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9 2 The Evidence Base – exercise, health and recreational horse riding 2.1 The evidence base – physical exercise and health 2.2 The evidence base – horse riding and health 13 3 Research Methods 3.1 Introduction 3.2 Methods – scientific trials and the measurement of exercise intensity 3.3 Methods – the questionnaire survey of recreational horse riders Page 3 Page 4 The health benefits of horse riding in the UK Executive Summary Key findings The physical health benefits of horse riding and associated activities l Horse riding and activities associated with horse riding, such as mucking out, expend sufficient energy to be classed as moderate intensity exercise.

Regular periods of trotting in a riding session may enhance the energy expended and associated health benefits. l l More than two thirds (68 percent) of questionnaire respondents participate in horse riding and associated activities for 30 minutes or more at least three times a week.

Sport England estimate that such a level of sporting activity will help an individual achieve or exceed the government’s recommended minimum level of physical activity.

A range of evidence indicates the vast majority (90 percent plus) of horse riders are female and more than a third (37 percent) of the female riders who took part in the survey were above 45 years of age.

Horse riding is especially well placed to play a valuable role in initiatives to encourage increased physical activity amongst women of all ages. l Amongst the horse riders who took part in the survey, 39 percent had taken no other form of physical activity in the last four weeks.

This highlights the importance of riding to these people, who might otherwise be sedentary. l Horse riders with a long-standing illness or disability who took part in the survey are able to undertake horse riding and associated activities at the same self-reported level of frequency and physical intensity as those without such an illness or disability. l The psychological and social benefits of horse riding l l Horse riding stimulates mainly positive psychological feelings. Horse riders are strongly motivated to take part in riding by the sense of well-being they gain from interacting with horses.

This important positive psychological interaction with an animal occurs in a very few sports. l Being outdoors and in contact with nature is an important motivation for the vast majority of horse riders. Page 5 Study methods The British Horse Society commissioned the University of Brighton in partnership with Plumpton College to research the physical health, psychological and well-being benefits of recreational horse riding in the United Kingdom.

Sport England UK have adopted a threshold value for the contribution of sport to meeting Government guidelines on the recommended intensity and frequency of exercise that is likely to achieve physical health benefits.

The threshold value measures the degree to which an individual participates in sport of moderate intensity activity for at least 30 minutes or more, three times a week.

The research, therefore, assessed whether horse riding can be classified as a moderate intensity exercise and examined the frequency with which individuals take part The research also examined the psychological and social benefits of horse riding.

Reliable existing evidence indicates that physical exercise produces well-being benefits linked to social interactions and changes in mood, anxiety, self esteem and other personal emotions.

Two scientific exercise testing trials were undertaken to analyse the physical exercise intensity of recreational horse riding using validated scientific measurements of energy expended and current definitions of what constitutes moderate intensity exercise in terms of energy expenditure measured in metabolic equivalents (METs).

The first trial involved 17 participants cycling in a laboratory to assess their aerobic fitness levels.

Measurements were also taken of their descriptive anthropometric characteristics.

In the second trial the same 17 participants rode a horse for 45 minutes at the Plumpton College equestrian centre following a protocol that replicated the pattern of a typical riding lesson.

A questionnaire survey was undertaken of 1,248 horse riders.

The quantitative and qualitative data gathered by the questionnaire allowed an analysis of the respondents’ self reported measures of exercise intensity and frequency, and their perceptions of the social and psychological benefits of horse riding.

Physical health benefits The scientific trials indicated general horse riding energy expenditure was equivalent to 3.7 METs and trotting equated to approximately 5.0 METs.

These levels are clearly within the moderate intensity exercise band recommended by the UK’s ABC of Physical Activity for Health guidelines that considers moderate intensity to be typically characterized as between three-six METs.

The national compendium of physical activities1 categorises energy expenditures for different recreational physical activities and reports levels of four METs for general horse riding and 6.5 METs for trotting, which are similar to those obtained in the scientific trials.

The compendium also reports that the energy expenditure for saddling and grooming was 3.5 METs which is in the moderate intensity band More than two thirds (68 percent) of questionnaire respondents achieved the government guidelines for exercise intensity and frequency (30 minutes for three times a week or more at moderate intensity) from horse riding and associated activities alone.

Of these respondents 69 percent achieved this level of intensity and frequency through horse riding and the other 21 percent did so through associated activities such as mucking out and grooming.

Women have been identified in government studies as a social group with relatively low levels of participation in physical activity.

Some 93 percent of questionnaire respondents were women and 49 percent of female respondents were aged 45 or above.

These are comparable figures to a major Sport England survey which found that 90 percent of those participating in equestrianism are women and 37 percent of the female participants in equestrianism are aged 45 or above.

The gender and age profile of equestrianism is not matched by any other sport in the UK2.

Thirty nine percent of questionnaire respondents indicated that horse riding was the only form of physical activity in which they had participated during the last four weeks.

These respondents, if they did not ride, would be sedentary people unless they changed their exercise habits, thus stressing the importance of horse riding for these individuals.

Qualitative data obtained in the questionnaire suggests that for some respondents with long-standing illnesses or disability, horse riding had actually improved their physical or mental condition. 1 2 Ainsworth, B, E., Haskell W, L., Whitt, M, C., Irwin, M., Swartz, A, M., Strath, S, J., O’Brien, W, L., Bassett, D, Schmitz, K., Emplaincourt, P., Jacobs, D. & Leon, A. (2000) Compendium of physical activities: an update of activity codes and MET intensities.

Medicine and Science in Sports Exercise, 32(9 Suppl), 498-504.

Sport England (2010) Active People Survey (2010/11) Page 6 Psychological and social benefits More than 80 percent of questionnaire respondents reported that horse riding made them feel ‘quite a lot’ or ‘extremely’ cheerful, relaxed, happy or active.

Qualitative data suggests that horse riding can play a role in managing negative feelings relating to anxiety and depression.

The experience of these psychological benefits amongst questionnaire respondents was not influenced by the frequency of participation in horse riding and most psychological benefits were experienced by riders who did not participate regularly.

Asked to rate different motivations for going horse riding 82 percent of questionnaire respondents rated the motivation of ‘interaction with horses’ as either ‘very important’ or ‘extremely important’.

No other motivation received such a high importance rating.

Existing evidence suggests that companion animals can provide owners with certain psychological benefits.

These findings suggest that the interaction with horses may be very positive psychologically for horse riders.

More than 80 percent of questionnaire respondents rated the motivations ‘contact with nature’ and ‘scenery and views’ ‘important’, ‘very important’ or ‘extremely important’.

Some personal development motivations identified as important by respondents included ‘escape’, ‘develop skills’, ‘challenge myself’, ‘experience excitement’, ‘to be physically active’ and ‘to relax’.

Participation in horse riding provides a range of psychological and social benefits, some of which are particular to the interaction with animals and nature and therefore would not be gained from other forms of sporting activity. Page 7 Page 8 1.

Introduction There is limited evidence available on the physical health, psychological and well-being benefits of horse riding.

Given this situation, the University of Brighton, in partnership with Plumpton College, were commissioned by The British Horse Society to carry out a study to identify the health and well-being benefits of horse-based sport and leisure.

The research was carried out by a multi-disciplinary research team that included sports scientists based at the University of Brighton Welkin Human Performance Laboratories, equine specialists from Plumpton College and social scientists from the University of Brighton with specialist expertise in leisure, health and outdoor environments.

Members of the research team have conducted major studies recently on outdoor recreation for the Environment Agency, Defra and Natural England.

The team was led by Professor Andrew Church who recently led the research into leisure and the environment for the recently published UK National Ecosystem Assessment that analyses the natural environment in terms of the benefits it provides for society and prosperity.

Evidence was collated using a variety of quantitative and qualitative research methods, including a literature search, physiological testing and a survey of recreational horse riders.

The research focused on recreational horse-based sport and leisure and did not consider the health benefits that are obtained by professional equestrian sports people.

The key findings based on the quantitative and qualitative data are reported in the executive summary above as well as in the main report which is divided in to six main sections: — l The detailed findings of the research are presented in sections 4-6 and key findings are highlighted in bold.

For people involved in horse riding some of the findings may be self-evident, such as the high level of female participants in horse riding or the importance of interacting with horses as a motivation for riding.

Many of the physical health and psychological dimensions of horse riding, however, may not be well known amongst key partner organisations that can play an important role in the future development of horse-based sport and leisure.

These organisations might include private business, the voluntary sector, government bodies and health sector organisations. Page 9 Page 10 2.

The Evidence Base – exercise, health and recreational horse riding (a more detailed version of this section is available in Appendix 1) 2.1 The evidence base – physical exercise and health There is now an abundance of evidence indicating the physical health, mental health and social benefits of physical activity (Department of Health, 2004, Foresight, 2007).

In particular, physical activity is associated with reduced risk of coronary heart disease, obesity, type 2 diabetes, and other chronic diseases and conditions (Department of Health, 2004).

An increasing body of research points to a positive effect of physical exercise on psychological health, including enhanced self-esteem, improved social networks and reduced anxiety and depression (Fox and Corbin, 1989; Martinsen, 1995; Landers, 1997; Farmer et al, 1998; Scully et al, 1998; Sonstroem et al, 1994; Pretty et al, 2003; Barton and Pretty, 2010).

Physical exercise, therefore, affects overall well-being not just physical health, with well-being defined in the UK as “a positive physical, social and mental state; it is not just the absence of pain, discomfort and incapacity” (Defra, 2007).

The existing evidence also indicates that the benefits of exercise, especially those relating to physical health, are in part influenced by the frequency and intensity with which an individual takes exercise (Blair et al, 1992; Blair et al, 1995).

As a result of existing evidence the Department of Health recommends that adults should participate in 150 minutes of moderate intensity physical activity per week, with the suggestion that this could be broken down into 30 minutes per day over five days (Department of Health, 2011).

Sport England (2010) have adopted the rationale that the appropriate contribution from sport to this guideline is at least three, moderate intensity 30 minute sessions per week (three x 30).

This is the threshold value for participation in the Sport England Strategy 2008-2011 and the measure used in their Active People survey, a major study of sports participation that has been running since 2005.

There is also existing evidence to show that three x 30 minutes per week of moderate intensity exercise alone can be sufficient to produce some physical health benefits (Tully et al, 2007).

This research project, therefore, examines both the intensity and frequency of exercise linked to horse riding.

In keeping with the approach adopted by Sport England this project assessed the degree to which horse riders are achieving the threshold value (three x 30 minutes of moderate intensity activity per week) for participation in sport that will contribute to meeting government guidelines on levels of physical activity that are likely to achieve physical health benefits.

People who participate less regularly in sport may gain other psychological or social well-being benefits (Barton and Pretty, 2010) and society may benefit from the development of social capital and networks (Dekker and Uslaner, 2001).

Consequently, another government survey called Taking Part (DCMS, 2007) has, since 2005, been measuring levels of voluntary participation in leisure, culture and sport in England in recognition of the social and cultural benefits of people being involved in sport on a regular basis even if the involvement is not of the frequency required to confer physical health benefits.

The research presented in this report was designed to explore not only the physical health benefits of riding but also the related mental health and social benefits.

The research methods used were designed to explore the key issues of exercise intensity and frequency that influence the physical health benefits arising from exercise.

In particular, the study aimed to assess using a variety of methods if recreational horse riding can be classified as a moderate intensity exercise and to examine the frequency with which individuals take part in horse riding and activities associated with horse riding such as mucking out and grooming.

There is also existing evidence that additional health and well-being benefits can occur through forms of exercise, such as horse riding, that involve outdoor natural environments, contact with nature and interaction with animals.

A number of studies have found that the presence of natural settings can actually act as a motivating factor for physical exercise and possibly increase the intensity of exercise and the energy expended. (Reynolds, 2002; Giles-Corti and Donovan, 2003; Netherlands Health Council 2004; Pretty et al. 2005; Pretty et al. 2007).

There are some uncertainties associated with this evidence base as the additional benefits of outdoor exercise compared to that in indoor environments are not fully understood (Thompson Coon et al. 2010) and the research into the health benefits of interaction with animals very rarely considers horses as it has focused mainly on companion animals (see for example Folse et al., 1994; Garrity et al, 1989; Hoffman et al., 2009; Scouter and Miller, 2007; Seilgel, 1990).

The methods used in this study, therefore, explored the significance for horse riders of interactions with outdoor environments, nature and horses. Page 11 2.2 The evidence base – horse riding and health Appendix 1 provides a detailed review of the evidence base on the health and well-being benefits obtained through horse riding.

The existing evidence is both conflicting and limited with the relatively small number of studies available varying in terms of the health effects they identify as associated with horse riding (see Devienne and Guezennec (2000) and Ainsworth et al (2000) and, Meyers (2006)).

This limited evidence highlights the importance of the research presented in this report.

The existing evidence base also indicates that issues of gender and disability may be of significance in considering the health and well-being benefits of horse riding.

Horse riding is a sport where the vast majority of participants are women but nationally women have lower participation than men in moderate intensity sport (Sport England, 2007; 2010).

Current evidence also suggests that people with disabilities may receive some specific health benefits from horse riding due to the nature of the physical activity involved (Crane, 1999; Bertoti, 1988; Kubota et al, 2006; Bronson et al, 2010; Hosaka et al, 2010).

The evidence base also reveals that a high proportion of riders depend on horse riding for their moderate intensity exercise as they do no other form of exercise and unless they changed their exercise habits might otherwise be sedentary (Sport England, 2007).

The research findings presented in this report, therefore, explore issues of gender, disability and the exercise characteristics of those who might otherwise be sedentary. Page 12 3.

Research methods (A more detailed version of this section is available in Appendix 2) 3.1 Introduction This section sets out the two research methods used to collect and analyse primary data.

The first method involved a group of 17 participants who took part in two scientific trials, one in a laboratory and another in an equestrian centre.

This provided an in-depth analysis of the physical exercise intensity of recreational horse riding based on a series of validated and tested scientific techniques.

The other primary data collection method used was a questionnaire survey of 1,248 horse riders.

Appendix 2 provides full details of both the methods used. 3.2 Methods – scientific trials and the measurement of exercise intensity The overall experimental design of the scientific trials used in this study is based on the national recommendations on what level of exercise intensity is associated with potential health benefits.

The purpose of the scientific trials was to evaluate the energy cost of horse riding using a portable gas analysis system and ascertain whether the intensity of exercise was sufficient to be classified as ‘moderate’ and therefore, confer health benefits to individuals involved in this leisure activity.

Importantly, technical innovations in the development of portable gas analysis systems have enabled the valid measurement of expired air and energy expenditure in non-laboratory and outdoor environments (Hausswirth, 1997; Macfarlane, 2001; McLaughlin, 2001; Pinnington, 2001).

In order to ascertain the exercise intensity of recreational horse riding, the group of 17 participants were asked to carry out two trials; one cycling in the University of Brighton, Welkin Human Performance Laboratories and one riding for 45 minutes at the Plumpton College equestrian centre replicating the pattern of a typical riding lesson.

The exercise testing (see Appendix 2 for full details) was specifically designed to explore the issue of intensity using scientific measurements and current definitions of what constitutes moderate intensity exercise in terms of energy expenditure measured in metabolic equivalents (METs). 3.3 Methods – the questionnaire survey of recreational horse riders The self completion questionnaire survey of 1,248 recreational horse riders was designed to gather both quantitative and qualitative data.

It comprised 25 questions in total, took approximately 15 minutes to complete and obtained standard socio demographic data on gender, age, occupation and long term illness/disability (see Appendix 5).

Physical health issues were addressed through questions that obtained self reported measures of physical exercise intensity and frequency for horse riding, activities associated with horse riding (such as grooming and mucking out) and other sporting activities.

Closed and open ended questions were used to investigate the social and psychological benefits respondents perceived they obtained from horse riding.

The population of interest for the survey were just recreational riders and it was not the aim to undertake a probability survey that would allow direct comparison with other groups of individuals such as nonriders.

The questionnaire recruitment methods were designed, therefore, to obtain a sample of a sufficient size to allow disaggregation of the data to examine particular sub-groups of the sample.

The recruitment methods proved to be successful in terms of responses and the target sample size of 600 was exceeded, with a total of 1,248 surveys deemed suitable for use in the analysis following a quality check.

The key demographic characteristics of the questionnaire respondents are summarised in Table 3.3 overleaf. Page 13 Table 3.3 Demographic summary data Frequency (as percentage of total sample of 1,248) Gender Male Female Age 16-24 24-44 45-64 65-74 75+ Longstanding illness/disability? Yes No Region where rode most regularly England Wales Scotland N.

Ireland Outside the UK Horse ownership Horse owner Non-horse owner Employment status Full-time employment Part-time employment Carer Full-time student Part-time student Retired Other Riding Skill level Beginner Intermediate Advanced Expert 4 54 37 5 46 22 1 11 1 10 9 79 21 69 6 15 5 5 23 77 14 38 42 5 1 7 93 Page 14 4.

Findings – exercise intensity and frequency 4.1 Introduction This section uses data from the scientific trials and the questionnaire survey to examine the issues of exercise intensity and frequency associated with horse riding.

The health benefits of physical activity are determined by the intensity and frequency with which exercise is undertaken.

One key aim of this study was to assess if recreational horse riding can be classified as a moderate intensity exercise and the scientific trials were specifically designed to ascertain whether a 45-minute riding session was sufficiently intense to be considered a physical activity of ‘moderate intensity’, so that if riders were to take part with sufficient frequency horse riding would provide longer term health benefits.

This section starts by analysing the findings from the scientific trials and is then followed by sections that examine the findings from the questionnaire survey based on respondents self reported measures of exercise intensity and frequency.

In all sections key findings are highlighted in bold and summarised at the end of the section. 4.2 Exercise intensity – scientific trials The 17 participants in the scientific trials undertook a cycling session in a laboratory and a 45-minute riding session, during which various physical characteristics affected by exercise were measured.

Before and after both sessions the participants also completed a fatigue questionnaire on the effects of the exercise intervention.

Descriptive data on the metabolic effects of the horse-riding session is presented in Table 4.1, which highlights the peak and mean values throughout the session and the ± figure indicates the standard deviation for each measure.

Of specific interest, is the average rating of perceived exertion (RPE) which was above 13, the average percentage of VO2max (oxygen uptake) which was 40 percent and the number of metabolic equivalent (METs) that riders were exercising at was between three and six.comparative data for METs associated with other forms of physical activity are provided towards the end of this section.

However, with an average energy expenditure of 5.42 kcal per minute, a horse riding session of 45-minutes would have an average energy expenditure of 244 kcal.

Table 4.1 Peak and Mean values ±SD for heart rate (HR), percentage of age-predicted peak heart rate (%HRpeak), rating of perceived exertion (RPE), absolute and relative oxygen consumption (VO2), percentage of peak oxygen uptake from incremental test (%VO2max minute ventilation (VE), metabolic equivalent (MET), percentage of metabolic reserve (%MET-R), respiratory exchange ratio (RER), and energy expenditure (EE) following the riding session.

Peak HR (b.min ) %HRpeak RPE VO2(L.min ) VO2 (ml.kg .min ) %VO2max VE(L.min ) MET a -1 -1 -1 -1 b -1 Mean 128 ± 10.12 67.4 ± 4.39 13.04 ± 2.22 0.930 ± 0.346 13.8 ± 4.06 40.3 ± 13.99 40.34 ± 9.40 3.7 ± 1.1 1.085 ± 0.12 5.42 ± 1.83 178 ± 21.94 14.5 ± 2.62 1.672 ± 0.496 24.6 ± 4.00 70.0 ± 14.6 66.11 ± 16.31 7.1 ± 1.1 – — ” Page 16 The main finding from the scientific trials for the mixed group of riders assessed was that on average, they exercised at an intensity that would be classified as moderate and that trotting was the element that contributed the most to achieving this desired intensity of exercise.

There is now an abundance of evidence to show that physical activity is associated with reduced risk of coronary heart disease, obesity, type 2 diabetes, and other chronic diseases and conditions (Department of Health, 2004).

The UK’s ABC of Physical Activity for Health guidelines recommended that an activity considered to be moderate intensity, is typically characterised as 3-6 METs, a rating of perceived exertion of 12 or 13 and 40-59 percent of VO2max (O’Donovan et al, 2010).

In our study, from the horse ride average METs (metabolic equivalent) were 3.7, average RPE (rating of perceived exertion) was 13 and the oxygen cost equated to 40 percent (VO2max).comparative evidence on the respective energy expenditures for recreational physical activities have been categorised in the compendium of physical activities (Ainsworth et al, 2000) and some of this data, including that for horse riding, is presented in Table 4.3 alongside data from the scientific trials.

The compendium reported general horse riding to be equivalent to 4 METs (Ainsworth et al, 2000), which would agree very closely with our findings of 3.7 METs.

The trotting element in the scientific trials equated to approximately 5.0 METs which is marginally lower to the 6.5 METs reported by the compendium (Ainsworth et al, 2000) but still clearly within the moderate intensity band.

The findings from the scientific trials and the data in the compendium (Ainsworth et al, 2000) both clearly suggest that horse riding and the associated tasks involved before and after a riding session are of a moderate intensity with the exception of walking while on the horse.

Table 4.3 Scientific trials measures of metabolic equivalents (METs) in relation to METs for other leisurebased physical activities as identified in the Compendium of Physical Activities (Ainsworth et al, 2000) In the current research there was substantial biological variability amongst our group of 17 participants Activity Horse riding Horse riding Horse riding Horse riding Horse riding Cycling Running Rowing Step aerobics Fishing/hunting Badminton Walking Swimming Description Scientific trials for current Study General Saddling & grooming horse Trotting Walking < 10mph At 8 mph Moderate effort 6-8 inch step Standing/Over undulating ground Recreational Walking dog at 2.5 mph Laps at moderate effort METs 3.7 4.0 3.5 6.5 2.5 4.0 13.5 7.0 8.5 3.0 4.5 3.0 7.0 and the UK’s ABC of Physical Activity for Health (O’Donovan et al, 2010) guidelines indicate the extent to which some activities are light, moderate, vigorous or very hard is dictated by the fitness levels of the individual.

The variability amongst the 17 respondents is exemplified by the standard deviation (± 1.1) around the mean number of METs (3.7) during the horse riding session.

Nevertheless, our variability is comparable with that reported by other studies looking at the energy expenditure of other physical activities (Bassett et al, 2000; Gunn et al, 2004, 2006).

It is likely that these between rider differences can be explained by people performing the activities at different intensities relative to their aerobic fitness levels and motivation towards the task.

That is, the fitter and more motivated participants may have performed the riding session at a greater intensity.

Similar to our data (see Figure 4.1), Devienne and Guezennec (2000) did note a large variability in %VO2max (25-70 percent), suggesting that some elements of a riding session were of insufficient intensity to be classed as moderate, while others were of a vigorous intensity and this varied between riders.

Guidelines suggest that exercise can be made up of a mixture of moderate and vigorous intensity which are associated with health benefits (O’Donovan et al, 2010). Page 17 4.3 Exercise intensity – questionnaire survey The questionnaire of horse riders examined frequency and intensity of exercise using self reported measures that are similar to those used in other surveys undertaken by Sport England (2010) and DCMS (2007) to assess participation in moderate intensity sport and active sport.

The questionnaire collected data on exercise intensity and frequency for activities associated with riding such as grooming and mucking out and the frequency of other forms of physical activity.

All other forms of physical activity were included in the survey as the existing evidence base highlights that a high proportion of riders do no other sporting activity.

In order to ascertain if such riders might be otherwise sedentary their participation in sporting activities and other forms of exercise, such as walking, needed to be determined.

The possible psychological and social benefits of horse-based sport and leisure are also considered in the questionnaire.

The 1,248 respondents were asked, using a series of questions, to self report the typical physical intensity of their riding sessions and activities associated with horse riding during the last four weeks using two different measures.

The first measure mirrored that used by the Sport England (2010) Active People survey and was based on questions asking respondents if the activity raised their breathing rate (a measure of moderate intensity exercise) or if the activity made them out of breath or sweat (a measure of high intensity exercise).

The second measure followed the approach used in a major survey of physical activity amongst anglers (Stolk, 2009) that asked respondents to rate the intensity of the activity, low, moderate or high but did not give any indication as to what physical feelings (being out of breath for example) were associated with each of the three categories.

In the survey of horse riders the terms low, medium and high were used as it was believed these terms were easier for respondents to interpret than low, moderate and high as they are terms more commonly used in social surveys.

The reasons for using two measures of self reported intensity in the survey of horse riders was to allow the measures to be compared and to provide a check that self reporting amongst questionnaire respondents was a consistent judgement even when the questions changed slightly.

Data was collected on the frequency of participation by asking respondents how many times in the last four weeks they had undertaken for at least 30 minutes the following activities: l l l horse riding, activities associated with horse riding, other sporting activities. The four week period was used to follow the approach used in the DCMS (2010) Taking Part survey and the Sport England (2010) Active People survey, both of which identify the frequency of participation in moderate intensity sport required to obtain health benefits as involving ‘participation on at least 12 separate days in the previous four weeks’. (DCMS, 2007) To investigate the perceived social and psychological benefits of horse riding respondents were asked to rate on a scale some different motivations for participation and the degree to which horse riding made them experience certain feelings.

There was also an open ended question that allowed respondents to provide qualitative data explaining their answers to questions on motivations and feelings.

In order to provide further in-depth data two questions were also included asking respondents to rate what they believed to be the three main a) mental and physical and b) social benefits of participation.

The results for the two self reported measures of the exercise intensity of horse riding are shown in Table 4.4.

Measure 1 mirrors that used by the Sport England (2010) Active People survey and indicates that 88 percent of respondents reported physical feelings (such as being out of breath) that indicated they were undertaking moderate (26 percent) or high (62 percent) intensity physical activity.

The second measure simply asked respondents to rate the exercise intensity low, medium or high and 73 percent of respondents reported it medium, and 16 percent high intensity.

The two measures differ, however, when the separate moderate and high categories for Measure 1 are compared with the medium and high categories for Measure 2.

Most respondents (73 percent) reported the intensity as medium on Measure 2 but for Measure 1 the descriptions of physical feelings meant the majority of respondents reported physical intensity as high.

This indicates the influence question design can have on answers.

Nevertheless, the similar figures for both measures of 88 percent and 89 percent for the combined upper physical intensity categories (moderate/high and medium/high) are reassuring since they indicate that different self reporting measures of exercise intensity produce similar results for the key issue concerning the degree to which horse riding involves at least moderate intensity physical activity.

Both self report measures indicate the vast majority of riders (nearly 90 percent) are undertaking riding sessions that involve at least moderate/medium intensity exercise. Page 18 Table 4.4 Self reported measures of physical intensity of horse riding activity The questionnaire survey also used the same two measures to examine the physical exercise intensity of activities associated with horse riding and the results are shown in Table 4.5.

As with the measures for horse riding the measures differ when comparing the separate medium and moderate and high categories.compared with horse riding a higher percentage of respondents – 22 percent compared to 12 percent – reported the intensity for activities associated with horse riding as low.

Nevertheless, on both measures 78 percent of respondents self reported activities associated with horse riding as involving moderate or high physical intensity exercise.

This is a significant finding since it indicates involvement in horse riding may provide health benefits from activities associated with horse riding, not just riding. Measure 1 – was the effort you put into horse riding usually enough to: No to either of the below (low) Raise your breathing rate (moderate) Make you out of breath or sweat (high) Total % Measure 2 – How would you describe the physical intensity of your activity when you go horse riding? Low Medium High Total % 12 26 62 100 11 73 16 100 The scientific trials indicated that certain parts of a riding session, such as walking, may not involve sufficient metabolic impacts to constitute moderate intensity exercise.

The self reporting measures, however, indicate that riders may obtain the health benefits of moderate or high intensity physical activity not only from parts of a riding session but also through activities associated with horse riding.

Table 4.5 Self reported measures of physical intensity of activities associated with horse riding (such as grooming, mucking out) ditto re this table Measure 1 – was the effort you put into these activities usually enough to: No to either of the below (low) Raise your breathing rate (moderate) Make you out of breath or sweat (high) Total % Measure 2 – How would you describe the physical intensity of these activities? Low Medium % 22 28 22 63 50 — 100 Total 100 Page 19 T4.4 Exercise frequency – questionnaire survey The health benefits of physical exercise are influenced not only by the exercise intensity but also the frequency at which exercise is undertaken.

The review of existing evidence in chapter two noted that while government guidelines recommend 30 minutes of moderate intensity physical activity at least five days per week (Department of Health, 1995) or 150 minutes a week (Donovan et.al 2010) there is also evidence that even light exercise three times a week can produce health benefits (Tully et al. 2007).

The Sport England (2010) Active People survey estimates the numbers of adults who take part every week in at least three, moderate intensity 30 minute sessions of physical activity (3×30) measured as participating on at least 12 separate days in the past four weeks.

The analysis of the questionnaire results takes a similar approach to the Active People survey and assesses the proportion of respondents who took part for at least 30 minutes in horse riding or activities associated with horse riding 12 times or more in the last month.

The findings are shown in table 4.7 and 53 percent of respondents had taken part for at least 30 minutes in horse riding activities 12 times or more in the last four weeks; 79 percent of respondents had taken part for at least 30 minutes in activities associated with horse riding 12 times or more in the last four weeks.

Table 4.7 Frequency of participation in horse riding and activities associated with horse riding in the last four weeks Frequency Did not take part in the last four weeks Less than 12 times in the last four weeks More than 12 times in the last four weeks Total Horse riding 4 43 53 100 Activities associated with horse riding 4 17 79 100 4.5 Measures of exercise frequency and intensity combined – questionnaire survey Further analysis of both the frequency and intensity data generated by the questionnaire indicates that 47 percent of respondents participated for at least 30 minutes in horse riding twelve times or more in the last four weeks AND rated their physical exercise intensity as moderate or high.

Furthermore, 21 percent of all respondents could be categorised as riding less than 12 times in the last four weeks BUT taking part in activities associated with horse riding more than 12 times in the last four weeks AND reporting the exercise intensity of these activities as moderate or high.

This group is likely to also be obtaining health benefits through the physical exercise gained by doing activities associated with horse riding.

Overall, therefore, 68 percent of respondents are likely to be achieving physical health benefits through riding and activities associated with horse riding since they are participating regularly enough (12 times per month) and they report their physical exercise intensity as moderate or high. 4.6 Exercise intensity and frequency – conclusions In summary, the scientific trials along with other existing evidence on the metabolic effects of physical activity indicate that horse riding expends sufficient energy to meet public health guidelines for moderate-intensity activity that will generate health benefits.

It is also noteworthy that regular periods of trotting in a riding session may enhance the associated health benefits.

The analysis of the self-reported measures of physical exercise intensity for horse riding obtained from the questionnaire adds clear support to the conclusions from the scientific trials and other studies that horse riding involves moderate intensity exercise.

Nearly 90 percent of respondents self-reported that their horse riding in the last four weeks had involved moderate or high intensity physical activity.

In addition, just over three quarters of respondents (78 percent) indicated that activities associated with horse riding in the last four weeks, such as grooming and mucking out, involved at least moderate intensity activity which may further enhance the health benefits that can be obtained through involvement in riding.

Importantly, the self reported measures of physical exercise intensity and frequency indicate that 68 percent of questionnaire respondents are likely to be achieving physical health benefits through riding and activities associated with horse riding as this involves them undertaking moderate or high intensity physical exercise at least 12 times a month. Page 20 5.

Findings – The psychological effects of horse riding 5.1 Introduction The review of previous evidence in Appendix 1 indicates that there is growing evidence of the positive psychological effects of physical exercise, including positive impacts on self-esteem, social networks, anxiety and depression (Fox and Corbin, 1989; Martinsen, 1995, Landers, 1997; Farmer et al, 1998; Scully et al, 1998; Sonstroem et al, 1994; Pretty et al, 2003).

There is also more tentative evidence that additional health and well-being effects, especially psychological benefits, arise when physical exercise involves interactions with outdoor natural environments, nature and the animals (Giles-Corti and Donovan, 2003; Hoffman et al, 2009; Thompson Coon et al, 2010; Barton et al, 2011).

The discussion of findings in this section considers, therefore, not only the general psychological effects of horse riding but also any specific effects relating to interactions with outdoor environments, nature and horses.

Examining psychological issues in a self completion questionnaire raises a number of challenges since the questions may not necessarily fully interrogate the complex nature of emotions and feelings.

The questionnaire for this study was designed, therefore, to examine the psychological effects of horse riding using different types of question including closed and open ended questions that generate both quantitative and qualitative data.

Two Likert scale questions obtained quantitative data on the feelings associated with horse riding and the different motivations for going horse riding.

An open ended question generated qualitative responses by asking respondents to enlarge on the effect of horse riding on their feelings.

This section examines the psychological effects of horse riding firstly by discussing the quantitative and qualitative findings on the feelings associated with horse riding.

This is followed by an analysis of the motivations for going horse riding which provides further insights into the psychological impacts of horse riding.

The qualitative data included in this section in the form of quotes provided by questionnaire respondents adds further insights that confirm the quantitative findings. 5.2 The feelings associated with horse riding – quantitative findings.

Table 5.1 presents the results from the Likert scale question asking respondents to what extent riding made them experience certain feelings.

The first ten rows of the table present the results for positive feelings that might be associated with horse riding such as feeling cheerful or inspired.

A number of positive feelings were strongly associated with horse riding by respondents.

More than 90 percent of respondents reported that horse riding made them feel ‘quite a lot’ or ‘extremely’ cheerful and the equivalent figure is in excess of 80 percent for feeling relaxed, happy and active.

The final seven rows in table 5.1 show the results for negative feelings that might be associated with horse riding.

Generally, negative feelings were not strongly associated with horse riding and more than 90 percent of respondents reported that when horse riding they experienced these negative feelings either ‘a little’ or ‘not at all’.

The majority of respondents (71 percent) were not at all dissatisfied with horse riding but 22 percent said it made them a little dissatisfied and five percent feel moderately dissatisfied.

Few respondents experienced feelings associated with anger, guilt or boredom.

However, nearly half (45 percent) respondents experienced at least ‘a little’ feeling of frustration and around a third indicated the same for lacking in confidence and being frightened.

Feelings of fear may not only be associated with the activity of riding but may also reflect the high proportion of female respondents since many women feel fear in outdoor countryside spaces (Curson and Kitts, 2000). Page 21 Table 5.1 Feelings associated with horse riding – all respondents Please note some rows do not equal 100 percent due to rounding to whole numbers To what extent does horse riding make you feel the following? Not at all (%) Positive feelings Cheerful Relaxed Tired Happy Confident Active Excited Proud Energetic Inspired Negative feelings Dissatisfied Angry Guilty Frustrated Bored Lacking in confidence Frightened 71 86 80 55.4 95 68 61 22 12 15 36.2 4 25.5 33 5 1 3 6 1 5 5 1 1 1 1.4 0 1 1 1 0 1 1 0 0.5 0 0 1 10 0 1 0.3 2 4 1 4 0 3 21 1 3 2 8.6 9 7 8 9 14 34 7 20 11.4 27.7 18 25 19 46 45 24 36 48 48 36.2 35 41 38 45 37 11 56 28 38.3 25.5 34 26 31 A little (%) Moderately (%) Quite a lot (%) Extremely (%) The quantitative findings from the questionnaire on the psychological effects of horse riding were analysed separately for respondents who participated less than 12 times in the last four weeks and are presented in Table 5.2.

A previous study concluded that some of the psychological effects of a number of forms of outdoor physical activity, including horse riding, did not vary by exercise intensity or frequency (Pretty et al, 2007).

A comparison of the results presented in Tables 5.1 and 5.2 suggest that the positive and negative feelings associated with horse riding do not differ markedly according to exercise frequency.

The noticeable differences between Tables 5.1 and 5.2 that can be identified are intuitively correct since those who had taken part less than 12 times in the last four weeks had lower percentages in the ‘quite a lot’ and ‘extremely’ categories for feeling active and energetic.

While riders who regularly participate less than 12 times over four weeks may not obtain significant physical health benefits, they may still experience psychological benefits. Page 22 Table 5.2 Feelings associated with horse riding for respondents who have participated in less than 12 riding sessions in the last four weeks To what extent does horse riding make you feel the following? Not at all (percent) Positive feelings Cheerful Relaxed Tired Happy Confident Active Excited Proud Energetic Inspired Negative feelings Dissatisfied Angry Guilty Frustrated Bored Lacking in confidence Frightened 76 88 80 60 95 64 57.4 18 10 16 31 3 27 34 4 1 3 7 1 7 7.2 1 1 1 1 1 1 1.2 1 0 0 1 0 1 0.2 0 1 10 0 1 0 2 5 4.3 5 0 3 21 1 5 2 8 9 9 11 10 16 36 8 21 12 28 19 17.3 19 45 42 23 35 47 53 37 35 35 36 45 38 10 56 26 33 25 32 34.4 29 A little (percent) Moderately (percent) Quite a lot (percent) Extremely (percent) — The health and well-being benefits of horse riding – frequency of exercise The benefits of exercise, especially those relating to physical health, are in part influenced by the frequency that an individual takes exercise (Blair et al, 1992; Blair et al, 1995).

As a result of existing evidence the Department of Health recommends that adults should participate in 30 minutes of moderate intensity physical activity at least five days per week (Department of Health, 1995), and if undertaken with suitable intensity it has been argued this can be achieved through activities including brisk walking, cycling, swimming, gardening, horse riding and conservation work (Bird, 2004).

In a similar vein, the Sport England (2010) Active People survey is a major study of sports participation that has been running since 2005 and seeks to identify the numbers of adults who take part in at least three, moderate intensity 30-minute sessions of sport and physical activity every week (3×30)5 since this is also seen as sufficient exercise to produce physical health benefits.

There are, however, uncertainties and debates in existing research regarding the frequency of participation required to achieve health benefits.

For example, Tully et al. (2007) measured the physical health of sedentary people aged between 40 and 61 involved in a walking programme compared to a similar group who were not and concluded that while the goal should be for adults to take exercise five days a week there were still benefits in terms of blood pressure and fitness associated with even light exercise three days a week.

People who participate less regularly in sport may gain other psychological or social well-being benefits.

In addition, society may benefit from the development of social capital defined as ‘the value (capital) of social networks bonding similar people and bridging between diverse people with norms of reciprocity’ (Dekker and Uslaner, 2001).

Consequently another government survey called Taking Part (DCMS 2007) has been measuring levels of voluntary participation in leisure, culture and sport in England since 2005.

This survey, like the Sport England Active People Surveys, assesses levels of participation in ‘moderate intensity sport’ defined as people taking part in sport on at least 12 separate days in the previous four weeks.

It also measures levels of participation in ‘active sport’ defined as people with one instance of participation during the past four weeks.

This recognises the social and cultural benefits of people being involved in sport on a regular basis even if this is not of the frequency required to confer physical health benefits.

These and other surveys provide existing data on the frequency of participation amongst people involved in horse riding in England, which indicates its popularity as a form of physical activity.

In the UK 42 percent of households have at least one member with an interest in equestrianism (including racing), the number of people estimated to go horse riding at some point over the course of a year is 4.3 million with 2.1 million participating on a regular basis (BETA, 2006).

The British Horse Society has more than 74,000 members and in 2010 there were 995 British Horse Society approved riding establishments worldwide, an increase of 278 on 2009 (The British Horse Society, 2011).

The number of riding clubs affiliated to The British Horse Society exceeds 430, with 21 riding centres and more than 34,000 members (The British Horse Society, 2011).

The Active People Survey 4 (APS4) (Sport England 2010) found the number of people participating in equestrianism at least once a week in England (aged 16 and above) to be 337,800.

This survey does not include participation in other countries within the UK and therefore comparisons cannot be made between the participation rates of this survey and the work carried out by BETA.

The first Active People Survey (Sport England 2007) also examined the other sports, if any, in which people participated.

As can be seen in Table 1 horse riding is distinctive as it is one of a number of sports where a high proportion of those people participating (48 percent) take part in no other sporting activity.

Only bowls, angling and golf have higher percentages6.

This is an important feature of horse riding since a high proportion of riders rely on horse riding for moderate intensity physical exercise and unless they changed their exercise habits would be otherwise sedentary. 5 Three separate occasions per week is defined as participation on at least 12 separate days in the previous four weeks. 6 Note that this does not include some other forms of physical exercise that Sport England does not class as sport, such as walking. Page 47 Table A 1 percentage of people who only participate in no other sporting activity by type of sport Sport Bowls Angling Golf Horse riding Dance exercise Shooting Swimming Archery Football Taikwando Fencing Judo Cycling Badminton Weightlifting Skiing Gymnastics Athletics Netball Hockey Rowing Tennis Canoeing Squash Cricket Rounders Mountaineering Rugby Union Baseball/softball Boxing Basketball Volleyball Percentage of participants who do no other sporting activity 67.1 percent 58.7 percent 50 percent 48.0 percent 47.9 percent 47.4 percent 46.7 percent 37.8 percent 35.0 percent 34.2 percent 33.3 percent 32.6 percent 30.1 percent 29.63 percent 29.3 percent 28.2 percent 27.7 percent 25.4 percent 24.6 percent 22.6 percent 22.2 percent 21.8 percent 21.3 percent 21.3 percent 21.0 percent 20.7 percent 20.0 percent 19.4 percent 18.4 percent 18.2 percent 16.5 percent 13.1 percent The survey of riders discussed in this report examined the issue of whether respondents would be otherwise sedentary if they did not ride, by collecting data on the frequency of participation not only in horse riding but also other activities associated with horse riding (such as mucking out and grooming) and other forms of physical activity.

The discussion of frequency in the analysis section of this report recognises, as do some of the studies discussed above, that while regular participation (12 separate days every four weeks) is normally required to generate physical health benefits, less regular participation (once every four weeks, for instance) may produce social and psychological benefits. Page 48 A 1.4 The health and well-being benefits of horse riding – key social groups The current evidence base on the health benefits of riding and the participation patterns in horse based sport and leisure suggests that attention should be paid to specific social groups when examining the health and well-being effects of horse-based sport and leisure.

There are a number of studies that measure the physical health of participants which show how horse riding exercise is of an intensity and form to result in the improved conditioning of both adults and children with specific physical disabilities (Crane, 1999; Bertoti, 1988; Bronson et al, 2010).

The general rationale behind using horse riding as a form of therapy for people with disabilities has focussed on the concept that riding provides the person with a disability a normal sensorimotor experience that contributes to the maintenance, development, rehabilitation and enhancement of physical skills (Crane, 1999).

Research involving the measurements of the health of those taking part has also identified that the regular use of a mechanical horse improves insulin in middle-aged (Hosaka et al, 2010) and elderly (Kubota et al, 2006) type II diabetic patients.

The Sport England APS4 survey reveals there are some important distinctive features of participation in equestrianism that are significant in relation to health.

The survey indicates that of those who participate in equestrianism in England on at least a weekly basis 90 percent were female.

This shows a far higher percentage of female participation in comparison to the overall participation rates for all sports combined where only 40 percent of those participating in at least three sessions a week of moderate intensity were female.

Women are identified as one of the key social groups with participation levels in sport well below the average.

The Taking Part survey for England in 2009/10 found that 59 percent of men had participated at least once in ‘active sport’ in the past four weeks, compared to 48 percent of women (DCMS 2010).

Policy initiatives such as Active England supported measures to encourage more women to participate regularly in sport (Sport England 2007).

A valuable dimension of horse-based sport and leisure, therefore, will be that the health benefits will be largely experienced by women as they make up the vast majority of participants and are a social group with below average levels of participation in sport as a whole.

The survey of riders considered issues of gender and disability.

A 1.5 The well-being benefits of exercise in outdoor environments and contact with nature There has been a recent growth in the body of evidence arguing that exercise, such as horse riding, which involves outdoor natural environments and contact with nature can confer additional benefits.

There are, however, some uncertainties in the evidence that need to be acknowledged.

A number of studies have found that the presence of natural settings can actually act as a motivating factor for physical exercise and possibly increase the intensity of exercise and the energy expended.

For instance, a report by the Netherlands Health Council (2004) cites a series of Dutch studies which found that fresh air and ‘simply being outdoors’ as increasing motivation for exercise (Urlings et al, 2000; Hildebrandt et al, 2002) and similar conclusions were drawn from a study in Australia that found the quality of the physical environment influenced exercise levels (Giles-Corti and Donovan, 2003).

There is also some evidence to show that exercising in an outdoor environment can improve adherence to exercise in the longer term.

In the UK, an evaluation of the walking the way to health initiative (WHI), a national scheme that encourages people to do regular short walks within their local community to improve their level of fitness, found that group walking in natural environments gave people an extra incentive to continue taking part (Reynolds, 2002).

A similar finding occurred in an evaluation of the ‘green gym’ project, an initiative of the British Trust for Conservation Volunteers, which promotes participation in local nature activities with a view to improving physical fitness and health.

These evaluations also revealed that schemes promoting indoor sports are the least successful in the long term with a 50 percent dropout rate after the first six months.

By contrast, the study of BTCV green gym project found that 70 percent of people were still participating six months after enrolling on the programme (Reynolds, 2002).

Not only is there some evidence that access to natural environments appears to increase the incentive to exercise and to continue to be active in the medium to longer term, but some studies have argued that exercise outdoors has an impact on the intensity of physical activity.

A study by Buchanan et al (2000) found that when comparing the level of physical activity in adults, the percentages of their maximum heart rate and walking speed were significantly higher when walking outdoors compared to indoor walking on a treadmill.

What is more, the rate of perceived exertion was similar for both, showing that when outdoors, people walked faster and used up more energy without feeling any additional exertion (Buchanan et al, 2000).

Varied scenery and the natural environment were cited as possible reasons for this as they ‘may provide a positive distraction from the actual exercise’ (Buchanan et al, 2000).

While these studies suggest there are additional physical benefits to be gained from outdoor exercise, other research is more cautious.

Thompson Coon et al (2011) undertook a systematic review of previous research and argued that uncertainties still exist over the extent to which exercise in outdoor environments produces a greater physical and mental well-being benefit compared to using indoor environments Page 49 (Thompson Coon 2011).

Recent research, however, suggests that for clinical populations suffering mental ill-health there is an additional benefit of outdoor over indoor activity (Barton et al, 2011).

A related body of evidence argues that there are psychological benefits of viewing or having direct contact with nature, including enhanced emotional well-being, improvements in mood and reduced stress and anxiety (Morris, 2003).

Various theories have been devised to explain this phenomenon, including the idea that humans are biologically disposed to affiliate with and respond positively to nature (Wilson, 1984); that viewing natural environments can help people recover from attention fatigue (Kaplan, 1989) or that natural environments can enable recovery from any form of stress through the triggering of positive emotional responses (Ulrich, 1999) Given this, it has been hypothesised that there may be synergistic psychological benefits in adopting physical activities whilst at the same time being exposed to nature (Mackay and Neil, 2010).

This has been termed ‘green exercise’ by Pretty et al (2005) and refers to physical activities undertaken whilst exposed to natural environments (Pretty et al, 2005).

There is an emerging body of research into the benefits of ‘green exercise’ and its effects on people’s psychological health.

Pretty et al (2007) looked at the effects of green exercise on mood and self-esteem using 10 pre-existing outdoor activity groups as case studies (these included, horse-riding, walking, cycling, fishing, canal boating and conservation activities).

It was found that green exercise leads to a significant improvement in both mood and self-esteem, and these results were consistent across all 10 activity case studies, indicating that the psychological benefits of green exercise do not vary significantly by age, gender, exercise intensity or type of exercise group (Pretty et al, 2007).

This study indicates that frequency of exercise, which is seen as important in influencing physical health impacts from exercise, maybe less of an influence on the experience of psychological benefits.

There is also a limited body of evidence to suggest that contact with nature can enhance social wellbeing.

Indeed, it has been shown that the presence of nature or green spaces can create the opportunity to increase quality of life and heighten social interaction, ‘and thus helps to enhance community spirit and foster a more socially inclusive society’ (Scottish Natural Heritage, 2002).

The current evidence base suggests to a reasonable level of certainty that contact with nature and the outdoors is valuable for psychological well-being.

The degree to which exercise that involves contact with the outdoors and nature confers additional health and well-being benefits compared to indoor environments is less certain (Thompson Coon et al. 2010).

Consequently, the survey of horse riders undertaken for this report was designed to produce some quantitative data on the importance to riders of the outdoors and contact with nature.

The open ended question in the survey produced qualitative data on this issue as a large number of respondents chose to write about the contribution of the outdoors and nature to their horse riding experiences.

A 1.6 The well-being benefits of exercise involving contact with animals An important difference between recreational horse-riding and most other outdoor activities is the presence of another sentient being (ie the horse) in the physical activity itself.

Whilst there have been a few studies which have looked at the therapeutic benefits of horses for people with certain physical or mental disabilities (Brock, 1989; Bertoi, 1988; Bronson et al, 2010; Hameury et al, 2009; Kaiser et al 2006; McKinnon et al, 1995; Shultz et al; 2007), there is very limited evidence examining how being with horses can be beneficial to people’s general physical and/or mental well-being (Brandt, 2004).

The evidence discussed earlier on the physical health benefits of riding did not consider the interaction between horse and rider.

There is, however, a multitude of research which suggests that being with animals generally can have a positive effect on human health and well-being. ‘Companion animals’ such as dogs and cats may be able to improve our short-term physical health (offer health benefits lasting for seconds or minutes, for example).

Indeed, the action of stroking an animal has been shown to decrease blood pressure and/or heart rate (Eddy, 1996; Katcher, 1981; Katcher et al 1983; Shiloh et al, 2003, Wilson, 1991), while merely being in the presence of a companion animal has been revealed to reduce autonomic responses to conditions of moderate stress.

For example, there have been a series of studies which show that when exposed to psychological stressors in a controlled environment, the presence of a companion animal can reduce heart rate and/or blood pressure (Katcher et al, 1983, Friedman et al. 1983, Allen et al 1991).

There is less research on the effects that companion animals can have on physical health over the longer term (over weeks, months or years, for instance) but there are a few studies which indicate that animals may also hold long term therapeutic benefits, such as preventing illness or even facilitating recovery from serious physical ailments.

For example, two studies by Headey (1998) and Seigel (1990) revealed that pet owners have been discovered to visit the doctor significantly less than individuals who do not own a companion animal.

There is also evidence to suggest that pet ownership may reduce people’s chances of developing more chronic conditions.

Anderson et al (1992) found that the risk factor for coronary heart disease was significantly lower for pet owners than non-pet owners; this was particularly true of males. Page 50 A long standing body of evidence suggests that contact with animals can also have certain psychological benefits, such as the potential to reduce levels of anxiety and depression (Folse et al, 1994; Garrity et al, 1989; Hoffman et al, 2009; Scouter & Miller, 2007; Seilgel, 1990), and enhance feelings of autonomy, competence and self-esteem (Beck and Katche, 1984; de Guzman et al, 2009; Kidd and Kidd, 1985; Levinson, 1972; Robin and Bensel, 1985; Tribet et al, 2008 ).

One possible reason for this might be that companion animals facilitate social contact between people and therefore reduce feelings of loneliness or isolation.

For example, it was found in a study by McNicholas & Collins (2000) that walking with a dog results in a significantly higher number of chance conversations with strangers than walking alone.

A number of studies have also explored the effect of companion animals on depression in humans.

Some of these have found a positive correlation between pet ownership and reductions in depression.

For example, Siegel et al (1999) discovered that when comparing self-reported levels of depression in men infected with AIDS, those men who were pet owners reported less depression than those who did not have a companion animal.

Elderly people with pets have also been shown to have fewer symptoms of depression than those without pets (Roberts et al, 1996).

Other studies in this area have not been so conclusive.

For example, Seigel et al (1999) found no relationship between pet ownership and depression in men infected with HIV.

What is more, similar negative findings have been reported in studies of people with Alzheimer’s (Fritz et al, 1995), unmarried men (Tower &Nokota, 2006) and elderly women (Miller &Lago, 1990).

It has been suggested that this conflict in findings is perhaps due to a lack of consistency with regards to the methodology used and participants recruited (Wells, 2009).

Therefore further work needs to be done in this area before conclusions can be made regarding the link between pet-ownership and depression The mental and physical interaction between horse and rider will be complex and highly personalised (Brandt 2004).

A number of questionnaire respondents also raised their very complex interactions with horses in the open ended questions that allowed them to discuss their feelings about riding.

A 1.7 Conclusion – key issues for research into the health and well-being benefits of horsebased sport and leisure This appendix has highlighted that there is abundant evidence indicating that physical exercise can lead to physiological, psychological and social benefits.

The evidence base on the degree to which such benefits are obtained through horse riding is both conflicting and limited highlighting the importance of the research presented in this report and the need for the research to focus on the issues of exercise intensity and frequency since these are important determinants of physical health benefits.

The exercise testing was specifically designed to explore the issue of intensity using scientific measurements and using current definitions of what constitutes moderate intensity exercise in terms of energy expenditure measured in metabolic equivalents (METs).

The questionnaire of horse riders examined frequency and intensity of exercise using self reported measures that are similar to those used in other surveys undertaken by Sport England (2010) and DCMS (2007) to assess participation in moderate intensity sport and active sport.

The questionnaire collected data on exercise intensity and frequency for activities associated with riding such as grooming and mucking out and frequency of other forms of physical activity.

All forms of activity were included in the survey for this piece of work as the existing evidence base highlights that a high proportion of riders do no other sporting activity.

In order to ascertain if such riders might be otherwise sedentary their participation in sporting activities and other forms of exercise, such as walking, needed to be determined.

The possible psychological and social benefits of horsebased sport and leisure are also considered in the questionnaire.

The existing evidence base suggests that issues of gender and disability may also be of significance in considering the health and well-being benefits of horse riding.

Horse riding is a sport where the vast majority of participants are women but nationally women have lower participation than men in both active sport and moderate intensity sport.

Thus it is important to identify if women are receiving health benefits from horse riding.

Existing evidence also suggest that people with disabilities may receive some specific health benefits from horse riding due to the nature of the physical activity involved.

There is also existing evidence that additional health and well-being benefits can occur through forms of exercise, such as horse riding, that involve outdoor natural environments, contact with nature and interaction with animals.

There are some uncertainties associated with this evidence base as the additional benefits of outdoor exercise compared to that in indoor environments are not fully understood and the research into the health benefits of interaction with animals does not consider horses as it has focussed mainly on companion animals.

The questionnaire explored the significance for riders of interactions with outdoor environments, nature and horses and produces qualitative data on these issues. Page 51 Page 52 APPENDIX 2 Research methods A 2.1 Introduction This appendix sets out the two research methods used to collect and analyse primary data.

The first method involved a group of 17 participants who took part in two scientific trials, one in a laboratory and another in an equestrian centre.

This provided an in-depth analysis of the physical exercise intensity of recreational horse riding based on a series of validated and tested scientific techniques.

This first method, therefore, focused on a key issue for this study to examine the degree to which horse riding can be considered moderate intensity activity and thus beneficial to physical health if undertaken frequently.

The other primary data collection method used was a questionnaire survey of 1,248 horse riders.

This survey also examined physical exercise intensity and the related issue of exercise frequency.

In addition, the survey collected data on the psychological effects of horse riding.

A 2.2 Methods – Scientific trials and the measurement of exercise intensity Existing scientific research into the health benefits of physical exercise often assesses the metabolic process linked to exercise which involves the breaking down of substances in the body to create energy.

The resting metabolic rate in addition to the metabolic cost of different physical activities, such as walking, running, working, and other sporting activities, is useful for assessing the energy expenditure of an individual during a representative day (World Health Organisation, the Food and Agriculture Organisation and the United Nations University (FAO/WHO/UNU) (1985).

In 2004 the Department of Health reported that 30 minutes of moderate intensity, physical activity for five or more days a week should be recommended for promoting physical activity and the prevention of diseases associated with inactivity (ie coronary heart disease, osteoporosis, hypertension, obesity and type II diabetes, Department of Health, 2004).

In 2010 the ABC of Physical Activity for Health was produced in the UK that extended these recommendations.

The guidelines stated that all healthy adults aged 18-65 years should aim to take part in at least 150 minutes of moderate-intensity, aerobic activity each week [or exercise at three to six metabolic equivalents (METs), where a MET is described as the ratio of work metabolic rate to a standard resting metabolic rate].

Vigorous-intensity, aerobic exercise for 75 minutes each week, or equivalent combinations of moderate- and vigorous-intensity aerobic activities were also recommended (O’Donovan et al, 2010).

Aside from METs being used as an indicator of moderate intensity exercise, the percentage of VO2max (a marker of aerobic fitness based on maximal oxygen uptake) has also been used, with exercise performed at 40-59 percent of VO2max being classified as moderate intensity (O’Donovan et al, 2010).

The overall experimental design of the scientific trials used in this study, therefore, is based on the national recommendation on what exercise intensity is associated with potential health benefits.

The purpose of the scientific trials was to evaluate the energy cost of horse riding using a portable gas analysis system and ascertain whether the intensity of exercise was sufficient to be classified as ‘moderate’ and therefore, confer health benefits to individuals involved in this leisure activity.

Importantly, technical innovations in the development of portable gas analysis systems have enabled the valid measurement of expired air and energy expenditure in the field (Hausswirth, 1997; Macfarlane, 2001; McLaughlin, 2001; Pinnington, 2001).

In order to ascertain the exercise intensity of recreational horse riding, a group of participants were asked to carry out two trials, one cycling in the laboratory and one riding for 45 minutes in an equestrian centre replicating the pattern of a typical riding lesson; both involved the assessment of aerobic fitness parameters.

This experimental design was chosen to achieve a blend of internal and external validity within this investigation.

It was important for the horse riding activity to take place on a ‘real’ rather than a ‘simulated’ horse, thereby ensuring strong ecological validity.

The experimental design also included a level of criterion validity where the horse riding activity and associated metabolic costs were compared to exercise carried out during the cycling trials in a laboratory environment, where there was good control of extraneous variables and the direct determination of maximal oxygen uptake – the principle outcome fitness measure.

The measurement of maximal oxygen uptake has traditionally been used as the criterial standard of cardiorespiratory fitness, as it is considered to be the single physiological variable that best defines the functional capacity of both the cardiovascular and respiratory systems (Åstrand and Rodahl, 1986).

The precision of oxygen uptake determination is calculated to be less than 1.5 percent (James et al 2007), suggestive that only small errors are associated with this measurement technique.

Participants in the trials visited the University of Brighton, Welkin Human Performance Laboratories where procedures were explained verbally to ensure understanding of a subject information sheet provided to volunteers prior to the visit (Appendix 4).

Written informed consent was obtained, in addition to written parental consent for those volunteers aged under 18 years (Appendix 5).

Height (m) and mass (kg) were obtained and body mass index (BMI) was calculated by dividing body mass by the square of the subjects’ height.

Skin fold thickness was measured and used to calculate body density and percentage body fat Page 53 was estimated from body density values using the Siri equation (Siri, 1961).

The Siri equation, which is based upon a two compartment model of body composition, represents the simplest and most commonly used fat estimating formula.

Like many equations that estimate body fat there are assumptions, such as the uniformity in the density of human fat, but the use of the Siri equations are still accepted and encouraged (Hawes and Martin, 2001).

Participants were introduced to the Multidimensional Fatigue Symptom Inventory – Short Form (MFSI-SF) (Stein et al, 1998; Stein et al, 2004) in advance of the main testing.

This is a 30-item questionnaire designed, validated and frequently used to assess the severity, frequency, and daily pattern of fatigue as well as its perceived interference with quality of life (Stein et al, 2004).

As this investigation was interested in evaluating the potential health benefits of horse riding, which would impact on quality of life indices, the MFSI was considered an appropriate measurement tool.

Participants were asked to complete the questionnaire before the horse riding and laboratory cycling trials to ascertain baseline values.

Post riding and cycling questionnaires were also completed to determine the effect of the respective exercise interventions.

Items were rated on a five-point Likert-scale indicating how true each statement is for the subject (0 = not at all; 4 = extremely).

The score [range, -24 (full of vigour) to +96 (fatigued)] provided an overall indication of fatigue.

Subjects performed an incremental cycling test to volitional exhaustion on an SRM cycle ergometer (SchrobererRadMeBtechnik, Weldorf, Germany) using a protocol and criteria recommended by the British Association of Sport and Exercise Science (1997).

Following a five-minute warm-up, the power was set to increase incrementally.

Prescribed starting power and increments were determined based on the answers by participants to the MFSI-SF survey.

Expired air was analysed using a portable cardiopulmonary exercise system (MetaMax®3X, Cortex Biophysik, Leipzig, Germany) to obtain peak oxygen uptake (V O2max) values.

The system was calibrated against known gases and volumes prior to every laboratory test.

Heart rate was also recorded continuously by the Metamax®3X system via a heart rate monitor (Polar Electro, Tampere, Finland).

Ratings of perceived exertion (RPE, a scale that evaluates perception of effort) were recorded in the last four-five seconds of each one minute stage (Borg, 1970).

Participants completed the MFSI-SF pre and post the incremental cycling test.

Participants subsequently completed a standardised 45-minute horse riding session at the equestrian centre at Plumpton College, led by an instructor.

This consisted of a protocol equivalent to a British Horse Society Stage 2 riding lesson, as outlined in Table A 2.1.

Table A 2.1 Horse-riding protocol used in horse riding trial Time 0-5 minutes 5-15 minutes 15-25 minutes 25-35 minutes 35-45 minutes Activity Walk warm up Trot (with stirrups) Trot and canter work Work without stirrups – sitting trot and walk Trot and canter work The MFSI-SF was also completed pre and post horse-riding session.

RPE was recorded at 15 minute intervals without disruption to the horse riding session.

Heart rate and expired air were analysed throughout the 45 minute protocol via the previously mentioned portable metabolic measurement system, which was calibrated using ambient air prior to every horse riding session.

A range of variables were obtained during subsequent download and analyses of the collected data, including oxygen consumption (V O2), carbon dioxide production (V CO2), respiratory exchange ratio (RER, a measure of fat and carbohydrate breakdown) minute ventilation (V E, the volume of air ventilated) before energy expenditure was calculated.

Seventeen mixed-ability recreational horse riders participated in this study.

The group consisted of one male and sixteen females, ranging in age from 17 to 54 years.

The participants were limited to volunteers with no contra indications to exercise as determined by a medical questionnaire (Appendix 6) and their descriptive anthropometric characteristics are presented in Table A 2.2. Page 54 Table A 2.2 Anthropometric and peak oxygen uptake characteristics of participants mean ± standard deviation] Age (years) Mean SD(±) 25.8 11.6 Height (cm) 165 8.7 Mass (kg) 68.3 18.8 BMI (kg.m-2) 24.9 5.3 Body Fat percent 30.5 6.2 Power @ VO2max (W) 189 45.7 Absolute VO2max L.min-1 1.672 0.496 Relative VO2max ml.kg-1.min-1 24.6 4.00 BMI, Body Mass Index; VO2max, Maximum amount of oxygen you can utilise during an incremental test to exhaustion The results in Table A2.2 indicate quite large variation amongst the participants in the scientific trials in terms of age and body size, although not gender.

The results of the Allied Dunbar National Fitness Survey (1992) where maximal oxygen uptake (VO2max) was estimated over 1,700 men and women in the UK, produced average values of 55 and 40 ml.kg-1.min-1 for men and women aged 16-24 years, respectively.

After this time, VO2max declined steadily with increasing age, resulting in average values of 30 and 25 ml.kg-1.min-1 for men and women aged 65-74 years, respectively.

Aerobic fitness levels of the participants in the current study (~ 25 ml.kg-1.min-1) might be considered lower than average, although this is in part due to the nature of the cycling activity which requires a smaller muscle mass to be recruited than when running.

Nevertheless, this is useful group of participants since they are a larger number compared to previous scientific studies (Devienne and Guzennec 2000, Meyers 2006) and also more heterogeneous in terms of age and body size.

A 2.3 Methods – the questionnaire survey of recreational horse riders The self completion questionnaire survey of recreational horse riders was designed to gather both quantitative and qualitative data.

It comprised 25 questions in total, took approximately 15 minutes to complete and obtained standard socio demographic data on gender, age, occupation and long term illness/disability (see Appendix 5).

Physical health issues were addressed through questions that obtained self reported measures of physical exercise intensity and frequency for horse riding, activities associated with horse riding (such as grooming and mucking out) and other sporting activities.

A series of questions generated two self reported measures of exercise intensity.

The first measure mirrored that used by the Sport England (2010) Active People survey and was based on questions asking respondents if the activity raised their breathing rate (a measure of moderate intensity exercise) or if the activity made them out of breath or sweat (a measure of high intensity exercise).

The second measure followed the approach used in a major survey of physical activity amongst anglers (Stolk, 2009) that asked respondents to rate the intensity of the activity, low, moderate or high but did not give any indication as to what physical feelings (being out of breath, for example) were associated with each of the three categories.

In the survey of horse riders the terms low, medium and high used as it was believed these terms were easier for respondents to interpret than low, moderate and high as they are terms more commonly used in social surveys.

The reasons for using two measures of self reported intensity in the survey of horse riders was to allow the measures to be compared and to provide a check that self reporting amongst questionnaire respondents was a consistent judgement even when the questions changed slightly.

Data was collected to show frequency of participation by asking how many times in the last four weeks the respondent had undertaken for at least 30 minutes horse riding, activities associated with horse riding and other sporting activities.

The four-week period was used to follow the approach used in the DCMS (2010) Taking Part survey and the Sport England (2010) Active People survey, both of which identify the frequency of participation in moderate intensity sport required to obtain health benefits as involving ‘participation on at least 12 separate days in the previous four weeks’. (DCMS, 2007) To investigate the perceived social and psychological benefits of horse riding respondents were asked to rate on a scale some different motivations for participation and the degree to which horse riding made them experience certain feelings.

There was also an open ended question that allowed respondents to provide qualitative data explaining their answers to questions on motivations and feelings.

In order to provide further in-depth data two questions were also included asking respondents to rate what they believed to be the three main a) mental and physical and b) social benefits of participation.

The survey was piloted and quality checked using a sample of 50 staff and students at Plumpton College to confirm that all the questions could be easily understood and that the completion time was approximately 15 minutes to ensure low rates of failure to complete all questions.

As a result of the pilot some minor changes were made to the survey but it was decided not to add further questions so as not to lengthen completion time. Page 55 A 2.4 Methods – the sample for the questionnaire survey of recreational horse riders The population of interest for the survey were just recreational riders and it was not the aim to undertake a probability survey that would allow direct comparison with other groups of individuals such as nonriders.

The questionnaire recruitment methods discussed below were designed, therefore, to obtain a sample of a sufficient size to allow disaggregation of the data to examine particular sub-groups of the sample.

The recruitment methods proved to be successful in terms of responses and the target sample size of 600 was exceeded so that a total of 1,248 surveys were completed that after quality checking were deemed suitable for use in the analysis.

This figure is a valuable sample size since it is equivalent to 0.35 percent of the 337,000 people that according to the Sport England (2010) Active People survey take part in equestrianism each week in England.

The Sport England Active People survey is based on a sample of 0.3 percent of the national population.

A variety of methods were used to recruit respondents between September 2010 and February 2011.

An on-line questionnaire was placed on the Plumpton College website and a web link to the questionnaire was made available from The British Horse Society website.

Respondents who did not wish to complete the questionnaire on-line could download a copy that could be returned via email or in hard copy through the post.

Hard copies of the survey were posted to those who did not have access to the internet.

A press release was issued to promote the web link amongst horse riders and the survey was advertised at a British Horse Society volunteer event.

The link was also forwarded through The British Horse Society volunteer network.

The British Horse Society membership is large, but to ensure respondents were drawn from a wide range of non-British Horse Society members, respondents were recruited via recreational riding establishments.

Using The British Horse Society ‘Where to Ride’ database a sample of riding centres, trekking centres, riding holiday centres and approved centres were contacted to see if they would be willing to take part.

The establishments that agreed were sent hard copies of the survey for their clients to complete.

In addition, the research team attended Blenheim Horse trials to distribute the survey in hard copy to individuals attending and exhibiting.

The recruitment methods were not, however, designed to obtain quotas for particular sub-groups of riders but response checking was used to achieve a sufficient sample size of people who rode regularly in each country within the UK to enable separate analysis in future for England, Northern Ireland, Scotland and Wales.

A question asked respondents in which country they most often took part in riding.

At the mid-point of the recruitment period a count was taken of the answers to this question and in the UK countries that at the mid-point of the survey had small sample sizes approaches were made to establishments in the ‘Where to Ride’ database so that they would to take part by issuing questionnaires to clients.

The key demographic characteristics of the sample are summarised in Table 2.3.

Some comparisons can be made between the characteristics of survey respondents and the characteristics of those who participate once a week in equestrianism as identified in the Sport England (2010) Active People Survey.

These comparisons must be treated cautiously since the Sport England survey only covers England and, importantly differs from the survey of horse rides because it does not report findings for those who participate less than once a week.

In the survey of horse riders 93 percent of respondents are female, which is similar to the figure of 90 percent in the Sport England survey.

The survey of horse riders has a higher percentage of respondents aged above 45 (48 percent) than the Sport England survey (33 percent).

This age profile may be linked to the fact that in the survey of riders 23 percent of respondents indicated they had a longstanding illness/disability compared to 10 percent in the Sport England survey.

The percentages of horse riders that ride most regularly in each UK country shown in Table 3.3 are not dissimilar to the percentage of the UK adult population that lives in each country.

The discussion of the current evidence base in Appendix 1 noted the need to understand issues associated with women and people with disabilities as part of an analysis of the health and well-being benefits of horse-based sport and leisure.

The comparisons and the data in Table A 2.3 indicate that both of these key demographic groups are well represented in the sample of horse riders obtained for the questionnaire survey.

The demographics also indicate a mix of respondents in terms of employment status that includes people working full time or part time, retired people and students.

The questionnaire also used a self reported measure of riding ability and 91 percent of respondents rated themselves as intermediate/advanced with only small proportions reporting they were beginners.

There are certain caveats associated with the survey that need to be taken into account when considering the findings presented in sections 4-6 of this report.

The recruitment methods were not designed to produce a strictly representative sample as this would have required a very expensive and large national survey of both riders and non-riders.

The survey was targeted at people who ride, so the recruitment methods were designed to ensure a large number of riders completed the survey to provide confidence in the findings.

The recruitment methods also aimed to ensure a range of riders took part in terms of key demographics such as age, disability and employment status and Table A 2.3 below suggests this aim has been achieved.

Another key caveat is that the survey collected self reported assessments of the Page 56 physical health and psychological effects of horse riding.

The questionnaire was designed, however, to assess the reliability of the self reported measures as it contained a number of such measures that could be compared.

As noted above, more than one self reported measure of physical exercise intensity was included.

The self reported measures of the psychological effects of horse riding were also examined in more than one question and respondents were asked not only how riding made them feel but also what motivated them to go riding.

Table A 2.3 Gender Male Female Age 16-24 24-44 45-64 65-74 75+ Longstanding illness/disability? Yes No Region where rode most regularly England Wales Scotland N.

Ireland Outside the UK Horse ownership Horse owner Non-horse owner Employment status Full time employment Part time employment Carer Full time student Part time student Retired Other Riding Skill level Beginner Intermediate Advanced Expert 4 54 37 5 46 22 1 11 1 10 9 79 21 69 6 15 5 5 23 77 14 38 42 5 1 7 93 Demographic summary data Frequency (as percentage of total sample of 1,248) Page 57 Page 58 — Parent/guardian’s consent (if subject is under 18 years of age): I ………………………………………………. (parent/guardian’s name) hereby give consent for ……………………………………… (child’s name) to take part in the fitness assessment(s)/training Signature of parent/guardian ………………………………………………………

Date: ………………………………………… Page 64 Appendix 5 Plumpton College The Health Benefits of Horse Riding Thank you for agreeing to participate in this survey Plumpton College and the University of Brighton are conducting research into the potential health benefits of recreational horse riding.

The answers you give to the following questions will be collated with those of other respondents and your responses will remain anonymous.

The data will be treated securely and stored on a PC with password protection.

The final report with the findings from the work will be available on the BHS website in Autumn 2011.

Please answer all the questions.

It should take you no longer than 15mins to complete. 1 In what country do you most often take part in horse riding? Wales/Scotland/Northern Ireland/England /outside the UK If England which region? South West/South East/London/Midlands/North West/North East 2 For how many days in the last four weeks have you been horse riding for at least 30 minutes? 3 Do you ride (please circle as appropriate) your own horse/a borrowed horse/shared horse/riding school horse/other? If other please state ……………….……………….……………….………………. 4 For how long have you been participating in horse riding activity? ………yrs………months 5 What motivated you to take up horse riding? 6 How would you rate your skill level? Beginner/Intermediate/Advanced/Expert 7 Do you take any other form of exercise on a regular basis? Yes/No If yes then what exercise do you take and how many times have you participated for at least Page 65 30 minutes in the last four weeks? Activity 1 2 3. 4 8 What type of equestrian activity do you most commonly take part in? Please circle just one Hacking/instruction/schooling/competitions/other If other please state……………………………………………………………………………………………….. 9 During the last four weeks, was the effort you put into horse riding usually enough to raise your breathing rate? Yes/No 10 During the last four weeks, was the effort you put into horse riding usually enough to make you out of breath or sweat? Yes/No 11 How would you describe the physical intensity of your activity when you go horse riding? Low/Medium/High 12 For how many days in the last four weeks, have you engaged in associated activities such as grooming and mucking out when you go horse riding? 13 During the last four weeks, was the effort you put into these activities usually enough to raise your breathing rate? Yes/No 14 During the last four weeks, was the effort you put into these activities usually enough to make you out of breath or sweat? Yes/No 15 How would you describe the physical intensity of these activities? Low/Medium/High Times in last four weeks Page 66 16 To what extent do the following motivate you to go horse riding? Very important Spend time with friends Spend time with family Be on my own Meet new people Enjoy scenery and views Contact with nature Interact with horses To escape Develop skills Challenge myself Experience moments of excitement To be physically active To relax To lose weight To improve fitness 17 In general to what extent does horse riding make you feel the following? Not at all Cheerful Relaxed Tired Happy Confident Active Excited Proud Energetic Inspired Dissatisfied Angry Guilty Frustrated Bored Lacking in confidence Frightened Page 67 Unimportant Neither Important important nor unimportant Very important Extremely important A little

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