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Powell L, Ackerman R, Reinhard CL, Serpell J, Watson B. A prospective study of mental wellbeing, quality of life, human-animal attachment, and grief among foster caregivers at animal shelters. PLoS One 2024; 19:e0301661. [PMID: 38776263 PMCID: PMC11111037 DOI: 10.1371/journal.pone.0301661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 03/20/2024] [Indexed: 05/24/2024] Open
Abstract
Foster care programs at animal shelters have emerged as an important tool for promoting animal welfare and supporting shelter life-saving efforts. Preliminary evidence suggests that foster caregiving may also be health-promoting for humans. The goals of this study were to investigate the experiences of foster caregivers at animal shelters based on measures of positive and negative affect, quality of life, and grief, and to describe human-animal attachment among foster populations. Between March 2022 and 2023, 131 foster caregivers from five shelters in the United States completed three online surveys before, during and after providing foster care to a shelter animal. Positive affect decreased significantly from baseline to post-foster (F = 5.71, p<0.01), particularly among dog caregivers (F = 6.17, p<0.01). Negative affect remained unchanged (F = 0.47, p = 0.63). Foster caregivers perceived their foster animal provided companionship, affection and emotional support, although dog foster caregivers reported significantly higher emotional (U = 313.50, p<0.01) and social/physical quality of life (t = 4.42, p<0.01) than cat foster caregivers. Caregivers reported low mean avoidant and anxious attachment, suggesting they were able to develop secure bonds with their foster animals. Retention of fosters was also strong, with 86% of caregivers reporting they were likely to provide foster care in the future. Our findings suggest that fostering at animal shelters may serve as a One Health intervention to offer companionship, affection and emotional support to human caregivers while promoting animal welfare. However, these benefits did not translate to improvements in caregiver mental wellbeing, so caution should be applied when considering foster caregiving as a potential mental health promotion tool.
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Affiliation(s)
- Lauren Powell
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Roxy Ackerman
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Chelsea L. Reinhard
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - James Serpell
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
| | - Brittany Watson
- School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
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Adams EK, Murray K, Trost SG, Christian H. Longitudinal effects of dog ownership, dog acquisition, and dog loss on children's movement behaviours: findings from the PLAYCE cohort study. Int J Behav Nutr Phys Act 2024; 21:7. [PMID: 38287372 PMCID: PMC10826268 DOI: 10.1186/s12966-023-01544-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 11/30/2023] [Indexed: 01/31/2024] Open
Abstract
INTRODUCTION Regular physical activity is important for children's physical and mental health, yet many children do not achieve recommended amounts of physical activity. Dog ownership has been associated with increased physical activity in children, however, there have been no longitudinal studies examining this relationship. This study used data from the Play Spaces and Environments for Children's Physical Activity (PLAYCE) cohort study to examine the longitudinal effects of dog ownership status on children's movement behaviours. METHODS Change in dog ownership from preschool (wave 1, age 2-5) to fulltime school (wave 2, age 5-7) was used as a natural experiment with four distinct dog ownership groups: continuing non-dog owners (n = 307), continuing dog owners (n = 204), dog acquired (n = 58), and dog loss (n = 31; total n = 600). Daily movement behaviours, including physical activity, sedentary time, sleep, and screen time, were measured using accelerometry and parent-report surveys. Differences between groups over time and by sex were tested using linear mixed effects regression models. RESULTS Girls who acquired a dog increased their light intensity activities and games by 52.0 min/day (95%CI 7.9, 96.0) and girls who lost a dog decreased their light intensity activities and games by 62.1 min/day (95%CI -119.3, -4.9) compared to no change among non-dog owners. Girls and boys who acquired a dog increased their unstructured physical activity by 6.8 (95%CI 3.2, 10.3) and 7.1 (95%CI 3.9, 10.3) occasions/week, compared to no changes among non-dog owners. Girls and boys who lost a dog reduced their unstructured physical activity by 10.2 (95%CI -15.0, -5.3) and 7.7 (95%CI -12.0, -3.5) occasions/week. Girls who lost a dog decreased their total physical activity by 46.3 min/day (95%CI -107.5, 14.8) compared to no change among non-dog owners. Continuing dog ownership was typically not associated with movement behaviours. Dog ownership group was not associated with changes in sleep and had mixed associations with screen time. CONCLUSION The positive influence of dog ownership on children's physical activity begins in early childhood and differs by child sex. Further research should examine the specific contributions dog-facilitated physical activity makes to children's overall physical activity, including the intensity and duration of dog walking and play.
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Affiliation(s)
- Emma K Adams
- Telethon Kids Institute, University of Western Australia, 35 Stirling Hwy, Perth, Western Australia, 6009, Australia.
- School of Population and Global Health, University of Western Australia, 35 Stirling Hwy, Perth, Western Australia, 6009, Australia.
| | - Kevin Murray
- School of Population and Global Health, University of Western Australia, 35 Stirling Hwy, Perth, Western Australia, 6009, Australia
| | - Stewart G Trost
- School of Human Movement and Nutrition Sciences, University of Queensland, Brisbane, Queensland, 4072, Australia
| | - Hayley Christian
- Telethon Kids Institute, University of Western Australia, 35 Stirling Hwy, Perth, Western Australia, 6009, Australia
- School of Population and Global Health, University of Western Australia, 35 Stirling Hwy, Perth, Western Australia, 6009, Australia
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Hielscher-Zdzieblik B, Gansloßer U, Serpell J, Froboese I. The Long-Term Influence of Puppy Acquisition on Physical Activity: Results of a 3-Year, Longitudinal, Pilot Study. Healthcare (Basel) 2022; 10:1687. [PMID: 36141299 PMCID: PMC9498865 DOI: 10.3390/healthcare10091687] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/30/2022] [Accepted: 09/01/2022] [Indexed: 12/02/2022] Open
Abstract
Dog ownership has been associated with increased levels of physical activity (PA), including increases in total PA and walking time in some but not in all studies. These earlier studies did not consider puppy acquisition, in particular, and were limited to a maximum of 10 months duration. The purpose of the current pilot study was, therefore, to analyze long-term changes in participants' PA behavior after puppy acquisition. Participants who acquired a puppy from one of nine preselected breeds differing in size and energy level were included. PA was assessed at baseline and 6, 12, 24 and 36 months after puppy acquisition using an online questionnaire. Participants, who were initially included, did not differ in their PA at baseline (n = 38). In the group that completed the trial (n = 11) total PA, leisure time walking, total dog-related PA, and total dog walking increased within the first two years and decreased while remaining above baseline values during the last year, coinciding with the COVID-19 pandemic. Non-dog-related PA did not change over time. We conclude that the acquisition of a puppy increases PA and thus, could have a long-lasting positive effect on physical health.
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Affiliation(s)
- Benedikt Hielscher-Zdzieblik
- Institute of Movement Therapy and Movement-Oriented Prevention and Rehabilitation, German Sport University Cologne, 50933 Cologne, Germany
- Institute of Zoology and Evolutionary Research, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - Udo Gansloßer
- Institute of Zoology and Evolutionary Research, Friedrich Schiller University Jena, 07743 Jena, Germany
| | - James Serpell
- Department of Clinical Sciences & Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Ingo Froboese
- Institute of Movement Therapy and Movement-Oriented Prevention and Rehabilitation, German Sport University Cologne, 50933 Cologne, Germany
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Hielscher-Zdzieblik B, Froboese I, Serpell J, Gansloßer U. Impact of Dog's Age and Breed on Dog Owner's Physical Activity: A German Longitudinal Study. Animals (Basel) 2022; 12:1314. [PMID: 35625158 PMCID: PMC9137655 DOI: 10.3390/ani12101314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/17/2022] [Accepted: 05/19/2022] [Indexed: 12/10/2022] Open
Abstract
Dog ownership contributes positively to physical activity (PA). The impact of different dog breeds and age on PA is less investigated in longitudinal studies. This study aimed to evaluate PA changes in dog owners as their dogs' ages increased and to explore whether there are differences in PA between owners of different breeds over a three-year period. Owners of different dog breeds were categorized into nine groups according to the perceived energy level and size of the breed. PA was monitored using an online questionnaire for three consecutive years. Linear mixed models (LMM) showed a small, but significant decrease in total PA, leisure time walking, dog-related PA and dog walking over three years. No decreases were found if only participants who attended at all time points were included. In all LMM analyses, a significant relationship between the dog breed and the outcomes of PA were shown. At baseline, dog owners performed different types of activities depending on their dog breed. In conclusion, owners of different dog breeds differ in their types of PA. The study emphasizes that age, size and energy level of the dog does not per se have an impact on dog owners PA.
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Affiliation(s)
- Benedikt Hielscher-Zdzieblik
- Institute of Movement Therapy and Movement-Oriented Prevention and Rehabilitation, German Sport University Cologne, 50933 Cologne, Germany;
- Institute of Zoology and Evolutionary Research with Phyletic Museum, Friedrich Schiller University Jena, 07743 Jena, Germany;
| | - Ingo Froboese
- Institute of Movement Therapy and Movement-Oriented Prevention and Rehabilitation, German Sport University Cologne, 50933 Cologne, Germany;
| | - James Serpell
- Department of Clinical Studies VHUP, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Udo Gansloßer
- Institute of Zoology and Evolutionary Research with Phyletic Museum, Friedrich Schiller University Jena, 07743 Jena, Germany;
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Returning a Shelter Dog: The Role of Owner Expectations and Dog Behavior. Animals (Basel) 2022; 12:ani12091053. [PMID: 35565480 PMCID: PMC9100056 DOI: 10.3390/ani12091053] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 04/13/2022] [Accepted: 04/16/2022] [Indexed: 02/04/2023] Open
Abstract
Simple Summary Most dog adopters are typically highly satisfied with dog ownership, although a number of adopted dogs are returned to animal shelters following adoption, which can be stressful for the owner and the dog. In this study, we looked at adopters’ expectations for dog ownership prior to adoption and their experience with dog behavior in the first days, weeks, and months following adoption relative to the risk of return. We found owners who returned their dog to the shelter within three months of adoption had higher expectations for their dog to be healthy, exhibit desirable behavior, and for the human–dog bond compared with adopters who did not return their dogs. There were no differences in expectations for ownership responsibilities and challenges between returning and non-returning owners. We also found two-thirds of owners experienced some behavioral problems following adoption, although behaviors such as training difficulty and fear decreased over time. Our findings may be useful for animal shelters to reduce returns by ensuring adopters have realistic expectations about the human–dog relationship and the occurrence of behavioral problems. Abstract Millions of animals are adopted from animal shelters in the United States each year, although some are returned post-adoption, which can decrease both the animals’ chances of future adoptions and the owners’ willingness to adopt again. In this study, we investigated the impact of adopter expectations for ownership and animal behavioral problems on post-adoptive dog returns at a large animal shelter in South Carolina. Between June–September 2021, 132 dog adopters completed a survey about their expectations for ownership through Qualtrics. Twenty-nine adopters returned their dogs to the shelter within three months of adoption, with a median length of ownership of eight days. Owners completed follow-up questionnaires about their perceptions of adoption and dog behavior at two days, two weeks, and four months post-adoption. Categorical principal component analysis revealed three factors pertaining to adopters’ expectations for ownership. Independent t-tests showed returning owners had significantly higher expectations for dog behavior and health (t = −2.32, p = 0.02) and the human–dog bond compared with non-returning owners (t = −2.36, p = 0.02). Expectations for ownership responsibilities did not differ between the groups. Two-thirds of adopters experienced dog behavioral problems post-adoption, although training difficulty decreased significantly between two days and four months (F = 5.22, p = 0.01) and nonsocial fear decreased between two weeks and four months post-adoption (X2 = 10.17, p = 0.01). Shelters may benefit from utilizing adoption counselling to ensure adopters understand the potential for dog behavioral problems in the early stages of ownership and develop appropriate expectations for the human–dog relationship. Post-adoption behavioral support may also help some owners to overcome behavioral difficulties as their dogs adapt to the new environment.
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Martin F, Bachert KE, Snow L, Tu HW, Belahbib J, Lyn SA. Depression, anxiety, and happiness in dog owners and potential dog owners during the COVID-19 pandemic in the United States. PLoS One 2021; 16:e0260676. [PMID: 34910761 PMCID: PMC8673598 DOI: 10.1371/journal.pone.0260676] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/12/2021] [Indexed: 01/07/2023] Open
Abstract
Major life events, such as the COVID-19 pandemic, affect psychological and physiological health. Social support, or the lack thereof, can modulate these effects. The context of the COVID-19 pandemic offered a unique opportunity to better understand how dogs may provide social support for their owners and buffer heightened symptoms of stress, anxiety and depression and contribute to happiness during a major global crisis. Participants (768 pet dog owners and 767 potential pet dog owners) answered an online survey, including validated depression, anxiety, happiness psychometric scales, attitude to and commitment towards pet, and perceived social support. Potential pet dog owners were defined as individuals who did not own a dog at the time of the survey but would be very or extremely interested in owning one in the future. Dog owners reported having significantly more social support available to them compared to potential dog owners, and their depression scores were also lower, compared to potential dog owners. There were no differences in anxiety and happiness scores between the two groups. Dog owners had a significantly more positive attitude towards and commitment to pets. Taken together, our results suggest that dog ownership may have provided people with a stronger sense of social support, which in turn may have helped buffer some of the negative psychological impacts caused by the COVID-19 pandemic.
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Affiliation(s)
- Francois Martin
- Nestlé Purina Research, Saint-Louis, MO, United States of America
| | | | - LeAnn Snow
- Nestlé Purina Research, Saint-Louis, MO, United States of America
| | - Hsiao-Wei Tu
- Nestlé Purina Research, Saint-Louis, MO, United States of America
| | - Julien Belahbib
- Nestlé Purina Research, Saint-Louis, MO, United States of America
| | - Sandra A. Lyn
- Nestlé Purina Research, Saint-Louis, MO, United States of America
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McDonald SE, Tomlinson CA, Applebaum JW, Moyer SW, Brown SM, Carter S, Kinser PA. Human-Animal Interaction and Perinatal Mental Health: A Narrative Review of Selected Literature and Call for Research. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:10114. [PMID: 34639416 PMCID: PMC8508333 DOI: 10.3390/ijerph181910114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/21/2021] [Accepted: 09/23/2021] [Indexed: 12/13/2022]
Abstract
There is a paucity of research exploring how relationships with household pets may impact maternal mental health. We are unaware of any study to date that has examined associations between individuals' relationships with their pets and psychological adjustment in the perinatal period. Using a biobehavioral lens, this paper provides a narrative overview of the literature on perinatal mental health and human-animal interaction (HAI). We focus on the role of social relationships, stress, and stress reduction in relation to perinatal mental health; the role of HAI in perceptions of social support, stressors, and stress reduction; and gaps in empirical knowledge concerning the role of HAI in perinatal mental health. Finally, we integrate contemporary biobehavioral models of perinatal mental health and HAI (i.e., Comprehensive Model of Mental Health during the Perinatal Period and the HAI-HPA Transactional Model) to propose a new conceptual framework that depicts ways in which HAI during the perinatal period may influence maternal and child health and wellbeing. To our knowledge, this is the first paper to consider the role of HAI in biobehavioral responses and mental health during the perinatal period. We conclude with recommendations for future research and improved perinatal care.
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Affiliation(s)
- Shelby E. McDonald
- Children, Families, and Animals Research (CFAR) Group, LLC, Richmond, VA 23223, USA
| | - Camie A. Tomlinson
- School of Social Work, Virginia Commonwealth University, Richmond, VA 23284, USA
| | - Jennifer W. Applebaum
- Department of Sociology and Criminology & Law, University of Florida, Gainesville, FL 32611, USA;
| | - Sara W. Moyer
- School of Nursing, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.W.M.); (P.A.K.)
| | - Samantha M. Brown
- School of Social Work, Colorado State University, Fort Collins, CO 80523, USA;
| | - Sue Carter
- The Kinsey Institute, Indiana University, Bloomington, IN 47405, USA;
| | - Patricia A. Kinser
- School of Nursing, Virginia Commonwealth University, Richmond, VA 23298, USA; (S.W.M.); (P.A.K.)
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Dogs at the Workplace: A Multiple Case Study. Animals (Basel) 2021; 11:ani11010089. [PMID: 33466471 PMCID: PMC7824880 DOI: 10.3390/ani11010089] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Revised: 11/16/2020] [Accepted: 12/29/2020] [Indexed: 11/22/2022] Open
Abstract
Simple Summary Pet-friendly policies are becoming more common in the workplace, but little is known about how the presence of dogs influences the work environment. For this reason, the paper includes a study on how dogs influence the work environment and under which circumstances companies can benefit from a pet-friendly policy. An inductive research approach was used for this study. Qualitative data were conducted by interviewing dog-owners who routinely bring their dogs to the office and persons in management positions in the same companies. Finally, the results of the evolving data analysis through successive iterations was formed into a grounded theory. The results of the study generally support the belief that dogs at the workplace can have a positive influence on individual and collective well-being of organizational members in an office environment. However, the study shows that these positive effects of dogs are linked to certain prerequisites that need to be fulfilled in the company. These include flexible hours, autonomy, and open communication. While those requisites are not necessary in order to be able to implement pet-friendly policies, they are highly relevant when companies seek to decrease stress for employees and improve the work atmosphere and social capital. Abstract As the work environment is increasing in competitiveness and stressfulness, more and more companies try to increase employee well-being. One option is allowing employees to bring their dogs to work, building on the considerable evidence that dogs have a positive influence on people’s well-being. However, little is known about how a dog’s presence influences the employees and the companies in offices. Therefore, we empirically scrutinize the presence of dogs in organizations and the impact of pet-friendly organizational policies, with multiple case studies with semi-structured interviews as their foundation. Based on an inductive approach for the data analysis, we found that organizational members consider that dogs can lower their stress, improve communication, and foster social cohesion when a flexible organizational culture is in place. This includes the following: Problems in the company are openly addressed; employees have job autonomy, with flexibility to take breaks; and mistakes and errors are allowed to be made by employees and their companions alike, and room to find solutions is given. The inflexible permission of pets at work can, on the contrary, create pressure and stress in employees. For the business world, this implicates that this kind of incentive only leads to success if the right framework and culture is in place, and it cannot only be seen as an instrument to increase employee well-being.
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Powell L, Edwards KM, Bauman A, McGreevy P, Podberscek A, Neilly B, Sherrington C, Stamatakis E. Does dog acquisition improve physical activity, sedentary behaviour and biological markers of cardiometabolic health? Results from a three-arm controlled study. BMJ Open Sport Exerc Med 2020; 6:e000703. [PMID: 32518673 PMCID: PMC7254141 DOI: 10.1136/bmjsem-2019-000703] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/22/2020] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES Dog ownership has been associated with improved cardiometabolic risk factors, including physical activity. Most of the evidence originates from cross-sectional studies or populations with established disease. This study investigated changes in physical activity and other cardiometabolic risk factors following dog acquisition in a sample of 71 community-dwelling adults. METHODS Participants self-allocated to three groups: 17 individuals acquired a dog within 1 month of baseline (dog acquisition), 29 delayed dog acquisition until study completion (lagged control) and 25 had no interest in dog acquisition (community control). Self-reported and thigh-worn accelerometer-based physical activity patterns, systolic and diastolic blood pressures, resting heart rate and VO2max were measured three times: baseline, 3 months and 8 months. Data were analysed using repeated measures analysis of covariance with owner age, season, sex and education included as covariates. Post hoc between-group tests were performed where there were significant overall effects (p<0.05). RESULTS We found significant effects in mean daily steps (F(4,64)=3.02, p=0.02) and sit-to-stand transitions (F(4,66)=3.49, p=0.01). The dog acquisition group performed an additional 2589 steps (p=0.004) and 8.2 sit-to-stand transitions (p=0.03) per day at 3 months, although these effects were not maintained at 8 months. We found a significant effect in self-reported weekly walking duration (F(4,130)=2.84, p=0.03) among the lagged control group with an 80 min increase between 3 and 8 months (p=0.04). Other cardiometabolic risk factors were unchanged following dog acquisition. CONCLUSION Our study provides encouraging results that suggest a positive influence of dog acquisition on physical activity in the short term but larger and more generalisable controlled studies are needed. TRIAL REGISTRATION NUMBER ACTRN12617000967381.
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Affiliation(s)
- Lauren Powell
- Charles Perkins Centre, Prevention Research Collaboration, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Kate M Edwards
- Charles Perkins Centre, Faculty of Health Sciences, University of Sydney, Sydney, New South Wales, Australia
| | - Adrian Bauman
- Charles Perkins Centre, Prevention Research Collaboration, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Paul McGreevy
- Sydney School of Veterinary Science, University of Sydney, Sydney, New South Wales, Australia
| | - Anthony Podberscek
- Charles Perkins Centre, Sydney School of Veterinary Science, University of Sydney, Sydney, New South Wales, Australia
| | - Brendon Neilly
- Royal Society for the Prevention of Cruelty to Animals (RSPCA), Sydney, New South Wales, Australia
| | - Catherine Sherrington
- Institute for Musculoskeletal Health, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | - Emmanuel Stamatakis
- Charles Perkins Centre, Prevention Research Collaboration, Faculty of Medicine and Health, Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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