Introduction
One health focuses on the interrelationships between the health of humans, animals, and the environment.1 The concept of one health dates back to at least the 1800s when the term “zoonosis” was introduced, linking human and animal diseases.2 The one-health concept has been amplified in response to recent zoonotic disease outbreaks with public health implications (eg, COVID-19, H1N1 influenza, severe acute respiratory syndrome, Ebola, and Zika). Currently, the one-health approach is endorsed by major health organizations, such as the CDC, WHO, Food and Agriculture Organization of the United Nations, and World Organization for Animal Health.3,4
According to the veterinary oath, veterinarians have an obligation to use their knowledge and skills for the promotion of animal health and welfare and the protection of public health.5,6 Companion animal practice has been increasingly recognized as an area of veterinary medicine that contributes to public health.7 In 2010, the World Small Animal Veterinary Association developed a one-health committee to emphasize the importance of companion animals within the One Health initiative.8 Since then, veterinary organizations including the AVMA (www.avma.org), Federation of Veterinarians of Europe (www.fve.org), and Canadian Veterinary Medical Association (www.canadianveterinarians.net), have released statements of support for one health.9 In the realm of companion animal practices, veterinarians contribute to public health as it relates to zoonoses, animal models in translational research, antimicrobial resistance (AMR), and the human-animal bond, including the impact of animals on human physical and mental health.7 Given the prevalence of pet ownership10 and potential avenues for companion animal veterinarians to contribute to the One Health initiative, documenting the current status of veterinarian-client communication regarding one-health topics would provide a useful baseline for future training initiatives.
AMR is a specific concern across all health sectors, including veterinary medicine. Antimicrobial-resistant organisms have been found in animals, humans, and the environment and have resulted in approximately 44,000 human deaths/y in the US, according to a 2013 CDC report.11,12 The 2019 CDC report stated that AMR-related deaths decreased by 18% since 2013, suggesting prevention efforts may have had some effect.12 Increased interaction between animals and humans over recent decades has augmented the threat of cross-species transmission of AMR traits between humans and animals, adding to the complexity of the phenomenon.13,14 While clinical guidelines for antimicrobial use in companion animal practice have been released,15 the content of antimicrobial-related discussions between veterinarians and companion animal clients remains unclear.
Veterinarians are provided with opportunities to educate clients regarding a variety of one-health topics throughout different life stages of companion animals.16 Time during the appointment has been identified as a limiting factor,17,18 necessitating that veterinarians prioritize which topics to address with clients.19 An assessment of veterinarian-client-patient interactions will ascertain a baseline of communication content related to one health in current practice. The findings will benefit veterinary organizations9 and veterinary colleges20 in the endeavor to foster a one-health approach among veterinarians. The objective of this cross-sectional study was to describe the prevalence and context of one-health conversations between randomly selected veterinarians and their clients in companion animal practices located in Southern Ontario, Canada.
Methods
The study protocol was approved by the University of Guelph Research Ethics Board (REB No. 17-08-009).
Participant recruitment
Participant recruitment has been described previously.21 In brief, a list of 2,234 companion animal veterinarians working at practices within 150 km from the Ontario Veterinary College in Guelph, Ontario, Canada, was retrieved from the College of Veterinarians of Ontario’s publicly available website (www.cvo.org). Veterinarians were randomly selected and contacted via email, followed by a phone call, within 5 business days of initial email contact, until 60 veterinarian participants were enrolled. Recruitment and data collection began in November 2017 and ended in January 2019. Inclusion criteria for veterinarians included those who were practicing primary-care companion-animal medicine at least 1 full d/wk, English speaking, and at least 18 years of age. On the first day of data collection with each veterinarian, the researcher reviewed the consent form and obtained written informed consent from the participating veterinarian, clinic owner, and any support staff who may be involved in the participating veterinarian’s appointments. All research participants were made aware that the purpose of the larger study, from which data were collected for the present study, was to describe and explore the impact of veterinarian-client-patient interactions and veterinarian wellness on the outcomes of veterinary care, including veterinarian-client communication, and veterinarian and client satisfaction. Veterinarians were provided an incentive of $100 CAD and an aggregated summary of their clients’ satisfaction responses for their participation that was collected for the purpose of a separate study.21
The researcher spent up to 3 days with each participating veterinarian recruiting a convenience sample of clients from the reception area of the clinic with a goal to recruit 20 clients/veterinarian to have their appointment audio-video–recorded and complete a postappointment survey. A member of the research team approached each client in the waiting area who was scheduled for an appointment with the participating veterinarian to seek participation and obtain written informed consent. Client participants were at least 18 years of age and English speaking. Participants were excluded from the video recording if (1) any individual in the examination room had not provided consent, (2) the appointment was a planned euthanasia or (3) the veterinarian thought the appointment had potential to become a euthanasia, or (4) there was an accompanying minor child present.
Data collection
Data collection has been previously described.22 In brief, each participating veterinarian completed an initial questionnaire within the first 24 hours of data collection, containing demographic questions and questions pertaining to their mental health, collected for a separate study.21 Veterinarian-level variables included gender (open text), clinic role (owner or associate/locum), hours worked per week (< 30, 30 to 40, or > 40), and years in practice. Upon the completion of 3 study days with a participating veterinarian or enrollment of 20 client participants, whichever occurred first, each veterinarian completed an exit survey including the questions, “Do you think that being videotaped interfered with your clinical performance?” and “Do you think you could be yourself in front of the camera?” Both questions were measured using a visual analog scale (0 = definitely not, and 100 = definitely yes) to assess veterinarian participants’ perceived impact of the Hawthorne Effect, which is the potential impact on behavior based on research participants’ awareness of being observed.23
Upon client enrollment, veterinary appointments were audio-video–recorded (Hero5 edition; GoPro Inc) within the examination room. Each client completed a questionnaire containing client demographic questions either before or after their appointment. Client-level variables included client income (< $35,000, $35,000 to $49,999, $50,000 to $74,999, $75,000 to $99,999, $100,000 to $149,999, or ≥ $150,000), education (less than high school, high school diploma or equivalent, some college or university, college diploma, bachelor’s degree, graduate degree, or professional degree), gender (open text), client age in years, number of years client has known veterinarian, and number of veterinary visits in the past year. Appointment-level variables included number of pets in appointment (1 or multiple pets) and pet species (dog[s], cat[s], or other), based on the client questionnaire; type of visit (preventive care, health problem, follow-up/recheck, or other) as identified by the veterinarian; and length of appointment, captured upon review of video recordings.
The initial data collection included 917 video-recorded appointments, 393 of which were preventive care, 270 were health problem, 172 were recheck, 32 included other reasons, and 50 had missing data regarding appointment type. For use in the current study, limited by time and resources, 100 video-recorded interactions were randomly selected from a list of preventive care and health problem appointments recorded during the initial data collection (15.1% [100/663]).
One-health coding
To characterize one-health conversations, a coding framework was developed. The first author (NJ) examined multiple veterinary organizations’ websites (eg, www.wsava.org, www.avma.org, www.canadianveterinarians.net) for topics in companion animal medicine that were described in relation to one health. Each website was examined for a web page devoted to one health. Codes were developed to represent each topic mentioned on one health web pages (eg, cat/dog bites, domestic violence, and zoonotic diseases) and were inputted into standard survey software (Qualtrics XM; Qualtrics) to create a one-health coding framework (Supplementary Material S1). The coding framework was reviewed by all authors for clarity of the framework and comprehensiveness of one-health topics based on their expertise. Based on author feedback, an open-text box was added to capture the content of discussions regarding social determinants of health (1) in relation to the animal patient and (2) unrelated to the animal patient. An open-text box was also added for the coders to provide information on any other one-health topics that were mentioned during the video review that were not captured by the coding framework. One survey was submitted for every veterinarian-client interaction recorded. A second survey was submitted for appointments that also involved a veterinary support staff–client interaction.
Using video-based observation research methods, coders reviewed each video-recorded appointment and simultaneously completed the one-health coding framework by selecting codes as being present or absent (if unselected). One-health discussions were further categorized as (1) animal-human (eg, a cat’s anxiety is discussed in relation to personality traits and actions of different individuals who interact with the cat, or a veterinarian describes differences between the pH balance of a dog’s skin vs human skin indicating that some products are not interchangeable between dogs and humans), (2) animal-environment (eg, a cat’s anxiety is discussed as in relation to recent changes in the home environment, or a veterinarian and client discuss the impact of the weather and natural environment on a dog’s atopic dermatitis), or (3) human-animal-environment (eg, a cat’s anxiety is discussed with respect to different environments [home vs clinic] as well as personality traits and actions of different individuals when interacting with the cat in those environments, or a veterinarian discusses the potential for a dog’s atopic dermatitis being due to the environment and compares this to how environmental factors can trigger eczema in humans). To capture details of discussions related to zoonotic disease, codes were developed for specific zoonotic diseases (eg, leptospirosis, rabies, etc) and specific intestinal parasites discussed (eg, tapeworm, roundworm, etc). In addition, codes were created for specific disease vectors associated with zoonotic diseases (eg, “tick-borne diseases,” “flea-borne diseases,” and “intestinal parasites”). While piloting the coding framework (described below), additional codes were created on the basis of the verbiage observed during the pilot interactions. For example, the code “parasite prevention” was created to categorize any conversation about parasite prevention medications, which may not have included a discussion of a specific zoonotic disease or disease vector.
The one-health framework was piloted by 2 coders using 20 randomly selected videos from the initial dataset of 917 appointments. The coders met after analyzing each set of 5 videos to compare and discuss items captured in the coding framework and to increase reliability of coding. Pilot videos were not utilized in the final dataset. Following coding of pilot videos, the 100 randomly selected appointments were coded by 1 of the 2 raters, with 20% of the appointments (n = 20) coded by both coders to assess intercoder agreement.
Statistical analysis
Descriptive statistics were calculated for the one-health content coded from the audio-video–recorded interactions, as well as client, veterinarian, and appointment demographic variables from surveys collected during the original data collection. Mean, median, SD, and range were calculated for continuous variables, and frequencies were calculated for categorical variables. Intercoder agreement was calculated using percent agreement for each one-health code in the framework to assess the level of error introduced as a result of coder inconsistency.24 All statistics were calculated using standard statistical software (R version 4.2.1; The R Project for Statistical Computing).
Results
Participant demographics
The sample of 100 randomly selected video-recorded appointments, included in the present study, incorporated 47 veterinarians. Most participating veterinarians self identified as women (62% [29/47]) and the remainder self identified as men (38% [18/47]). Forty-five veterinarians practiced small animal medicine only, while 2 practiced mixed animal medicine. The majority (45% [21/47]) of veterinarians worked between 30 and 40 h/wk, while 36% (17/47) worked > 40 h/wk, and 19% (9/47) worked < 30 h/wk. Fifty-eight percent (27/47) were practice owners, while 42% (20/47) were associate veterinarians or locums, with a mean of 21.0 years in veterinary practice (median, 23.0 years; range, 3 to 38 years). Most participating veterinarians graduated from an AVMA-accredited veterinary college (83% [39/47]).
Of the 100 interactions randomly selected for inclusion in this study, 60% (60/100) were preventive care appointments and 40% (40/100) were health problem appointments, as identified by participating veterinarians. Almost three-quarters of the patients were dogs (67/91), 24% (22/91) were cats, and 2% (2/91) were rabbits, as identified by participating clients.
Most clients self identified as women (65/91), while 29% were men (26/91), with a mean age of 43.5 years (SD, 15.3; range, 19 to 82 years). Clients had known their veterinarians for a median of 7.5 years (mean, 9.2 years; SD, 7.1; range, 1 to 24 years; n = 88). Twelve percent (10/85) of clients had not visited their veterinarians in the past year, 47% of clients had visited the veterinarian once or twice in the past year, and 41% (35/85) had 3 or more visits in the past year. Differences in denominators are due to missing data.
One-health content
A total of 78% (78/100) of visits included a one-health discussion with the veterinarian, and 29% (10/35) of appointments that involved an interaction with veterinary support staff included a one-health conversation between the veterinary support staff and client. Eight appointments involved a one-health discussion between the client and both the veterinary support staff and veterinarian, resulting in 2 appointments that included a one-health conversation with veterinary support staff and not the participating veterinarian. Topics that evolved from a conversation about the animal into a one-health discussion with a veterinarian, from most prevalent to least prevalent, were zoonoses (28% [28/100]), animal behavior (25% [25/100]), illness/disease (20% [20/100]), activity level/exercise (16% [16/100]), nutrition (16% [16/100]), dentistry (6% [6/100]), body weight (3% [3/100]), animal welfare (3% [3/100]), dog/cat bites (2% [2/100]), cannabis (2% [2/100]), and aging (1% [1/100]). The prevalence of one-health conversations broken down by category (ie, animals-humans, animals-environment, or human-animal-environment) are presented (Table 1).
Prevalence of one-health discussions (animal-human, animal-environment, or animal-human-environment) between 47 veterinarians and 100 of their clients during 100 randomly selected companion animal veterinary appointments (60 preventive care and 40 health problem appointments) that were video recorded in Southern Ontario, Canada, between November 2017 and January 2019.
| Topics | Animal-human (n [%a; %b]) | Animal-environment (n [%a; %b]) | Animal-human-environment (n [%a; %b]) |
|---|---|---|---|
| Animal behavior (n = 39) | 2 (5.4; 2.0) | 11 (28.2; 11.0) | 12 (32.4; 12.0) |
| Animal welfare (n = 8) | 1 (12.5; 1.0) | 1 (12.5; 1.0) | 1 (12.5; 1.0) |
| Antibiotics (n = 27) | 0 (0.0; 0.0) | 0 (0.0; 0.0) | 0 (0.0; 0.0) |
| Cannabis (n = 3) | 2 (66.7; 2.0) | 0 (0.0; 0.0) | 0 (0.0; 0.0) |
| Aging (n = 21) | 1 (4.8; 1.0) | 0 (0.0; 0.0) | 0 (0.0; 0.0) |
| Dentistry (n = 43) | 5 (11.6; 5.0) | 1 (2.3; 1.0) | 0 (0.0; 0.0) |
| Activity levels/exercise (n = 33) | 0 (0.0; 0.0) | 14 (42.4; 14.0) | 2 (6.1; 2.0) |
| Nutrition (n = 63) | 8 (12.7; 8.0) | 5 (7.9; 5.0) | 3 (4.8; 3.0) |
| Body weight (n = 42) | 2 (4.8; 2.0) | 1 (2.4; 1.0) | 0 (0.0; 0.0) |
| Illness/disease (n = 68) | 5 (7.3; 5.0) | 11 (16.2; 11.0) | 4 (5.9; 4.0) |
| Dog/cat bites (n = 10) | 1 (10.0; 1.0) | 1 (10.0; 1.0) | 0 (0.0; 0.0) |
a% = n/number of appointments that the topic was mentioned in relation to the animal.
b% = n/total number of appointments.
Zoonoses were mentioned in 65% (65/100) of appointments. One-health conversations related to zoonotic diseases occurred in 43% (28/65) of appointments that contained a discussion regarding zoonotic diseases in relation to the animal. Most frequent zoonotic diseases mentioned during appointments included rabies (41% [41/100]), leptospirosis (29% [29/100]), heartworm (21% [21/100]), and Bordetella (19% [19/100]). The prevalence of one-health conversations in relation to zoonoses discussed in appointments, coded on the basis of terminology used during the discussion, is described (Table 2).
Prevalence of one-health discussions (animal-human, animal-environment, or animal-human-environment) related to zoonoses, between 47 veterinarians and 100 of their clients during 100 randomly selected companion animal veterinary appointments (60 preventive care and 40 health problem appointments) that were video recorded in Southern Ontario, Canada, between November 2017 and January 2019.
| Terminology | Animal-human (n [%a; %b]) | Animal-environment (n [%a; %b]) | Animal-human-environment (n [%a; %b]) |
|---|---|---|---|
| General | |||
| Flea-borne disease (n = 17) | 0 (0; 0) | 5 (29.4; 5.0) | 0 (0; 0) |
| Intestinal parasites (n = 19) | 0 (0; 0) | 3 (15.8; 3.0) | 1 (5.3; 1.0) |
| Tick-borne disease (n = 16) | 0 (0; 0) | 7 (43.7; 7.0) | 2 (12.5; 2.0) |
| Parasite prevention (n = 26) | 0 (0; 0) | 4 (15.4; 4.0) | 0 (0; 0) |
| Specific | |||
| Anaplasmosis (n = 1) | 0 (0; 0) | 0 (0; 0) | 0 (0; 0) |
| Bordetella (kennel cough; n = 19) | 0 (0; 0) | 0 (0; 0) | 0 (0 ;0) |
| Dermatophytosis (ringworm; n = 1) | 0 (0; 0) | 0 (0; 0) | 0 (0; 0) |
| Giardia (n = 1) | 0 (0; 0) | 0 (0; 0) | 0 (0; 0) |
| Heartworm (n = 21) | 0 (0; 0) | 5 (23.8; 5.0) | 0 (0; 0) |
| Hookworms (n = 6) | 1 (16.7; 1.0) | 1 (16.7; 1.0) | 0 (0; 0) |
| Influenza (n = 2) | 0 (0; 0) | 2 (100.0; 0.0) | 0 (0; 0) |
| Leptospirosis (Lepto; n = 29) | 0 (0; 0) | 7 (24.1; 7.0) | 2 (6.9; 0.0) |
| Lyme borreliosis (Lyme disease; n = 8) | 1 (12.5; 1.0) | 2 (25.0; 2.0) | 0 (0; 0) |
| Rabies (n = 41) | 1 (2.4; 0.0) | 0 (0; 0) | 0 (0; 0) |
| Roundworms (n = 8) | 2 (25.0; 2.0) | 0 (0; 0) | 0 (0; 0) |
| Salmonella (n = 1) | 0 (0; 0) | 1 (100.0; 1.0) | 0 (0; 0) |
| Tapeworms (n = 4) | 0 (0; 0) | 2 (50.0; 2.0) | 0 (0; 0) |
| Other (n = 3; coccidia, 1; whipworm, 1; corona, 1) | 0 (0; 0) | 0 (0; 0) | 0 (0; 0) |
a% = n/number of appointments that the topic was mentioned in relation to the animal.
b% = n/total number of appointments.
Twenty seven percent of appointments included the mention of antibiotics, yet none progressed into a one-health conversation. Of the 27 discussions related to antibiotics, 18 led to a prescription (2 discussions included 2 antibiotic prescriptions), 2 included over-the-counter antibiotic creams, and in 7, antibiotics were discussed but not prescribed. None of the antibiotic discussions were initiated by the client. In 6 additional appointments, it remained unclear whether a prescribed medication was an antibiotic or not; for example, if the veterinarian stated, “I will send you home with some ointment,” with no further detail provided. Thirty-two percent (7/22) of the antibiotics prescribed during appointments included diagnostic testing related to the indication for which the antibiotic was prescribed (3 cytology, 2 corneal stains, 1 blood test, and 1 fecal test). All diagnostic test results were provided within the same appointment, except 1 cytology. In this single case, there was no recommendation for that client to wait for the diagnostic test results before starting their pet on the antibiotic prescribed. No communication relating to the submission of bacterial cultures to a laboratory was identified. The type of information provided regarding antibiotics and the indication for antibiotics discussed are presented (Tables 3 and 4).
Details provided by veterinarians in relation to the antibiotics discussed for 20a appointments during which antibiotics were prescribed and 7 appointments during which antibiotics were discussed but not prescribed from the appointments described in Tables 1 and 2.
| Indication for antibiotic | Antibiotics prescribed (n)/n = 22 | Antibiotics discussed, not prescribed (n)/n = 7 |
|---|---|---|
| Antimicrobial resistance | 1 | 0 |
| Drug name | 9 | 0 |
| Dose and/or frequency | 12 | 0 |
| Recommendation to give full dose of antibiotics | 3 | 0 |
| Duration | 11 | 0 |
| Route of administration | 20 | 1 |
| Public health (human impact) | 0 | 0 |
| Disposal (environmental impact) | 0 | 0 |
aTwo appointments included 2 antibiotic prescriptions; 1 recommended to only give if probiotics weren’t effective.
Indications for antibiotics discussed during veterinary appointments, whether antibiotics were prescribed (n = 22) or only discussed (7) from the appointments described in Tables 1 and 2.
| Indication for antibiotic | Antibiotics prescribed (n)/n = 22 | Antibiotics discussed, not prescribed (n)/n = 7 |
|---|---|---|
| Skin | 7 | 1 |
| Ears | 5 | 1 |
| Eyes | 3 | 0 |
| Gastrointestinal | 4 | 1 |
| Respiratory | 0 | 1 |
| Urinary | 2 | 1 |
| Dental/oral | 1 | 0 |
| Postoperative | 0 | 1 |
| Tick borne | 0 | 1 |
Three of 100 (3%) appointments included a discussion of the physical health of the client or the client’s family, and 17 of 100 (17%) appointments included a conversation about the mental health of the client and/or the client’s family. Of the conversations about mental health, 13 of 17 (76%) were directly related to the client’s concern regarding their pet’s health. Additionally, 17% (17/100) of appointments included a conversation related to the client’s concerns associated with the cost of veterinary care. Coder agreement for individual items in the one-health coding framework ranged from 76.2% to 100% (mean agreement, 90.4%). Codes with the lowest agreement were animal behavior (76.2%) and tick-borne diseases (76.2%).
Impact of video recording on veterinarian participants
On the exit surveys administered to participating veterinarians on their last study date, it was reported to a great degree that the video recording did not interfere with their clinical performance, with a median score of 7.5 out of 100 (mean, 17.2; SD, 24.48; n = 47). Veterinarians largely felt that they could be themselves in front of the camera, with a median of 93 out of 100 (mean, 83.0; SD, 27.30; n = 47).
Discussion
This was the first observational study, to the authors’ knowledge, to examine the prevalence and context of communication related to one health during companion animal appointments. For the purpose of this study, a one-health discussion was defined as a conversation related to the animal and environment, animal and humans, or animal, humans, and environment. One-health matters appeared in most appointments. Nevertheless, a comprehensive examination of the results indicate that opportunities persist for companion animal veterinarians to expand their discussion in ways that contribute to client education regarding one-health topics in an effort to promote optimal health for animals, humans, and the environment.
Of note, none of the discussions about antibiotics in the current study led to a one-health conversation. Additionally, only 1 appointment included the mention of AMR, despite recent attention to antimicrobial-resistant infections across healthcare professions.12,25,26 Companion animal veterinarians have been found to perceive their own contribution to the overall issue of AMR as minimal.27 With this perception, veterinarians may not feel positioned to use their appointment time to expand on topics such as AMR, even though veterinary clients’ general understanding of AMR and specific knowledge of AMR related to pets is relatively low.28 An interdisciplinary approach to antimicrobial stewardship is likely required; however, more research is needed to understand the knowledge, expectations, and barriers that exist in relation to AMR within different professions and the communities they serve.
Approximately a quarter of appointments that involved a discussion of the potential use of antibiotics did not result in the veterinarian dispensing antibiotics for the patient. All discussions related to antibiotics were initiated by the veterinarian. This finding may suggest that veterinarians were being proactive by introducing conversations about the use of antibiotics, and this does not always lead to an antibiotic being prescribed. Veterinarian-client communication aside, companion animal veterinarians have expressed wanting more guidance when deciding on the type and duration of antimicrobial administration.25,29 Various initiatives have been taken to enhance veterinarians’ knowledge of antimicrobial use including best practice guidelines and a smartphone app to help veterinarians utilize guidelines for prescribing antibiotics.30–32 Veterinarians’ awareness of antimicrobial drug use guidelines has been reported to be considerably higher in recent years, with a 2022 survey33 that found 60.5% of US veterinarian participants were aware that these guidelines existed, compared to a 2015 AVMA survey29 reporting that 12% of respondents were aware of the guidelines. While implementation of clinical guidelines has been associated with decreased use of antimicrobials in a veterinary teaching hospital,34 there remains a disparity between awareness of guidelines and implementation.33 A combination of improved awareness of current guidelines and increased support for effective implementation of guidelines could provide a foundation for veterinarians to discuss antimicrobial stewardship with veterinary clients.
During interactions in which antibiotics were dispensed in the current study, clients were primarily educated on the route of administration, while dose, frequency, and duration of antibiotics were mentioned only half of the time—details that have also been found to be inconsistently recorded in patients’ medical records.35 Veterinary clients’ compliance to antibiotics can be significantly impacted by dosing regimen.36 Thus, veterinarian-client communication regarding dosing, including frequency, offers an opportunity for veterinarians to identify client barriers to compliance and ultimately their capacity to commit to stewardship programs. In addition to communicating details of a prescription with clients, veterinarians should also educate clients regarding the proper disposal of unused medications,37 which was not observed in the present study when antibiotics were prescribed.
In the present study, none of the antibiotic prescriptions included discussion of a bacterial culture and susceptibility test prior to the dispensing of an antibiotic. Some of the case presentations that received antibiotics in the present study do not currently have guidance regarding culture and susceptibility testing; therefore, there may be fewer cases for which guidelines would suggest culture and susceptibility testing than what is represented in the current results. Previous research examining antimicrobial use in cats and dogs found that a bacterial culture and susceptibility test were performed in < 5% of patients that were prescribed antibiotics.38 Despite agreement among veterinarians that results of a bacterial culture and susceptibility test are the most important factors when selecting antimicrobials,29,39 the cost of testing is considered a barrier to recommending these tests among practicing veterinarians29 and veterinary students.40 Through a one-health approach, veterinarians should be encouraged to consider the possible long-term implications of their daily choices, such as avoiding recommendations for clients to pursue a bacterial culture and susceptibility test, to both the animal and society.15 Risks of antimicrobial-resistant bacteria extend beyond animal welfare from failed treatment, as resistant infections could become more financially taxing on clients due to an increased need for recheck appointments, repeated diagnostic testing, and continued monitoring for adverse effects. Moreover, failed treatment has the potential to impact the mental health of pet owners, as 3 out of 4 veterinary clients who discussed mental health with their veterinarian in the present study discussed it in relation to concerns about their pet’s health. Prior to prescribing antibiotics, veterinarians should educate clients about AMR and discuss both immediate and long-term benefits of performing a bacterial culture and susceptibility test.
Fewer than 50% of appointments with a discussion of at least 1 zoonotic disease in the current study incorporated information regarding humans, the environment, or both. Close to a quarter of pet owners surveyed in Australia had never considered the risk of contracting a disease from their pet.41 In this study, pet owners who were aware of important zoonoses in their region were found to have low levels of knowledge regarding exposure pathways and animal sources.41 Veterinarians are important resources for reliable public health information and have the opportunity to educate their clients concerning zoonoses from various sources. Prophylaxes, such as parasite prevention, have become common practice within veterinary medicine, yet the present study suggests there are numerous occasions for veterinarians to provide more information on the prevention of zoonotic diseases. Taking a one-health approach when educating pet owners about zoonotic diseases has the potential to enhance pet owners’ knowledge of their own risks.42 While most veterinarians consider this to be an important aspect of their job, less than half of veterinarians have reported initiating discussions about zoonoses on a daily basis with clients.43
Most pet owners believe their veterinarian should take primary responsibility for educating their clients regarding zoonoses, although half of pet owners consider human medical professionals to play a valuable role in zoonotic disease education as well.41 Physicians have also expressed their reliance on veterinarians to educate pet owners about zoonotic diseases.44 This perception could explain why high-risk patients do not always receive essential information about diseases acquired from pets from their own medical professionals.42 Present results highlight an opportunity for veterinarians to help address this information gap when discussing zoonotic diseases with pet owners, especially those considered high-risk. Although human medical professionals are likely to have more awareness regarding their patient’s health status, veterinary professionals can elicit information regarding human-pet contact while gathering a history; for example, asking open-ended questions, such as, “Tell me about who your pet comes in contact with” or “Who is involved in your pet’s life?” A question could also be added to client intake forms to identify whether there are people in the pet’s life that are high-risk. Similarly, human medical professionals could use a comparable approach to explore the presence and role of any pets in their patients’ lives. Building on current literature45 investigating professional responsibilities of veterinarians and human medical professionals in the management and education of zoonoses is needed to enhance interprofessional communication and collaboration, ultimately increasing the effectiveness of one-health clinical practitioners.
In the current study, 1 in 6 clients discussed the mental health of themselves or a member of the family, the majority of which were related to their concerns or distress regarding their pet. In addition, 17% of clients expressed concerns related to the cost of veterinary care. Caregiver burden has been increasingly recognized within the field of veterinary medicine.46–48 Pet owners with a dog or cat with a serious illness have been identified to experience higher levels of stress and symptoms of depression compared to owners of healthy pets.47,48 The current study did not assess the severity of the patient’s illness; however, results are informative in relation to the frequency that clients told the veterinarian about their distress over their pet’s health. Though pet owners experience more positive aspects of pet caregiving and lower overall burden compared to those caring for family members with dementia, pet owners are found to experience similar levels of financial strain, guilt, and fear about what the future holds.48 Clients’ financial strain is thought to contribute to veterinarian burnout,49 emphasizing the need for greater understanding of veterinary-related influences on both clients’ and veterinary professionals’ mental health.
The results of this cross-sectional study provide a preliminary description of one-health conversations occurring within a sample of examination-room interactions from companion animal appointments across Southern Ontario, Canada. Results suggest that veterinary support staff contribute to one-health discussions during veterinary visits. Close to one-third of the appointments in which veterinary support staff was present contained a one-health discussion between the veterinary support staff and client. Demographics were not collected from veterinary support staff, presenting a limitation, as the titles of paraprofessionals involved in this study are unknown (eg, credentialed veterinary technician, veterinary assistant, etc). An understanding of the role that paraprofessionals have in client-communication regarding one-health matters, such as zoonoses and AMR, is vital to being able to support veterinary hospitals’ efforts to promote greater awareness of one-health topics.
The Hawthorne effect was a drawback of the present research methods, as participants may have changed or attempted to improve their behaviors knowing that communication was a primary focus of the study. Nevertheless, participating veterinarians mostly reported minimal impact from being recorded. While veterinarians were randomly selected to participate in the study, it is possible that veterinarians who felt more confident in their communication skills were more likely to participate, as self-consciousness was a common reason that veterinarians declined, resulting in an unrepresentative sample. Percent agreement was selected as a measure of interrater reliability, as it allowed for identification of problematic codes during the coding process and can be easily interpreted.24 While minimal guessing was anticipated during the coding process, percent agreement does not account for chance agreement.24 Current findings should be interpreted with caution, as the study was conducted in 1 specific geographic region of Canada with a sample of veterinarians and a convenience sample of their clients. In addition, the prevalence and risk of specific zoonotic diseases will vary on the basis of geographic region, limiting the generalizability of findings from the present study. Further, cannabis was not legalized in Canada during most of the data collection period50; therefore, the prevalence of cannabis discussions is likely underestimated compared to those that occur currently. Finally, the findings of this study are limited to the interaction between veterinarians and their clients within the examination room. Client education outside of the examination room was not captured (eg, via pamphlets, posters, telemedicine, social media, and e-newsletters). Therefore, future researchers may wish to examine client education related to one health in a more holistic manner by incorporating forms of client education beyond the examination room.
Results of the present study establish a preliminary understanding of the prevalence and context of one-health discussions during veterinarian-client interactions in companion animal practice. Although most interactions examined as part of the current study contained at least 1 conversation relevant to one health, findings confirm that opportunities for more comprehensive one-health conversations are abundant. Continued integration of one-health concepts into veterinary college curricula and veterinarian continuing education will help expand the role of veterinarians in enhancing one health.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org
Acknowledgments
The authors recognize the contribution of Oviya Sriananthan for her dedication to video-coding for this project.
Disclosures
Dr. Coe regularly receives research funding from, consults for, and receives honoraria from various veterinary organizations and commercial companies including Zoetis and Royal Canin. Dr. Coe currently holds the VCA Canada Chair in Relationship-Centred Veterinary Medicine at the Ontario Veterinary College, University of Guelph.
The authors declare that there were no conflicts of interest.
No AI-assisted technologies were used in the generation of this manuscript.
Funding
The video data collection for this project was funded by a gift to the Ontario Veterinary College from Royal Canin and was conducted in collaboration with a study supported by Zoetis Canada. The funding sources did not have a role in the design, analysis, interpretation, or reporting of results from this study.
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