participants to touch the service dogs to induce their confidence of making social connections and also build trust between each other
      Brief interactionWeek 3 Get to know the puppies—“stand up, sit down”
      • 1.
        Stimulate the participants' sense of autonomy by establishing simple instructions to the service dogs
      • 2.
        The success of establishing instructions to the service dogs impacts the participants by increasing their confidence in their problem solving skills
      Week 4 “embrace and admire”
      • 1.
        The service dogs will lay down beside the participants, making the participants feel secure and trusted
      • 2.
        Reflecting on the participants' emotional dilemmas by sharing one's thoughts and listening to others' advices
      Week 5 “Take a walk together”
      • 1.
        From walking the service dogs, the participants get to improve their social interaction skills
      • 2.
        The activity can increase the participants' physical flexibility and also increase their ability to get along with other people
      Week 6 Feeding
      • 1.
        Increase the participants' feeling of being able to control matters and boost their confidence by the sense of accomplishment after feeding process to the service dogs
      • 2.
        Let every participant experience the achievement felt through feeding and commanding
      Deeper interactionWeek 7 Groom and talk
      • 1.
        Train the participants' communication and social interaction skills through group activities and talking to each other
      • 2.
        Foster the participants' confidence during social interactions
      Week 8 Repeat week 1–7
      • 1.
        Hold competitive games to help increase the participants' confidence, sense of accomplishment, and self-efficacy
      • 2.
        Increase the time of physical activities to train the participants' physical coordination and flexibility through group activities
      Week 9 Go through the tunnel together
      • 1.
        Improve interactive skills between both participants and service dogs through group activities
      • 2.
        The use of competitive games can provoke the participants' aggressiveness and increase their sense of accomplishment and confidence, hence accumulate their feelings of self-efficacy
      Week 10 Touching puppies without seeing
      • 1.
        Increase the participants' awareness to others' sound and concentrate through the game
      • 2.
        The participants are able to feel other people physically by touching the service dogs, at the same time practice the appropriate way to control their strength during physical interactions with others
      Week 11 Depict the puppy in their most beautiful way
      • 1.
        Deepen the impression of other participants and the service dogs through painting
      • 2.
        By holding a group talk session, the participants can share their inner thoughts, receive feedback, and encourage each other
      Week 12 Wave goodbye
      • 1.
        Enhance positive emotions when the participants think back about the memories of group activities
      • 2.
        Stimulate harmonious relationship between the participants by group activities
      The AAT program proceeded as usual, being held in the reception hall. Activities were carried out by the researchers and social workers, along with the participation of two service dogs and two professional AAT therapists. The dogs had received training for at least 3 months and were amicable. The AAT therapists had undergone at least 6 months of dog-related training and professional courses and had experience providing services to people with disabilities. The control group participated in discussion groups once per week, sharing their thoughts about life; these activities were led by the researchers and social workers. For the blinding of the participants, short films about animals were provided for the members of the control group to watch. Videos of cute animal documentaries were 10–15 minutes length each. Participants will then share their thoughts afterward. The intervention duration and frequency were identical for both groups.

      Data analysis

      All statistical analyses were conducted using SPSS V23.0 (IBM Corporation, Armont, NY, USA). Participants who did not attend the first and last sessions or were absent for ≥2 sessions were excluded from the analysis. Data are presented as the mean (M) ± standard deviation (SD) or frequency (n) and percentage (%). Chi-square tests and independent-samples t tests were used to compare demographic variables between the two groups. The effectiveness of the intervention with respect to social functioning, social adaptive functions, and quality of life was compared using paired t tests for within-group comparisons and a generalized estimating equation (GEE) for between-group repeated comparisons. According to “Goodness of fit,” the best QIC value is “unstructured” correlation structure in the study. Using the matrix, a GEE analysis was conducted.

      Results

      The research period for this study was from January 31, 2021, to September 12, 2021. A total of 98 residents met the inclusion criteria, eight of whom refused to participate in the study. Ninety participants completed the study and were included in the data analysis.

      Participant demographics

      The experimental group and the control group each consisted of 45 participants. The participants of two groups have even gender distribution. The mean age in experimental group was 50.2 years and 49.5 years in control group. Table 2 shows that both groups had no significant differences in terms of eight demographic attributes, including sex, marriage, and education. Participants in the experimental group received significantly more family visits than those in the control group (p = .03).
      Table 2Demographic Data (n = 90).
      VariablesParticipants (n = 90)Experiment group (n = 45)Control group (n = 45)
      n (%)n (%)n (%)χ2p
      Sex0.04.833
       Female45 (50.00)23 (51.11)22 (48.89)
       Male45 (50.00)22 (48.89)23 (51.11)
      Marriage0.05.829
       Single55 (61.11)28 (62.22)27 (60.00)
       Married/divorced35 (38.89)17 (37.78)18 (40.00)
      Educational level0.00.999
       Below high school58 (64.44)29 (64.44)29 (64.44)
       University or above32 (35.56)16 (35.56)16 (35.56)
      Religious belief0.73.677
       No6 (6.67)4 (8.89)2 (4.44)
       Yes84 (93.33)41 (91.11)43 (95.56)
      Employment0.56.455
       No69 (76.67)33 (73.33)36 (80.00)
       Yes21 (23.33)12 (26.67)9 (20.00)
      Family visiting4.87.027∗
       No16 (17.78)4 (8.89)12 (26.67)
       Yes74 (82.22)41 (91.11)33 (73.33)
      Experiencing side effects1.11.292
       No45 (50.00)25 (55.56)20 (44.44)
       Yes45 (50.00)20 (44.44)25 (55.56)
      M ± SDM ± SDM ± SDtp
      Age50.2 ± 9.649.5 ± 9.551.0 ± 9.7−0.74.459
      Age of morbidity30.6 ± 11.029.7 ± 11.131.4 ± 10.9−0.75.457
      Note: M (SD) Continuous variables used Independent t test; n (%) Categories variables used Chi-square test or Fisher's exact test; ∗p < .05.

      Effectiveness of MHSFS

      Within-group comparison (Table 3): In the experimental group, the MHSFS scores of participants were significantly higher at T2 (M = 52.80, SD = 11.93) than at T1 (M = 50.56, SD = 11.89) (p < .01), but the MHSFS scores at T3 (M = 46.07, SD = 14.36) were not significantly different from those at T1 (p > .05). Participants in the control group had significantly higher MHSFS scores at T2 (M = 55.18, SD = 14.34) than at T1 (M = 54.09, SD = 13.80) (p < .05), but their MHSFS scores at T3 (M = 54.81, SD = 12.97) were not significantly different from those at T1 (p > .05). The results revealed that both groups improved their social functioning after the intervention; however, this effect was not permanent.
      Table 3Effectiveness of AAT on Social Function (MHSFS), Social Adaptive Function (SAFS) and Quality of Life (WHOQOL) among Patients with Schizophrenia (N = 90).
      VariablesControl group (n = 45)Experimental group (n = 45)
      T1T2T3T1T2T3
      Social function M ± SD54.09 ± 13.8055.18 ± 14.3454.81 ± 12.9750.56 ± 11.8952.80 ± 11.9346.07 ± 14.36
      Social adaptive function M ± SD11.87 ± 7.6710.51 ± 8.2110.16 ± 7.4611.56 ± 7.669.87 ± 7.699.30 ± 8.73
      Quality of life M ± SD78.38 ± 11.8981.02 ± 16.8275.16 ± 13.8179.33 ± 13.4086.42 ± 17.9886.64 ± 15.92
      Social function t1/t22.45∗1.204.12∗∗−1.85
      Social adaptive function t1/t2−2.52∗−2.95∗∗−4.18∗∗−1.60
      Quality of life t1/t21.85−1.834.10∗∗3.08∗∗
      BSEPadj
      Group (reference: control group)
       Experimental group−2.88
      Social function.
      /−0.34
      Social adaptive function.
      /1.23
      Quality of life.
      2.84
      Social function.
      /1.71
      Social adaptive function.
      /3.26
      Quality of life.
      .116
      Social function.
      /.649
      Social adaptive function.
      /.021∗
      Quality of life.
      Time (reference: baseline)
       T21.09
      Social function.
      /−1.36
      Social adaptive function.
      /2.64
      Quality of life.
      0.39
      Social function.
      /0.40
      Social adaptive function.
      /1.40
      Quality of life.
      <.01∗∗
      Social function.
      /<.01∗∗
      Social adaptive function.
      /<.01∗∗
      Quality of life.
       T31.14
      Social function.
      /−1.91
      Social adaptive function.
      /−3.48
      Quality of life.
      1.80
      Social function.
      /1.13
      Social adaptive function.
      /2.48
      Quality of life.
      .478
      Social function.
      /.043∗
      Social adaptive function.
      /.536
      Quality of life.
      Group × time (reference: control group × baseline)
       Experimental group × T21.16
      Social function.
      /−0.33
      Social adaptive function.
      /4.44
      Quality of life.
      0.55
      Social function.
      /0.57
      Social adaptive function.
      /1.98
      Quality of life.
      .043∗
      Social function.
      /.671
      Social adaptive function.
      /. 044∗
      Quality of life.
       Experimental group × T3−5.37
      Social function.
      /−0.52
      Social adaptive function.
      /11.06
      Quality of life.
      2.53
      Social function.
      /1.59
      Social adaptive function.
      /3.50
      Quality of life.
      .037∗
      Social function.
      /.734
      Social adaptive function.
      /.007∗∗
      Quality of life.
      Family visiting Yes vs. No−3.67
      Social function.
      /0.14
      Social adaptive function.
      /−1.56
      Quality of life.
      3.34
      Social function.
      /2.00
      Social adaptive function.
      /3.60
      Quality of life.
      .101
      Social function.
      /.841
      Social adaptive function.
      /.578
      Quality of life.
      Note: T1: baseline; T2: postintervention; and T3: post 3 months follow-up.
      t1: baseline and postintervention comparison; t2: baseline and post 3 months follow-up comparison.
      Padj: P-value must be adjusted for the multiple comparisons by Bonferroni.
      p < .05; ∗∗p < .01.
      a Social function.
      b Social adaptive function.
      c Quality of life.
      Repeated measurements were conducted with respect to both groups. At T2, MHSFS scores increased significantly, indicating improved social functioning in both groups. The interaction of group × time indicated that the MHSFS scores of the experimental group at T2 were significantly higher than those of the control group at T1 (B = 1.16, p < .05). However, the MHSFS scores of the experimental group decreased significantly at T3 (B = −5.37, p < .05). The results suggested that the social functioning of the experimental group improved significantly immediately after the intervention; however, their social functioning decreased significantly 3 months after the intervention. Inclusion of the only dissimilar demographic variable between the two groups—family visits—into the analysis did not yield a significant difference.

      Effectiveness of SAFS

      Within-group comparison (Table 3): In the experimental group, the SAFS scores of participants at T2 (M = 9.87, SD = 7.69) were significantly lower than those at T1 (M = 11.56, SD = 7.66) (p < .01). However, the decrease in SAFS scores at T3 (M = 9.30, SD = 8.73) did not indicate a significant difference (p > .05). The control group had significantly lower SAFS scores at T2 (M = 10.51, SD = 8.21) and T3 (M = 10.16, SD = 7.46) than at T1 (M = 11.87, SD = 7.67) (both p < .05). Thus, social adaptive functions improved in both groups after the intervention, and the effectiveness of the intervention on the control group persisted 3 months after the intervention.
      Repeated measurements were conducted with respect to both groups (Table 3). At T2 and T3, SAFS scores decreased significantly (p < .01 and p < .05, respectively), indicating that both groups achieved significant improvement in terms of their social adaptive functions. The interaction of group × time indicated that the experimental group did not achieve a significant decrease in SAFS scores at T2 and T3 as compared with the control group (p > .05). The results suggested that the experimental group did not exhibit a significant difference in terms of the level of improvement in their social adaptive functions as compared with that of the control group. Inclusion of the demographic variable of family visits into the analysis did not yield a significant difference.

      Effectiveness of WHOQOL-BREF

      First, a within-group comparison was conducted (Table 3). The WHOQOL scores of the experimental group at T2 (M = 86.42, SD = 17.98) and T3 (M = 86.64, SD = 15.92) were significantly higher than their scores at T1 (M = 79.33, SD = 13.40) (both p < .01). The WHOQOL scores of the control group increased at T2 (M = 81.02, SD = 16.82) and decreased at T3 (M = 75.16, SD = 13.81); however, none of these differences were significant (all p > .05). The results revealed that the quality of life of the experimental group improved significantly after the intervention and that such improvement persisted for 3 months.
      Repeated measurements and comparisons of the experimental and control groups were conducted. At group, WHOQOL scores of the experimental group were significantly higher compared with the control grop. At T2, WHOQOL scores increased significantly, indicating improved quality of life in both groups. The interaction of group × time indicated that the experimental group exhibited a significant difference in terms of the level of increase in their WHOQOL scores at T2 and T3 compared with the changes exhibited by the control group (p < .05). The inclusion of the demographic variable of family visits did not yield a significant difference in terms of quality of life.

      Discussion

      The objective of this study was to explore the positive effects of AAT for patients with chronic schizophrenia. The research results see great improvements in social function, experimental group at postintervention, but a clear downward trend 3 months after the intervention. However, we saw no great improvements in both social adaptive function and experimental group at postintervention until 3 months later. In terms of the quality of life, the experimental group saw significant improvement at postintervention until three months later. The positive effects on social function and quality of life meant that through animal interactions schizophrenia patients can build social skills and improving their quality of life. Meanwhile, the lack of improvement in social adaptive function is unprecedented considering previous studies [
      • O'Haire M.E.
      • McKenzie S.J.
      • McCune S.
      • Slaughter V.
      Effects of classroom animal-assisted activities on social functioning in children with autism spectrum disorder.
      ,
      • Wesenberg S.
      • Mueller C.
      • Nestmann F.
      • Holthoff-Detto V.
      Effects of an animal-assisted intervention on social behavior, emotions and behavioural and psychological symptoms in nursing home residents with dementia.
      ], and there will be related discussed on said topic.
      The effects on social function in our study, there was no significant difference in the social function between the experimental group (M = 54.09) and control group (M = 50.56) in the pretest, meaning that the two groups have the same social function level. At T2, both groups exhibited increased social functioning scores. The control group might have been subjected to the Hawthorne effect [
      • Abdulraheem S.
      • Bondemark L.
      Hawthorne effect reporting in orthodontic randomized controlled trials: truth or myth? Blessing or curse?.
      ]. During the AAT activities, researchers participated in the activities of both groups to maintain blindness. The control group engaged in routine discussion groups and watched short films about animals, which were not part of their original discussion group. This change may have caused residents to believe that they were of an experimental group and affected their postintervention behavioral performance, thereby leading to a significant effect. In repeated measurements and comparisons between the two groups, the T2 scores of social functioning exhibited by the experimental group increased significantly compared with those of the control group. The intervention effectiveness indicated that the AAT intervention improved participants' social functioning. O'Haire et al. [
      • O'Haire M.E.
      • McKenzie S.J.
      • McCune S.
      • Slaughter V.
      Effects of classroom animal-assisted activities on social functioning in children with autism spectrum disorder.
      ] used 8 weeks of AAT to improve the social functioning of people with autism spectrum disorder. Wesenberg et al. [
      • Wesenberg S.
      • Mueller C.
      • Nestmann F.
      • Holthoff-Detto V.
      Effects of an animal-assisted intervention on social behavior, emotions and behavioural and psychological symptoms in nursing home residents with dementia.
      ] demonstrated AAT to 17 dementia patients, and we saw great increase in patients' social interaction and positive emotion (pleasure). The results of that study revealed that AAT not only improved patients' social skills but also reduced their social withdrawal. During the AAT process used in the present study, interactions between residents and service dogs helped residents understand their internal emotional changes and develop a trusting and interactive relationship with the dogs. Consequently, residents could practice the capabilities required to develop mutual trust and social skills with people, thereby increasing their social functioning. However, at T3, the social functioning of the experimental group decreased significantly, possibly because of the effects of the COVID-19 pandemic. After May 2021, the Taiwan Center for Disease Control announced that no visitors were allowed to enter hospitals, nursing centers, and institutions for psychiatric rehabilitation, including family members. During the study, the researchers found that compared to the control group, the participants in the experimental group received visits from family significantly more frequently. However, the no-visiting regulation was established during T2 to T3. For participants in the experimental group whose family did not visit, the lack of social interactions could lead to the degeneration of their social function. There is negative influence to social function when patients with Schizophrenia lack familial support [
      • Dziwota E.
      • Stepulak Z.M.
      • Wloszczak-Szubzda A.
      • Olajossy M.
      Social functioning and the quality of life of patients diagnosed with schizophrenia.
      ]. The situation is shown and proved by previous experimental results by Ma et al. [
      • Ma J.
      • Hua T.
      • Zeng K.
      • Zhong B.
      • Wang G.
      • Liu X.
      Influence of social isolation caused by coronavirus disease 2019 (COVID-19) on the psychological characteristics of hospitalized schizophrenia patients: a case-control study.
      ]. At the same time, to reduce contact between residents of psychiatric rehabilitation and other people, two of the institutions in the experimental group limited the outdoor time of residents (no such limitations were reported by the other four institutions); residents decreased their amount of time spent on outdoor activities and lacked normal social interactions with others in the institutions. Since MHSFS scores were calculated using staff's evaluation of the residents' social life over the last 3 months, the scores of the experimental group decreased significantly. The results were similar to those reported by studies of COVID-19. The pandemic reduced social interaction and social support [
      • Chou W.P.
      • Wang P.W.
      • Chen S.L.
      • Chang Y.P.
      • Wu C.F.
      • Lu W.H.
      • et al.
      Voluntary reduction of social interaction during the COVID-19 pandemic in Taiwan: related factors and association with perceived social support.
      ]. Thus, the present study assumed that the results were caused by the limitation of residents' interactions by institutions to mitigate the effects of the pandemic.
      The social adaptive functions of the experimental group improved significantly at T2 compared to T1, which corresponds to the results found by Chang et al. [
      • Chang B.H.
      • Chang S.Y.
      • Yeh M.L.
      The healing process of chronic schizophrenic patients in animal-assisted therapy.
      ]. However, no significant improvement was noted at T3, possibly because of the larger SD (8.37) of the T3 sores in experimental group, which indicated marked inter-individual differences. This result may be explained by the stricter pandemic prevention measures implemented by two of the institutions in the experimental group. Some residents remained in their rooms by themselves most of the time. The staff evaluation of the residents' day-to-day living abilities at T3 changed from “active completion” to “needs reminders by others.” When the social interaction of institutional residents is reduced, their social adaptive functions can easily decrease [
      • Karabulut H.K.
      • Dinç L.
      • Karadag A.
      Effects of planned group interactions on the social adaptation of individuals with an intestinal stoma: a quantitative study.
      ]. The between-group comparison results revealed that the experimental group did not exhibit significant improvement at T2 and T3. There are other reasons that could have influenced the effect of the intervention—social function and social adaptation are both subjective perceptions, leading to the potential for different perceptions due to their analysis from different aspects. For instance, it is very challenging for residents and experts to evaluate social adaption and communication about the forced migration issue from their perspectives; hence, subjective perceptions need to be evaluated [
      • Grech H.
      Impact of forced migration on communication and social adaptation.
      ]. In addition, Ortega et al. [
      • Ortega L.
      • Montalvo I.
      • Monseny R.
      • Burjales-Martí M.D.
      • Martorell L.
      • Sanchez-Gistau V.
      • et al.
      Perceived stress, social functioning and quality of life in first-episode psychosis: a 1-year follow-up study.
      ] performed a follow-up on social function for a year after the first onset of psychosis and used a self-report questionnaire. Considering the objectiveness of the evaluation, the MHSF and SAFS in this study were completed by institutional staff. The study was limited by the lack of consideration on differences in perceptions that would influence the results, so it is recommended that researchers collect information from both participants and staff for reference in future studies.
      The quality of life of participants in the experimental group at T2 and T3 significantly improved compared with preintervention. The quality-of-life scores of the experimental group at T2 and T3 were significantly higher than those of the control group. The results implied that AAT not only benefited participants immediately after the intervention but also had persistent effects 3 months after the intervention. The positive effect on quality of life described in other studies were also proven [
      • Olsen C.
      • Pendersen I.
      • Bergland A.
      • Enders-Slegers M.J.
      • Ihlebæk C.
      Effect of animal-assisted activity on balance and quality of life in home.
      ,
      • Sahebalzamani M.
      • Rezaei O.
      • Moghadam L.F.
      Animal-assisted therapy on happiness and life quality of chronic psychiatric patients living psychiatric residential care homes: a randomized controlled study.
      ]. Moreover, the quality of life of the experimental group was not affected by the pandemic. Smolarczyk-Kosowska et al. [
      • Smolarczyk-Kosowska J.
      • Szczegielniak A.
      • Legutko M.
      • Zaczek A.
      • Kunert Ł.
      • Piegza M.
      • et al.
      Assessment of the impact of a daily rehabilitation program on anxiety and depression symptoms and the quality of life of people with mental disorders during the COVID-19 pandemic.
      ] explored the effects of a rehabilitation program on patients with psychiatric disorders during the COVID-19 pandemic and identified positive effects on their emotions and quality of life that are consistent with the results of the present study. The present study used AAT to improve the quality of life of patients with schizophrenia significantly. During the AAT process, group activities and the development of supportive environments, including physiological, psychological, social, and environmental aspects, were fundamental factors influencing the quality of life of patients with psychiatric disorders [
      • Chang B.H.
      • Chang S.Y.
      • Yeh M.L.
      The healing process of chronic schizophrenic patients in animal-assisted therapy.
      ]. Thus, the present study identified the positive effects of AAT with respect to improving the quality of life of patients with chronic schizophrenia.
      During the COVID-19 pandemic, the regulations established by institutions to mitigate the effects of the pandemic affected residents' social functioning and social adaptive functions. These regulations were environmental factors that could not be eliminated, and they serve as limitations for the present study. Another limitation was randomization in one institution and each group. The effects of intervention is easily influenced by the environment of the institutions, random assignment is a method that can be considered in future studies.

      Conclusion

      Because of the COVID-19 pandemic, institutions for psychiatric rehabilitation established stricter regulations that interfered with the results of this study. The AAT program effectively improved the social interaction and quality of life of patients with chronic schizophrenia. In the case of the quality of life, the effectiveness of the intervention lasted for only up to 3 months after the intervention. Nevertheless, the proposed intervention program can assist patients with chronic psychiatric disorders in returning to social life and can serve as a reference for personnel working in community institutions for psychiatric rehabilitation. This intervention can help improve patients' physiological and psychological health, strengthen their social functioning and social adaptive functions, and promote their return to a healthy life.

      Data availability

      The data that support the findings of this study are openly available in ResMan clinical trial management public platform at http://www.medresman.org.cn, Reg number ChiCTR2200061715.

      Author contributions

      Study conception and design: Chieh-An Shih, Man-Hua Yang. Data collection: Chieh-An Shih. Data analysis and interpretation: Chieh-An Shih, Man-Hua Yang. Drafting of the article: Chieh-An Shih, Man-Hua Yang. Critical revision of the article: Man-Hua Yang.

      Funding

      The research was funded by Taiwan Nurses Association (TWNA- 1101024).

      Conflicts of interest

      The authors declare that we do not have any commercial or associative interest that represents a conflict of interest in connection with the work submitted.

      Acknowledgments

      The authors acknowledge the six institutions for psychiatric rehabilitation for the assistance they provided during enrollment.

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