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O'Louglin M, Edwards R, Bould E, Devine S, Downing S. Animal-assisted interventions in adult hospital rehabilitation settings: A scoping review. Nurs Health Sci 2024; 26:e13138. [PMID: 39013555 DOI: 10.1111/nhs.13138] [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: 09/18/2023] [Revised: 05/27/2024] [Accepted: 06/19/2024] [Indexed: 07/18/2024]
Abstract
Animal-assisted interventions (AAIs) have the potential to enhance people's well-being and function and are increasingly being implemented across a range of settings. This scoping review explored how AAIs have been used in adult hospital rehabilitative care. Using JBI and PRISMA-ScR guidelines, a systematic search of four databases was undertaken. Inclusion criteria involved adults, aged >18 years, who had received AAIs in the hospital rehabilitation setting. Twenty-two articles met the inclusion criteria. Results identified two intervention types: visitation activities (n = 8 studies) and structured therapeutic interventions (n = 14 studies). Dogs were the most common animal species. Improvements in social and emotional well-being were reported across both types of interventions, with improvements in ambulation, motor skills, and verbal communication reported by those engaged in structured therapeutic interventions. Implementation challenges included a dependency on volunteer dog-handlers; the need for better recording of interventions in medical records to enable evaluation; and cost, safety, infection control, and animal welfare considerations. Strengthening the planning of AAIs is fundamental for the realization of potential outcomes from human-animal interactions in hospital rehabilitative care.
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Affiliation(s)
- Mary O'Louglin
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Cairns, Queensland, Australia
| | - Rachael Edwards
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Cairns, Queensland, Australia
| | - Em Bould
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Cairns, Queensland, Australia
- Department of Occupational Therapy, School of Primary and Allied Health Care, Monash University, Melbourne, Victoria, Australia
| | - Sue Devine
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Cairns, Queensland, Australia
| | - Sandra Downing
- College of Public Health, Medical and Veterinary Sciences, James Cook University, Cairns, Queensland, Australia
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Choi YS, Gu M, Sok S. Using of Hot Red Bean Bag on the Symptoms of Depression, Sleep, and Fatigue in Stroke Patients. IRANIAN JOURNAL OF PUBLIC HEALTH 2024; 53:1077-1086. [PMID: 38912139 PMCID: PMC11188652 DOI: 10.18502/ijph.v53i5.15589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/17/2023] [Indexed: 06/25/2024]
Abstract
Background Symptoms of depression, sleep, and fatigue in stroke patients are associated with each other, and intervention development for improving of these symptoms is needed. This study aimed to examine the effects of hot red bean bag on depression, sleep state, sleep satisfaction, and fatigue among Korean stroke patients. Methods A quasi-experimental pretest-posttest control group design was employed. The study participants included 57 stroke patients (Intervention: n=28, Control: n=29) in a hospital in Seoul, South Korea from Aug 2017 to Mar 2018. Hot red bean bag, as an intervention, was heated in a 2,450 MHz microwave oven for 3 min, and applied for 30 min at 41±6 °C in the lower limbs of the intervention group for 5 days. Results There were statistically significant differences on depression (P<0.001), sleep state (P<0.001), sleep satisfaction (P<0.001), and total fatigue (P<0.001) between the two groups. Conclusion Hot red bean bag was an effective intervention for decreasing depression and total/subcategories fatigue, and for improving sleep state and sleep satisfaction of Korean stroke patients. Research on complementary and alternative therapies for stroke patients needs be studied continuously.
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Affiliation(s)
- Ye Seul Choi
- Graduate Student, Department of Nursing, Graduate School, Kyung Hee University, Seoul, Republic of Korea
| | - Minkyung Gu
- Department of Nursing, College of Health Science, Daejin University, Pocheon-si, Gyeonggi-do, Republic of Korea
| | - Sohyune Sok
- College of Nursing Science, Kyung Hee University, Seoul, Republic of Korea
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Mittly V, Farkas-Kirov C, Zana Á, Szabó K, Ónodi-Szabó V, Purebl G. The effect of animal-assisted interventions on the course of neurological diseases: a systematic review. Syst Rev 2023; 12:224. [PMID: 38007472 PMCID: PMC10675848 DOI: 10.1186/s13643-023-02387-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 11/10/2023] [Indexed: 11/27/2023] Open
Abstract
BACKGROUND In our experience, working with a therapy animal strengthens endurance, maintains motivation, provides a sense of achievement, and boosts overall mental resilience. The aims of this work were to summarize the results of quantitative research on the possibilities of animal-assisted intervention (AAI) among people with neurodegenerative and cerebrovascular diseases and to attempt to assess the effects of animal-assisted interventions in an objective manner and to find supporting evidence based on published literature. METHODS Our target groups are people diagnosed with Parkinson's disease, multiple sclerosis, or stroke. A systematic search of relevant articles was conducted by two independent researchers in April 2021 and August 2023. The search for studies was conducted using PubMed, Google Scholar, Web of Science, Scopus, and Ovid databases, specifying keywords and search criteria. The qualitative evaluation of the research reports was conducted by four independent researchers, using the Newcastle-Ottawa Quality Assessment Form. RESULTS According to the scientific criteria and based on the Newcastle-Ottawa Quality Assessment Form, thirteen publications met the search criteria, out of which 9 publications were rated good and 4 publications were rated poor. Evaluating the publications we found evidence that AAI had a measurable impact on participants, as their physical and mental health status significantly improved; however, mental health improvement was more prominent. CONCLUSIONS By developing evidence-based research methodology and standardized research settings, AAI could be measured effectively as part of health care practice. This would bring significant benefits to the rehabilitation of patients in need. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42021255776.
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Affiliation(s)
- Veronika Mittly
- Institute of Behavioral Sciences, Semmelweis University, Nagyvárad Square 4, 1089, Budapest, Hungary.
- South-Pest Central Hospital National Institute of Haematology and Infectology, Centre for Rehabilitation, Jahn Ferenc, Street 62-66, 1196, Budapest, Hungary.
| | - Cecilia Farkas-Kirov
- Creanova Organisation and Management Development Consulting Ltd., Zichy Géza Street 5, 1146, Budapest, Hungary
| | - Ágnes Zana
- Institute of Behavioral Sciences, Semmelweis University, Nagyvárad Square 4, 1089, Budapest, Hungary
| | - Kata Szabó
- Támasz Foundation, Sándor Street 1, 7626, Pécs, Hungary
| | | | - György Purebl
- Institute of Behavioral Sciences, Semmelweis University, Nagyvárad Square 4, 1089, Budapest, Hungary
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Hamilton-Bruce MA, Young J, Nottle C, Hazel SJ, Milton AG, McDowall S, Mani B, Koblar S. Developing and Planning a Protocol for Implementing Health Promoting Animal Assisted Interventions (AAI) in a Tertiary Health Setting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:6780. [PMID: 37754639 PMCID: PMC10531378 DOI: 10.3390/ijerph20186780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 09/08/2023] [Accepted: 09/13/2023] [Indexed: 09/28/2023]
Abstract
The Ottawa Charter identifies that multiple levels of government, non-government, community, and other organizations should work together to facilitate health promotion, including in acute settings such as hospitals. We outline a method and protocol to achieve this, namely an Action Research (AR) framework for an Animal Assisted Intervention (AAI) in a tertiary health setting. Dogs Offering Support after Stroke (DOgSS) is an AR study at a major tertiary referral hospital. AAI has been reported to improve mood and quality of life for patients in hospitals. Our project objectives included applying for funding, developing a hospital dog visiting Action Research project, and, subsequent to ethics and governance approvals and finance, undertaking and reporting on the Action Research findings. The Action Research project aimed to investigate whether AAI (dog-visiting) makes a difference to the expressed mood of stroke patients and their informal supports (visiting carers/family/friends), and also the impact these visits have on hospital staff and volunteers, as well as the dog handler and dog involved. We provide our protocol for project management and operations, setting out how the project is conducted from conception to assess human and animal wellbeing and assist subsequent decision-making about introducing dog-visiting to the Stroke Unit. The protocol can be used or adapted by other organizations to try to avoid pitfalls and support health promotion in one of the five important action areas of the Ottawa Charter, namely that of reorienting health services.
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Affiliation(s)
- M. Anne Hamilton-Bruce
- Stroke Research Programme, Basil Hetzel Institute, The Queen Elizabeth Hospital, Central Adelaide Local Health Network, Woodville South 5011, Australia;
| | - Janette Young
- Allied Health and Human Performance, University of South Australia, Adelaide 5000, Australia; (J.Y.); (C.N.)
| | - Carmel Nottle
- Allied Health and Human Performance, University of South Australia, Adelaide 5000, Australia; (J.Y.); (C.N.)
| | - Susan J. Hazel
- School of Animal and Veterinary Science, The University of Adelaide, Roseworthy Campus, Roseworthy 5371, Australia;
| | - Austin G. Milton
- Adelaide Medical School, The University of Adelaide, Adelaide 5005, Australia; (A.G.M.); (S.K.)
| | - Sonya McDowall
- School of Animal and Veterinary Science, The University of Adelaide, Roseworthy Campus, Roseworthy 5371, Australia;
| | - Ben Mani
- Allied Health and Human Performance, University of South Australia, Adelaide 5000, Australia; (J.Y.); (C.N.)
| | - Simon Koblar
- Adelaide Medical School, The University of Adelaide, Adelaide 5005, Australia; (A.G.M.); (S.K.)
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Prado CMCS, Pinheiro SL. Fisioterapia com brinquedos e terapia assistida por cães em lactentes: estudo observacional. FISIOTERAPIA E PESQUISA 2022. [DOI: 10.1590/1809-2950/21024329022022pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
RESUMO O objetivo deste trabalho foi comparar a fisioterapia com brinquedos com a terapia assistida por cães no desenvolvimento neuromotor de lactentes de quatro meses de idade com e sem alterações neuromotoras. Trata-se de pesquisa descritiva e observacional de caráter qualitativo, realizada com 10 lactentes, que foram avaliados pela escala motora infantil de Alberta (EMIA), divididos em grupo 1 (G1) e grupo 2 (G1) e subdivididos em grupo brinquedo (G1B e G2B) e grupo cão (G1C e G2C) para a realização das intervenções quinzenais. O questionário Affordances in the Home Environment for Motor Development - Infant Scale (AHEMD-IS) foi escolhido para avaliar as oportunidades presentes no ambiente domiciliar. A análise de dados qualitativos foi feita por meio de fotos e filmagens. A presença do cão nos grupos G1C e G2C resultou em um ambiente descontraído e divertido, interesse dos lactentes em tocar o pelo do animal, movimentos alternados de membros, contato visual, emissão de sons, evolução na interação social e sentimento de segurança. Nos grupos G1B e G2B, constatou-se diminuição da motivação, ausência de emissão de sons pelos lactentes e contato visual e interesse pelo toque restrito a brinquedos que tivessem diversas cores e sons, havendo pouca agitação e motivação para as habilidades motoras nesses grupos. Conclui-se que a presença do cão promoveu melhores resultados motores, sociais, afetivos e cognitivos. A terapia assistida por animais pode ser um método eficaz para auxiliar na fisioterapia convencional de lactentes com atraso no desenvolvimento neuropsicomotor.
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Prado CMCS, Pinheiro SL. Physical therapy with toys and dog-assisted therapy in infants: observational study. FISIOTERAPIA E PESQUISA 2022. [DOI: 10.1590/1809-2950/21024329022022en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
ABSTRACT This study aimed to compare physical therapy with toys with dog-assisted therapy in the neuromotor development of 4-month-old infants with and without neuromotor alterations. This is a qualitative descriptive and observational study carried out with 10 infants, who were evaluated by the Alberta Infant Motor Scale, divided into Group 1 (G1) and Group 2 (G1), and subdivided into Toy Group (TG1 and TG2) and Dog Group (DG1 and DG2) for the performance of fortnightly interventions. By the Affordances in the Home Environment for Motor Development - Infant Scale, we assessed the opportunities present in the home environment. Qualitative data were analyzed using photos and videos. The presence of a dog in DG1 and DG2 resulted in a relaxed and fun environment, infants interested in touching the animal’s fur, alternating limb movements, eye contact, sound production, increased social interaction, and feeling of security. In TG1 and TG2, decrease in motivation was observed as well as the absence of sound production and eye contact by infants, and interest in touch restricted to toys that had different colors and sounds, with little agitation and motivation for motor skills in those groups. We concluded that the dog’s presence promoted better motor, social, affective, and cognitive results. Animal-assisted therapy can be an effective method to support conventional physical therapy for infants with delayed neuropsychomotor development.
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Teo JT, Johnstone SJ, Römer SS, Thomas SJ. Psychophysiological mechanisms underlying the potential health benefits of human-dog interactions: A systematic literature review. Int J Psychophysiol 2022; 180:27-48. [PMID: 35901904 DOI: 10.1016/j.ijpsycho.2022.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 06/22/2022] [Accepted: 07/19/2022] [Indexed: 10/16/2022]
Abstract
While the symbiotic nature of human-dog relationships and perceived benefits to human health have attracted much scientific interest, the mechanisms through which human-dog interactions may confer health benefits to humans are still poorly understood. The aim of this systematic literature review was to synthesize evidence of physiological changes associated with human-dog interactions with relevance to human health. Electronic databases were systematically searched (PubMed, MEDLINE with full text, Scopus, PsycINFO, CINAHL Plus with Full Text, and Web of Science Core Collection) for relevant studies. Of the 13,072 studies identified, 129 met the inclusion criteria, with approximately half being randomized trials (Level 2) based on the Oxford Centre for Evidence Based Medicine level system. Measures employed to study human physiological changes associated with human-dog interactions most commonly involved cardiac parameters and hormones, with negligible research of brain activity. The main positive findings were increases in heart rate variability and oxytocin, and decreases in cortisol with human-dog interactions. These physiological indicators are consistent with activation of the parasympathetic nervous system (PNS) and oxytocinergic system (OTS), and down-regulation of hypothalamic-pituitary-adrenal (HPA) axis activity. These results provide evidence of specific pathways through which human-dog contact may confer health benefits, likely through relaxation, bonding, and stress reduction. However, these findings should be interpreted contextually due to limitations and methodological differences. Previous research using other biological variables was limited in quantity and quality, thus impeding firm conclusions on other possible mechanisms. Further research is needed in some psychophysiological domains, particularly electroencephalography, to better understand central nervous system (CNS) effects. The findings of this review have implications for human-dog interactions to positively affect several stress-sensitive physiological pathways and thus confer health benefits. This supports their incorporation in various clinical, non-clinical, and research settings to develop evidence-based interventions and practices for cost-effective and efficacious ways to improve human health.
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Affiliation(s)
- Jillian T Teo
- School of Psychology, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia.
| | - Stuart J Johnstone
- School of Psychology, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia.
| | - Stephanie S Römer
- School of Psychology, Faculty of the Arts, Social Sciences and Humanities, University of Wollongong, Wollongong, NSW 2522, Australia.
| | - Susan J Thomas
- School of Medicine, Faculty of Science, Medicine and Health, Illawarra Health and Medical Research Institute, University of Wollongong, 2522, Australia.
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Boldig CM, Butala N. Pet Therapy as a Nonpharmacological Treatment Option for Neurological Disorders: A Review of the Literature. Cureus 2021; 13:e16167. [PMID: 34367777 PMCID: PMC8336327 DOI: 10.7759/cureus.16167] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 11/05/2022] Open
Abstract
Animal therapy and ownership have been studied as a nonpharmacologic treatment option for cardiovascular and psychological disorders. Animal companionship is less studied in neurological disorders such as stroke, dementia, Parkinson's disease, multiple sclerosis, Huntington's disease, epilepsy, and acute brain injury. This review examines the effects that emotional support dogs, dog therapy, or dog ownership has on these specific neurological disorders. It may serve as a nonpharmaceutical option to improve patient symptoms, quality of life, or the disease course itself. Articles were gathered which studied the effect of animal-assisted therapy, pet therapy, dog ownership, and physical activity on neurological disorders. Studies relating to the topic were then assessed for the impact on neurological disorders which ranged from cognition, mobility, quality of life, mood, and improvement of disease course. Dog therapy and ownership were found to improve mood, quality of life, and disease symptoms across multiple neurological disorders. It also encouraged physical activity which was shown to help many diseases studied, even ones associated with skeletal muscle apoptosis, such as Huntington's disease. Dog therapy and ownership are a safe and effective nonpharmaceutical approach to treating chronic and progressive neurological disorders.
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Affiliation(s)
- Catherine M Boldig
- Neurology, University of South Florida Morsani College of Medicine, Tampa, USA
| | - Nitin Butala
- Neurology, Baptist Medical Center Jacksonville, Jacksonville, USA
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Effects of Animal-Assisted Therapy on Gait Performance, Respiratory Function, and Psychological Variables in Patients Post-Stroke. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115818. [PMID: 34071529 PMCID: PMC8198745 DOI: 10.3390/ijerph18115818] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Revised: 05/20/2021] [Accepted: 05/24/2021] [Indexed: 12/02/2022]
Abstract
Background: Animal-assisted therapy using dogs is being administered to patients post-stroke for the purpose of recovering psychological and physical activity. Objective: This study was conducted to confirm the effect of animal-assisted therapy using dogs on gait performance, pulmonary function, and psychological variables in patients post-stroke. All outcomes were analyzed using two-way repeated-measure analysis. Methods: In total, 30 post-stroke patients were divided into an experimental group (gait training by animal-assisted activity, n = 15) and a control group (gait training, n = 15). Gait performance (cadence, gait speed, stride length, symmetric index), respiratory pulmonary function (forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), peak expiratory flow (PEF), maximal inspiratory pressure (MIP), maximal expiratory pressure (MEP)), and psychological variables (rehabilitation motivation and depression assessment) were measured before and after eight weeks of intervention. Results: Gait performance, respiratory pulmonary function, and psychological variables significantly increased in the experimental group compared to the control group. Conclusion: Based on this study, it was found that animal-assisted therapy using dogs is an effective intervention for recovery of psychological and physical activity in patients post-stroke.
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Rodrigo-Claverol M, Malla-Clua B, Marquilles-Bonet C, Sol J, Jové-Naval J, Sole-Pujol M, Ortega-Bravo M. Animal-Assisted Therapy Improves Communication and Mobility among Institutionalized People with Cognitive Impairment. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E5899. [PMID: 32823839 PMCID: PMC7459682 DOI: 10.3390/ijerph17165899] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 08/02/2020] [Accepted: 08/12/2020] [Indexed: 11/17/2022]
Abstract
Disorders of communication, social relationships, and psychomotricity are often characterized by cognitive impairment, which hinders daily activities and increases the risk of falls. This study aimed to evaluate the efficacy of an animal-assisted therapy (AAT) program in an institutionalized geriatric population with cognitive impairment. The variables evaluated included level of communication and changes in gait and/or balance. We performed a two-arm, parallel controlled, open-label, nonrandomized cluster clinical trial in two nursing home centers from an urban area. Patients in the two centers received 12 weekly sessions of physiotherapy, but the experimental group included AAT with a therapy dog. The study included a total of 46 patients (23 Control Group [CG], 23 Experimental Group [EG]) with a median age of 85.0 years. Of these, 32.6% had mild-moderate cognitive decline (Global Deterioration Scale of Reisberg [GDS] 2-4) and 67.4% severe cognitive decline (GDS 5-6). After the intervention, patients in the CG and EG showed a statistically significant improvement in all the response variables. When comparing both groups, no statistically significant differences were found in any of the Tinetti scale results (measuring gait and balance). However, the communication of patients in the EG, measured on the Holden scale, showed a statistically significant greater improvement postintervention than that of patients in the CG. AAT can be useful as a complementary, effective treatment for patients with different degrees of cognitive decline.
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Affiliation(s)
- Maylos Rodrigo-Claverol
- Primary Health Care Center Bordeta-Magraners, Catalan Institute of Health, 25001 Lleida, Spain; (B.M.-C.); (C.M.-B.); (J.J.-N.)
- Ilerkan Association, 25005 Lleida, Spain;
| | - Belén Malla-Clua
- Primary Health Care Center Bordeta-Magraners, Catalan Institute of Health, 25001 Lleida, Spain; (B.M.-C.); (C.M.-B.); (J.J.-N.)
| | - Carme Marquilles-Bonet
- Primary Health Care Center Bordeta-Magraners, Catalan Institute of Health, 25001 Lleida, Spain; (B.M.-C.); (C.M.-B.); (J.J.-N.)
| | - Joaquim Sol
- Research Support Unit Lleida, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08007 Barcelona, Spain; (J.S.); (M.O.-B.)
- Institut Català de la Salut, Atenció Primària, 25007 Lleida, Spain
- Metabolic Physiopathology Research Group, Experimental Medicine Department, Lleida University-Lleida Biochemical Research Institute (UdL-IRBLleida), 25198 Lleida, Spain
| | - Júlia Jové-Naval
- Primary Health Care Center Bordeta-Magraners, Catalan Institute of Health, 25001 Lleida, Spain; (B.M.-C.); (C.M.-B.); (J.J.-N.)
- Ilerkan Association, 25005 Lleida, Spain;
| | | | - Marta Ortega-Bravo
- Research Support Unit Lleida, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08007 Barcelona, Spain; (J.S.); (M.O.-B.)
- Institut Català de la Salut, Atenció Primària, 25007 Lleida, Spain
- Research Group in Therapies in Primary Care, Research Support Unit Lleida, Fundació Institut Universitari per a la recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 08007 Barcelona, Spain
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