In end-of-life situations, the phrase “do everything” is sometimes invoked by physicians, patients, or substitute decision-makers (SDM), though its meaning is ambiguous. We examined instances of the phrase “do everything” in the archive of the Ontario Consent and Capacity Board (CCB) in Canada, a tribunal with judicial authority to adjudicate physician–patient conflicts in order to explore its potential meanings.We systematically searched the CCB’s online public archive from its inception to 2018 for any references to “do everything” in the context of critical care medicine and end-of-life care. Two independent assessors reviewed decisions, collected characteristics, and identified key themes.Of 598 cases in the archive, 41 referred to “do everything” in end-of-life situations. The phrase was overwhelmingly invoked by SDMs , typically to advocate for life-prolonging measures that contradicted physician advice. Physicians generally related “doing everything” to describe the interventions they had already performed , using it to recommend focusing on patients’ quality of life. SDMs were generally reluctant to accept death, whereas physicians found prolonging life at all costs to be morally distressing. The CCB did not interpret appeals to “do everything” legally but followed existing laws by deferring to patients’ prior wishes whenever known, or to concepts of “best interests” when not. The CCB generally recommended against life-prolonging measures in these cases , focusing on patients’ “well-being” and “best interests.”In this unique sample of cases involving conflict surrounding resuscitation and end-of-life care, references to “do everything” highlighted conflicts over quantity versus quality of life. These appeals were associated with signs of cognitive distress on the behalf of SDMs who were facing the prospect of a patient’s death, whereas physicians identified moral distress related to the prolongation of patients’ suffering through their use of life-sustaining interventions. This divergence in perspectives on death versus suffering was consistently the locus of conflict. These findings support the importance of tools such as the Serious Illness Conversation Guide that can be used by physicians to direct conversations on the patients’ goals, wishes, trade-offs, and to recommend a treatment plan that may include palliative care.Not applicable. Regrettably, conflicts surrounding end-of-life decisions may arise at the bedsides of critically ill patients in up to 80% of cases  and haveIn the course of such conflicts, the phrase “do everything” may be introduced by physicians, patients, or substitute decision-makers (SDM) . For exaHealth Care Consent Act (HCCA) to adjudicate disputes surrounding substitute decision-making in a fair and unbiased manner. In order for cases to reach the CCB, patients have to be incapable such that they do not understand relevant information for decision-making and are unable to appreciate the foreseeable consequences of their decision or lack of decision. Therefore, relevant parties may include the patient’s authorized substitute decision-makers (SDM), other stakeholders, and the medical team. Both the medical team or a patient’s SDM can apply to the CCB if an intractable conflict arises , although hopeful of a recovery, could not or refused to accept the expert doctors’ opinions that his father [patient] would not recover.” [possibility of recovery, the medical team deemed the recovery improbable. Decision-making based on the possibility of recovery can be a “tyranny of hope”, which has been described in the bioethics literature as a paradoxical effect where a focus on hope and recovery causes acceptance of physical and emotional suffering at the expense of loss of function and independence [In response to the recognized ambiguity surrounding the phrase “do everything” as it appears in the course of medical communication , this stecover.”  The meanpendence . It is tSecond, appeals to “do everything” were associated with expressions of distress from the SDMs and the medical team, albeit of different kinds. SDMs’ statements suggest a certain cognitive distress about the prospect of the patient’s death, while the medical team expressed moral distress regarding patient suffering due to life-prolonging interventions. This once again contrasts the importance placed by the SDMs and the medical team on death versus suffering, respectively. Previous research has similarly demonstrated that SDMs perceive palliative approach as a choice between life or death, around which they express unresolved questions or even resentment towards the medical team , 29. OthWhen SDMs invoke “do everything”, how then should physicians respond? Our results suggest that emphasizing a patient’s prognosis may fail to address SDMs’ cognitive distress and may only heighten tensions, since SDMs may choose to reject the medical team’s assessments. Some physicians have appealed to the concept of “best interest” , but priStructured tools such as the Serious Illness Conversation guide (SICG)  may be hIt is important to note that there is significant global variability surrounding the practice of withdrawal of life-sustaining treatment. For example, withdrawal of life-sustaining treatment is more prevalent in countries in North America and Europe than in the Middle East and Asia . This maThe strengths of our study include its novelty in the use of legal transcripts to explore the meaning of phrases used in medical communication, as well as its ongoing relevance. The increasing frequency of appearances of “do everything” in the CCB archive may indicate increased public awareness of life-sustaining measures from medical and non-medical literature , 3, publThe main limitation of this study is that it furnishes only an indirect understanding of “do everything” since we are analyzing transcripts of testimony to the CCB, and not specific conversations between physicians and patients or SDMs. We acknowledge that since these were extreme cases that required adjudication by the CCB, they may not represent the typical local processes of goals of care discussions between physicians and SDMs, which generally end with consensus. Because findings of the CCB can be appealed, the absolute final verdict or outcome of each decision has not been explored and is outside the scope of this study. Our analysis was based on cases that appeared in the CCB archive as of 2018 and therefore we cannot speak to cases that may have occurred since then.This work points to the complexities of physician–patient and physician-SDM communication in the care of the critically ill, and the importance of clarifying whether one’s appeal to “do everything” has as its goal the patient’s quality of life or quantity of life. This divergence in perspectives on death versus suffering was consistently the locus of conflict. Clarity and transparency are to be valued, and potentially ambiguous phrases such as “do everything” should be avoided. To better understand the origins and limitations of “do everything” and similar utterances, future studies could seek to characterize and analyze such rhetorical phrases using a historical or philosophical lens.


Previous knowledge about animal sheltering systems and perspectives of staff working in animal shelters has been centered around Western countries. However, staff in Indian shelters must tackle different kinds of problems, such as care of free-ranging dogs. We conducted interviews with ten participants working in animal shelters in India to begin to gain an understanding of their experiences. Participants reported that inadequate funding, community conflict, and too many animals in need created a challenge for animal shelter work. However, flexibility and positive relationships in their workplace, feelings of duty to animals, and understanding animal needs were identified as positive factors. The perspectives of Indian animal shelter staff showed that certain issues are similar to those encountered in Western shelters; however, other issues are specific to social, political, and cultural influences. Context specific research in animal sheltering is needed to gain a broader world understanding of human–animal relationships.Animal shelters in India are at the forefront of efforts to improve free-ranging dog welfare and tackle animal overpopulation. In terms of cultural and political context, access to resources, and public health challenges, they operate in a very different environment than Western counterparts. Despite these distinctions, current sheltering literature is largely centered around countries such as the United States. The goal of this exploratory study was to examine the experiences of Indian animal shelter staff. Researchers conducted ten semi-structured interviews, in a mix of Hindi and English, with managers, veterinary nurses, and animal caretakers from three shelters. Using thematic analysis, shelter challenges as well as resiliency factors that enable staff to cope with these challenges were identified. Key challenges were inadequate funding, community conflict, and high intake numbers. Resiliency factors included flexibility, duty of care, co-worker relationships, and understanding animal needs. The results of this qualitative study revealed that the experiences of shelter staff are shaped by social, political, and cultural factors and that there is a need for further, context specific research on Indian sheltering rather than only relying on Western perspectives. In the past 25 years, the goals and activities of shelters in Western countries have changed drastically . Rowan aRowan and Kartal (2018) suggest that successful shelter practices in the US can act as a useful “template for other countries with large street dog populations”, such as India. However, given that Indian and Western shelters operate in very different socio-cultural and political environments , there iLike many countries in the Global South, India faces a significant dog overpopulation problem, with recent estimates projected at 59 million . Free-raUntil the late 1990s, Indian dog populations were controlled through mass culling, using methods such as poisoning and electrocution. From 1993 to 1999, this “catch-and-kill” approach was gradually replaced with high volume spay-neuter and vaccination programs, with Delhi becoming the first city to implement an Animal Birth Control—Anti Rabies Vaccination (ABC-ARV) facility in 1993 . While the ABC Rules identify the government’s responsibility for funding population control efforts, Animal Welfare Organizations (AWOs) are tasked with the actual implementation of these programs. Animal Welfare Organizations are shelters or SPCAs officially registered with the Animal Welfare Board of India . The terWhile many run spay-neuter programs, Indian AWOs are not official regulators of population control. Sterilization practices are government regulated, and outlined in the 2009 Standard Operating Procedures for the Sterilization of Stray Dogs. Under this legislation, Indian AWOs are responsible for using state and municipal funding to run ABC programs “with a standard code of professional practice” . This inDespite the lack of India-specific research, a broad body of literature has looked at the occupational health of animal shelter staff in other countries. Studies conducted in the US, Canada, Australia, and the United Kingdom (UK) have identified the risk of poor mental health outcomes, such as compassion fatigue and moral injury, amongst animal shelter staff.Arluke and Sanders (1996) define compassion fatigue as a form of secondary trauma, wherein staff in ‘caring professions’ are psychologically impacted by their distressed patients . SurveyiAt the same time, reduced exposure to euthanasia does not always correspond to improved employee well-being. Andrukonis and Protopopova (2020) examined shelter staff’s experiences in the US. Here, although job satisfaction increased with less euthanasia within animal shelters, the levels of burnout, moral injury, and secondary traumatic stress were also higher . RegardlPrevious research also demonstrates how staff exhibit ‘resiliency factors’ that help them with the stressors of their jobs. These may include positive shelter activities, social support, and personal attitude . PositivShelter staff with strong social support may also be more resilient in their jobs. Amongst 150 shelter staff from Melbourne, Australia, satisfaction with professional and personal relationships was the most significant predictor of euthanasia-related traumatic stress . EmployeFinally, personal attitudes may influence staff outcomes in a shelter environment. Reeve and colleagues (2004) found higher rates of job satisfaction amongst euthanasia technicians with an attitude of acceptance towards euthanasia . SchabraIt appears that animal shelter staff are at risk of a range of negative mental health outcomes from the demands of their jobs. Further, findings on resilience suggest that interventions to mitigate compassion fatigue can focus on increasing positive job activities, social connections, and personal feelings of acceptance to one’s job.Existing literature on sheltering and animal care is centered around Western countries, despite significant differences in animal welfare challenges and socio-cultural contexts in the Global North and South.This may force Indian organizations to draw from research and resources that are not locally relevant. Cultural factors have been identified as a close predictor of the effectiveness of occupational health interventions . Thus, eThe current study provides initial insight into the experiences of Indian shelter staff through qualitative interviews with managers, animal caretakers, and veterinary nurses. This exploratory research will identify future opportunities for cross-cultural collaboration as well as the areas of Indian sheltering that require context-specific research and interventions. Deyvika Srinivasa is an undergraduate Global Health student at the University of British Columbia. She identifies as being female and of South Indian heritage. Deyvika spent her early years in the US but grew up primarily in Bengaluru, India. Throughout her childhood, she was an active volunteer at animal rescues and community-based spay-neuter programs in her city. Kai von Alain Rentzell is a graduate student in the Animal Welfare Program at the University of British Columbia. He has experience with qualitative research and a specific interest in cross-country dog importation. Kai identifies as male and is of Japanese and German upbringing. He has engaged in companion animal care in multiple contexts through working at veterinary clinics in Japan and volunteering at Canadian dog rescues. Dr. Rubina Mondal (RM) is a postdoctoral scholar at the Indian Institute of Science. She is educated in behavioral ecology and has a particular interest in the welfare and adoption of free-ranging dogs. Rubina identifies as female, lives and works in Kolkata, India, and is actively engaged in dog rescue work in her community. Dr. Alexandra Protopopova, the study supervisor, is an assistant professor in the Animal Welfare Program at the University of British Columbia. Alexandra identifies as female, is of Russian and Swedish upbringing, and has lived and worked in the US, primarily with animal shelters in the south, and Canada. She is educated in behavior analysis and ethology and is particularly interested in animal sheltering and dog behavior and welfare. All four authors offered distinct academic and cultural perspectives, which allowed us to adopt ‘insider’ and ‘outsider’ positions as researchers. An insider perspective was developed by having an investigator of Indian heritage (RM) conduct several interviews in Hindi. In this way, staff were able to engage in the research process and share their experiences in a language and with an interviewer with whom they were comfortable. At the same time, our team’s background in American and Canadian animal sheltering placed us in an outsider position. This was beneficial during the analysis process, allowing us to draw cross-cultural comparisons between Western and Indian shelters. However, an outsider positioning may have also led to biases and the interpretation of participants’ responses based on previous researchers’ previous understandings of Western shelter staff. To address these shortcomings, researchers engaged in ongoing self-reflection and implemented a collaborative approach to interview coding and writing. The Participants were recruited between July and August 2021 through non-probabilistic, convenience sampling techniques . The study utilized convenience sampling, wherein participants were recruited from three shelters that researchers had already established relationships with. As a result, participants were only recruited from three states , and results do not represent sheltering across the country. The impact of a restricted convenience sample is further examined in the Limitations section.All three shelters had been registered as official Non-Governmental Organizations (NGOs) under the Indian Trust Act for at least eight years. Shelter names and cities have been removed to retain confidentiality, but basic descriptive data collected from shelter managers is presented in During recruitment, shelter managers were emailed a study flyer that outlined the purpose and format of the research and asked to pass on details to eligible staff. Interested employees were then instructed to contact researchers directly by email or phone. The study flyer included a local mobile number (belonging to the co-author based in India) to ensure easy communication between participants in India and the research team. In the two weeks following recruitment, posters were sent to shelters managers, the authors received replies from ten participants, who reached out directly using the phone or email indicated on the poster. At this point, the shelter managers were informed that recruitment was complete, and we no longer required additional participants at this time.To be eligible, participants had to be over the age of 18, living in India, currently employed at an Indian animal shelter, and working as a manager, veterinary nurse, or animal caretaker. Participants were recruited from three shelters in three different states . At the time of the interviews, all ten participants were actively employed and working in person (not remotely) at their respective shelters. The final sample consisted of 10 animal shelter workers . Five inThe study received approval from the University of British Columbia Human Ethics Board (H21-01759).The interviews were conducted between July and August of 2021. During recruitment, participants selected an interview time from three to four proposed slots. These times were outside employees’ working hours to reduce the likelihood of staff engaging in interviews at their place of work. If participants were unavailable at these proposed times or only had access to the internet or a phone at the shelter, interviews were scheduled during work hours. Participants were asked if they preferred to conduct their interview in English or Hindi. Six out of ten participants opted for Hindi interviews, all of which were conducted by the same member of the research team (RM). The remaining four interviews were conducted in English by the first author (DS). There was no prior relationship between researchers and participants prior to study commencement. Participants received a consent form by email or text message to fill out prior to the interview and return back. The written consent form informed participants of the specific goals of the research, including an examination of the attitudes and experiences of Indian animal shelter staff.A semi-structured interview guide was used, divided into three lines of questions: Occupational Health, Dog Management Strategies, and Perceptions of Animal Welfare. The authors aimed to gain a broad understanding of shelter experiences by asking questions on individual, organizational, and societal and cultural levels. The guide contained open-ended questions, such as “Can you talk about your relationship with your co-workers?” as well as closed-ended ones like “Do you feed community dogs?”. The preliminary guide was pilot tested amongst members of the research team and shortened to ensure all questions could be asked in a 60 min period to improve interview flow. The final interview guide consisted of eleven open-ended questions and four closed-ended questions . All resAll interviews were conducted virtually over Zoom or phone call and audio only was recorded for transcription. The interview length ranged from 23 min to 1 h 9 min, with an average time of 35 min. At the start of the interview, participants were re-informed of the purpose of the study, and the approximate duration. Participants were also reminded of consent protocols, including their right to leave the interview at any time or refuse to answer questions. Each participant received INR 500 (∼8.55 CAD) as compensation for their involvement. No repeat interviews were conducted due to technological errors or lost data and none of the participants withdrew their data post-interview.The second author (RM) and the first author (DS) transcribed, manually verbatim, their respective conversations to generate written transcripts. English transcripts were edited to remove non-standard speech patterns and grammatical errors as laid out by Chang and Spector (2011) . TranscrTranscripts were not returned to participants for correction or comment. However, anonymized interview data was shared with an independent contractor to assess the accuracy of Hindi-English translations. The contractor produced ‘back translations’ of all Hindi interviews by converting English transcripts back to Hindi as laid out by Blauner (1987) . They thThe present study drew from bounded relativist ontology, which defines knowledge as the common ideas within a ‘bounded group’  and constructionist epistemology, which identifies that knowledge is generated through interactions between members of this group. Drawing from these foundations, the study implemented an interpretivist theoretical perspective, attempting to situate and interpret participants’ responses in local context and culture . Researcshelter challenges and resiliency factors was used as the final research framework and aligned with both research objectives as well as participant narratives.Given the limited past literature on Indian sheltering and staff experiences, it was not possible to replicate an existing framework before conducting the interviews. Instead, a broad-based interview guide was designed that addressed Occupational Health, Shelter Goals, and Perceptions of Animal Welfare . After cThe study used a phenomenological methodology, centering subjective human lived experiences in descriptive data. By applying an interpretive lens, researchers were able connect staff’s lived experiences to a broader social and cultural context. An interpretative phenomenological approach promoted a focus on staff’s overt responses in the interviews as well as their broader experiences in the Indian context. The theoretical approach influenced data interpretation and analysis. Researchers specifically incorporated the idea of situated freedom into the analysis process. This concept identifies that while individuals are the ‘experts’ in their own experiences, they are also impacted by their social, cultural, and political environment . When anThe use of an interpretivist lens in all aspects of the study generated a deep, contextual understanding of Indian sheltering, centered around participants’ lived experiences. At the same time, in line with the idea of co-constitutionality, the results do not represent the only ‘true meaning’ that can be drawn from the interviews, but rather a blend of ideas and interests from participants and investigators. After transcription and back translation, the interviews were analyzed using thematic analysis. Analysis was performed as laid out by Vaismoradi and colleagues (2016), wherein themes are generated through a process of categorizing and summarizing qualitative data .“Can you describe your role and main responsibilities within your organization?”:The first author (DS) read all ten interviews multiple times and developed short summaries for each response to a question. The summaries included both basic information provided in participants’ answers as well as interpretation of how this reflects the shelter staff’s attitudes and experiences. For example, the following summary was created based on Participant 5’s response to the question Participant 5 is involved in a range of shelter operations . She can prioritize tasks depending on the shelter’s needs on a given day and work with a flexible schedule.The transcripts were then re-read to identify corresponding quotes and evidence for each summary. To assess the level of support for the analysis and establish coding reliability, the summaries were reviewed by the entire research team. All the summarized interviews were reviewed at least once by another co-author. Those with insufficient evidence were either discarded or modified. During this phase, co-authors also identified instances of leading questions and misinterpretation of questions caused by language barriers. The researchers identified one leading question in interviews with Participant 8 and Participant 10. Responses to leading questions were removed from the analysis and not incorporated as evidence for any summary. Finally, the summaries for individual questions were compared across participants and used to generate broad themes and sub-themes. Through the entire analysis phase, researchers met weekly to discuss recurring ideas, select important evidence, and refine themes. RM and DS did not make consistent written field notes during interviews but reflected on firsthand interactions with interviewees during group discussions. During group discussions, researchers also discussed data saturation and the potential need for additional interviews. Guest, Bunce, and Johnson (2006) define data saturation as the point at which no new themes emerge from the data and no additional data collection is needed . In the From the interview responses, the authors identified themes relating to shelter challenges as well as resiliency factors that enable staff to cope with these barriers. Luthar, Cicchetti and Becker (2000) describe ‘resilience’ as the process of rebounding from significant adversity and resultant stress . As statThe original interview guide included questions on three topics: occupational health, shelter goals and practices, and perceptions of animal welfare. Interestingly, participants’ responses did not divide distinctly across these lines of inquiry. Instead, themes often overlapped in different sections of the interviews. For example, many participants identified that conflict with community members impacted their occupational health as well as their shelter’s practices. Because of this overlap, results were not reported as three separate lines of inquiry, but rather in terms of broad Challenges and Resiliency factors described by staff. For further details on the selection of this research framework, see In the present study, key shelter challenges were inadequate funding, community conflict, and high intake numbers. In the face of these barriers, resilience factors were the duty of care, co-worker relationships, and understanding of animal needs. The themes and sub-themes are in All participants spoke about the difficulties with managing high animal intake with limited resources. Participants described intake challenges in relation to pet abandonment, animal death, animal overpopulation, and seasonal fluctuations. Participant 1 identified the high rates of abandonment for purebred dogs in India, stating, “The more frustrating part is when people buy breed dogs, pedigree dogs, and they abandon them”. He also highlighted the low outflow of animals from the shelter, explaining that “Local adoptions are not so popular. Nobody wants abandoned dogs”. In addition to abandoned pets, staff also linked shelter numbers to large free-ranging dog populations. Participant 1 stated, “In India there is an uncontrolled population of stray dogs… [It is] so hard for Indian organizations because there are too many cases, too many dogs that are on the street, that we have to help”. Participant 2 identifies high intake as a commonality between Indian and Western shelters, stating, “I do feel like we are similar in many ways. We [both] get a lot of animals in and are all overwhelmed… So, I think that is one thing that really unifies us”. Parallels in inflow patterns are also seen in existing literature in the US, where the intake of both stray dogs and abandoned pet animals to shelters is well documented. Data from the National Council on Pet Populations indicates that approximately 30% of dogs entered shelters as owner-surrenders from 1994–1995 , while sA lot of Western NGOs… have quite different situations from what we have in India… We are very [different] in terms of having stray animals as a part of Indian community.I know it’s not physically possible right now. But I just wish we could reach that stage where all of our dogs are spayed and neutered.At the same time, there appear to be distinctions between Indian and Western shelter intake in terms of scale of inflow, the primary source of animals, and reasons behind pet relinquishment to shelters. When asked about the difference between Western and Indian shelters, Participant 2, stated:Here, Participant 2 identifies that Indian organizations grapple with a significantly higher caseloads than those in Western countries and may find common objectives, such as population control, more challenging as a result.Previous literature also indicates distinctions in terms of the primary source of animal inflow. Participants identified that most of their shelter’s work involves the care of free-ranging dogs, through veterinary treatment or sterilization. Participant 2 explained that, when providing treatment for “dogs that are on the street… and part of the Indian community”, staff travel to the animal’s street location as opposed to bringing them into the physical shelter environment. The Pet Care and Facilities Act identifies five primary categories for animal intake  which are commonly used in the design of shelter tracking software . It is eAdditionally, the inflow of abandoned pets may also be unique at Indian shelters. Participant 1 identifies that many owners “buy breed dogs, pedigree dogs, and they abandon them”. This contrasts with the American context, where most owner-surrendered dogs at shelters are not purebred . In a scIn the monsoon, healing takes so much time. In our animal birth control program, we have to release the dogs after like 10 days. Otherwise, in other seasons, we can release them after five days because healing processes [are] fast.Participants also identified how intake numbers fluctuate throughout the year, increasing significantly during the monsoon (rainy) season, from June-September. Participant 1 stated, “Monsoons are pretty tough because there are lots and lots of cases of maggots and it’s a mating season as well”. Here, she identifies a seasonal spike in the intake of free-ranging dogs for emergency treatment and sterilization. Participant 5 also explains that animal recovery slows at this time:With the onset of dog mating, coupled with increased emergency cases, Indian shelters experience larger caseloads from June to September. Western shelters may see similar seasonal fluctuations: Janke and colleagues (2018), for example, report an increase in the admission rate of cats at the Guelph Humane society during spring “kitten season” . AdditioWhat happens is sometimes people feel that, you know, I don’t want to see those animals dying in front of my house or inside my house… [They say], ‘if I can afford to pay 5000 rupees, I will send her to a shelter, but I will not see the animal dying in the shelter. What happens in the shelter is not my problem’.Participant 3 describes a slightly different phenomenon; he focused on injured or ill free-ranging dogs, as opposed to abandoned pets, being ‘dumped’ at shelters:Our Indian ideology is that people think that we will pick up stray animals, put them in a cage and keep them there lifelong by giving them food. But that is not what we experience, no? That is not what we see. [We see] animals dying on us and, you know, it’s very painful at times.Here, Participant 3 describes how many residents are inclined to take injured community dogs to shelters, perceiving them as a haven for animals. Participant 3 describes the contrast between these public perceptions of a shelter environment and the reality that staff experience:You’re suddenly in a place with a hundred animals who are bleeding, who have wounds, who have maggots in their wounds, who are paralyzed, can’t walk, and whatnot. You’re suddenly in the middle of the room and you’re like, okay, I have to take care of them. It’s not that you are not alone, but you do feel alone.This response reveals the striking volume of animal death to which staff are exposed. It also appears that the public is largely unaware of the reality of overcrowded shelters. Participant 3 expanded on this, describing the typical struggles of new staff at her shelter:These insights demonstrate how emergency cases contribute to the intensity of the Indian shelter environment, creating conditions in which staff must cope with an extremely high prevalence of death. The relationship between intake volume and staff wellbeing is well-documented. In a survey of 127 South Australian veterinary nurses, staff with longer work hours and higher contact with distressed clients or animals reported higher levels of work burnout . AdditioWhat happened is that the funding that we were supposed to get was all diverted to these COVID activities. A lot of big donors who said they are going to support us, at the last moment, they said, ‘right now I think it’s better to help people rather than animals.All participants reported funding shortages as a significant barrier at their shelter. Participant 1, a shelter manager, stated, “Sometimes we are out of funds for the dogs, and we have to pay the staff less amount of money”. Participant 3, a manager at a different shelter, expanded on this, describing how these shortages were exacerbated during the global pandemic of coronavirus disease 2019 (COVID-19):Here, he identifies that, at the height of the pandemic, shelter donors shifted their focus from animal to human support. Participant 7, an animal caretaker from the same shelter, reaffirmed this, stating, “Because of the lockdown, there has been a decrease in the donations”. Inadequate funding has also been reported in a Western context: Turner and colleagues (2012) highlight the increasing importance of volunteers in the Canadian context, with many shelters unable to ‘afford’ enough paid staff to deliver animal care . FinanciIn the current study, funding challenges at Indian shelters were influenced by three main factors: lack of government support, government policy, and cultural and religious beliefs. Participant 5, a veterinary nurse, “We don’t get any support or help from the government. There are a few locals who help us. But we don’t get any help from the government”. Additionally, the public may lack an understanding of the inadequate support that shelters receive. Participant 3, for example, stated, “Most people think non-profit organizations are getting aid from the administration and the government, but that is not true”.The Indian government brought a law saying that, you know, you have to streamline your foreign contribution. That took us a really long time to get all the work done, opening your bank account. So that was again a little painful.In addition to a lack of government funding, government policy may create additional barriers. Participant 3 revealed a specific challenge with securing foreign grants. Here, he references the Foreign Contribution Regulation Act —a set ofDi Russo (2011) describes the FCRA as the “primary source of the power of the Indian government over volunteer organizations” . This poThis tight government control is quite distinct from the regulation of shelters in North America. Past research on the US charitable sector demonstrates that non-profits are under little federal control. With the assumption of their “good faith” intentions, the government relies on non-profits to “police themselves” . This isIt is evident that Indian and Western non-profits face varying degrees of government regulation, and that the activity of Indian shelters is shaped by a unique political context. Further, there are broader differences in how shelters in the Global North and South sustain themselves: while the latter can rely on domestic financial resources, Global South countries, like India, appear to access both international and local funds.Many times, people accuse us [of not doing our jobs]. We tell them that yes, we are an animal rescue, but we don’t have space to keep large animals. We can treat them, but we can’t keep them. It feels bad to tell them that.Beyond government barriers, participants noted difficulties with gaining community donations. Dog rescues may struggle to gain local support because of the greater cultural and religious importance of large animals in Hindu communities. For example, Participant 1 stated, “We don’t take large animal cases like cows and donkeys and all that stuff. People really don’t want to donate for dogs. That’s why we have very few donations”. Participant 4, an animal caretaker at the same shelter, also spoke to the prioritization of large animal welfare and push back from locals when the shelter is unable to house cattle and goats:Participants 1 and 4, who lived and worked in the Northern states of Rajasthan and Himachal, respectively, both describe community members’ frustration that shelters prioritize free-ranging dogs over the care of large animals, such as cows, buffalo, and donkeys. Large animals in India are part of a complex “cultural ecology”: buffaloes and donkeys hold economic importance in the country’s largely agricultural economy, while cows have great religious, social, and political significance . ChigateThe relationship between religion, culture, and donations at Indian shelters illustrates another potential divergence from Western counterparts. Surveying communities in the US, Wang & Graddy (2008) found little relationship between religiosity and charitable behavior: though participants were more likely to donate to their specific religious group, they were no more likely to donate to secular causes . Though The current study was constrained to religion in the Indian context; Hindu communities in other countries may offer a different perspective. Past research has examined religion and animal attitudes in Bali, Indonesia, where over 80% of the province practices Hinduism . AnalyziAdditionally, religious beliefs may not entirely dictate the treatment of animals. While Hindu principles prevented community involvement in dog culling, participants did not oppose the discarding of unwanted female puppies near garbage dumps or waterways . In BaliParticipants in the current study demonstrated that, though financial instability is typical in animal welfare work, their experiences were shaped by a combination of religious, cultural, and political dimensions. A deep understanding of this complex local context is crucial to effectively tackling funding challenges at Indian shelters. Conflict with community members was another key challenge reflected on by participants. Participant 3, a shelter manager, explained the impact of clashes with the community: “See, handling animals is very easy, but handling people is very, very tough [laughs]. So that is something that really, you know, that takes a toll on you”. These conflicts were of three main types: rescuer pressure, resident pushback, and incorrect community care.There was this one scenario I still remember. There was a dog with a broken pelvic bone—the pelvic was broken into almost three to four pieces. So, there was no way to repair that dog… But the rescuer said, ‘No, I don’t want to euthanize this animal.’ She said she’d like to take it to some other place. So, she took the dog, did the surgery, and the dog died on the table.All three shelter managers identified struggling with the large volume of calls from rescuers. Participant 1 stated: The biggest challenge for me is the helpline that I manage here. The people call up for rescues and many other things. I have to properly deal with them, make them understand. Participant 2 also explains her distress when sorting through these requests, identifying that “Every day we’re getting around a hundred complaints to prioritize… Whom do you need to reach first? Who will die?”. There seemed to be a lack of understanding amongst the public about these experiences and the sheer volume of requests shelters receive. Participant 2 speaks to this issue, stating, “The other person just sees oh, the ambulance could not reach. Whereas we are actually sitting in between a hundred calls and going ‘Oh god, what do we do?’”. Beyond the volume of requests, staff also navigated difficult conversations with individual community members. When asked to recall a recent challenging case, Participant 3 described the following:Cases such as these, where an animal’s life is at risk, emphasize the emotional burden placed on staff when speaking with community members. Participant 3 highlighted the intensity of their jobs’, stating, “You have to deal with people who bring in those animals and sometimes it’s a lot of emotions, you know? The working environment in a shelter is never not stressful”. When asked about how community members impact her on a personal level, Participant 2 explained that “When somebody loses their animal, who is super, super attached to it. You get a load of people who are coming in and saying that you did not do enough”. There are some people who do not like shelters… Sometimes, if we have to catch a dog, people will chase it away. They will not tell us where the dog is or if there is any problem or if they have to put in some effort.In contrast to rescuers who blame staff for ‘not doing enough’, local residents may also oppose any shelter activity in their area. Participant 5 describes this challenge:Participant 3 also identified pushback to mandatory spay-neuter protocols at his shelter, stating, “A lot of time people are against it, but we tell them, this is mandatory”. Despite receiving pushback, all shelter staff were willing to uphold shelter policies relating to animal birth control, even if it resulted in conflict with community members.Shelter staff in Western countries appear to navigate very similar situations. Loyd and Miller (2010) surveyed Illinois homeowners and identified that most participants opposed their local shelter’s TNR (trap-neuter-return) programs for controlling feral cat populations, favoring relocation of the animals instead . AshfortAnd there are a lot, a lot of unethical feeders. So, yeah, rather than solving any issues, it creates a lot of problems: These people are keeping them with milk and rice and non-veg. Milk and rice will give them loose motion. So, the dogs are going to be pooping near all these peoples’ houses and no one will feel comfortable to clean it after feeding them. [People in the community] say: ‘You know what? You take them to your house, look out for them in the house. Don’t feed them here. We don’t want these dogs here. So, there’s a lot of conflict.While there were challenges with residents who oppose shelter activities, Participant 3 also described issues created by individuals who provide incorrect care to community animals. He specifically identified the challenges with residents who feed free-ranging dogs:[And] you know, not like three meals a day, if you’re feeding them, feed them every alternate day, because the animals shouldn’t be dependent on one particular person. So, when you start feeding them on a daily basis, you are killing their survival instincts. You know, it becomes very difficult for the animals to survive.Here, Participant 3 identifies food, such as meat or eggs (“non-veg”), and milk and rice, that are commonly fed to free ranging, but potentially unsuitable for them. The manager sees a connection between unethical feeding, increased dog disruptions in the community, and heightened ‘anti-dog’ sentiment from residents who do not feed. Participant 3 also highlights the negative impact of incorrect feeding practices on free-ranging dog welfare:According to Participant 3, the role of a feeder is to supplement community dogs’ diets, without making them entirely dependent on human support. It seems that many residents struggle to strike this careful balance. Participant 3 further identifies that with a strong focus on daily feeding, other important activities may be neglected. He stated, “When you feed a stray dog, you need to take the responsibility to make sure that the animal is sterilized and vaccinated”. While residents are eager to engage in low-barrier forms of care, such as feeding, they may be more reluctant to help coordinate sterilization and vaccinations programs that are crucial for long term animal welfare. Here, it is apparent that Indian shelters must strike a careful balance between encouraging the feeding of community dogs while allowing them to retain independence and, in this way, performing an educational role similar to a wildlife rescue. Indian shelters must engage community members in nuanced discussions of the needs of free-ranging dogs. In contrast to Western shelters, who operate in areas with lower numbers of or no free-ranging dogs, Indian shelters may navigate a more complex set of responsibilities and community conflicts. The parallels between challenges at Western and Indian shelters, in terms of funding, managing overcrowding, and navigating community conflicts indicate the potential for greater collaboration and information sharing on population control efforts and community engagement between the two countries. At the same time, context-specific factors, such as religious influence, government funding policy, and free-ranging dog feeding, highlight the unique barriers faced by Indian staff and need for context-specific interventions.In addition to identifying shelter challenges, interviews also revealed important resiliency factors that allowed staff to cope and succeed in their jobs. Researchers divided the resiliency factors into four main categories: flexibility and prioritization, co-worker support, duty of care, and understanding animal needs.If I am doing some work, like if there is some priority case, then we handle them first. If someone’s clothes  are wet, we change them immediately. If they need hot water, we get it done… If someone hasn’t eaten, then we retry feeding them. If someone needs an extra egg, we give them to ensure that the feeding is complete. If someone’s clothing is dirty, then we change those.All participants displayed an immense amount of adaptability. Amongst animal caretakers, this was seen through their comfort with varied working hours and responsibilities. Participant 9, for example, stated, “It’s not fixed working hours… For three to four weeks, I worked in the 7-4 pm shift. Then 10-7 pm for four weeks. Now I am working the night shift”. While Participant 10 described the fluctuations in her day-to-day tasks:I am that sort of person who ends up taking more on her plate than she can manage, even if it’s just going and checking up on somebody and spending 15 min there and I’m like ‘Oh god I could do something else!’, but that was important for me at that particular point in time.Rather than sticking to a rigid set of protocols, Participant 10 was capable of monitoring her environment and making decisions to optimize the comfort of shelter animals. From Participant 1’s responses, we saw that adaptability is also important in a management role. Despite having a range of administrative duties, her priorities were very similar to that of animal caretakers - tasks directly related to animal care were placed at the top of her list:No ma’am, we don’t have an X-ray machine. We go to a private clinic for those. There are some in [shelter city]. We have a CBC [Complete Blood Count] machine now. Any other biochemical tests are done in private clinics.Flexibility was also seen in staff’s response to emergency cases. Participant 10, for example, described how her shelter contacts other frontline groups to facilitate large animal rescues: “Sometimes we contact the fire brigadiers. They send over a team. They are already trained for large animals. So, for large animals, they come when we ask them to”. Participant 4, a veterinary nurse, described similar collaboration in a veterinary context:Participants’ ability to adapt to fluctuating schedules, caseloads, and resource limitations, may indicate their high levels of ‘psychological flexibility’. Kashdan & Rottenberg (2010) describe psychological flexibility as the human ability to adapt to situational demands, shift behavior, and remain open to new mindsets . PreviouSo, nine hours of working plus like about two hours of traveling every day… It almost consumes my entire life. So, it’s like, my coworkers are the entire family and friends I have, my life is very sad [laughs].The sentiment of collaboration was also seen amongst co-workers. Participants saw relationships as incredibly important for their wellbeing and described having an intimate, family-like environment at the shelter. Individuals that had moved to a city, from rural areas, to pursue employment had particularly deep connections, based on their shared backgrounds. Participant 4, for example, stated, “We are from the same village, four of us boys. We are from the same village, so it feels good to work together”. Participant 4 also had positive interactions with higher level management and explained, “My boss is also good. Quite good. So, it’s fun to work.” Participant 9, another animal care worker, even noted an absence of rigid hierarchies in his organization: “Nobody thinks that he is a worker, he is a compounder or doctor, there is nothing like that. We speak to each other lovingly. They call me [omitted], my name”. This significance of workplace friendship was also seen in management. Participant 2 described relying on her colleagues for social connection given the amount of time she spends at the shelter:If things are being changed then, I want them to understand that it’s for the bigger animal welfare picture. I try to explain to them why a certain decision is being made. Or if I’m scheduling them somewhere, then why is it so important, why them and not somebody else.These informal, family-like relationships seemed to have positive effects on the working environment. Participant 5, for example, explained that she trusts that her co-workers will support her and stated, “If there’s any time that there’s too much work and I am unable to handle it, I can go and tell someone that I am unable to handle or finish this job and ask them for help to do it. So, it gets managed”. Participant 2 described her collaborative decision-making approach as a manager:[I try to be] emotionally available for [new staff], because this [work] is so overwhelming… So, we try to gradually and slowly move them forward, and also be there and try and talk to them as to how they feel about it. I’m always trying to always find a balance where people can be able to express themselves and not get overwhelmed.Beyond including employees in decisions, Participant 2 also prioritized providing emotional support to staff:A lot of women that we get from the local villages have so much responsibility. They need to go back home and cook for their husbands. And sometimes they are not in the best situations. So, I really want to make these women feel more comfortable, not just in their workspace. But also, that it’s okay to say, ‘I’m not in a good place at home’.If they’re going through something at their home place and you see that someone is down, like their energies are not as they used to be, we try to talk to them sometimes and see if we can help them out sometimes. Because it’s already too much to go through in the workplace—we are continuously stressed and you’re working nine hours a day. And then you go back home, and you have another issue.Managers also offered nuanced and individualized forms of support, with the goal of improving staff’s equity and autonomy both in and outside the shelter. Participant 3, for example, explained how she created safe spaces for her female employees:I would say about 35 to 40% women and then the rest of them are men. It’s still predominantly men, but the shelter area is handled by women. [Name omitted] and [name omitted] two of our very strong women, they’re like the best caregivers that we have. Any new staff who enters the shelter, irrespective of their gender, needs to know that both of them are their bosses. It’s also important to make them feel empowered. You are working. It’s you who is running the family. You are as independent as a man out there. So don’t, in any area, feel like you don’t do enough or feel like you are obliged to something.Participant 2 put her views on equity into action by implementing with tangible structural changes, such as promoting female staff to positions of authority:Participant 2’s approach to management, focused on promoting staff’s professional and personal wellbeing, is quite distinct from shelter governance in North America. Yoffe-Sharp (2012) examined the culture in US humane societies, identifying rigid hierarchical operations that may heighten staff conflict, worsen communication and create perceptions of unfair treatment by management . By contIn addition to a commitment to coworkers’ wellbeing, participants also demonstrated a deep sense of duty towards animals. All staff saw their work for animals as an essential service, found ways to ‘manage’ high shelter intake, refusing to turn animals away, and extended care to community dogs outside their working hours. This mindset was seen in Participant 1 who, after describing overcrowding at her shelter, stated, “We cannot neglect any rescue, [by] saying that we don’t have space. We have to manage”. Participant 4 reflected a similar sentiment. After explaining that there is “no space” for new rescues, he quickly emphasized, “We cannot refuse calls for large animal rescue either”. A duty of care mindset is also reflected in the high quality post-operative care protocols for sterilized animals. Participant 10, an animal caretaker, stated, “Our shelter has facilities for their stay, food and water, and good care. Some can stay ten days, some five days. Meaning, till the animal requires time to get better”. Participant 5 reflects a similar practice at her shelter, stating, “If any animal is very weak, then we first nurse them back to health. Then we do the surgery and only then release it back”. Despite dealing with a very high volume spay-neuter program, staff appear committed to the individual recovery and welfare of sterilized animals. Non-negotiable care was also extended to community animals. For many participants, caring for free-ranging dogs outside of their work was part of their daily routines. When asked about this topic, Participant 2 stated, “I have nine dogs that I take care of every single day. They sleep in my house. I get beds for them”. Participant 1 also reported caring for many local animals but focused on feeding dogs on the streets as opposed to sheltering them in her home. She stated, “I have 32 stray dogs with me that I have rescued myself. So, whenever I see a dog and I’m feeding and they come outside my gate, yes, I feed them. I love to feed dogs.” Me and my husband, daily we feed around 30 dogs. After we come back [from work], all the dogs are there. ‘When they come, when they come!’ They are waiting for their meal [laughs].Some staff have family members who also care for community dogs. Participant 8 described feeding dogs along with her spouse:Yes, I feed them sometimes. For example, if I come across some dogs on the road and they approach me, I give them something. And if I know some dog, especially the dogs suffering from mange, you see a lot of mange-infested dogs around, so for treating them I usually put the tablets in some food and give it.In contrast to staff who fed daily, some participants explained that they simply extended care as needed. This was the case for Participant 6, a veterinary nurse:When I return, they get very happy. Sometimes they start fighting on seeing me or during feeding. They otherwise usually don’t fight among themselves… The moment they see me, they come to me running.While the exact type of care varied, all participants had strong emotional connection with their community animals. Participant 9, whose neighborhood dogs appeared to trust and have a strong bond with him:I have made them different kennels, so they stay in their kennels. Every day I pick up their poop and all that stuff because I’m used to it, because I work in an NGO and it’s my daily work.Further, staff did not view feeding as a burden on top of shelter duties. In fact, Participant 1 identified that her shelter role put her in a good position to care for community animals:It seems that many staff felt their jobs made them an asset to the community. Participant 4, a veterinary nurse, expressed his willingness to provide treatments outside the shelter, stating, “I have told them [hotel staff] that you are doing a very good job feeding them [dogs]. If there’s any problem with any of them, call me, I will personally come to treat them”.High exposure to animal suffering, animal death, and large volumes of stray animals appear to increase shelter staff’s vulnerability to compassion fatigue . DespiteTo be very, very honest, I don’t feed any animals in my neighborhood. The reason is because, what happens is when I start feeding them people will start asking me or there have been cases where people will dump animals into my house. So, when they know that I’m associated with an association like this, they’ll be like you know what, take away this dog. So, it becomes a huge problem for me and for my family members. People will ask you for medication, people will ask you for breed dogs, where do you get it, what do you do, how to get rid of this dog, cat. Answering all of these queries sometimes is really very stressful.Of all ten participants, only Participant 3 identified a hesitancy to care for community animals, citing fears of being ‘harassed’ by local residents:While a sense of duty towards animals may connect shelter staff to their work, Participant 3’s responses also highlight the dangers of this mindset. When the protection of all animals in their shelter and home environment is seen as non-negotiable, staff may be unable to draw boundaries and combat feelings of overwhelm and stress. In addition to engaging in animal feeding and care, participants differentiated between free-ranging and pet dogs, and reflected on their unique needs. While staff identified the importance of human care for dogs’ physical health, they stressed that animals’ emotional wellbeing—that is, what they need ‘to be happy’—was maximized with greater autonomy and reduced human intervention. Adopting a nuanced perspective, which acknowledges physical and emotional experiences, allowed staff to identify their specific responsibilities to community animals, while also acknowledging limits of their support. Participants specifically identified unrestricted movement, autonomy, and community care as the most important ‘metrics’ for free-ranging dog welfare.Sometimes if we get them adopted, then they [the dog] starts wondering, why have I been restricted. For example, if we are suddenly asked to leave our house and start staying somewhere else, we will also feel odd and face issues.All participants identified unrestricted movement as the most important aspect of good welfare for free-ranging dogs. Unrestricted movement referred to the ability of free-ranging dogs to move freely in their neighborhood, independent of human control. Participant 4 described his fears that free-ranging dogs would be uncomfortable if treated as traditional pets:Abandoned dogs cannot survive outside. They have no idea how to walk on the road, where to get food, water. They have no idea about anything. So, we should definitely try from our end to find them homes, good homes.Expanding on these ideas, Participant 8 recounted her personal experience with keeping free-ranging dogs in her home, stating, “One time I put them in my compound, they were very afraid. They felt uncomfortable. Now, they want food two times a day and they feel happy.” By referring to their happiness and need for space, it is evident Participant 4 considered the animals’ physical and emotional state as part of their overall welfare. Participant 5 expands on these ideas, identifying, “The street dogs that are there, they have a life. They like to stay open, unrestricted”. She further draws a distinction between free-ranging and purebred abandoned dogs:Distinguishing them from typical pet dogs, which require direct care and supervision from their owners, Participant 5 emphasizes that free-ranging dogs are highly robust and able to live independently, without human control. My [community] dogs have the best living situation as then they can go around and chase whoever they want. My home is forever open for them, so they can walk in whenever they want, and they can walk out wherever.The idea of autonomy was also connected to positive welfare. Participants described the community dogs as capable of making independent decisions. Participant 2 spoke to this idea:We don’t tie up those dogs, so they roam around. We have a lot of open space here. They know they will get food in the evening. They come back at that time.Here, Participant 2 emphasized the importance of the animal ‘choosing’ the human and making a conscious decision to return to their home. Participant 4 described a similar relationship with his community dogs, who are not kept in his house, but come back to him willingly:I think these dogs can be kept at home, but they are street dogs. They should be allowed to roam out as well as allowed to stay inside the house. It shouldn’t happen that the dog is kept inside the house 24 × 7 and only sees the humans of that house. They should mix with others too.He identifies that community dogs can actively make decisions, informed by patterns in their environment, without directions by a human owner. Participant 6 extends the idea of independence to social behavior:Here, we see the importance of varied social interactions for free-ranging dogs and their ability to forge relationships autonomously. Participant 6 identifies that community dogs thrive on interactions with both humans and conspecifics and thus, need to be able to move independently in their environment to form these varied social connections.Some dogs may be taken care of by the locals. If something is wrong with them, the medicines are handed over to their local caretakers. Then there is no need to send them to the shelter… We need to make the local people aware of ABC and sterilization and that they can go to any shelter/NGO to get it done. Or if they are having trouble, then they can gather a few people for help and go to a government hospital and get that done.Finally, many participants highlighted the importance of community-based care to ensure the welfare of free-ranging dogs. Participant 6 stressed that local residents can easily reduce injury and harm to community animals, stating, “They will have a better life on the streets ma’am. If people drive a little more carefully and if it’s [the dog] taken care of, then they will be happier on the streets”. Participant 6 further identified the potential involvement of community members in medical care and animal birth control programs. He suggested that a decentralized animal care system may ease the burden placed on animal shelters:I absolutely disagree to say that if they’re living on the streets, then they don’t have a good life if they have people in the community to take care of them. As long as these dogs on the street are community dogs, dogs that the entire community takes care of. I don’t see an issue in it.This notion of community-based care was also seen in conversations with Participant 2. When asked if free-ranging dogs can have a ‘good quality of life’, she stated:If a community does decide to take care of these dogs, they don’t have to take care of like a hundred dogs. They know that these nine dogs will stay in my lane. So, they will develop a relationship with these dogs because they stay there, and they know these dogs. They know, this one eats a lot. You know all those small details. She further highlighted the power of collective actions, encouraging each community to take responsibility for a few animals in their locality and identified the importance of the first step of ‘getting to know’ your neighborhood dogs:reduced human intervention, contrasts attitudes to animal welfare in the West. Tuan (2003) identifies that Western human-dog relationships are based on a combination of domination and affection: owned dogs are constrained physically within a home and restricted socially to a specific owner [In relation to dogs’ physical health, participants acknowledged the role of community members. However, when asked about the animals’ emotional wellbeing, staff stressed the autonomy and unrestricted movement. This perspective, which promotes ic owner . At the ic owner . These pic owner . Additioic owner . Thus, sic owner . Indian While animal attitudes vary between cultures, they may also fluctuate within them. In the present study, participants saw native free-ranging dogs as being independent but expressed that abandoned purebred dogs “cannot survive outside” and require “good homes”. Their understanding of pet dogs resembles Western attitudes on animal ownership and control. It appears that the emphasis on autonomy was not applied ubiquitously to all dogs, but rather specifically to community dogs. Fluctuations in animal attitudes are also seen in the Western context: Jorgensen and Brown (2014) investigated leash-law on public beaches amongst pet owners in McConaughy, Nebraska and found that less than 25% of owners abided by regulations, despite expressing negative beliefs about unleashed dogs .It is apparent that attitudes to animals are neither universal nor consistent within “cultural landscapes” . Yet, thThere were several limitations in the study that must be acknowledged. Participants were selected from only three states . As a result, our results do not reflect the diversity of cultural experiences and animal care across Indian states. In the present study, participant recruitment was restricted as the research team was only able to conduct interviews in Hindi or English. Future projects can prioritize collaborations with translators who are to facilitate interviews with shelter staff in their local language. There may be general challenges with conducting reliable trans-linguistic interviews. In this study, the translation of Hindi interviews to English was performed by one member of the research team and an independent contractor was used to identify any translator errors. Lopez and colleagues (2008) propose a more rigorous protocol for conducting reliable cross-cultural research. The authors describe a seven-step methodology which includes the use of multiple independent translators, and group discussions about variations in meaning based on region and dialect . Future In the present study, the use of audio recordings alone may have limited the depth of the results as researchers were not able to record the subtleties of non-verbal expression. Furthermore, conducting interviews over Zoom may have impacted participants’ responses if they were uncomfortable with using an online platform. Repeating this study with in-person interviews would allow researchers to pick up on the participant’s body language and remove any barriers created by technology. While this qualitative study offers initial insight into Indian sheltering, large-scale quantitative research may be needed to see whether the discovered themes represent overarching challenges and resiliency factors in a representative sample of Indian animal shelter staff. This methodological triangulation would allow for a more comprehensive understanding of staff experiences and improve the credibility of the current findings. This may be important when considering the impact of government policies, such as the FCRA, that regulate foreign funding. Future surveys can identify how many Indian shelters rely on foreign funding and are, in turn, impacted by such legislation. Additional investigation into the psychological experiences of shelter staff is also needed. Many participants were reluctant to discuss mental health and the emotional challenges of their jobs and denied experiencing any burnout or compassion fatigue. While this may reflect staff’s resilience, it may also be the result of cultural stigma around mental health and openly addressing one’s struggles. In future research, implementing a mixed-methods approach  may make Indian staff more comfortable, if they were not, in opening up about the emotional experiences in a shelter environment.While past literature has largely focused on the Global North, this study demonstrates the importance of recognizing Indian sheltering as a distinct area of interest. This is demonstrated by challenges, such as government regulation and cultural preferences for large animal care, that are specific to the Indian context and impact a shelter’s ability to sustain animal care operations. At the same time, the identified resiliency factors indicate that Indian staff also cope with job stressors in unique ways. Participants in this study may harness relationships with both animals and humans to increase resilience and maintain their mental health. This ‘relationship-centered’ perspective can be applied to the Western context to design preventative measures against compassion fatigue that focus on deepening staff’s connection with one another and the animals for which staff care. Furthermore, others can use insights about the identified needs of dogs, such as a need for autonomy, to reduce any potential ethnocentric biases in the determination and improvement of animal welfare. While such cross-cultural knowledge exchange may be very powerful, this study also highlights the need for far more research focused specifically on the Indian context. Further studies should investigate the specific challenges and staff experiences at Indian shelters and how socio-cultural and political factors influence the capacity to support both human and animal welfare.


Screening is often recommended as a first step in frailty management. Many guidelines call to implicate frailty screening into practice in the primary care setting. However, few countries or organizations implement it. Understanding and clarifying the stakeholders’ views and issues faced by the implementation is essential to the successful implementation of frailty screening. However, the systematic review on stakeholders’ views of frailty screening in primary care is decidedly limited. Our objective was to explore the perspective of older adults, caregivers, and healthcare providers on frailty screening and determine the enablers and barriers to implementing frailty screening in primary care.A systematic search of six databases and other resources was conducted following JBI’s three-step search strategy. The search resulted in 7362 articles, of which 97 were identified for further assessment according to the inclusion criteria. After the full-text screening, quality assessment and data extraction were carried out using the tools from Joanna Briggs Institute (JBI). Moreover, reviewers used the approach of meta-aggregative of JBI to analyze data and synthesis the findings.Six studies were included. A total of 63 findings were aggregated into 12 categories and then further grouped into three synthesized findings:1) capacity of healthcare providers and older adults; 2) opportunity in the implementation of frailty screening; 3) motivation in the implementation of frailty screening. These themes can help identify what influences the implementation of screening from the perspective of stakeholders.This meta-synthesis provides evidence on the barriers and enablers of frailty screening in primary care, from the aspects of psychological, physical, social, material, etc. However, stakeholder perspectives of frailty screening have not been adequately studied. More research and efforts are needed to explore the influencing factors and address the existing barriers.The online version contains supplementary material available at 10.1186/s12877-022-03173-6. Increasing life expectancy leads to the rapid ageing of populations around the world . By 2050Screening is a process for evaluating the possible presence of a particular problem . It diffPrimary Care, as the first point of contact for patients, is the appropriate setting for addressing most of the population’s healthcare need . FurtherThe previous reviews focused on the concept of frailty, frailty interventions, and the frailty screening instruments in primary care , 40–43. This qualitative systematic review was performed by the process and principles recommended by the Joanna Briggs Institute (JBI) approach . The JBIThis review followed JBI’s three-step search strategy. First, a search has been undertaken, followed by analyzing the text words contained in the title MEDLINE and CINAHL and abstract, and of the index terms used to describe the article. Secondly, a comprehensive search strategy was conducted to seek all available studies. We searched the following six databases for the earliest available date to June 2021: CINAHL(EBSCOhost), PubMed (OvidSP), Embase (Ovid), Scopus, Web of Science and PsycINFO. Third, the reference list of all studies selected for critical appraisal will be searched for additional studies. Lastly, reviewers hand searched the database to acquire more studies. The research was limited to the English Language. Moreover, the full search strategy is provided in Additional file The inclusion criteria were chosen according to the PICo review : (a) quaFollowing the search, all citations were imported into Endnote version X9, and duplicates were removed. We initially screened the title and abstract according to inclusion criteria. Furthermore, we retrieved the selected studies’ full text for assessment to ensure they met inclusion criteria. Two reviewers (NJH and DYZ) undertook each study selection process independently, and there were no disagreements.The Joanna Briggs Institute Qualitative Assessment and Review Instrument (JBI-QARI) was used to assess the methodological quality of the included papers by two reviewers independently . We estaQualitative data will be extracted from papers included in the review using the standardized data extraction tool from JBI-QARI. The first author extracted relevant data from the six studies. The data extracted will include specific details about the populations, context, culture, geographical location, study methods, and the phenomena of interest relevant to the review question and specific objectives. The two reviewers (NJH and DYZ) carefully read the included articles, appraised and attributed all qualitative findings a level of credibility by two reviewers according to the following criteria: (1) unequivocal (U)-findings accompanied by an illustration that is beyond reasonable doubt and therefore not open to challenge; (2) credible (C)-findings accompanied by an illustration lacking clear association with it and therefore open to challenge; (3) unsupported (Un)-findings are not supported by the data. There is no disagreement with the credibility level of each finding.This review uses a meta-aggregative approach to the synthesis of qualitative evidence. It contains a three-stage process that was conducted by NJH and DYZ. First, the reviewers extracted all findings from all included articles and established a level of credibility. Secondly, developing categories for findings that are sufficiently similar, with at least two findings per category. Only unequivocal and credible findings will be included in the aggregation. Not-supported findings will be presented separately. Finally, developing one or more synthesized findings of at least two categories, looking for conceptual or descriptive commonality. After synthesizing, reviewers used the ConQual tool to evaluate the confidence of the synthesized findings .The initial searches located 7362 references and removes 2431 duplicates by software. After screening the title and abstract, 97 papers were for further assessment. Finally, six papers were included in this review after reading the full text. Figure Among the six studies included in this review, four , 52, 53 All included studies scored 7–9. And no included papers were excluded. Among the six studies, all papers met criteria 2, 3, 5, 8, 9, and 10. However, five papers were unclear in the philosophical perspective (criteria 1), as papers did not clearly state the philosophical or theoretical premise on which the study is based. Table Sixty-three findings were extracted from six papers. The findings were extracted from older adults and HCPs, and reviewers cannot extract valuable data from caregivers. Most of the findings were rated ‘unequivocal,’ two were rated ‘credible,’ and two were rated ‘unsupported.’ The unsupported finding did not include in the aggregation. Therefore, the 61 findings were aggregated into 12 categories according to the similarity of meanings, then developed three synthesized findings from the categories. Table It is essential to recognize that stakeholders’ capability influences the implementation of frailty screening. Education and training are needed to improve healthcare professionals’ knowledge and skills and improve older adults’ perception.I think … you know, you can assess people’s frailty within four seconds of looking at them, really ….… within the first couple of seconds you know what’s going on; you can see how long it takes them to get up, you can see if they use the armrest, you see if they don’t need to do that, if they’ve got a walker or a frame or a stick, or if someone’s helping them, if they’re stooped over, their pace within the room.  et al., , P429)Healthcare providers lack knowledge and skills for frailty and screening. They have an incomplete understanding of frailty and regularly apply an intuitive screening through several typical warning signs and clinical judgment.I have been a GP thirty-five years-plus and these are new terms to us for our understanding … who is severely frail and who is moderately frail.’ et al. , , P607)Some of those who used frailty screening tools are also doubtful about how to apply them, and it hampered HCPs’ ability to identify and manage older people.When asked if frailty was preventable, there was a sense among participants that it may be possible to delay the symptoms of frailty and maintain wellbeing for some length of time but that it was not possible to prevent the inevitable, ‘to stave off the evil day?!’, i.e. that older adults will become frail if they continue to live.  et al., , P1243)This was exemplified by one community-dwelling participant who stated, ‘I think people would know without having to do a survey whether they were frail or not’ .et al. , , P229)Older adults lack of perception of frailty and screening. They think frailty is not preventable and query the necessity of formal frailty screening.It must be noted that opportunity is an essential factor influencing the implementation of frailty screening. An awareness of the factors that reduce opportunities to implement frailty screening, including lack of a proper tool and lack of a clarity implementation pathway, is important. Moreover, a sensitive implementation approach and communication are conducive to creating a trusting relationship, and it can facilitate participation in frailty screening among older adults. Involving the multidisciplinary team can also promote the implementation of screening.There is definitely under-identification of people who are frail but don’t necessarily have lots of long-term conditions.’‘Having undertaken quite a lot of reviews of patients who are tagged by the electronic Frailty Index as being severely frail, we found out that, actually, they are either not frail at all or moderately frail.’ It would throw up surprising people as having [a] high frailty index [score] … we looked at the top one hundred patients and I would think [of] at least twenty that we saw, there is no way they should be on this index.’ et al. , , P608)Many formal screening tools have been developed for HCPs, and each one has different properties and characteristics. Older people and HCPs think these tools lack sensitivity, specificity, logic, and accuracy.HCP: “one of the things that frustrates me is when there is no cognitive screening…I’m big on cognitive screening…I don’t care if they’re here for a non-cognitive reason. I want to know what their cognition is like because maybe they are here because their falling and maybe that’s because a person is taking a blood pressure pill twice a day instead of once a day and maybe that’s because they have dementia.” et al. , , p.28)Healthcare providers recommend that there be found and use a proper tool for more consistency. This proper screening tool should be multifactor, including functional ability, nutrition, psychological, pharmacy, and pain, and quick and easy to administer.PT1: I don’t think there’s much point in implementing something like this (EFS), into an assessment, unless we have a pathway to follow through on it  et al., , P36)Participants reported that the screening pathway was unclear. There is a lack of a consensus on when screening is best applied and the screening frequency. Moreover, it needs the pathway to analyze the meaning of results and provide action to address the needs.One is detecting at risk … versus one already with a condition. … That’s more an assessment of how bad it is; the other one is … a predictive value about where this may be going ...  et al., , P429-P4Healthcare providers recommend that it is crucial to understand the screening purpose and context. They think screening should be distinguished between universal screening and targeted screening according to the purpose.As one participant expressed, ‘if the person knows that they’re five out of ten, does that then say to them okay, well you know I don’t have to try. You know I’m on my way out sort of thing ... that’s more of a deterrent’.Shorter tools were preferred to avoid giving up, or ‘feeling agitated and upset and nervous’ (e.g. with an hour-long test). . et al. , P230)Considering that the term frailty is perceived negatively by older adults, it is emphasized that providers need a sensitive approach to implementing screening. Some factors that administer a frailty-screening tool; and the length, terminology, and structure of the tool itself were regarded as necessary for sensitive screening.As one community-dwelling male expressed, ‘if the tool could diagnose what’s going to happen to me, then I’d be better placed to go forward’ . et al., , FG2).OA: “you want to know sort of how it would affect your physical health and how it would progress that you would maybe ugh, you’d want to like do, manage things for yourself as long as you could.”  et al., , P35)OA: “this is where, you know, these clinics that some doctors have set up, are an excellent idea. Because you’ve got a dietician, you’ve got a physiotherapists, you’ve got an occupational therapist, you know you’ve got all these people, and so you know the doctor can call on all these people for extra assistance.” , as an integrated management approach, provide an excellent opportunity to screen. Older adults also support the use of MDT for their health.Motivation is those brain processes that energize and direct behaviour in implementing frailty screening. Healthcare providers’ positive attitude and the belief in the benefits of screening facilitate the implementation. Factors that hinder the implementation include the lack of supportive evidence of screening effectiveness, older adults’ fear of frailty, and doubt about community insufficient resources.‘In principle, it is a really good idea … What I think it does and the reason I think it does have value is that it helps us identify cohorts of patients who are potentially at risk and who will benefit.’Prevention is better than cure, so if you identify somebody that would be a good place to start.’  et al., , P.607)Proactivity is reflected in the fact that most HCPs hold a positive view of frailty screening and realize its benefits. Providers think they can accept it and recognize the benefits of formal screening, which can identify and address frailty early and help elders in a holistic approach.‘We can identify and label people with diseases, but actually if there is not much you can do about it … I am not sure who is happier, or if anybody is.’  et al., , P607)Lack of support evidence of screening effectiveness may hinder some providers from implementing screening. The proof that screening led to improved older adults’ frailty is lacking, and the HCPs think little could be done to influence frailty.‘am I frail? Will you test me? There’s no way you’re going to go in and say that and if you answer all their questions right which you know as well as anybody, they can answer questions really good. Go out the door and say something stupid but they can...the GP is not going to pick it up’  et al., , P229)Older adults fear frailty and even escape it, limiting them from participating in screening. They regard frailty and screening with fear and apprehension, and they do not want to know whether they are frail.It would be very expensive. Access to health care would be improved.  et al., , P1244)‘we need someone to take up on the people that are frail and is there the resources available to fix it. I doubt that’. et al., , P230)Older adults think the formal screening should be consultative and inform specific actions, but they question whether the community has sufficient resource to provide services.This review using the system ‘ConQual’  to rate This systematic review identified six qualitative studies from diverse countries on primary care and included the views of different stakeholders: older adults and health care providers. Two papers involved caregivers but did not extract enough data to be valuable. This review developed three themes by systematically synthesizing qualitative research: stakeholder capacity, opportunity in the implementation of frailty screening, and motivation in the implementation of frailty screening. Furthermore, these themes reveal crucial factors that promote or hinder the implementation of frailty screening in primary care. It is timely, with the strongly recommended frailty screening in the primary care setting and the lack of implementation .Stakeholders’ capacity is the crucial factor that affects the successful implementation of frailty screening in primary care. This finding is consistent with the other clinical settings; for example, the lack of knowledge and understanding about frailty and screening was a significant barrier in acute care settings and hospitals , 57. FraIt has been found that challenges mainly focus on the field of opportunity. Healthcare professionals indicated a lack of a proper tool in screening and expressed their concerns about the tool’s accuracy, sensitivity, and specificity. Dozens or hundreds of frailty tools have been developed with the increasing interest in frailty . Many exRecognizing motivation in screening is very important in promoting successful screening implementation. Healthcare providers hold a positive attitude towards the implementation of screening. They believe formal screening can identify frailty or the risk of frailty early and increase their holistic awareness of the patient . Even thThis review provides researchers insights into the perspectives of stakeholders on frailty screening and enhances researchers’ understanding of the potential factors that may influence frailty screening practice. However, this review has some limitations. Firstly, we only included research reported in English. The language limitation may lead to overlooking some studies. Secondly, we only included six articles, so the information may not be sufficient. Furthermore, because of the limitations of included articles, we did not conduct a stratified analysis according to the types of healthcare providers. Thirdly, our review could not extract valuable caregivers’ data from the included studies. Finally, all the studies were conducted in developed countries, so the findings may not be applicable elsewhere.The meta-synthesis has provided synthesized qualitative evidence that can guide the implementation of frailty screening in primary care. Three themes identified in the systematic review are stakeholder capability, opportunity in the implementation of frailty screening, and motivation in the implementation of frailty screening. These themes can help identify what influences the implementation of screening. In addition, more high-quality quantitative and qualitative papers are needed to explore stakeholders’ perspectives in different countries  to establish evidence or strategy to implement frailty screening in primary care successfully.Recommendations for practice arising from the review are provided in Additional file Additional file 1. Search Strategies.Additional file 2. QARI data extraction of included studies.Additional file 3. Results of meta-synthesis.Additional file 4. Recommendation for practice.