The Temple Grandin Equine Center (TGEC) at Colorado State University (CSU) and the Professional Association of Therapeutic Horsemanship, International (PATH, Intl.) formed a working group of A/TR interested parties. The working group was developed and met prior to this study. The ongoing work group consists of 11 members, selected because they represent different perspectives related to A/TR, including CTRIs, leadership from PATH, Intl. centers, researchers, and representatives from: TGEC, PATH Intl, the American Hippotherapy Association Inc., and the Horses and Humans Research Foundation. This work group provided feedback that greatly influenced the methods presented below.

This study was approved by the CSU Institutional Review Board (#3229) and a study survey was distributed to A/TR interested parties. To be eligible to complete the survey, respondents were required to be age 18 or older, understand English, and self-identify as one of the following A/TR interested parties: CTRI, center leadership, A/TR volunteer, A/TR participant, or caregiver of an A/TR participant. To be included in analyses, survey respondents had to complete at least 50% of the survey. Survey responses were submitted anonymously.

The survey was created in Research Electronic Data Capture (REDCap), a secure, web-based software platform (10, 11). The survey was distributed to a national mailing list of A/TR interested parties maintained by PATH, Intl., the educational and credentialing body for A/TR professionals and centers. The email invitation included details of the study, including that participation was voluntary and 1 respondent would be randomly selected to receive a $100 gift card; clicking the survey link indicated consent. The survey was open for 8 weeks. Survey questions fell into five categories: (1) general information about the respondent; (2) if and how the respondent currently measures A/TR outcomes (for CTRIs and PATH., Intl leadership only); (3) the perceived importance and likelihood to change of possible participant outcome constructs (e.g., horsemanship skills, social skills, physical improvements); (4) benefits of and barriers to implementing standardized outcome assessments in community-based A/TR; and (5) considerations that may affect the usefulness of standardized assessments in the A/TR context (e.g., time and cost, etc.). The survey consisted of Likert-scale questions, “Select all that apply” questions, “Yes or No” questions, and open-ended short-answer questions (e.g., “Please describe,” or “Please list…”). The survey included 107 distinct questions, and operated using branching logic, such that each respondent answered a set of questions based on their previous answers; for example, respondents who self-identified as a CTRI were presented with different questions than those who self-identified as an A/TR participant. Depending on their answers, respondents were presented with an average of 50 questions. The survey allowed respondents to save their responses and return at a later time.

Survey data were exported from REDCap and downloaded to Microsoft Excel for analysis. We calculated descriptive statistics such as frequencies, percentages, medians, and interquartile ranges (IQR). For “Select all that apply” questions, total percentages across all response options summed greater than 100%, as respondents were allowed to select multiple responses. For short-answer questions, we category-coded responses into pre-existing answer options or created new codes derived from participant answers; we report category counts to summarize the short-answer responses (12).

Three hundred forty-seven total respondents completed portions of the survey. Two hundred seventy-seven participants completed at least 50% of the survey and therefore, were included in further analyses. Two hundred sixteen (78%) respondents identified as A/TR instructors, 99 (36%) identified as PATH, Intl. Center staff, 23 (8%) identified as A/TR volunteers, and 8 (3%) identified as either an A/TR participant or a caregiver of an A/TR participant. Due to the dearth of volunteer, participant, and caregiver respondents, we chose to focus all further analyses on respondents who identified as either A/TR instructors or PATH, Intl. center staff. A total of 233 A/TR instructors or PATH, Intl. center staff completed at least 50% of the survey, and 221 completed the entire survey. The remainder of the manuscript provides the results from these 233 A/TR instructors or PATH, Intl Center leadership.

Of the 216 respondents who identified as A/TR instructors, 200 (93%) identified as CTRIs; 27 (13%) identified as Advanced Therapeutic Riding Instructors (ATRIs), and 11 (5%) identified as Master Therapeutic Riding Instructors (MTRIs). These instructor types were combined for further analysis and will be hereafter identified as CTRIs. One hundred forty-one (65%) respondents reported being employed at a PATH, Intl. A/TR center, 37 (17%) reported working at a non-PATH, Intl. A/TR center, 22 (10%) reported contracting with PATH, Intl. centers, and 22 (10%) reported not currently working with an A/TR center.

One hundred and ninety-one respondents (82%) reported they currently measure participant outcomes of A/TR. Table 1 includes participant outcome constructs currently assessed by survey respondents.

Among the 191 survey respondents who reported tracking participant outcomes, respondents reported using several methods, including progress notes (n = 178, 93%), interviews (n = 78, 41%), unstandardized assessments (n = 71, 37%), standardized assessments (n = 24, 13%), and “other” (n = 12, 6%). “Other” reported methods included observation (n = 4), tracking skills/objectives (n = 3), conversations/stories from participants and caregivers (n = 3), and end-of-session reports (n = 1). Respondents who currently assess A/TR participant outcomes reported measuring outcomes for various reasons, including the following:

“Other” responses included demonstrating progress to participants, instructors, or the public (n = 8), improving the quality of services (n = 3), student projects (n = 1) and to support future research (n = 1).

Among the 71 respondents using unstandardized assessments, respondents most commonly implemented the assessment before and after a session, which was defined as a period of consecutive weeks or months during which A/TR lessons are provided (e.g., a 10 weeks session of A/TR lessons; n = 42; 59%). The next most common time to implement the unstandardized assessment was after a lesson, defined as a single A/TR lesson (n = 23; 32%). Similarly, of the 24 respondents using standardized assessments, they most commonly implemented the assessment before and after a session (n = 17; 71%) or after a lesson (n = 4; 17%). Respondents reported spending a median of 15 min (IQR = 10–30) implementing unstandardized assessments and a median of 20 min (IQR = 20–30) implementing standardized assessments.

Respondents identified utilizing several different types of unstandardized assessments, including participant and caregiver surveys (n = 18, 25%), “in-house” assessments created by A/TR centers (n = 9, 13%), modified standardized assessments (n = 2, 2.5%), and surveys completed by A/TR instructors (n = 1, 1.4%). The most common standardized assessments were Goal Attainment Scaling [GAS; n = 9, 38%, (13)] and the Rider Instruction, Development, and Evaluation System [RIDES, n = 3, 13%, (14)]; these both represent a standard manner of setting and measuring progress on individual horsemanship goals. Other standardized assessments measure a diverse range of constructs and were only used by 1–2 respondents each:

Figure 1 illustrates the extent to which CTRIs and PATH, Intl. staff believed it is important to identify a standardized assessment to measure participant outcomes of A/TR. While a notable minority (29%) found it “unimportant” or “very unimportant”, most respondents (64%) reported it was “important” or “very important” to identify standardized assessments to measure participant outcomes of A/TR.

Figure 2 illustrates the participant populations for whom respondents believed it would be important to measure outcomes. Over 90% of respondents reported that it would be important to measure A/TR outcomes in all participant age and diagnosis groups.

Table 2 illustrates respondents’ perception of the importance and likelihood to change of several different potential participant A/TR outcomes that could be measured. Twenty-six survey respondents reported “other” outcomes which they believed were important or likely to change. Their responses were coded as: outcome importance depends on individual goals and abilities (n = 4, 15%), connection with the horse (n = 4, 15%), self-regulation (n = 3, 12%), sensory integration (n = 2, 8%), relationship building (in a family or between peers; n = 2, 8%), academic performance (n = 2, 8%), and self-confidence and leadership skills (n = 2, 8%).

Respondents reported several benefits of identifying an assessment to measure A/TR outcomes, including gathering data to demonstrate the value of A/TR to society (n = 197, 85%), communicating outcomes to potential A/TR funders (n = 183, 79%), communicating outcomes to participants (n = 176, 76%), communicating outcomes to future participants (n = 172, 74%), guiding how A/TR is delivered or implemented (n = 146, 63%), other (n = 22, 9%), and none (n = 3, 1%). The “Other” responses fell into several categories, including advocating for insurance coverage/funding (n = 7, 32%), instructor benefit (n = 4, 18%), research (n = 3, 14%), communication with other professionals (n = 3, 14%), and increasing the credibility of the A/TR profession (n = 2, 9%).

Respondents also reported potential obstacles to implementing standardized assessments at their A/TR centers, including: time constraints (n = 152, 65%), lack of a system to organize assessments (n = 149, 64%), lack of expertise in administering standardized assessments (n = 137, 59%), lack of staff to implement assessments (n = 118, 51%), assessment cost (n = 94, 40%), participant buy-in for assessments (n = 59, 25%), lack of knowledge about which assessments to implement (n = 48, 12%), other (n = 26, 11%), and “none” (n = 12, 5%). “Other” responses were coded into the following categories: diversity of PATH, Intl. centers and services provided (n = 7, 27%), individual participant variability (e.g., ages, diagnoses, contexts, cultural considerations; n = 7, 27%), participant/family burden (n = 3, 12%), increased focus on assessment results rather than providing high-quality services (n = 2, 8%), and variability inherent to community-based A/TR (e.g., changes in volunteers/horses, participant absences, n = 1, 4%).

Given the perceived benefits of and barriers to implementing outcome assessments, respondents were asked to report how likely they would be to use standardized outcome assessments if they were recommended by PATH, Intl. Most respondents reported they were likely (46%, n = 108) or very likely (39%, n = 90) to implement recommended standardized assessments, while fewer reported they were unlikely (12%, n = 28) or very unlikely (3%, n = 7).

Most survey respondents (n = 178, 76%) reported that CTRIs would be the best individuals to report on A/TR participant outcomes, followed by A/TR participant caregivers (n = 134, 58%), A/TR participants (n = 118, 51%), and “other” (n = 31, 13%). Respondents indicated that they would be willing for CTRIs to complete assessments that require a median length of 20 min (IQR = 10–22.5), and that they would feel comfortable asking A/TR participants to complete assessments lasting a median length of 10 min (IQR = 10–20). Additionally, of the 221 total survey respondents, 97 respondents (44%) indicated that they would prefer assessments via a computer/iPad, 94 respondents (43%) identified that they would implement assessments in either computer/iPad or pencil/paper format, and 30 respondents (14%) stated that they would prefer pencil/paper assessments. Finally, most respondents identified that that they would only use assessments that are either free (n = 106, 48%) or cost $1–2 per use (n = 79, 36%). Fewer respondents stated that they would use assessments costing $3–5 per use (n = 33, 15%) or $6–10 per use (n = 3, 1.4%).

Most respondents reported currently measuring participant outcomes of A/TR participation, primarily through progress notes, interviews, or un-standardized assessments. While these commonly reported methods of recording participant information may be useful to track progress or communicate about participants within centers, they do not easily facilitate communication across centers, between professionals, and to the public. Outward Bound, an organization that provides outdoor education programs, provides an example of how a community-based recreation and learning program can benefit from a standardized assessment to measure participant outcomes. The Outward Bound Outcomes Survey “allows all 11 regional Outward Bound schools to collect consistent data on how students are impacted by their Outward Bound experiences in key areas of social–emotional development” (23). Therefore, this comparable program that provides recreational access to both general and vulnerable populations may serve as a model for how the A/TR profession may begin using standardized assessments to measure participant outcomes, facilitating communication between centers and to the public.

While the majority of respondents (64%) reported that it is important to identify standardized assessments to measure outcomes of A/TR participation, a notable minority (29%) of respondents did not think it was important. The rationale for those respondents who reported that it is “not important” to identify a standardized outcome assessment is not clear, as respondents did not have the opportunity to describe why they selected their answers. Other authors have reported that community-based service professionals feel that standardized assessments may not reflect the unique characteristics of their community, programs, and the skills and resources of their participants (24). Furthermore, education on standardized assessments is not included in CTRI training materials (25); therefore, the “unimportant” responses could result from a lack of knowledge about standardized assessments. Despite this disagreement among respondents on the importance of standardized assessments, a large majority of respondents stated they would be either likely or very likely to implement standardized assessments recommended by PATH, Intl. Therefore, results of this survey suggest that if standardized assessments were available and recommended for A/TR professionals, they would be likely to use them. However, the lack of standardized assessment availability is indicated by the fact that only 13% of respondents reported currently using standardized assessments. Therefore, this study substantiated that there is currently an unmet need to identify or develop standardized assessments to measure participant outcomes of community-based A/TR.

Given the barriers to using standardized assessments discussed above, it is critical that standardized assessments identified to measure participant outcomes of community-based A/TR are useful in the A/TR context. Usefulness is particularly important for A/TR professionals, as they often serve diverse populations with varying needs and abilities and are constrained by the limited time they spend with their participants, limited financial resources, and credentialing restrictions. Over 90% of respondents reported that a useful standardized outcome assessment would be appropriate for use with A/TR participants of all ages and diagnoses/life experiences. Additionally, respondents consistently reported that a wide variety of outcome constructs (i.e., cognitive outcomes, communication outcomes, emotion regulation, and physical outcomes, etc.) are important to measure in A/TR practice. The outcome constructs identified by respondents are consistent with research findings in the A/TR literature; specifically, research has demonstrated that A/TR can improve mental functions (33), social functioning (34), emotional regulation skills (35), communication skills (34), physical function (36, 37), quality of life (38, 39), and community integration (40). Given these findings, a battery of standardized outcome assessments proposed for use in the A/TR setting should measure a wide variety of outcomes in A/TR participants from a variety of age groups, diagnoses, and life experiences. Such a battery of assessments would then likely need to be accompanied by a decision-tool and training to guide A/TR professionals in selecting and implementing the assessment(s) most pertinent to the participants they serve.

Regarding the logistics of implementing standardized assessments, there was not consensus among survey respondents about who should provide information for the assessment (i.e., CTRI-administered assessment vs. participant or caregiver-completed questionnaire), or how the assessment should be delivered (i.e., computer/iPad, paper-pencil, or both). The best standardized assessment format likely depends on individual characteristics of A/TR facilities so it would be beneficial for standardized assessments to be available in both virtual and paper/pencil forms. Most respondents agreed that assessments should not take longer than 10–20 min to administer and should be freely available or low-cost. Therefore, if multiple assessments are identified, they should require no more than 10–20 min total, and the cost for administering assessments should remain minimal.

This study includes several limitations. Firstly, respondents were not asked their geographical location or demographic information. These data would have allowed us to understand if trends existed in different areas across the country or based on gender, age, race, or ethnicity. Such demographic data should be included in future studies. Additionally, some sections of the survey did not include a short-answer section, forcing respondents to identify a pre-written response and limiting our capacity to understand the nuances of their answers. Finally, this study is limited by the absence of responses from A/TR participants and their caregivers, whose opinions should be considered in relation to if assessment is important to them, what outcomes should be assessed, and how much time they would be willing to dedicate to participating in an assessment.

To our knowledge, this is the first study to gather information from A/TR professionals about the potential usefulness of standardized assessments in community-based A/TR services. Future research should identify or develop standardized assessments that may be useful. To this end, a Delphi study of A/TR experts could aid in developing a prioritized list of potential standardized assessments to measure participant outcomes of A/TR. Once assessments are identified, they should then be piloted in community-based A/TR to understand whether they are feasible in actual A/TR environments. Future directions may also include bolstering community-academic partnerships, to support the implementation of standardized assessments in community-based A/TR. Overall, implementation of standardized assessments in A/TR could enhance the credibility of the profession and provide a means for communicating the vast benefits of community-based A/TR to a variety of audiences.