Perception of stress in cats by German cat owners and influencing factors regarding veterinary care

Abstract

Objectives

Visiting the veterinarian is generally perceived as a stressful situation for cats. Previous studies have shown that the perception of stress may influence cats’ healthcare. In order to minimise stress in cats during the veterinary consultation, feline-friendly handling has gained importance and is increasingly being used. The aim of this study was to find out whether cats experience stress during a visit to the veterinarian (and, if so, to what extent), and which factors influence the perception of stress and whether feline-friendly handling techniques have an impact.

Methods

An online survey was conducted among German cat owners. In total, 889 questionnaires were evaluated. The results were analysed with binary logistic regression and a χ² test. A principal component analysis was used to detect the main influencing factors on the perception of stress.

Results

Most of the cats (88.7%, n = 732/825) were perceived as stressed during a veterinary consultation, while only about half of the owners (50.8%, n = 419/824) stated that they felt stressed themselves. The cat owners (n = 819) who perceived visiting the veterinarian as a stressful situation also described their cat as stressed significantly more often compared with owners who did not feel stressed (χ² = 101.113, P <0.001). The probability that owners experienced stress themselves was significantly increased if they perceived their cat to be stressed too (odds ratio 0.073, 95% confidence interval 0.016–0.328). One factor that influenced whether an owner was stressed was the stress behaviour of their cat (P <0.001). Furthermore a feline-friendly demeanour by the veterinarian led to less stress in the owners (P <0.001).

Conclusions and relevance

The owner’s stress influences the perception of their cat’s stress. By adhering to feline-friendly handling guidelines, veterinarians can reduce owner stress associated with veterinary visits, thereby promoting optimal veterinary care and health for their feline patients.

Introduction

Approximately 14.7 million domestic cats are kept in Germany. ¹ Cats are, after dogs, the animals presented most frequently to German veterinary practices, with preventive healthcare being the most common presenting problem. ² It is recommended that a cat is taken to a veterinarian at least once a year to ensure its good health. ³ The vaccination status of cats is determined to be a good indicator for regular healthcare; however, veterinary visits for vaccination may cause stress for the animal. ⁴ Stress in cats can arise when they experience a loss of their safety-providing territory and control over their environment and vital key resources, ⁵ which may occur during a visit to the veterinarian, even if only briefly. Emotions, such as fear and frustration, can be seen in cats as a result of stress during veterinary consultations.^6,7 Previous studies have shown that cat owners often perceive a visit to the veterinarian as stressful for their animal.^8,9 In the past, pet owners have also been described as anxious or emotionally stressed during a visit to the veterinarian. ¹⁰ Whether there is a connection between owner and cat stress levels, and whether cats react to negative emotions shown by the owner at the veterinarian, has not yet been explicitly investigated. However, it is known that cats can understand subtle signals from humans, ¹¹ and display reference glances to them in unfamiliar situations. ¹² As it seems that cats relate their behaviour to signals from their owners, an extrapolation to the situation of a visit to the veterinarian appears feasible. Therefore, we hypothesised that owners who perceive their cat as very stressed also feel more stressed themselves vs those who assess their cat to be less stressed or not stressed at all.In 2011, the Feline-Friendly Handling Guidelines (FFHG) of the American Association of Feline Practitioners and the International Society of Feline Medicine ¹³ were released to help minimise stress in cats during veterinary visit, to improve owner compliance and to reduce anxiety among owners. The effect of treating cats according to these guidelines on the owner’s perception of stress remains to be quantified. We hypothesised that the owners of cats that experience feline-friendly handling, and thus are less stressed during veterinary visits, will feel less stressed themselves. The perception of stress can also depend on the human–cat relationship. It is assumed that this relationship is comparable to a parent–child relationship, ¹⁴ and that the owner’s personality and communication have an impact on the behaviour of the cat. ¹⁵ In order to evaluate the influence of the human–cat relationship on the perception of stress in cats and owners during the visit to the veterinarian, participants were initially asked to agree or disagree with individual statements about feelings they have towards their cat.

The aim of this study was, by conducting a survey among German cat owners, to show the extent to which cats experience stress during a visit to the veterinarian according to their owners, to determine factors influencing owners’ experiences of stress and to show how feline-friendly handling influences owner perceptions of their cat’s stress.

Materials and methods

Data collection

To survey cat owners in Germany a questionnaire was created, encompassing questions about the cat–human relationship, cat behaviour, stress when visiting the veterinarian and feline-friendly treatment in veterinary practice (see the questionnaire in the supplementary material).

To test whether cat owners can correctly interpret the emotions and behaviours of cats, participants were asked to describe six pictograms of cats. ¹⁶ For all pictures, owners could select between rejecting, aggressive, tense, fearful, attentive, relaxed friendly, curious and neutral. In addition, the owners had the option of providing an alternative answer if none of the response options provided was applicable from their point of view.Owners who lived in multi-cat households were instructed to select one cat from their household and to answer the questionnaire with regard to this cat. In addition, owners had the option not to answer a question and omit it, which led to some incomplete records. Before publishing, the questionnaire was checked for comprehensibility and completeness in a pilot study by four test persons. Answering the questionnaire took about 20 mins. The survey took place exclusively online and was available for participation via LimeSurvey from 12 June 2020 to 31 December 2020. Cat owners from all over Germany were recruited to take part in the anonymous survey. The link to the online survey was published on Facebook, Instagram, in cat forums and a trade magazine, which resulted in a convenience sample of cat owners.

Survey response

A total of 1075 people took part in the survey, of which 186 records were not included in the analysis because the survey was terminated prematurely. A total of 889 questionnaires were evaluated descriptively. As answering particular questions was not mandatory to continue in the survey, not all participants answered all questions. However, all questions that were answered were included in the study.

Data analysis

Statistical evaluation was carried out using IBM SPSS Version 27 statistics software. A descriptive summary of all responses was created. In order to be able to recognise dependencies and connections between different statements, the data were statistically analysed using linear regression. Binary logistic regression was used for calculating probabilities. For correlation analysis a χ² test was performed; the main influencing factors were determined using a principal component analysis (PCA) with varimax rotation (Table 1). In all statistical tests, P <0.005 was considered significant.

Table 1.

Main influencing factors on the perception of cats’ stress and owners’ stress, which were determined by principal component analysis (PCA) and used to detect mutual dependencies by linear regression and correlations by χ² test

	Factors	Kaiser–Meyer–Olkin criteria	Bartlett test for sphericity			Rotated sums of squared loadings
			χ²	Degrees of freedom	Significance	Total	Percentage of variance	Cumulative percentage
Human–cat relationship	The cat plays a very important role as a social partner in the relationship	0.745	1213	45	<0.001	2	24	24
	The cat is a self-sufficient and independent individual					1	13	37
	The cat serves as a kind of status symbol (one-dimensional view of human relationships)					1	12	49
	The cat as a mood barometer and mood brightener					1	12	62
Stress at the veterinary visit	The cat is stressed and fearful at the veterinarian	0.852	2935	45	<0.001	3	27	27
	The owner feels stressed and uncomfortable about visiting the veterinarian					2	23	50
	Bad experiences with the veterinarian result in fear and aggression in the cat					2	23	72
Cat stress behaviour	The cat shows aggressive behaviour towards the veterinarian	0.815	3251	45	<0.001	3	29	29
	The cat shows fear and no exploratory behaviour on the examination table					3	3	56
	The cat shows frustration in the carrier					1	14	70
Feline-friendly veterinarian	The veterinarian is perceived as patient, empathetic and feline-friendly	0.629	590	28	<0.001	2	24	24
	The veterinarian takes steps to convey a feeling of security to the cat and to reduce fear					1	18	42
	When making appointments cats are taken into consideration					1	14	56

Results

Animal and owner data

Overall, 93.8% (n = 686/731) of the survey respondents were women and 5.5% (n = 40/731) men. The average age of the survey respondents was 31–40 years. Most cats were domestic shorthairs (61.0% [n = 446/731]), whereby the distribution between males (52.7% [n = 386/732]) and females (47.3% [n = 346/732]) was comparable. Of the owners, 31.2% (n = 228/731) had a single-cat household, 46.8% (n = 342/731) kept two cats and 22.0% (n = 161/731) had more than two cats.

Cat–human relationship

While 98.3% (n = 864/879) of the cat owners stated that their cat plays an important role in their life, 63.1% (n = 555/879) of the owners also stated that their cat plays a very important role in their social life. Although a total of 72.2% (n = 634/878) also stated that a cat can never replace social contact with other people. For 90.7% of the owners (n = 797/879), a close relationship with their cat can be supposed, as they agreed to statements such as ‘I like to spend a lot of time with my cat’ or ‘without my cat I would feel lonely sometimes’. In order to assess the attitude of cat owners to cats in general, they were asked to agree or disagree to statements such as ‘my cat can perceive my moods and reacts accordingly’ or ‘I think my cat enjoys being petted’. In agreeing to these statements, most cat owners showed an anthropomorphic attitude towards cats in general, while only 11.4% (n = 100/876) agreed with anthropocentric statements such as ‘my cat is primarily useful; it is supposed to keep rodents and other pests away’.

Cat behaviour

Based on the identification of emotions in the six pictograms (Table 2), most owners recognised obviously aggressive emotions such as hissing and having the ears pointed back and laid flat (74.1% [n = 659/889] and 73.3% [n = 652/889], respectively). More subtle signs of a negative emotional state, such as flattened ears, but without showing bare teeth or piloerection, were only partially correctly described by the owners (varying from 6.2% [n = 55/889] for aggression to 63.2% [n = 562/889] for tension). A maximum of 54.7% (n = 486/889) of the owners were able to recognise signs of fear. The results also varied for gestures showing positive emotions. Facial expressions with erect and forward-pointing ears as a sign of curiosity (68.7% [n = 611/889]) or attention (71.3% [n = 634/889]) were still recognised comparatively well by the owners, as only 28.2% identified (n = 251/889) this as a friendly behaviour.

Table 2.

Pictograms used in the survey to assess the accuracy of the owners’ interpretation of feline behavioural patterns

	Description of solitary behavioural patterns according to UFAW definitions 16	Behavioural category according to Stanton et al 17	State of mind according to behaviour defined as:	Response options defined as not applicable
© UFAW 1995	The cat is hissing, the ears are laid back and flattened	AggressiveFear	Negative	Attentive Relaxed Friendly
© UFAW 1995	The cat’s ears are erect and point forwards	Active Calm Exploratory	Positive	Aggressive Fearful Rejecting Tense
© UFAW 1995	The cat’s ears are flattened	Aggressive	Negative	Attentive Relaxed Friendly
© UFAW 1995	The cat lays half side, the ears are erect and point forwards. The tail is parallel to the ground	Active Calm Exploratory	Positive	Aggressive Fearful Rejecting Tense
© UFAW 1995	The cat shows a body arch with piloerection and is hissing. The ears are laid back and flattened, the tail is attached to the body	Active Aggressive Agonistic Fear	Negative	Attentive Relaxed Friendly
© UFAW 1995	The cat crouches, the ears are erect and point forwards	Active Calm Exploratory	Positive	Aggressive Fearful Rejecting Tense

UFAW = Universities Federation for Animal Welfare

Stress during the veterinarian visit

About half of the owners in this study associated a visit to the veterinarian with negative emotions for themselves, such as nervousness (57.7% [n = 476/825]), anxiety (65.0% [n = 536/825]) or discomfort (44.1% [n = 364/825]). Half of the owners (50.8% [n = 419/824]) also stated that a visit to the veterinarian is stressful for them. Of these owners, 44.9% (n = 188/419) avoided going to the veterinarian with their cat as much as possible and 89.1% (n = 373/419) believed that their cat can feel the discomfort they are feeling. The PCA showed that owners felt stressed or uncomfortable about a visit to the veterinarian if the cat is perceived as a social partner in the human–cat relationship (P = 0.004) or if the cat shows stress behaviour in the treatment room (P <0.001) or frustration behaviour in the carrier (P <0.001) (Table 1). However, the age of the owners had no influence on whether they felt stressed during a visit to the veterinarian (P = 0.165).Even if only about half of the owners stated that they perceived the veterinarian visit as a stressful situation, the majority of owners (88.7% [n = 732/825]) perceived this situation for their cat as stressful. Only a minority (39.5% [n = 326/825]) reported that the cat had previously had a bad experience at the veterinarian, related to examinations and treatments of the cat in which owners were personally present. Of those owners who mentioned a bad experience, 65.4% (n = 213/326) reported that their cat was more fearful at the following veterinarian visits and 30.4% (n = 99/326) stated that their cat even showed aggressive behaviour in subsequent visits. In general, cats that are perceived as fearful in unknown situations by their owners were almost all described as stressed during a visit to the veterinarian (95.4% [n = 607/636]).

Cat owners (n = 819) who felt stressed during a visit to the veterinarian also described their cat as stressed much more often than owners who did not feel stressed (χ² = 101.113, P <0.001). Owners (n = 819) who assumed that their cat was stressed during the veterinary consultation also experienced more stress themselves (χ² = 153.447, P = 0.001) than owners who did not perceive their cat to be stressed. The probability that owners (n = 819) who experienced stress themselves when visiting the veterinarian would also perceive their cat as stressed was 83 times higher (odds ratio [OR] 0.012, 95% [CI] 0.002–0.085) than owners who were not stressed. Also, if owners (n = 819) perceived their cat to be stressed when they visited the veterinarian, the probability that they would experience stress themselves was significantly increased (OR 0.073, 95% CI 0.016–0.328). There was an association between the cat’s presumed stress and the actual extent of the cat’s stress reactions at the veterinarian, in this case for fear. The stronger the signs of fear, such as freezing (n = 820 [χ² = 230.438, P <0.001]) and trembling (n = 821 [χ² = 218.529, P <0.001]), the more fearful the cat was assessed to be by the owners. There was a greater effect size with freezing (Φ = 0.530) than with trembling (Φ = 0.516). Overall, a majority of cats could usually be petted by the veterinarian (57.6% [n = 474/823]) and had never shown aggressive behaviour towards the veterinarian, such as hissing (58.9% [n = 485/823]) or biting and scratching (73.3% [n = 601/820]) (Figure 1). Whether a cat showed signs of stress and fear during treatment had a direct impact on whether the owner perceived their cat as stressed and fearful. The PCA revealed that the more stress the owners perceived in their cats, the stronger the described signs of stress and fear during a veterinary visit were (P <0.001). Cats were also perceived to feel more stressed and fearful if scruffing is or has already been carried out by the veterinarian (P <0.001).

Figure 1.

Cat owners’ assessments of their cats’ stress behaviours relating to a veterinary visit (expressed as percentage)

Owner reports of feline-friendly handling in veterinary practice

Just under half of the cats of the surveyed owners were routinely, or had in previous visits, been restrained by scruffing (47.7% [n = 377/790]). Based on our survey data, feline-friendly examination methods are rarely implemented in German veterinary clinics, such as examining the cat on a (prepared) blanket (16.6% [n = 131/789]), the use of the wrapping technique (14.7% [n = 116/790]) or conducting the examination on the owner’s lap (24.2% [n = 191/790]). However, around half of the cats were allowed to remain seated in the bottom half of their carrier during the examination (57.4% [n = 454/791]). In the waiting area, feline-friendly recommendations were apparently only implemented in a few cases. Seventeen percent (n = 136/790) of the owners reported a dedicated waiting area for cats; even fewer reported specifically designed (cat-only) consultation hours for cats (3.0% [n = 24/792]). Blankets that can be placed over the carrier during the waiting period were rarely used (4.7% [n = 37/791]). A third of the waiting areas had increased storage space for cat carriers (34.3% [n = 271/791]).Regardless of this, the majority of owners agreed that veterinarians want cats to feel comfortable during visits (81.3% [n = 643/791]) and that as much time as needed is taken to treat the animal without hurry (88.2% [n = 698/791]). A clear majority of owners (89.0% [n = 704/791]) described their veterinarian as feline-friendly, even if they had mentioned that they experience stress when visiting the veterinarian (83.3% [n = 263/316]). Here, other factors influence whether owners perceived their veterinarian to be patient, empathetic and feline-friendly. They described the veterinarian as more feline-friendly if they did not perceive any stress in their cat (P = 0.004), the cat only showed a few signs of stress during treatment (P <0.001), the cat did not show aggression towards the veterinarian (P = 0.002) or had not had any bad experiences with the veterinarian (P <0.001). At the same time, it showed that a feline-friendly veterinarian can influence whether cat owners experience stress during the veterinarian visit, and a high degree of empathy on the part of the veterinarian leads to less stress for the owner (P <0.001).To evaluate the distribution of the Cat Friendly Clinic (CFC) campaign across Germany, owners were asked if they recognised the CFC sign (Figure 2). Only a minority recognised the sign (13.2% [n = 104/787]); and only a few of those recognising the sign visited a certified CFC regularly (37.5% [n = 39/104]).

Figure 2.

Cat Friendly Clinic sign

Discussion

The results showed that many cat owners perceive having a close relationship with their cat. It must be noted that every owner may have a different understanding of a cat as a family member. In order not to impair comparability, the owners were asked explicitly about their own feelings. It is not only the owner’s personality,^14,18,19 but also other factors such as interactions between humans and cats, emotional closeness and the quality of the bond between both, that affect the human–cat relationship.^15,20 With the aim of getting a more objective view of owners’ attitudes to their cats, anthropomorphic and anthropocentric statements were presented in the survey (see questionnaire in the supplementary material), which the owners could agree or disagree with. Responses were used to classify respondents into two basic human attitudes towards animals (anthropomorphism and anthropocentrism), as described by Serpell. ²¹ As we suspected, most of the cat owners not only expressed a close relationship with their cat, but also shared an anthropomorphic attitude towards cats in general.

We also hypothesised that, because of this close relationship, owners are largely able to recognise the emotions of cats, but this could only be partially confirmed. The main focus was placed on the recognition of fear and aggression, as these emotions are most often shown in veterinary practice in connection with stress in cats,^7,22 as a protective mechanism and to evade interaction with people. ²³ The UFAW pictograms ¹⁶ were selected for this purpose and an interpretation was determined according to the ethogram of Stanton et al ¹⁷ in order to be able to assess the accuracy of the owners’ interpretation of the facial expressions and postures of the cats (Table 2). Owners seemed to recognise clearly aggressive gestures by cats, but the recognition of more subtle stress-associated behaviour seemed to raise difficulties, which is in line with previous studies on this topic.^9,24 An assessment of the cat’s state of mind may be difficult without knowledge of the context in which the cat shows the presented behaviour, and interpreting moving images (eg, video) can also be easier, as the movements of the tail, ears and eyes, muscle tone and vocalisations should also be accounted for in order to accurately assess the cat’s state of mind.^6,13 The fact that even positive emotions could not always be recognised by the owners may be due to the topic of the survey. The owner might have unconsciously linked the title of the survey and negative associations with ‘stress’, and incorporated them into their assessment of the pictures. The pictograms were included in the survey to determine whether signs of stress in cats can actually be assessed by owners, although descriptive statistics revealed that a statement by the owner alone is not sufficient.The subjective perception of stress, which can be directly described by humans, can only be guessed at in cats by asking their owners, or interpreting feline body language and behavioural reactions. Cortisol determinations can be used to measure stress in cats^25,26 but does not always correlate with heart rate, respiratory rate and body temperature, ²⁷ or the behaviour of the cat. ²⁸ In studies, stress is usually evaluated by feline behaviourists, because cats often only give subtle information about their emotional state. ⁶ The Cat Stress Score ²⁹ is mostly used for assessment^30–33 but does not match our study design, as it is very detailed and has so far mainly been used by behavioural experts and not by owners themselves.

Owing to the complexity of stress, the question arises to what degree it can be accurately measured in non-human animals. Understanding stress as an overall condition that is the result of many different factors, one could conclude that stress cannot be objectively measured in a meaningful way; ³⁴ it can only be felt individually. This is why we decided to ask the owners about their perception, especially as owners seemed to find it easier to evaluate their own cats than to evaluate pictures of unfamiliar animals.

The owners’ assessment correlated with the behavioural reactions of the cat, as those cats showing signs of fear at the veterinarian visit were also perceived as more stressed by their owners than those that showed fewer signs of fear.

A visit to the veterinarian itself is seen as a stressor in cats,^22,35,36 and some owners have also stated in the past that they perceive the veterinary visit as stressful, ⁸ or feel anxious and emotionally stressed. ¹⁰ In our survey, only about half of the owners reported feeling stressed when visiting the veterinarian. With our results we cannot assume that owners’ stress has a direct effect on the perception of cats’ stress, or that the perception of stress of the owner and the cat mutually influence each other, but we know that cats are able to recognise human emotions, ³⁷ show reference gazing and adapt their behaviour to human emotions.^11,12 Therefore, it cannot be ruled out that the owner’s perception of stress could have an influence on the perception of stress in the cat.

Although it seems that the conditions for a feline-friendly veterinary visit in Germany have not yet been implemented across the board, owner satisfaction is still high. This could be owing to the fact that feline-friendly handling can also be given if the cat is treated patiently and respectfully, even if not all recommendations of the FFHG are implemented. ¹³ Additionally, there are only a few CFCs available in Germany, which can lead to the assumption that owners are not aware of the option of taking their cat to a feline-friendly practice.In this setting, we specifically examined the restraint method of scruffing and its effect on the owner’s perception of stress in their cats. We were able to demonstrate direct effects of scruffing on cats. Cats were perceived as being significantly more fearful and stressed, which is in line with the results of Moody et al, ³⁸ who showed that cats responded negatively to scruffing. Scruffing seems to be a widespread practice among German veterinarians, despite the fact that it is not advocated by feline-friendly practices and the FFHG, because scruffing leads to more severe defensive reactions and stress ²² than gentler methods like passive restraint or wrapping techniques.^13,22,38One possibility of increasing feline-friendly handling in Germany may be to motivate more veterinary practices and clinics to join the CFC programme. In our study, a veterinarian who was described by owners as feline-friendly, patient and empathetic was associated with lower stress in cat owners, maybe because owners can be assured that his/her cat is treated with little stress. In general, when interpreting the results of cat-friendly practices, one should keep in mind that it is possible that owners may not be aware of all feline-friendly measures used by a given practice. For example, the practice could refrain from providing blankets prepared with synthetic pheromones because waiting areas and treatment rooms are equipped with pheromone diffusers, which the owner has not noticed.

In German veterinary practices, examinations (like taking blood or ultrasound examinations) are commonly carried out, whenever possible and if they do not require sedation, in the presence of the owner. In the survey the owners were explicitly advised to only evaluate those treatments for which they are or were present in the treatment room themselves.

The study was conducted as an online survey. The recruitment of cat owners also took place mainly online. Owners were approached via social media, cat forums and a trade magazine to take part in the survey, which led to a convenience sample of cat owners. The main disadvantage of such a sampling method is that only committed owners who are explicitly interested in cat content took part in this study. A second limitation of the study was that 93.8% of the respondents were female. Therefore, we were not able to point out sex-specific differences in the perception of stress during veterinarian visits and the results of the study are biased towards female cat owners. This seems to be a common circumstance associated with survey studies among cat owners, as previous studies with comparable sampling methods report a similar gender distribution among the respondents.^14,20,39

Conclusions

In daily veterinary practice not only the cat’s stress during a visit to the veterinarian, but also the owner’s stress, should be given more attention.

Many cat owners perceive visiting the veterinarian as stressful for their cat and those owners who experience stress themselves describe more stressful behaviour in their cats than owners who do not feel as stressed by veterinary visits. This should encourage veterinarians to respond to the owner’s feelings in order to minimise anxiety, nervousness and discomfort as much as possible. One way to accomplish this is by using feline-friendly handling of feline patients, which may help to create a more relaxing situation for cats and their owners.

By responding appropriately to negative emotions, veterinarians can foster better healthcare for the cats by counteracting avoidance behaviour by cats and their owners to veterinary visits. Avoiding stress for owners and cats in the veterinary clinic is, among other aspects, related to the cat’s perception of stress, such as low-stress handling of the cat by the owner in preparation for the visit to the veterinarian and also in the hands of the veterinarian. It should therefore be considered extremely important from the point of view of animal welfare, as well as from an economic perspective in the sense of good practice management.