To live with a wagging tailed assistant – Service and hearing dog ownership from the perspective of Swedish owners

Abstract Individuals who have a functional or health impairment, are often in great need of conventional healthcare, social care and support, as well as help from family and friends. The use of dogs may be an important assistive support for this population. Assistance dogs are trained to assist with their owners’ specific needs. The aim of this study is to explore service and hearing dog ownership from the owner´s perspective, by examining the owner's expectations before training a dog, and experiences after having a certified dog. This study was designed as a longitudinal intervention study with pre‐post design. The participants included in the study trained their own dogs to become service or hearing dogs. A number of open‐ended questions were answered by the participants before the training of the dog started, three months after the dog was certified, and 1–3 years after the first follow‐up. Data were analysed using thematic content analysis. The participants’ expectations of what the dog would contribute after being certified was high. Their perceived experiences in many ways reflected their expectations. For example, they perceived that the dog contributed to improved health status, a more active lifestyle, improved ability to feel secure, and that they had become more independent. They also felt that the dog had strengthened their social relationships. Negative experiences were also identified. Not being allowed to bring their dog into public places and negative attitudes from other people were examples of this. This study shows that individuals being supported by an assistance dog experience the dog as an invaluable help in their everyday life. By improving the owners’ lives in many ways, a certified service or hearing dog is a novel and important assistive support for people with a functional or health impairment.


| INTRODUC TI ON
This article focuses on individuals with a functional or health impairment who receive an assistance dog. Having a functional or health impairment often means being in great need of conventional healthcare, social care and support, as well as being in need of help from family and friends (McPhail, 2016). Having a disability also increases the risk of social isolation and thereby a more restricted lifestyle (Tough, Siegrist, & Fekete, 2017).
An assistance dog as an assistive support can be used by people with different diseases and/or functional impairments since the training of the dog, and thus what they can help with, can be customised to the needs of the owner. The assistance dogs term includes three types of dogs: guide dogs, hearing dogs and service dogs. Furthermore, the service dog concept can be divided into subcategories such as physical service dogs, diabetes alert dogs, sei- In this study, the focus will be on service and hearing dogs in a Swedish context.
In Sweden, there are three possible ways to obtain a certified service or hearing dog. The most common is that the owner in collaboration with a certified instructor trains a dog (The Swedish Working Dog Association (personal communication, June 23, 2020)). In between the training sessions with the instructor, the owner must train the dog on her own. A second possible way is to purchase a dog that has been fully trained by a certified instructor. If this is the case a match between the dog and the intended owner is made based on a number of criteria and when the dog is judged to be ready to meet the new owner, the instructor trains the dog and the intended owner together for a while (The Swedish Working Dog Association, 2020a, 2020b. Finally, the owner can conduct the training of a dog on their own. All situations require that the owner, together with the dog, passes an examination. Only then it is possible to get the vest as proof that the dog is certified. To keep the dog certified the dog and the owner must pass an annual certification maintenance test (The Swedish Working Dog Association, 2020a, 2020b. The test is conducted to ensure that the dog and the owner maintain the standards. The Swedish Agency for Participation is responsible for financing and controlling a support function that can guarantee the quality/ standard of the assistance dogs and their training (The Swedish Agency for Participation, 2020). Today that support function is the Swedish Working Dog Association.
Sweden has three levels of government: national, regional and local. At the regional level there are 21 regions and at the local level there are 290 municipalities. Both regions and municipalities have their own self-governing local authorities which are responsible for different activities in the community (Swedish Association of Local Authorities & Regions, 2020). In Sweden today, there are no national regulation regarding how to finance assistance dogs as supporting aids. In addition, guidelines on how regions or municipalities can contribute with financial support is lacking (1177( Vårdguiden, 2020. Funding of a service or hearing dog is therefore mostly achieved by grants, or by the owner personally. However, the regions and municipalities do have the responsibility to provide individuals, with functional or health impairment, individually adapted care and rehabilitation. Hence, it is possible to give financial support, both in terms of grants for the purchase cost or grants for the training cost (The Swedish Working Dog Association, 2020a, 2020b). Another aspect not nationally regulated is the assistance dog public access rights, this is instead decided by the local municipalities (The Swedish Kennel Club, 2020). Access to public places can therefore differ depending on where in Sweden you are. Furthermore, access to restaurants and grocery shops is recommended to be permitted based on existing guidelines from the National Food Agency (The National Food Agency, 2006). These guidelines state that assistance dogs should be allowed as long as it does not pose a risk for food to become contaminated. However, since it is not regulated in Swedish law, the shopkeeper can deny access.
Findings from previous research have shown that the use of dogs may be an important assistive support for this population (Lundqvist, Levin, Roback, & Alwin, 2018). It has been shown that assistance dogs may have a positive impact on health related quality of life (HRQoL), well-being and activity level (Hall, MacMichael, Turner, & Mills, 2017;Lundqvist et al., 2018;Shintani et al., 2010 (Allen & Blascovich, 1996;Collins et al., 2006). A number of studies have used qualitative methods to explore the use of assistance dogs (Camp, 2001;Herlache-Pretzer et al., 2017;Rodriguez, Bibbo, Verdon, & O'Haire, 2019). In summary, the studies identified both benefits and drawbacks with having an assistance dog. As a complement to previous research, this study will use qualitative data to explore in what way assistance dog enable improvements found in HRQoL, well-being and activity level. The meaning of assistance dog ownership from the owner's perspective is an important aspect to understand in-depth the use of an assistive dog as a supportive aid.
The aim of the present study is to explore service and hearing dog ownership from the owner´s perspective by examining the owner's expectations before training a dog, and experiences after having a certified dog.

| ME THODS
This study is based on the Service and Hearing Dog Project, which has been reported previously (Lundqvist et al., 2018). The intention of the project was to give the participants, in collaboration with a certified instructor, the possibility to train a companion dog to become a certified service or hearing dog.  (Lundqvist et al., 2018). Comparing the participants HRQoL scores with HRQoL scores for the general population showed that the participants had scores that were remarkably low (Lundqvist et al., 2018). The poor HRQoL indicated that the participants were in bad condition with substantial needs.
The dogs included in the study are presented in table 1 All participants who had not answered any of the questionnaires received one or two reminders after the initial questionnaire had been sent. The research group constructed the questions.

| Analysis
A thematic content analysis of the open-ended questions was carried out. The analysis was conducted in accordance with Braun and Clark (Braun & Clarke, 2006). An interlay inductive approach was used to identify patterns and categorise the quotes into themes. To reduce the risk of the analysis being driven by the questions, the answers were separated from the questions. In order to still be able to deduce the answer to a specific question, all answers were colour-coded before the questions were removed. However, the colours were not considered when conducting the analysis. To familiarise and get a sense of the data the author who conducted the analysis (ML) read the answers several times. Thereafter, the sorting of the answers was conducted based on identified patterns perceived as important in relation to the overall research question. To ensure transparency and to minimise the risk for the analyse being influenced by ML's perception, the analytic process was constantly discussed with A-CN. Furthermore, the analysis was reviewed by the research group.

| FINDING S
In the following section, we highlight the expectations that the participants had before training the dog. In addition, we present their perceived experiences, positive as well as negative, after the training of the dog was complete and the dog was certified as a service or hearing dog. The perceived experiences will be presented both in the short-term (three months after the dog was certified) and in the long-term (1-3 years after the first follow-up). Table 2 summarise the findings.

| Expectations before
The expectations we identified were categorised into sub-themes, which consistently reflected the participants' thoughts ( Table 2). The sub-sub-themes specified these thoughts.

TA B L E 2
Expectations brought up before the training of the dog started and perceived positive and negative experiences brought up after the training of the dog was complete Several of the participants were afraid of having a diabetic coma.
They hoped that the dog could decrease the risk of hyperglycemia as well as hypoglycemia. Skills of the dog that could decrease blood sugar fluctuations were closely related to the participants' ability to feel secure.

| Security and independence
An increased sense of security permeated the participants' expectations. In addition to security related to diabetes, they expected security in their everyday life. The participants also hoped that increased security would give them better confidence.
Feeling secure in everyday life. Feeling freedom in everyday life. Less need for help. Feeling needed, someone who needs me. (P73) That it will give me a greater sense of security to go outside the home and to attend courses, meet friends, etc. (P10) Expectations of increased security also made the participants reflect on their wish to become more independent. The term "independence" was frequently mentioned in several different contexts.
Becoming more independent could mean both that the participants hoped to be able to expand their surroundings, but also that they would not have to rely on others as they were used to doing.
With help from a physical service dog I will become more independent and will have the chance to strengthen my self-confidence and become more independent. I believe it will improve my living conditions, I will have a life that is simply better.
Several participants mentioned that one big relief would be that the dog would be able to pick up dropped items. The opportunity to become more independent seemed important for all participants, irrespective of the assistance dog type.

| The training
The participants also had expectations of the training. Some hoped that guidance from professional instructors would help them achieve the expectations they had of their future certified dog. The participants also expected that the training would mean growth and devel- The training was perceived important to ensure that the dog would be able to help them as expected.

| Overall life changes
The participants had an anticipation and desire to create a bond between themselves and the dog, and the overall expectations of their future assistance dog were high: Improved quality of life, being more independent.
That me and my family will feel safe. My mental health will improve. My chances to survive will increase.
The participants projected that receiving a certified dog in many ways would be life changing. Accordingly, the participants had high expectations of their future assistance dogs.

| Perceived positive experiences
The perceived experiences in many ways reflected the expectations they had expressed before training their dog, see table 2. However, using a certified dog as an assistant had given them both positive as well as negative experiences.

| Health status
In general, the participants felt that their health status was bet- In addition, the participants mentioned, in accordance with the short-term follow-up, that the dog had positive effects on their mental health, blood sugar levels and epileptic seizures.

| Being active
The participants pointed out two different reasons for perceiving their life as more active at the short-term follow-up compared to baseline. The possibility to be more active due to the presence of the dog was one of them.

| Security and independence
The participants' increased sense of security permeated their an- Closely related to the increased sense of security was the possibility to be more independent. The dog had expanded the participants' surroundings and they also felt relieved to not constantly have to rely on others.
I can do things I couldn't do before, for example to travel (on train), take walks in the woods etc. (D15) I have a chronic disease so my dog can´t affect the disease itself but he increases my sense of independence.
It also gives me improved ability to do things on my own with the certainty that for example a dropped phone or dropped car keys won't be a problem = Security!
Independence was also frequently mentioned as a positive experience at the long-term follow-up. Participants at the long-term follow-up who expressed an increased feeling of independence all had a physical service dog.

| Social relationships
The participants also highlighted the positive effects that the dog had had on their social relationships. The dog had for instance meant that As at the short-term follow-up, one participant at the long-term follow-up pointed out that the reason for having an assistance dog was to receive assistive support, not to make new friends.

| The dog is the best thing that happened to me
The perceived positive experiences were directly related to their health state, but also connected to their emotional state of mind.
Having a certified dog had for instance become life changing: He [the dog] is the best thing that has happened to me. (P20) The dog has given me a new life.

| Additional positive experiences in the longterm
In the long-term the participants also perceived that the dog had become a great support in their everyday life and that it felt meaningful to have someone to look after and take care of.
He [the dog] is a "support".
Calmer, not that alone, better routines, someone to take care of, feel no mental obstacles.
Additional positive experiences brought up at the long-term follow-up were the importance of the community with other dog owners that occurred during the training process, and the possibility to get help from competent instructors during the training, Table 2.

| Perceived negative experiences
Beside the positive experiences, the dog also contributed to some negative experiences, Table 2. Several of these experiences were beyond the participants' control and possibility to prevent.

| Negative attitudes and limited access to public places
Access to restaurants, grocery stores or other shops is not always permitted when bringing a dog. The participants stated that this occurred even though the dog wore the cape that identified the dog as a service or hearing dog carrying out a job.
Not being allowed to bring the dog everywhere reduced their surroundings.
The participants perceived the negative attitudes and their sometimes limited access to public places as offensive.

| Reduced freedom and feeling stressed
In certain situations, the participants expressed that the dog gave them reduced freedom and flexibility. For example, when undertaking travel for work purposes, when visiting friends who were allergic or in general when it felt difficult to bring the dog. Visiting friends with fur allergies was even sometimes impossible because of the dog.
Limited social situation. Can´t visit allergic friends etc. (D300) In addition, the participants perceived it as stressful when not being able to give the dog enough exercise and activity.

| The training
The participants also identified a few obstacles with the training. For some of them the distance to the course of training was a problem, they had to travel a long way to be able to participate.
The training is challenging due to the long journey, for example 1200 kilometres round-trip to take the certification test. (P3) In addition, participants training their second dog felt that they had to go through steps in the training process with which they were already familiar. training. (P33) One participant also testified that the training was very time-consuming. It had infringed upon the participant's job.

| Additional negative experiences in the longterm
The ability to control the dog and the fact that the dog made the house dirty were additional negative experiences the participants brought up at the long-term follow-up (Table 2).
Big, happy dog that can be difficult to control in all situations. (LP19) It´s dirtier at home, greater wear on furniture, clothes etc.
Other negative experiences mentioned at the long-term follow-up were in line with the negative experiences mentioned at the first follow-up.

| D ISCUSS I ON
In this article we have looked into the dog owners' expectations before the training of the dogs, and their perceived experiences (both in short-and long-term) after the dogs became certified. The expectations expressed before were closely related to the tasks the dog was intended to carry out after being certified. For instance, if the participant intended to train a diabetes alert dog, he or she expected the dog to be able to alarm for fluctuations in their blood sugar. Before training the dog, the participants also felt insecure both in their everyday life in general but also in specific situations, such as taking a walk or going to the grocery store. They hoped that the dog would contribute to an increased sense of security in these situations. The expectations were expressed irrespective of the assistance dog type they intended to train.
The expectations expressed before training a dog in many ways reflected the participants' experiences after the dog was certified.
The participants perceived that their desire for a safer and more independent everyday life had been fulfilled. In addition, the dog had affected the participants' perceived health status. For instance, participants with a diabetes alert dog experienced that they were able to keep their blood sugar steady, and participants with a physical service dog thought that the dog had made them more mobile but also reduced their anxiety. In addition, the participants hoped that the dog would contribute to increased happiness. However, being accompanied by a certified dog turned out to be more overwhelming than they could have imagined in advance. They felt that the dog had given them a different life and become their best friend. In addition to the expectations, other positive experiences were identified. For instance, through the dog, the owner was invited to a more physically active lifestyle and the dog was also a catalyst for social interactions. The dog being a catalyst for social interactions has also been established in previous research (Camp, 2001;Hubert, Tousignant, Routhier, Corriveau, & Champagne, 2013). The participants also stated that the dog reduced family members worrying. This is consistent with results presented in a recent study .
The positive experiences brought up directly after the dog had become certified also reflected the positive experiences identified over time. Worth noting though was that the bond between the dog and the owner seemed to become stronger and stronger.
Furthermore, when entering the project none of the participants thought that the dog would mean something negative. However, negative experiences were brought up and these experiences re-  .
In a previous study, potential consequences for the participant's HRQoL, well-being and activity level, of having a certified service or hearing dog, were studied with generic instruments (Lundqvist et al., 2018). The results indicated that there were positive effects of having a certified dog. This study can be seen as a complement to the previous study. It demonstrates the importance of supplementing quantitative data with qualitative data to identify and depict the multifaceted effects of an intervention. Compared to the previous study, where the results were statistically uncertain, the results from this study are convincing. The participants perceived that the certified dog had a positive impact on both their physical and mental well-being.
When summarising existing research findings, indications of positive consequences of having a certified dog in terms of HRQoL, well-being and activity level, can be seen (Lundqvist et al., 2018).
In addition, economic analyses show that certified service dogs are cost saving in comparison to regular companion dogs (Lundqvist, Alwin, & Levin, 2019) and, as has been shown in this study, participants perceive their certified dog as an assistive support that is worth its weight in gold. Is this research providing enough evidence to establish guidelines regarding prescription and subvention of an assistance dog as a supportive aid in Sweden? Only time will tell.
The limitations of this study should be acknowledged. First, since the participants were self-selected there may be a risk of self-selection bias. The selection-bias may lead to the sample not being representative, or the opposite, the sample may feel committed to take part and thereby provide more meaningful insights than if being randomly selected. We believe that the selection-bias in this case is minimal if generalising our results to people training a certified dog on their own. However, generalising the results to those purchasing a fully trained dog may not be possible. Secondly, the design of the questions (open-ended) may have influenced the responses we received. However, the participants had the opportunity to add other aspects, in regard to having a certified dog, than those highlighted in the questions. Despite these limitations, our study gives valuable insights into what service and hearing dogs can contribute, and how that affects their owners. Hence, this study offers valuable input to decision-makers when prioritising individually adapted care to people who can potentially benefit from being assisted by a certified dog.

| CON CLUS IONS
This study shows that individuals who are supported by an assistance dog experience the dog as an invaluable help in their everyday life. They feel that the dog has a positive impact on their health status. In addition, they perceive that the dog gives them the ability to become more independent and active and feel more secure. The dog also strengthens their social relationships. The poor understanding in society of the role played by the assistance dog is one negative part of assistance dog ownership. By improving the owners' lives in many ways, a certified service or hearing dog is a novel and important assistive support for people with a functional or health impairment.
Additional f ile 1 Questions asked at baseline: 1. What are your expectations of training a certified service or hearing dog? 2. How do you think the dog will influence your situation after becoming certified?
Additional f ile 2 Questions asked at first and second follow-up: