COMPREHENSIVE CHILD AND ADOLESCENT NURSING

2016, VOL. 39, NO. 4, 256–271

http://dx.doi.org/10.1080/24694193.2016.1196266

Hospital-Based Therapy Dog Walking for Adolescents with

Orthopedic Limitations: A Pilot Study
Coley Vitztum, RN, PhD, CNS-BCa, Patricia J. Kelly, PhD, MPH, APRNb, and
An-Lin Cheng, PhDb
a
Children’s Mercy Hospital, Division of Orthopedic Surgery, Kansas City, Missouri, USA; bSchool of
Nursing and Health Studies, University of Missouri-Kansas City, Kansas City, Missouri, USA

ABSTRACT ARTICLE HISTORY

Nine out of 10 adolescents fail to achieve recommended levels of Received 2 April 2016
aerobic and muscle-strengthening physical activity leading to dele- Accepted 21 May 2016
terious consequences for individuals and a public health epidemic. KEYWORDS
Whereas all adolescents comprise a vulnerable population because Physical activity;
of minimal levels of physical activity, those with an orthopedic human-animal interaction;
limitation, including slipped capitol femoral epiphyses or Blount’s dog-walking
disease, are at greater risk despite shared characteristics with the
general adolescent population such as normal cognition and inde-
pendent ambulation. Few, if any, interventions examine effective
strategies for physical activity in this population. Therapy dog-
walking is proposed as an original approach for physical activity.
Although this form of human-animal interaction is a potential
strategy for increasing physical activity, it lacks credibility due to a
paucity of studies using well-constructed, experimental designs.
The objective of this pilot study was to use a one group (n = 7),
prospective, pre/post design to assess feasibility and acceptability,
and to serve as the foundation for future research on therapy dog-
walking in this population. Feasibility and acceptability were
assessed by results of the recruitment strategy, by process evalua-
tion, and by participant satisfaction survey and interview.
Descriptive statistics summarized participant demographics and
protocol requirements, including the use of accelerometers.
Wilcoxon matched pairs tests were used to assess participants’
experience with the dogs. Paired samples t-tests compared physi-
cal activity levels before, during, and after the dog-walking inter-
vention. Pender’s health promotion model was the guiding
framework for this study. Physical activity levels were significantly
increased during the intervention compared to before (p = .049)
and after (p = .025) as well as during the walking sessions them-
selves (p = .000). Participants expressed high enthusiasm for the
program: 6 of the 7 participants attended 100% of the walking
sessions when no restrictions to physical activity participation were
present. No differences between the participant’s pre and post-
intervention dog experience were found. These findings indicate a
therapy dog-walking program is an acceptable and feasible strat-
egy for increasing physical activity in this population. Additional
research with a larger sample size, more rigorous methodological
design, and refinement of the data collection methods is required.

CONTACT Coley Vitztum cvitztum@cmh.edu Children’s Mercy Hospital, Division of Orthopedic Surgery,
2401 Gillham Road, Kansas City, MO 64108.
© 2016 Taylor & Francis
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 257

Introduction
Adolescent inactivity has an immediate public health impact exemplified by the
now commonplace occurrence of diagnoses historically reserved for adults such as
cardiovascular disease, diabetes, obesity, osteopenia, and even premature death
(USDHHS, 2011). Up to 85% of adolescents fail to meet the criteria for regular
physical activity (60 minutes of aerobic activity, 7 days per week) and 7% of
adolescents are considered totally inactive (CDC, 2012). Since adolescence is the
period of life associated with the greatest decline in physical activity, the high
prevalence of sedentary behavior is especially troubling (CDC, 2012). Reinforcing
the significance of this issue is the evidence demonstrating that behavior patterns
for physical activity established in adolescence perpetuate into adulthood
(USDHHS, 2011).
Adolescents who are restricted from traditional forms of physical activity
increase the urgency of this concern. The Pediatric Strategic Planning Group of
the U.S. Bone and Joint Decade (USDBJ) has given the highest priority to research
and interventions aimed at increasing physical activity for adolescents who are
limited from traditional physical activity due to the diagnoses of slipped capitol
femoral epiphyses or Blount’s disease (USDBJ, 2010). Position statements pub-
lished by the National Association of Orthopaedic Nurses and the American
Academy of Orthopaedic Surgeons support this approach (AAOS, 2011;
NAON, 2014). Slipped capitol femoral epiphyses (SCFE), a condition in which
the proximal femoral epiphyses is depicted as “slipping” from the femoral head, is
a predisposing factor for inactivity (Gettys, Jackson, & Frick, 2011). Blount’s
disease, a progressive deformity of the medial aspect of the proximal tibia leading
to malalignment of the knee joint, is a consequence of obesity-related inactivity
(Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Both conditions typically occur
between the ages of 11 and 15 years of age, with males being affected three times
more often than females (Gettys et al., 2011). The incidence of SCFE is 10 cases/
100,000 adolescents whereas Blount’s disease affects 1% of this age group (USDBJ,
2010). More than 80% of the adolescent population having SCFE or Blount’s
disease have a body mass index (BMI) greater than the 95th percentile at the time
of diagnoses: This excess weight leads to an increase in the incidence and decrease
in the age of onset for both diseases (Ogden et al., 2010; USDBJ, 2010). The strong
correlation between obesity and its co-morbidities associated in the presence of
either diagnoses suggest that alternative forms of physical activity are needed.
Adolescent physical activity interventions have generally involved the
adolescent population as a whole with results demonstrating modest
increases in physical activity (Iannotti & Wang, 2013). The lack of research
specific to the type of activity and/or certain adolescent populations increases
the ambiguity of the results, which are also weakened by the minimal use of
empirical designs (Dobbins, DeCorby, Robeson, Husson, & Tirilis, 2009;
Iannotti & Wang, 2013). There is a gap in the literature examining the
258 C. VITZTUM ET AL.

physical activity needs of adolescents with an orthopedic limitation including

adolescents with the diagnoses of SCFE and Blount’s disease. Adolescents
with an orthopedic limitation are characterized as a group of otherwise
healthy individuals with normal cognitive ability that are in need of physical
activity modifications because their diagnoses alter the physical mechanics of
the lower extremity. Whereas running and contact sports are often prohib-
ited in this population, activities such as walking are considered appropriate
and within this group’s capabilities (Gettys et al., 2011).
Human-animal interaction (HAI), in the form of therapy (non-pet)
dog-walking, is such an approach with high potential for increasing
physical activity in this population. Several studies investigating the use
of HAI interventions for physical activity document decreases in cardi-
ovascular risk factors along with positive psychological impacts
(Esposito, Griffin, McCune, & Maholmes, 2011; Marino, 2012). The
use of dog-walking for physical activity has been proposed as an effective
means of increasing physical activity in some populations due to the
positive interaction between the human and animal (Johnson &
Meadows, 2010). The presence of a partner, such as a dog, is linked to
physical activity engagement and sustainability (Johnson & Meadows,
2010; Kushner, Blatner, Jewell, & Rudloff, 2006). The use of a non-pet,
therapy or shelter dog, offers a potential source of purpose and emo-
tional support that has been previously demonstrated in adult HAI
studies (Johnson & Meadows, 2010). Similar to physical activity studies
in this population, gaps in this research include the limited use of non-
pets, minimal attention to adolescents, and a paucity of experimental
studies (Esposito et al., 2011).
The objective of this exploratory pilot study was to assess program feasibility
and acceptability, and to serve as the foundation for determining the efficacy
of HAI in the form of therapy dog-walking for the target population on
physical activity. This innovative intervention was aimed at enhancing the
connection between physical and purposeful activity as a conduit to health
in the population of adolescents with orthopedic limitations. The findings from
this study will provide the framework for the development of longitudinal
research studies testing the relationship between the presence of the animal,
increased physical activity and long-term health outcomes in this population.
The use of HAI in the form of therapy dog-walking for physical activity in
adolescents with orthopedic limitations had not been previously studied;
thus, the intervention effect was unknown. As a preliminary study, the goal
was not to test a hypothesis; rather, the results offer information related to
sample size and outcome measures for future study designs. The study
addressed the following specific aims:
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 259

Specific Aim 1
To examine the feasibility of a therapy dog-walking program to improve physical
activity levels in adolescents with an orthopedic limitation through evaluation of
participant recruitment, retention, and experience, as well as specifics of interven-
tion implementation. The research questions related to this aim were: 1) what is
the impact of protocol requirements on the participant’s daily routine? And, 2)
what is the effect of a dog in a walking program on physical activity commitment
and adherence in adolescents with an orthopedic limitation?

Specific Aim 2
To assess the acceptability and the utility of multiple data collection methods to
determine intervention impact and required effect size in future therapy dog-
walking studies for physical activity in adolescents with orthopedic limitations.
The research questions related to this aim were: 1) what is the extent of a therapy
dog-walking program on the outcome variable, physical activity? And, 2) how do
data collection results inform effect size for future studies?

Theoretical Framework
The health promotion model (HPM) served as the theoretical framework for
this study. The concepts, assumptions, and propositions of the HPM are
geared toward recognizing the behavioral-specific cognitions and effect of an
individual in attempt to facilitate and foster subsequent behavioral outcomes
(Pender, Murdaugh, & Parsons, 2011). The components of this research
study within the HPM included: the individual characteristics specific to
adolescents with an orthopedic limitation, the treatment intervention of
therapy dog-walking and its influence on behavior, and the desired outcome
of increased physical activity commitment and adherence. The HPM con-
structs of self-efficacy, perceived emotional support, and purposeful activity
guided this approach.

Methods
Potential participants were to be identified from the seven Orthopedic Clinic
locations in the Children’s Mercy Hospital and Outpatient Clinics (CMH&C)
system. Recruitment included collaboration with the participant’s treating
physician to confirm the subject has the diagnosis of SCFE (ICD-9 #732.2) or
Blount’s disease (ICD-9 #732.4) and was released to physical activity.
Inclusion and exclusion criteria are identified in Table 1. The inclusion of
only those willing to interact with the dog introduced selection bias, but was
deemed necessary on this critical confounding variable. The perceived risks
260 C. VITZTUM ET AL.

Table 1. Inclusion and exclusion criteria.

Inclusion criteria
Adolescents, ages 10–17.5 years
Residence within 60 mile radius of program site
Confirmed diagnosis of Blount’s disease or SCFE
Written release to participate from treating
orthopedic surgeon
Parental consent and adolescent assent
Willingness to interact with dogs including
completion of a one-time training session
Exclusion criteria
Cognitive and/or physical impairments interfering
with independent participation
Inability to provide verbal understanding of the
program and written assent
Other diagnosis requiring active medical treatment
Non-English speaking
Allergy to dogs

for participants were injury occurring during the walking session and/or
related to the dog interaction. Institutional Review Board (IRB) approval
(#14050232) was granted by CMH&C for this study.

Measures
Demographic data collected by the researcher included age, gender, ethnicity,
diagnoses, co-morbidities, health insurance status, zip code, year in school,
single or dual parent household, number of siblings, and characteristics of
pets in the household. Attendance was recorded for the 16 planned walking
sessions in the intervention phase in addition to the pre and post-interven-
tion sessions.
Physical activity was measured from baseline to post-intervention-four weeks
after the conclusion of the program. The ActiGraph® accelerometer, model
wGT3X-BT (ActiGraph, LLC., Pensacola, FL), was used to measure physical
activity level. Using this instrument, physical activity level was operationalized
as normal movement, step count, and physical activity intensity in 30-second
intervals (epochs) using triaxial vector magnitude (VM) counts (Salmon,
Timperio, Chu, & Veitch, 2010; Zhu, Chen, Zhuang, 2013). Measurements were
based on an accepted 30-second epoch length used in previous adolescent physical
activity studies (Cain, Sallis, Conway, Van Dyck, & Calhoon, 2013; Edwardson &
Gorley, 2010) and 66 active hours per week. Active hours per week were based on
accelerometer valid day definitions (10 hours for weekdays, 8 hours for weekend
days) previously defined in adolescent physical activity studies (Cain et al., 2013).
Weight was measured at pre-intervention by the use of a calibrated,
electric scale (Scale Tronix Bari-Scale, serial number 6702-7325). Weight
was measured to the nearest 10g with a within participant variability of
1.5% of the measured weight to substantiate reliability of this instrument
(Himes, 2009). BMI was calculated using standardized anthropometry mea-
surements and growth chart guidelines (Hastings, Anding, & Middleman,
2011; Himes, 2009). The inclusion of weight and BMI was for descriptive
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 261

analysis as significant weight changes in an eight week period were not

expected or reliable (Himes, 2009; Iannotti & Wang, 2013).
Accelerometer wear compliance was addressed by the number of “valid”
days the device was worn each week. A day was considered to be valid when
the device was worn for 10 hours on a weekday and eight hours on a
weekend day. The use of these two time points for measurement has been
validated in previous adolescent physical activity studies using this device
(Cain et al., 2013; Rowlands, 2007). The ActiLife 6.11.7 software (ActiGraph
Corporation, 2015) associated with the device provides this information in
the form of Wear Time Validation (WTV) using contiguous time to deter-
mine the number of hours of wear and non-wear time. Sixty minutes of
consecutive zeros counts per minute is supported for defining a non-wear
period in adolescents (Cain et al., 2013; Rowlands, 2007). Accelerometer wear
acceptability was assessed by a Researcher-developed questionnaire using a 4-
point Likert scale with a higher score indicating greater tolerability. This data
collection measure was administered post-intervention.
The dogs and physical activity (DAPA) tool (Christian, nee Cutt, 2007)
was used to measure the participant’s experience with the dog. The scale was
administered at the pre-intervention training session and at the conclusion of
the program, post-intervention. The DAPA tool is a self-report tool designed
to measure dog-walking behavior including individual, social, and environ-
mental factors as well as attachment that occurs from the dog interaction
(Christian, 2007). Responses use 5-point and 7-point Likert scales with a high
score indicative of a bond between the therapy dog and participant
(Christian, 2007). The tool has an alpha level range of 0.65–0.92 and test-
retest reliability of greater than 0.70, demonstrating moderate to strong
internal class correlations and reliability (Cutt, Giles-Corti, Knuiman, &
Pikora, 2008; Wilson & Netting, 2012). For the purposes of this study’s
objective and specific aims, the 13 sub-scale, 5-point items of dog attach-
ment, individual (normative) beliefs, and social factors (motivation to com-
ply) (Christian, 2007; Cutt et al., 2008) were used. Items about dog ownership
were reworded to reflect the inclusion of a non-pet therapy dog in a program
setting. The DAPA tool items specific to pet ownership were included in the
demographic questionnaire and used for descriptive analysis.

Data Analysis
Data analysis was performed using SPSS Version 22 (IBM Corporation, 2013)
and the ActiLife Version 6.11.7 software associated with the accelerometer
(ActiGraph Corporation, 2015). An alpha level of p < 0.05 was used to
determine significance. Missing data was managed by the statistical proce-
dures of case mean substitution (Polit & Beck, 2012).
262 C. VITZTUM ET AL.

Descriptive analysis was performed for the demographic statistics and walking
session attendance rate, and accelerometer wear compliance. Wilcoxson Matched
Pairs tests were used to compare the differences between the average scores, sum
scores, and subscale sum scores of the modified DAPA tool items pre and post-
intervention. Accelerometry data in this analysis was used to measure weekly step
counts, step counts during the dog-walking sessions, and for the calculation of
average hourly step counts during and outside of the dog-walking sessions. Paired
sample t-tests were used to compare the differences in pre and post-study activity
levels (step count) as well as the differences between activity level (step count)
during the walking session and average daily activity level (calculated on a weekly
basis). The effect size from the results measuring physical activity were used to
conduct a sample size calculation to ensure the necessary sample size needed to
protect against Type I and Type II errors in larger, experimental designs. Effect
size calculations based on the results of the paired sample t-tests measuring the
outcome variable, physical activity, were performed using the formula for Cohen’s
d, one sample dependent groups, d ¼ ptffiffin (Lakens, 2013).

Results
A total of 32 potential participants were identified as eligible from the
medical record query. Twenty-five of the 32 potential participants were
given an informal survey flyer at the time of their orthopedic clinic appoint-
ment with the remaining eight potential participants missing and/or resche-
duling their orthopedic appointment outside of the recruitment time-frame.
Fourteen of the 25 flyers were returned to the Researcher for a response rate
of 56%. Reasons identified for declining program participation included no
interest in participation, other commitments at the time the program
occurred, the program location being too far from home their home, and a
dislike of dogs. Attrition occurred with one participant’s voluntary with-
drawal for academic reasons in Week Two of the intervention phase of the
study, for a final sample size of 7 participants. Data from this participant
were not included in the analysis due to the limited time of study participa-
tion and less than 2% percent of data collection completed.
The dog-walking sessions occurred during an 8-week time period in the
months of April and May. Weather for the sessions varied greatly with
temperatures ranging from 7oC (45oF) to 29oC (85oF) at the time the sessions
occurred and two sessions occurred in rainy conditions. Fifteen of the 16
planned walking sessions were completed with the Researcher canceling one
session because of lightning in the area at the time of the walking session.
The age of the participants ranged from 11–14 years; all attended middle
school. Gender was nearly evenly split (4 females, 3 males). The majority of
the participants (71%) had a diagnosis of SCFE; 60% had this diagnosis for 10
weeks or less from the time of orthopedic surgical intervention. A minimum
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 263

of 6 weeks from surgical intervention was required for participant eligibility.

Participant weight ranged from 64.4kg–122.8 kg and the average BMI for the
study group was 33.59, which is considered obese in BMI classifications
(Hastings et al., 2011). Seventy-one percent of the participants were partici-
pating in physical education class at the time of the study, 6 of 7 lived in a
two-parent household; all participants had at least one sibling, and all had
health insurance. Five of the 7 participants owned a dog and the 2 partici-
pants without a dog reported no previous dog ownership. Of the 5 partici-
pants with a pet dog, less than 30% of participant families reported walking
their dog more than once a week and only 1 participant was the primary dog-
walker.
Four of the 7 participants (57%) attended 15/15 walking sessions for a
100% attendance rate. Two participants attended 11 sessions (73%) and 1
participant attended 10 sessions (67%). With adjustment made for the 2
participants requiring temporary physical activity restrictions related to
their orthopedic diagnosis during the intervention, 6 of 7 participants
(85.7%) attended 100% of the walking sessions when no restrictions to
participation were present. Walking sessions missed by the remaining parti-
cipant were related to transportation issues experienced in route to the three
identified sessions.
Accelerometer device wear was the highest during the intervention phase
at 86% compared to 71.5% pre-intervention and 57.2% post-intervention.
The average number of valid days was worn was 5.7 days (SE = 0.61, SD =
1.60) in the baseline week, 6.02 days (SE = 0.32, SD = 0.85) during weeks 1–8,
and 4.75 days (SE = 0.75, SD = 1.99) in weeks 9–12. Figure 1 provides
representation of the mean of each participant for the three phases of the
study: pre-intervention (baseline), intervention (weeks 1–8), and post-inter-
vention (weeks 9–12). Eighty-five percent of the participants stated they liked
the size of the device and the device was easy to use. Four of 7 participants
stated the device was too noticeable. There was no consensus on the wearing
the device on the wrist and the device’s comfort.
Results of the Wilcoxson Matched Pairs tests indicated no statistically
significant differences in the average pre and post-intervention scores.
Evaluation of the pre and post-intervention average score mean differences
indicated decreased post-intervention scores in 12/13 items and one item
unchanged (Table 2).
There were no statistically significant differences pre and post-intervention
(Z = -0.95, p = 0.34). The highest reported sum scores for the modified
DAPA tool were 64.00 pre-intervention and 63.00 post-intervention based on
a maximum score of 65.00. The subscale scores for the modified DAPA tool
included seven items evaluating dog attachment, three items related to
normative beliefs, and three items assessing participant motivation to
264 C. VITZTUM ET AL.

Figure 1. Time of accelerometer wear.

Table 2. Modified DAPA tool pre and post-intervention item scores.

Pre- Post-
Intervention Intervention
mean (SD) mean (SD)

I consider the dog a friend 5.00 (0.00) 4.43 (1.15)

Walking a dog adds to my happiness 4.71 (0.49) 4.00 (1.41)
I talk to others about walking with a dog 3.71 (1.38) 3.57 (1.81)
I often play with the dog before or after the walking session 4.67 (0.82) 4.00 (1.55)
The dog knows how I feel about things 4.67 (0.52) 3.86 (1.07)
I would consider the dog to be part of my family 5.00 (0.00) 4.29 (1.25)
Walking in the program with the dog makes me walk more 4.50 (0.84) 4.14 (1.07)
My family thinks I should walk with the dog in the dog-walking program 4.71 (0.76) 4.14 (1.07)
My friends think I should walk with the dog in the dog-walking program 3.71 (1.50) 3.57 (0.98)
My doctor thinks I should walk with the dog in the dog-walking program 4.71 (0.49) 4.00 (1.41)
I want to be physically active because it is what my family members think 3.86 (1.46) 3.86 (1.35)
I should do
I want to be physically active because it is what most of my friends think I 3.57 (0.98) 3.29 (1.11)
should do
I want to be physically active because it is what my doctor thinks I should 4.43 (0.79) 3.86 (1.46)
do

comply. There were no statistically significant differences in the three sub-

scale sum scores pre and post-intervention.
Results of the paired sample t-tests indicate significant differences in step count
during the weeks the dog-walking sessions compared to baseline (t = 2.461, p =
.049) and Weeks 9–12 (t = 2.98, p = .025) when there are no dog-walking sessions.
There were also significant differences in step count during the hours the dog-
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 265

walking sessions occurred compared to the hours there were no dog-walking

sessions in Weeks 1–8 (t = 9.20, p = .000) and Weeks 9–12 (t = 10.80, p = .000).
There were no significant differences between the step count at baseline and the
end of the intervention (Week 8) (t = -.006, p = .995) as well as the end of the study
(Week 12) (t = -1.19, p =.108). The results for the weekly step counts are illustrated
in Figure 2 and average hourly step counts in Figure 3. The paired t-tests scores are
provided in Table 3.
Effect size ranged from 0.002 to 4.08 with a median effect size of 1.03,
suggesting a large effect (Cohen, 1992). Using the median effect size of 1.03,
an alpha level of 0.01, and a power level of 0.9, a sample size calculation was
performed with the use of sample size calculator software, G* Power 3.1.9.2
(Faul, Erdfelder, Lang, & Buchner, 2007) and confirmed by the use of
existing power analysis tables (Cohen, 1992). Results of the sample size
calculations for future studies with a two-group design identify a minimum
sample size of 32 participants (16 per group).

Discussion
The findings of the study indicated that participant activity levels (step
count) increased during the hours/weeks the dog-walking sessions, in addi-
tion to program acceptability that was substantiated by actual and adjusted
attendance rates of 85.7% for the intervention. The results from the physical
activity paired t-tests were appropriate for a power analysis determining the

Figure 2. Physical activity weekly step counts.

266 C. VITZTUM ET AL.

Figure 3. Physical activity weekly step counts.

Table 3. Physical activity paired t-tests scores.

Mean
(SE) Standard Deviation 95% Confidence Intervals
Baseline (Week 0) step count and average 10601.56 11399.67 Lower: 58.63
step weeks 1–8 (including dog walks) (4308.67) Upper: 21144.50
Baseline step count and week 8 step -32.74 14732.22 Lower: -13657.77
count (5568.25) Upper: 13592.27
Baseline step count and week 12 step -22784.27 31908.31 Lower: -52294.53
count (12060.21) Upper: 6725.99
Average step count weeks 1–8 (including 25883.57 22978.86 Lower: 4631.67
dog walks) and average step count (8685.19) Upper: 47135.47
weeks 9–12
Average hourly step count during dog 1373.37 394.84 Lower: 1008.21
walks and average hourly steps counts (149.23) Upper: 1738.53
weeks 1–8 (excluding dog walks)
Average hourly step count during dog 1723.22 422.02 Lower: 1332.92
walks and average hourly step counts (159.51) Upper: 2113.52
post-intervention (weeks 9–12)

sample size needed to assess significance in larger studies (Fritz, Morris, &
Richler, 2011). Despite the lack of significant findings in the assessment of
the participant’s experience with the dog, the results of the study’s other data
collection methods offer preliminary findings about the impact of the dog on
physical activity commitment and adherence. The findings also met the
theoretical assumptions proposed for this study, confirming the health pro-
motion model (HPM) as useful framework.
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 267

The appropriateness of the program’s timing and length was confirmed by

the study’s ability to recruit and retain participants. This format is further
supported in previous dog-walking studies with an identified after-school
timeframe and activity of low to moderate intensity and short duration that
allows for a break in the sedentary activities of school and evening homework
activities (Lentino, Visek, McDonnell, & DiPetro, 2012). The program’s
setting was convenient for the participants based on a review of residence
zip codes, easy access with free on-site parking, and the proximity to a
familiar location, CMH&C. Despite being a public park, the park was nearly
unpopulated at the majority of the walking sessions with other walkers noted
at 5/15 sessions and other walkers with a dog at only one session. As the
circumference of the walking path is relatively small (0.27 kilometers), the
absence of other walkers supported the practicality of seven groups walking
concurrently. The weather had minimal impact on the program despite the
variability in temperature over the eight week span of the intervention.
Program attendance and acceptability were strongly demonstrated by a
high attendance rate and all participants stating they would be participate in
the program again during the exit interview. Despite a group mean accel-
erometer wear time of 6 days per week that is greater than the average of 5
days reported in previous adolescent physical activities (Cain et al., 2014), the
median and variability illustrated in the box plots of Figure 1 reveal device
wear in the post-intervention phase dramatically decreased. Rationale for the
decrease and variability in wear compliance can be attributed to several
factors including the device’s inability to be worn while swimming (the
post-intervention timeframe occurred in the month of June), decreased
commitment to wearing the device when the dog-walking sessions were
completed, and significant concerns with the device’s appearance articulated
in the results of the Researcher-developed questionnaire. The importance of
these findings in this study was the impact device wear had on the outcome
variable because physical activity data could not be collected if the device was
not worn.
There were no statistically significant differences in the modified DAPA
tool average, sum, or subscale sum post-intervention scores compared to the
pre-intervention scores. Consideration is given to the following factors con-
tributing to these results: 1) The sample was comprised of participants with a
baseline affinity for dogs; thus, explaining the minimal variability of pre/post
average scores on several items, 2) Participants did not walk with one dog for
the duration of the intervention; rather, dog team assignments were made on
a rotating basis allowing all participants to walk with all of the dogs. The
original DAPA tool was developed as a measure of the relationship/bond
occurring from the interaction between an owner and pet dog (Christian,
2007). It is posited this study’s approach of interactions with multiple dogs
influenced the results of this data collection measure; particularly the seven
268 C. VITZTUM ET AL.

subscale items specific to dog attachment. And 3) the original DAPA tool
had not been previously tested in adolescents. Despite modifications made to
accommodate this age group, difficulty with interpretation of the tool’s
statements may serve as one rationale for the findings.
There were statistically significant differences in physical activity levels
(step counts) during the hours the dog-walking sessions occurred and during
the eight weeks of the interventions suggesting a therapy dog-walking pro-
gram promotes increased physical activity in adolescents with orthopedic
limitations. The significant results of increased step count levels during the
dog-walking sessions and the eight weeks of the program indicate that
activity level is impacted by the presence of a dog and supports the need
for further research of the intervention itself.
The results of the paired sample t-tests on the outcome variable, physical
activity are indicative of a large effect size. The results of the outcome variable
in this study also make a significant contribution to the power needed in future
studies demonstrated by the magnitude of the mean differences in the data sets
and the practical significance of the large effect size (Fritz et al., 2012; Lakens,
2013). However, the interpretation of these data necessitate caution because of
the study’s small sample size and the inability to determine statistical inference.
The use of this information in future studies will also require consideration of
the logistical issues associated with this proposed sample size.
Strengths of this study are recognized in the study’s assessment of feasi-
bility and acceptability. The decision for study implementation during a mild
weather pattern (spring), at an after-school timeframe, and sessions of a short
duration (60 minutes or less) supported study feasibility and was demon-
strated in the recruitment and enrollment numbers for this study.
Study acceptability was demonstrated in the program’s attendance rate and
perceived positive experience with the dog despite the results of the modified
DAPA tool. The baseline measurements of weight, BMI, and activity level
appeared to have little impact on actual participation levels based on the
objective measurement of physical activity levels as well as the reported
increases in these levels during the intervention phase. The use of the
HPM as the study’s theoretical framework was manifested in the presence
of the theoretical constructs (self-efficacy, purposeful activity, and perceived
emotional support) in the study’s acceptability (attendance rate, program
experience, and increased levels of physical activity). The study’s use of the
HPM may also serve as an explanation for the results of the modified DAPA
tool by identifying the distinctions in the constructs of this study’s frame-
work compared to the concepts of the Theory of Planned Behavior (beha-
vioral control, intent) that guided the original DAPA tool (Cutt et al., 2008).
Limitations include the lack of a randomization, absence of control group,
and inability to determine causality inherent to a one-group pilot study
design. The study’s small sample size limits its generalizability and statistical
 COMPREHENSIVE CHILD AND ADOLESCENT NURSING 269

inference. Study length is also a concern due the inability to assess long-term
commitment and adherence in a physical activity intervention as well as
intervention sustainability. Threats to validity include selection bias due to
narrow inclusion criteria, participant bias because of a pre-existing affinity
for dogs, and maturation related to potential physical changes related to the
participant’s orthopedic condition that may have occurred during the time of
the study. The confounding variables of the novelty effect of the animal, the
intervention’s Hawthorne Effect, and the presence of the dog handlers as well
as the Researcher should also be considered. Further research with a larger
sample size in a two-group design comparing outcome measures for walking
the same dog for the entirety of the program versus a different dog each
session is recommended as one means to address the identified limitations.

Conclusion
Addressing the physical activity needs of a specific population is central to
achieving the activity fit for the participant based on the activity type. The
length of the study’s walking sessions substantiates the use of short bouts of
low-intensity for adolescent physical activity engagement and participation
(Lentino et al., 2012). The use of a hospital-based location and outdoor
setting further reinforces the importance of the fit of the activity in physical
activity interventions. The value of being in close proximity to the healthcare
professionals involved in their care was demonstrated by two participants
with the early recognition of the need for and access to orthopedic treatment
during the intervention phase. By completing a high number of walking
sessions in a variety of weather conditions, this study also illustrates the
ability of the physical activity intervention to easily adapt to an outdoor
setting. This study further supports the recommendation for future HAI
interventions to explore the environmental benefits of dog-walking in this
population (Christian et al., 2014).
The study’s use of a non-pet in a physical activity intervention offers a
significant contribution to the use of HAI in healthcare. The study’s dog-
walking program identified a use for therapy dogs in a new, unique setting
that may provide increased interactions and sessions of a longer duration
than traditional companion-style therapy dog visits (Chur-Hansen,
McArthur, Winefield, Hanieh, & Hazel; Westgarth, Christley, & Christian,
2014). An added benefit of the development of this form of HAI is the
crossover effect of becoming a physical activity intervention. The participant
retention identified in this study’s dog-walking session attendance also
demonstrates a commitment to the physical activity program when it is
perceived as a purposeful activity. Further research is needed to explore
and test the impact of the program as well as therapy dog-walking on
physical activity in adolescents with orthopedic limitations.
270 C. VITZTUM ET AL.

Acknowledgments
The authors would like to thank Children’s Mercy Hospital and Clinics, Kansas City, USA,
Division of Orthopaedic Surgery Rex and Lillian Diveley Research Endowment Fund as well
as the Department of Nursing and Allied Health who funded this research.

Declaration of Interest
The authors report no conflicts of interest. The authors alone are responsible for the content
and writing of this paper.

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