Knowledge and attitudes of veterinarians with regard to pain and welfare in cats: an educational intervention

Freedom from pain is a key component of animal welfare, and treatment depends on its effective recognition. Since veterinarians play an important role in alleviating animal pain, they must be equipped with the knowledge and ability to recognise and treat painful conditions. In addition, it has been suggested that individuals’ attitudes and knowledge may influence how they manage and treat pain in animals. In this work, knowledge is defined as (i) knowing what, (ii) knowing how and (iii) knowing when and why to do a certain action. Attitudes involve beliefs or ideas associated with a particular psychological object. In this thesis, I aimed (i) to survey veterinarians’ attitudes and knowledge with regard to cat pain and welfare (i.e. using a set of questionnaires), (ii) to explore barriers experienced by veterinarians when trying to achieve good post-operative cat management in practices, (iii) to use findings from (i) and (ii) to develop an educational intervention, and (iv) to test the efficacy of that educational intervention among veterinarians. In order to gather data relating to attitudes and knowledge of veterinarians with regard to cat pain and welfare, a set of quantitative questionnaires were designed and distributed to the UK and Malaysian veterinarians. To validate the results gathered from the questionnaire in Malaysia, data from direct observation in practices was collected. Although Malaysian veterinarians’ attitudes towards pain in cats were good, the behaviours in practice raised welfare concerns. Results from both the questionnaire and direct observation then suggested a follow-up study aimed to explore barriers experienced by Malaysian veterinarians to use good post-operative management in their practice. Basic barrier types were assessed by quantitative questionnaire, with more data richness being gathered using qualitative semi-structured interviews. Findings from quantitative surveys, the natural data collection and the qualitative interviews were used to inform the choice of behavioural theory that aimed to develop a behaviour change intervention study, the Health Action Process Approach (HAPA) based questionnaire and video intervention. Further testing of the efficacy of the video intervention which aimed to understand the process of human behaviour change were performed using a HAPA-based quantitative questionnaire plus direct observation in practice (i.e. to validate the respondents’ responses). In Chapter 2, a questionnaire showed that Malaysian and UK veterinarians demonstrate similar levels of concern about pain management in cats. In both countries, there is good awareness of the impact of pain on cats’ welfare and the possible treatment options. 98.2% UK and 87.1% Malaysian veterinarians agreed or strongly agreed with the statement ‘Pain compromises the quality of a cat’s life’. However, questionnaire results do not always correspond to what is happening in practice. Subsequent observations of practice in Malaysia and the UK demonstrated differences in the levels of care for post-operative cats. There was a significant gap in the uptake of optimal cat care (i.e. basic environmental resources provided to cat patients. Cage criteria recommended by https://catfriendlyclinic.org/) into Malaysian practices even though research has demonstrated that environmental management in veterinary practices is crucial for cat welfare. However, this gap could be partly due to the availability of learning resources which are mainly in English and predominantly developed in the ‘West’ and partly due to education or awareness not dispersing from other Asian countries. For example, this research found that Malaysian cats were often being housed with little comfort post-operatively (e.g. bedding, litter trays, hiding places), suggesting that cat patients may experience discomfort due to increase postural changes. This may be suggestive of stress, and could, in turn, lead to a misinterpretation of behavioural indicators of pain. There may be many factors that contribute to poor post-operative environments. In Chapter 3, a mixed-methods approach (i.e. questionnaire and semi-structured interview) investigated what barriers Malaysian veterinarians experienced in providing good post-operative cat care in practices. Results from the mixed-method study revealed that apart from the cost constraints experienced by veterinarians, a lack of practice management skills (i.e. skills dealing with how to have an efficient managerial system that can be applied in practices, for a practice that had insufficient staff, time and resources) was the other main reason for not providing better post-operative recovery environments for cats. They also recognised that comfortable post-operative environments help recovery, but they did not describe the relationship between reduced stress and pain assessment. Thus suggesting that participants might hold a lower significance for using or providing environmental resources for cat patients. This was because participants’ understanding of the use of bedding only focused on the comfort and safety purposes. Participants did not offer critical awareness relating to the ‘why’ or the potential relationships between providing comfort and a safe place with reduced stress in cats. A number of previous studies have indicated positive correlations between reducing environmental stress and pain assessment scoring ability - i.e. if the subject is relaxed it is easier to score their pain. The majority of these studies come from human clinical settings, but due to the similarity in stress and pain physiology and behaviour seen in mammals, one would expect to see a similar relationship in cats. In fact, as many of the behaviours associated with stress in cats could also be used in pain assessment, it is vital that veterinarians can tell the difference. Therefore, minimizing the development of negative emotions, for example, through environmental management should be prioritized in order to reduce the likelihood that such negative emotions override or modulate the pain behaviours. Therefore, findings from these studies (Chapter 2 and 3) assisted in developing an educational intervention which aimed to illustrate cost-effective ways to promote good cat welfare in the clinic. Moreover, the mixed-method study in Chapter 3 concluded that attitudes and knowledge might not fully contribute to behavioural action development without the contribution of social cognitive variables such as action planning and self-efficacy. In Chapter 4, the Health Action Process Approach (HAPA) theory used in health psychology, including aspects of both planning and self-efficacy was applied to understand both the current behaviour and behaviour changes among Malaysian veterinarians regarding the provision of comfortable bedding to post-operative cats. HAPA-based questionnaires were developed and used in three different time frames (i.e. Motivational phase, Pre-action phase and Actional phase). In Chapter 5, the Behaviour Change Wheel (BCW) framework was used to guide the development of this video intervention. BCW is a new 2011 behaviour model that comprises the following functions: (i) Capability (C), (ii) Opportunity (O) and (iii) Motivation (M). These three functions are needed for developing or influencing Behaviour (B). This framework identifies which of the possible psychological determinants need to be changed before the intervention function for the development of an educational intervention can be selected. The BCW framework was applied to current research findings (Chapter 2 and 3), to produce guidance for developing a video-based educational intervention entitled ‘How to have good post-operative cat management in practices’. In Chapter 6, the HAPA questionnaires identified three different behavioural stages: Actors (who always provided bedding to post-operative cats), Intenders (who provided bedding inconsistently) and Non-intenders (who did not provide bedding). Most Actors completely agreed with all social cognitive variables statements (e.g. risk assessment, outcome expectancy, self-efficacy, action planning, and self-monitoring) compared with Intender and Non-intenders who did not always agree. Although the HAPA theory was a useful tool for understanding the intention behaviour gap, HAPA was limited in developing our understanding about the connection between Pre-action (i.e. after a participant has developed intention to provide bedding to post-operative cats) to Actional phase (i.e. participants that already provide bedding to post-operative cats). This suggests that there is a possible gap in the application of HAPA theory in investigating other underlying factors such as habit (i.e. the unconscious processes that are behind the repeating or routine behaviour that normally happens in a situation-specific manner). Although my current research attempted to incorporate the role of emotion (i.e. an unconscious process involving strong feelings deriving from one’s circumstances) in predicting the behaviour of providing bedding to post-operative cats in the HAPA-questionnaire, this was insufficient to show the involvement of emotions in providing bedding to post-operative cats. One possible reason could be due to the low sensitivity of the scale to show increased or significant effects. Although the empathy scale in the present study was reliable and internally consistent, it was not specific enough to help predict the behaviour. In addition, it could be that the sample size in the present study was too small. Thus, reevaluating the usefulness of the empathy scale using a larger sample size in future research is suggested. In conclusion, this research study provides a better understanding of the attitudes and knowledge of Malaysian veterinarians with regard to cat pain and welfare. Additionally, this research also provides better insights into the barriers that contribute to the development of human behavioural issues (e.g. a lack of post-operative cat care management). All of this information has facilitated the design and implementation of a video educational intervention. The intervention shows the feasibility of using behavioural science (i.e. using any of various disciplines such as sociology, psychology and others in dealing with the subject of human actions) to improve cat welfare in practices. Future animal welfare studies could benefit from adapting this approach. Some limitations were noted in the current study. For example, as mentioned above, the HAPA framework used in the current study was limited in its ability to fully explain the unconscious social-cognitive factors (e.g. habit and emotion). This is because in order to change to the targeted behaviour, one should consider both conscious and unconscious social-cognitive factors in order to achieve a successful behaviour change. Future studies should attempt to gain a thorough understanding of both the original behaviour and the participants in order to choose the best theory for designing the interventions. In addition, the current study only managed to test the efficacy of intervention among veterinarians, thus further, refined and validated the current measurement scales (i.e. HAPA questionnaires) and video intervention could be considered to be conducted among other relevant stakeholders (e.g. veterinary nurses, veterinary students). Plus, using other targetted populations could potentially reduce the risk of survey fatigue among veterinarians and limit the over-use of similar target participants in future.