Shifts from direct implementation to advocacy-based programming have been documented across many non-governmental organisation (NGO) sectors, including animal welfare. Semi-structured interviews with 32 staff from different positions within animal welfare NGOs explored recent programming changes. Maintaining a balance between direct implementation and advocacy-based activities emerged as a strong theme. The findings suggest that risks are associated with both the direct implementation status quo and transitioning to an advocacy-based focus. Risks of the former include treating symptoms rather than root causes of welfare problems. Organisational change can be disruptive and necessitates realignment of core competences, in turn influencing NGO mission. Identified risks of transition include loss of individuals whose values fail to align with new programming directions, increased upwards accountability requirements for accessing institutional donors and difficulties when phasing out direct implementation approaches. Whilst having to be dynamic, NGOs need to evaluate the risks associated with programming decisions, considering their vision, mission and staff identity in order to ensure that welfare programming is as effective as possible.
Belief in animal sentience and the quality of human-animal relationships play a significant role in animal welfare. However, the link between an individual animal's welfare and the beliefs and emotional connection of the owner to the animal is understudied and focussed on single cultures, limiting generalisability. In this study, we explored potential links between owner attitude, beliefs in animal sentience, and working equid welfare across four continents. This study used a welfare assessment protocol alongside a questionnaire exploring owner attitudes to assess 378 participants across six countries. Overall, the general health status and body condition of equids belonging to owners with an affective (versus instrumental) perspective and those owners who believed that their equids could feel emotions, were significantly better. Equids belonging to owners who believed that their animals could feel pain were also significantly less likely to be lame. Potential causal relationships between factors and theories explaining these beliefs are discussed. These results can inform future welfare initiatives by highlighting the importance of the human-equid relationship and the role that beliefs regarding animal sentience play in influencing equid welfare.
Slavery, in the form of 'debt-bondage', is rife in Indian brick kilns, where the enforcement of labour laws is poor. Working equids support brick-kiln workers by transporting raw bricks into the kilns, but the situation of equids and their owners within the brick kilns is relatively unknown. We describe the welfare of donkeys (Equus asinus) owned under conditions of debt-bondage, examine the links between owner and donkey behaviour, and outline the living conditions of both donkeys and humans working in the brick kilns of Gujarat, India. We then explore the unique experience of debt-bondage by donkey owners, compare migration trends to those of non-donkey-owning workers and assess impacts on their children's education. The physical and behavioural conditions of donkeys reflected that of their owners, creating negative feedback loops and potentially reducing productivity. All donkey owners experienced debt-bondage and were particularly vulnerable to unexpected financial loss. Donkey owners, unlike non-owners, migrated within their home state, enabling their children to attend school. Our work highlights the need for policy reform within the brick-kiln industry to acknowledge the pivotal role of working donkeys in supporting human livelihoods.
Equids in general experience transient lives where ownership may change multiple times, for working equids this can be more extreme where ownership changes are not only numerous but abrupt, and situations encountered prove difficult, diverse and tough for equids to adapt. In this study, we investigate the life cycle of pack mules in Nepal, investigating the challenges they face during their lives through to end of life. To gain insight into the lives of mules, we conducted semi-structured interviews and livelihood surveys with 27 key informants, gathering the perspectives of the people working with mules. Welfare assessments of the mules were undertaken via the Equid Assessment Research and Scoping tool (EARS) by a trained assessor. Mules had to adapt swiftly to changes in industry type, enduring long distance transportation in overloaded vehicles and across country borders with no checks for biosecurity or welfare. Mules had to show swift adaptation to their new environment, to respond to and learn new tasks via inhumanely administered training, using inappropriate techniques, delivered by owners lacking in understanding of mule behaviour and learning. Environmental conditions were often hard; the negotiation of difficult terrain and challenging weather conditions during monsoon and subsequent high-altitude working without acclimatisation likely pushed mules to their biological limits. This study investigates the lives of a population of mules in the mountains of Nepal, developing a better understanding of their needs and their 'truth' or 'telos' informing what measures will help them to thrive.
NGOs utilise a range of programming to bring about desired changes. This study examines the advantages and limitations of the range of approaches used by one particular NGO sector: working equid welfare organisations, from the perspective of NGO staff. NGO staff hold a wealth of knowledge regarding the design and implementation of welfare improvement initiatives; however this knowledge is rarely systematically documented. Through 32 semi-structured interviews the experiences of staff across multiple organisations were explored. The nine most commonly utilised approaches within equid focussed NGO programming were discussed with participants. Many themes resulting from the interviews centred around the strengths and disadvantages of these individual approaches, implemented both historically and presently by different NGOs. The influences of the context in which initiatives took place and barriers to welfare improvement that existed across approaches were also examined. Striking a balance came through as a strong theme at many levels. Balancing top-down versus bottom-up approaches was a frequently voiced concern, as was balancing the utility of certain approaches against associated factors warranting caution. Combinations of approaches that were felt to be complementary provided a balance that drew on the strengths and mitigated for the weaknesses of different approaches. The need to tailor approaches to individual contexts was also raised and is especially relevant to INGOs working across multiple countries, cultures and political structures. The study provides an informed insight into potential factors to consider when designing future welfare initiatives. The collaborative pooling of experience across different NGOs could help make welfare initiatives more effective and provide a framework for NGOs in other fields to learn from each other's collective knowledge.
Developing Countries , Organizations , Animals , Humans
Donkeys (Equus asinus) are facing a global crisis. Their welfare, and even survival, is being compromised as the demand for their skins increases. This demand is driven by the need to supply raw materials to produce ejiao, a Traditional Chinese Medicine made from collagen extracted from donkey skins. Since there is no productive chain for donkey skin production outside of China, the global trade is an entirely extractive industry that has resulted in the decimation of some local donkey populations. The donkey skin trade is demonstrably unsustainable, from the ethical issues associated with poor welfare, to the biosecurity and human health risks the trade poses; and it violates both legal frameworks and moral expectations at both a national and global level.
This paper challenges assumptions that the health management of working equids among some of India's poorest communities is mainly dependent upon income, economic influence, or access to veterinary services. Using a mixed-methods approach, hierarchies of treatment practices are revealed through an examination of the 'lived experience' of equid owners in brick kilns and construction sites in northern India. Semi-structured interviews with 37 equid owners and corresponding livelihood surveys, combined with data from two focus groups with professional animal health practitioners and the welfare data of 63 working equids collected using the Equid Assessment, Research, and Scoping (EARS) tool, contributed to the findings of the study. Four principal influencing factors were found to affect the decision-making practices of equid owners. Infrastructural factors, community characteristics and experience, owners' characteristics and experience, and economic factors all impact the belief structures of equid owners. However, without verifying the validity of the treatment measures being employed, some animals are at risk from hazardous treatment behaviours. By understanding decision-making using the theory of planned behaviour, the findings of this study can provide a crucial contribution to informing future interventions involved in the health management and welfare of working equids.
Working equids play an essential role in supporting livelihoods, providing resilience and income security to people around the world, yet their welfare is often poor. Consequently, animal welfare focussed NGOs employ a range of initiatives aimed at improving standards of working equid welfare. However, there is debate surrounding the efficacy of welfare initiatives utilised and long term monitoring and evaluation of initiatives is rarely undertaken. This study compares equid welfare and the social transmission of welfare information across Mexican communities that had previously received differing intervention histories (veterinary treatment plus educational initiatives, veterinary treatment only and control communities) in order to assess their efficacy. Indicators of equid welfare were assessed using the Equid Assessment Research and Scoping tool and included body condition score, skin alterations, lameness, general health status and reaction to observer approach. Owners were interviewed about their involvement in previous welfare initiatives, beliefs regarding equid emotions and pain, and the social transmission of welfare knowledge, including whether they ask advice about their equid or discuss its health with others and whether there is a specific individual that they consider to be 'good with equids' in their community. In total 266 owners were interviewed from 25 communities across three states. Better welfare (specifically body condition and skin alteration scores) was seen in communities where a history of combined free veterinary treatment and educational initiatives had taken place compared to those that had only received veterinary treatment or control communities. The social transfer of welfare knowledge was also higher in these communities, suggesting that the discussion and transfer of equid welfare advice within communities can act as a mechanism to disseminate good welfare practices more widely. Our results suggest that using a combined approach may enhance the success of welfare initiatives, a finding that may impact future NGO programming.
Animal Husbandry/methods , Animal Husbandry/statistics & numerical data , Animal Welfare/statistics & numerical data , Animals , Equidae , Female , Horses , Knowledge , Male , Mexico
Assessment of chronic pain is very important for monitoring and improving welfare and quality of life in donkeys. Freedom from disease and pain is one of the 'five freedoms' underlying animal welfare. The aim of the current study was to develop a pain scale for assessment of chronic pain in donkeys (Donkey Chronic Pain Scale; DCPS), including behavioural and facial expression-related parameters. The scale was applied to 77 donkeys (38 donkeys diagnosed with chronic health problems by means of clinical examination and additional diagnostic procedures and 39 healthy control animals). Animals were assessed twice daily for three consecutive days by two observers that were not masked to the condition of the animals but were unaware of the analgesic treatment regimens. Both composite, facial expression-based and combined DCPS pain scales showed excellent inter-observer reliability (Cronbach's alpha = 0.98, 0.96 and 0.98 respectively; P < 0.001). Individual composite and facial expression-based pain scores and the resulting combined DCPS showed significant differences between donkeys with chronic conditions and control donkeys at all time points (P < 0.001). A DCPS cut-off of 6 showed good sensitivity and specificity (92% and 82.5% respectively) for presence of a chronic painful condition. Facial expression-related parameters separately showed low sensitivity. In conclusion, it is possible to use a composite pain scale for assessment of chronic pain in donkeys, based on behavioural and facial expression-based parameters. Further studies are needed to validate this pain scale before it can be used in veterinary practice.
Chronic Pain/veterinary , Equidae , Pain Measurement/veterinary , Animal Welfare , Animals , Behavior, Animal , Chronic Pain/physiopathology , Facial Expression , Observer Variation , Pain Measurement/methods , Sensitivity and Specificity
Three donkeys were presented with progressive lameness and distal suspensory ligament breakdown in multiple limbs. Treatment with nonsteroidal anti-inflammatory drugs was only partially effective and eventually the donkeys were euthanized due to further progression of the lameness and concerns for their welfare. At necropsy, the distal part of the suspensory ligaments in multiple limbs, including the suspensory ligament branches, was markedly thickened, enlarged, and mottled white and brown on cut section. In one case, adult Onchocerca sp. nematodes were grossly identified embedded within the suspensory ligaments. Histopathologic examination revealed chronic, multifocal to coalescing, moderate to severe, lymphoplasmacytic, eosinophilic, and fibrosing desmitis and tendinitis with intralesional, coiled adult nematodes of Onchocerca sp., accompanied by osseous and cartilaginous metaplasia. To the authors' knowledge, this is the first histopathologic description of suspensory ligament desmitis and tendinitis associated with Onchocerca sp. in donkeys.
Horse Diseases , Lameness, Animal , Animals , Equidae , Horses , Ligaments , Onchocerca
BACKGROUND: Factors affecting working equid welfare are wide-ranging and reflect cultural, economic and climatic conditions, the type of work equids are used for, and individual differences in the practices of their handlers. In Mexico working equids are widely used for facilitating agricultural activities, however, welfare issues are common. OBJECTIVES: To assess working equids across three communities in Mexico, identify predominant welfare problems and document how these problems vary across locations, associated working roles and species type. STUDY DESIGN: Cross-sectional survey. METHODS: The study combined the administration of a wide-ranging questionnaire to equid handlers/owners and a welfare assessment of their animal. 120 equid owners were asked about their equid management practices, the working conditions and health status of their animal. The welfare of their equids (56 donkeys, 7 mules, 57 horses) was assessed by evaluating body condition, signs of illness or injury and behavioural indicators. RESULTS: Welfare varied by species, working role, sex and location. The poorest welfare was seen in one of the two arid regions (the third location having a tropical climate). Donkeys had poorer welfare than horses, and equids used for packing had poorer welfare than those used for riding and agroforestry. Overall poor body condition and wounds were the most common problems seen. MAIN LIMITATIONS: Work type, species type and location strongly co-varied, thus the impact of each factor could not be assessed in isolation. The sample size was relatively small. CONCLUSIONS: Results showed significant regional variations in welfare, suggesting that environmental and/or cultural variations are producing a major effect on welfare.
Animal Welfare , Equidae , Animals , Cross-Sectional Studies , Horses , Mexico , Surveys and Questionnaires
BACKGROUND: Across Asia the brick-kiln industry is expanding. In Nepal, urban dwelling has increased in recent years, raising requirement for low-cost, mass produced bricks to meet the population needs. Working equids (WEs) play a key role in non-mechanised kilns. Assessing the welfare of these equids is the starting point to addressing concerns. In line with One Welfare principles, the health and welfare of animals, people and the kiln environment are interlinked. MATERIALS AND METHODS: In December 2019, 119 WEs were assessed in seven brick kilns in three districts of Nepal, using the Equid Assessment Research and Scoping tool, developed by The Donkey Sanctuary. The objective was to measure welfare at the start of the brick kiln season. RESULTS: Horses were the predominant species of WE. Hazardous housing and environments were seen in all kilns. Behaviour responses were mixed. Owner responses and animal examination indicated poor working conditions. Signs of harmful practice were evident in most animals. The majority were underweight, with poor general health, skin alterations and musculoskeletal issues. CONCLUSION: The welfare of equids prior to starting brick kiln work is poor, posing significant concerns for the actual working period. Intervention to enhance health and welfare is required.
Animal Welfare/statistics & numerical data , Animal Welfare/standards , Equidae , Manufacturing Industry , Animals , Nepal
Multidrug resistance (MDR) is already occurring among some equids in India. Donkeys and mules are a mobile species moving between regions and international borders, often populating areas of India where private community pharmacies, or medical stores, are the primary healthcare provider for both humans and animals. This article highlights how the capacities of drug retail outlet workers might affect their antibiotic dispensing practices, particularly in relation to donkeys and mules, in order to consider how this might impact the development of antimicrobial resistance (AMR) on a wider scale. A mixed-methods approach was implemented using patient simulation method (n = 28), semi-structured interviews (SSIs) (n = 23), focus group discussions (FGDs) with veterinary practitioners and non-governmental organisation animal health workers (n = 2 FGDs), and participant observation. Fewer than 48 per cent of drug retail outlet workers admitted to having had any formal training in pharmaceuticals at all, while 78 per cent reported having no formal training in animal-related pharmaceuticals. Moreover, 35 per cent of all participants sold antibiotics without a prescription, unprompted and without specifically being asked for antibiotics. Of the antibiotics dispensed, only 21 per cent were correctly dispensed for the symptoms presented, and all dosages dispensed were incorrect (underdosed). Furthermore, 43 per cent of drug retail outlet workers interviewed believe that some antibiotics can be legally dispensed without a prescription. Equine owners in northern India are frequently being sold antibiotics without a prescription and, in most cases, with incorrect diagnoses, treatment choice, and dosage. A substantial gap in capacities exists amongst Drug Retail Outlet (DRO) workers, with few being sufficiently qualified or trained to dispense antibiotics to animal owners. The study highlights the need for further training of private DRO workers as well as knowledge extension and awareness training for both DRO workers and animal owners regarding antimicrobial resistance and its potential impact upon livelihoods. It also illustrates the need to identify a balance whereby greater enforcement of regulation at all levels is implemented, while at the same time maintaining sufficient access to medicine for rural populations.
Equids fulfil many different roles within communities. In low- to middle-income countries (LMICs), in addition to providing a source of income, equids also provide essential transport of food, water, and goods to resource-limited and/or isolated communities that might otherwise lack access. The aim of this investigation was to understand the welfare conditions that donkeys, mules, and horses are exposed to whilst working in Nepalese brick kilns. To understand the welfare conditions of equids in Nepalese brick kilns, the Welfare Aggregation and Guidance (WAG) tool in conjunction with the Equid Assessment, Research and Scoping (EARS) tool was used to understand the health, behaviour, nutrition, living and working conditions in brick kilns. Further analysis of individual EARS responses focused on key indicator questions relating to demographic information was used to investigate specific areas of welfare concern and attitudes of handlers towards their equids. Trained staff carried out welfare assessments between December 2018 and April 2019. The information gathered using the EARS tool was summarised using the WAG tool to pinpoint areas of welfare concern and suggest possible strategies to mitigate poor welfare conditions and suggest areas to improve the welfare of equids. Overall, the results indicate that to improve the welfare of equids working in Nepalese brick kilns, there should be better provision of clean water, both when working and stabled, equipment should be removed and shade provided during rest periods, with improvements made to housing to allow the equids to rest and recuperate when not working. Further work should also focus on collaborating with owners and equid handlers to improve their attitudes and practices towards their equids. Such improvements can be implemented via training of equid handlers and kiln owners whilst using the EARS and WAG tools to provide a sound basis on which to monitor the effectiveness and impact of education programs on equid welfare.
Recently, the need for a more holistic approach to welfare assessment has been highlighted. This is particularly pertinent in the case of working equids who provide vital support for human livelihoods, often in low- to middle-income countries, yet suffer from globally low standards of welfare. This study aimed to provide insight into the welfare status and traditional use of working equids in rural Western European communities using the new EARS welfare tool, designed to provide a broad view of the welfare of working equids and the context in which they are found. Other questions on the topics of equid management practices, social transmission of expertise, environmental stressors, and traditions, alongside physical and behavioural welfare assessments were also included to explore the impact of these wide-ranging factors on an understudied population of working equids. The protocol was trialled on 60 working equid owners from communities in Portugal and Spain where, despite the decline in traditional agricultural practices and livestock keeping, donkeys and mules remain working animals. Many owners stated that the help donkeys provided was invaluable, and donkeys were considered to be important for both farming and daily life. However, participants also recognised that the traditional agricultural way of life was dying out, providing insights into the traditional practices, community structure, and beliefs of equid owners. Questions investigating the social networks and social transfer of information within the villages were effective in finding local sources of equid knowledge. Overall, welfare was deemed fair, and the protocol enabled the identification of the most prevalent welfare problems within the communities studied, in this case obesity and the use of harmful practices. The findings suggest that the new protocol was feasible and detail how contextual factors may influence equid welfare. Increasing understanding of the cultural context, social structure, and attitudes within a community, alongside more traditional investigations of working practices and animal management, may, in the future, help to make equid welfare initiatives more effective.
Non-governmental organizations (NGOs) work across the globe to improve the welfare of working equids. Despite decades of veterinary and other interventions, welfare issues persist with equids working in brick kilns. Engagement with all stakeholders is integral to creating abiding improvements to working equid welfare as interventions based purely on reactive measures fail to provide sustainable solutions. Equid owners, particularly those in low to middle-income countries (LMICs), may have issues such as opportunity, capacity, gender or socio-economic status, overriding their ability to care well for their own equids. These "blind spots" are frequently overlooked when organizations develop intervention programs to improve welfare. This study aims to highlight the lives of the poorest members of Indian society, and will focus on working donkeys specifically as they were the only species of working equids present in the kilns visited. We discuss culture, status, religion, and social influences, including insights into the complexities of cultural "blind spots" which complicate efforts by NGOs to improve working donkey welfare when the influence of different cultural and societal pressures are not recognized or acknowledged. Employing a mixed-methods approach, we used the Equid Assessment Research and Scoping (EARS) tool, a questionnaire based equid welfare assessment tool, to assess the welfare of working donkeys in brick kilns in Northern India. In addition, using livelihoods surveys and semi-structured interviews, we established owner demographics, socioeconomic status, ethnicity, religion and their personal accounts of their working lives and relationships to their donkeys. During transcript analysis six themes emerged: caste, ethnicity, inherited knowledge; social status, and impacts of ethnic group and caste; social status and gender; migration and shared suffering; shared suffering, compassion; religious belief, species hierarchy. The lives led by these, marginalized communities of low status are driven by poverty, exposing them to exploitation, lack of community cohesion, and community conflicts through migratory, transient employment. This vulnerability influences the care and welfare of their working donkeys, laying bare the inextricable link between human and animal welfare. Cultural and social perspectives, though sometimes overlooked, are crucial to programs to improve welfare, where community engagement and participation are integral to their success.
Animal welfare can be represented by an array of indicators. There is, however, increasing demand for concise welfare assessments that can be easily communicated and compared. Previous methods to aggregate welfare assessments have focused on livestock systems and produced a single welfare score, which may not represent all aspects of welfare. We propose an aggregation method for the recently developed Equid Assessment Research and Scoping (EARS) welfare assessment tool that results in grades for five welfare categories: housing conditions, working conditions, health, nutrition, and behavior. We overcome the problems associated with existing approaches by using a single aggregation method (decision trees) that incorporates the most important welfare indicators in a single step. The process aims to identify equids with the poorest welfare and aid decision-making when allocating resources. We demonstrate its application using a case study of over 6000 equids across Europe and Asia, where equids in India and Pakistan had the poorest welfare status in terms of health (respiratory disease and open wounds) and behavior (signs of fear and distress, and limb tethering practices). We recommend identification of the specific causes of these issues, using either existing detailed welfare data or through issue-specific assessments by an appropriate professional, to guide the development of appropriate interventions and, ultimately, improve equid welfare.
Working donkeys (Equus africanus asinus) are vital to the development and support of people's livelihoods in rural, peri-urban, and urban areas of Ethiopia. However, despite their critical role in providing transport, food security, and income generation to some of the poorest and most marginalized households, donkey contributions to human livelihoods have been largely unexplored. Donkey users, veterinary surgeons, business owners, and civil servants were interviewed to investigate the role humans play in shaping donkey lives while furthering our understanding of the social and economic impacts of working donkeys to human lives. Findings are discussed through seven guiding themes; donkeys as generators of income, the relationship between donkeys and social status, donkeys and affect, empowerment through donkeys, the role of donkeys in reducing vulnerability and encouraging resilience, donkey husbandry, and gender dynamics all of which gave a broader and richer insight into the value of donkeys. Donkeys are an important support in rural, peri-urban, and urban settings through the creation of economic security, independence, and participation in local saving schemes. In addition, donkeys provide social status, empowerment to marginalized groups such as women and the very poor and provide a sense of companionship. Whether the interviewee was a donkey user or a key informant appeared to influence their views on donkeys and their welfare, as did their location. The variations in views and practices between urban and rural settings suggests that assessing the socioeconomic value of donkeys in different locations within the same area or country is critical, rather than assuming that similar views are held between compatriots. Despite their centrality to many people's lives in Ethiopia, working donkeys often hold lowly status, are misunderstood, and given little husbandry and healthcare.
Objective pain assessment in donkeys is of vital importance for improving welfare in a species that is considered stoic. This study presents the construction and testing of two pain scales, the Equine Utrecht University Scale for Donkey Composite Pain Assessment (EQUUS-DONKEY-COMPASS) and the Equine Utrecht University Scale for Donkey Facial Assessment of Pain (EQUUS-DONKEY-FAP), in donkeys with acute pain. A cohort follow-up study using 264 adult donkeys (n = 12 acute colic, n = 25 acute orthopaedic pain, n = 18 acute head-related pain, n = 24 postoperative pain, and n = 185 controls) was performed. Both pain scales showed differences between donkeys with different types of pain and their control animals (p < 0.001). The EQUUS-DONKEY-COMPASS and EQUUS-DONKEY-FAP showed high inter-observer reliability (Cronbach's alpha = 0.97 and 0.94, respectively, both p < 0.001). Sensitivity of the EQUUS-DONKEY-COMPASS was good for colic and orthopaedic pain (83% and 88%, respectively), but poor for head-related and postoperative pain (17% and 21%, respectively). Sensitivity of the EQUUS-DONKEY-FAP was good for colic and head-related pain (75% and 78%, respectively), but moderate for orthopaedic and postoperative pain (40% and 50%, respectively). Specificity was good for all types of pain with both scales (91%-99%). Different types of acute pain in donkeys can be validly assessed by either a composite or a facial expression-based pain scale.
The assessment of animal welfare poses numerous challenges, yet an emerging approach is the consolidation of existing knowledge into new frameworks which can offer standardised approaches to welfare assessment across a variety of contexts. Multiple tools exist for measuring the welfare of equids, but such tools have typically been developed for specific contexts. There is no 'one size fits all' which means that resulting datasets are generally non-comparable, creating a barrier to knowledge-sharing and collaboration between the many organisations working to improve equid welfare around the globe. To address this, we developed the Equid Assessment, Research and Scoping (EARS) tool, which incorporates pre-existing validated welfare assessment methods alongside new welfare indicators to deliver a larger and more comprehensive series of welfare indicators than currently exists, creating a single resource that can be used to assess equid welfare in any context. We field-trialled three welfare assessment protocols within the EARS tool, and applied these to welfare assessment of equids in a variety of contexts across nineteen countries. The EARS tool proved a useful, versatile and rapid method for collecting welfare assessment data and we collected 7464 welfare assessments in a period of fifteen months. We evaluate the EARS tool and provide ideas for future development.
