With the aim of preventing children from being exposed to secondhand smoke, we examined to which level lower socio-economic status (SES) households had implemented home smoking rules and the factors that hampered parents in their process of change toward a complete smoke-free home (SFH). We conducted a qualitative study including semi-structured in-depth interviews with 14 parents of young children living in a lower SES neighborhood of a provincial town in the Netherlands. Interview transcripts were subjected to a qualitative content analysis. Three distinct levels of SFH implementation emerged: complete SFH, flexible SFH, and partial SFH. Differences between parents at these three levels essentially concerned: (1) the role of child-related moral considerations in their motivation for an SFH; (2) whether they felt they had the agency to set and enforce home smoking rules; (3) the difficulties they experienced in changing their smoking habit from smoking indoors to smoking outdoors. Parents also had different opinions about the role their children could play in facilitating the parental process of change. We conclude that the current level of SFH implementation may serve as a starting point for developing tailored interventions. Such interventions should probably address other factors than the commonly used awareness–knowledge–commitment approach. Worldwide, 40% of children are exposed to secondhand smoke . The preA promising preventive action in this respect is the—voluntary—implementation of smoke-free homes (SFHs). Having an SFH implies that both family members and visitors are prohibited from smoking anywhere inside the home . SFHs haA potential solution is to use interventions to support parents in the implementation of an SFH. Many of the current SFH interventions are school-based and offer information, education and/or a smoke-free promise for families to sign ,20,21,22Examining the parental process of change that leads to an SFH could provide useful information . A recenIn sum, especially in lower SES households, the proportion of SFHs is low ,5,6, whiBetween May and July 2017, we performed a qualitative study in which we held semi-structured in-depth interviews with smoking and non-smoking parents living in a lower-SES neighborhood of a provincial town in the Netherlands. In 2016, this neighborhood scored 9 on an SES indicator scale  ranging from 1 (high SES) to 10 (low SES).The inclusion criteria for parents were: being 18 years or older, having at least one child aged 0–14 years, being part of a household in which at least one adult smokes or has smoked in the past, or with regular visits by smokers, being able to speak and understand Dutch, and having no crisis situation in the family, such as being mixed-up in a divorce, as to avoid family tensions arising or intensifying. Parents were recruited within their own neighborhood, at schools, community centers, and local events . The main recruiters were the second author [R.I.O.] and other officials from the Regional Public Health Service. They were supported by local health care providers and social workers. The best recruitment strategy appeared to be person-to-person talks in which local residents were invited to participate in a study about smoking in the home environment without raising the subject of SFHs. These talks were supported by flyers with information about the study. About 100 local residents had to be approached to reach a sufficient sample size.Interviews were conducted by the second author [R.I.O.] at parents’ homes or local community centers. Parents signed an informed consent form before the start of the interview. Interviews took approximately one hour, and addressed topics such as family composition, living condition and smoking behavior, current home smoking rules, and the motivation for, intention to, and process of implementing an SFH see . The intTranscripts were subjected to a qualitative content analysis  in MaxQDThe first three transcripts were coded independently by two authors [EvW and R.I.O.]. They discussed their differences regarding the coding of these transcripts and memos about newly emerging themes  until consensus was reached. For some themes , new sub-codes were added to the thematic framework for further analysis. The remaining transcripts of the interviews were independently coded by one of the authors. They checked each other’s coded transcripts and memos and discussed disagreements until they reached consensus. The definitions of codes and sub-codes were continuously updated during this process.In the subsequent cross-case analysis, the first and last authors [E.C.v.W. and J.H.] compared the levels to which respondents had implemented an SFH by reading through the full transcripts again while taking into account the memos and coding. Three different implementation levels emerged: complete SFH, flexible SFH, and partial SFH. For each of these three levels, the first author [E.C.v.W.] summarized the codes and sub-codes for home smoking rules, and the motivation for, intention to, and process of implementing an SFH in three separate matrices . The comAccording to the Dutch Medical Research Involving Human Subjects Act, this study did not require approval by a medical research ethics committee in the Netherlands. However, the research proposal was reviewed by the independent funder of the study. In addition, the procedure to obtain informed consent underwent internal peer review. We followed the ethical principles for medical research involving human subjects, as laid down in the Declaration of Helsinki and adopted by the World Medical Association.n = 14) included five parents with a complete SFH, three with a flexible SFH, and six with a partial SFH. Most respondents were female (n = 13) and smoked (n = 8). The mean age of the respondents was 38.8 years (SD = 5.0), the mean age of their children 8.3 years. Ten respondents had a partner, most of whom smoked (n = 6), about half had a paid job (n = 8). The majority lived in a single-family home (n = 10), while the others inhabited an apartment (n = 4).The study sample The start of an SFH had always been part of a life transition, due to, for instance, pregnancy, childbirth, moving house or renovations, while the parents’ primary motivation for an SFH was the health and well-being of their children.“The fact that my children would inhale smoke, that will bother them. I mean, as a mother, I don’t want that for my children, I just want them [...] to live in a healthy home.”In addition, smoke was perceived as ‘filthy’.Parents with an SFH tended to strictly enforce the smoking rules, in which they succeeded by high levels of assertiveness and willpower, despite initial resistance among smokers and the risk of losing touch with friends or family.“I used to have some friends when I was still living in that flat, and I actually lost them because they found it [the implementation of an SFH] ridiculous. I said: ‘Why do you think it’s ridiculous? It’s my life. After you’ve left I’m sitting there in the stench’ [...] But I do think that when you have children, you have to take that into account. You want your children to grow up healthy.” Most smoking family members and friends accepted the rules after a while, and now they all automatically went outside to smoke. Barriers to the implementation of an SFH were hardly reported. Facilitators were related both to the built environment  and the social environment .“Nowadays, everyone just asks if they may smoke inside, and then it’s also very easy to say: ‘no, there’s no more smoking indoors’.” In households that included at least one smoker, respondents experienced some additional advantages of an SFH, such as a healthier living environment and less smoking by the smoker.“When you smoke indoors it’s very easy to light a cigarette. Now you have to make the effort because you have to go all the way outside, so then you’re going to smoke less, and that was also a reason for me, I thought like, you know, that I would smoke less.” Few respondents identified a role for their children in the implementation of an SFH, such as putting pressure on parents, reminding them of the rules, or setting home smoking rules together.“I think [as a parent] you’re more confronted with the arrangements you make with your children.” Although all respondents with a flexible SFH smoked , they to“We used to smoke inside the home before we got children. In principle, we still don’t smoke inside the home. It happens sometimes, for instance when we have visitors or have a party or things like that.”  For these parents too, the start of an SFH had been part of a life transition, but their primary motivation originated from actual or anticipated feelings of guilt. Children do not choose to be exposed to smoke, and parents were afraid to be blamed for it if their children became ill in the future.“But at any rate I don’t want her to say, later, yes my mother used to smoke, and now I have this. That it’s my fault. That I feel that it would be my fault if she gets ill.”  Additional motives for implementing an SFH were health or wellbeing in general and a clean and fresh-smelling house.“It’s also for the children, but also because I just find it’s filthy inside. Everything stinks and turns yellow, I think it’s filthy. It means I don’t have a fresh-smelling house.”  Parents with a flexible SFH were less passionate and assertive, and thus more relaxed in their discussion and enforcement of the home smoking rules.“What has occasionally happened, is that when we’re sleeping, the children and I, and my friend is still awake, and he gets a visitor, then they sit here at the table to talk, and then they sometimes light a cigarette, but it’s not a rule or a habit. […] I don’t have so many problems with it, although I still think it’s a pity that it happens. […] It’s not such a problem.” Although the rules were accepted, the smoking parents had found it quite hard to break their own strong habit of smoking indoors, for instance on the couch while watching TV. Although it took some time, they eventually succeeded in changing this habit to mostly smoking outdoors.“We didn’t quit smoking indoors from one day to the next [...] In the beginning, we also occasionally lit a cigarette when we were watching TV in the evening and the children were already sleeping upstairs. But at a certain point, that was no longer necessary, because you grow accustomed to it [only smoking outdoors]. You know that you’re breaking the rule when you smoke inside. You gradually phase it out, and now I can say for myself when I watch TV: ‘I don’t even want to smoke’.”  A typical facilitator in the built environment was having a comfortable outdoor place to smoke. Other facilitators were having the necessary willpower, removing ashtrays from the home, and planning a farewell ritual .“It was, like, this is the last night, now smoking is still allowed in the house, and after today it’s finished. Tomorrow I’m going to wash the curtains, wash the pillows. And that’s how it went.” A common barrier to smoking outdoors was bad weather. However, in combination with the home smoking rules, bad weather conditions could also serve as an encouragement not to smoke—at least temporarily.“Then I just don’t smoke [when it is raining], unless that monster [smoking addiction] should be so bad and it’s dark in the evening, then I would sometimes secretly smoke at the front door, but I think that’s no longer for the fun of it, so you better just suppress that monster and just go to bed.” Regarding the advantages experienced, for parents with a flexible SFH having a clean house seemed to be more important than a healthy home environment.“First smoke outside, and then decide to quit. But if you smoke outside, you can already start cleaning your house, and you will notice how fresh it smells.” children, such as supporting their parents in implementing home smoking rules.Parents with a flexible SFH also suggested a greater variety of roles for their “But they can involve their children [in programs to implement SFHs]. Give them the task to support mummy and daddy and to help their parents to remember or... Sure they’ll like that.” Nevertheless, implementing an SFH was seen as basically the responsibility of the parents.Most respondents with a partial SFH  were smo“There’s simply no smoking in the house, except for the kitchen, but nowhere else, not in the living room.” Although their primary motivation for these rules was also related to children, pregnancy, and childbirth had been a far less important stimulus. Also, the child-related motivation was often much less specific than the other motives, including the dirtiness of smoking, a new house, having puppies, being a non-smoker, or having a non-smoking partner.“Because my partner doesn’t smoke, and he says: ’I am in your smoke, and it stinks, and everything here smells, the living room, my clothes’. I’m a smoker, so I do not smell it that much, but for someone who doesn’t smoke, they notice it. And you also notice it in the morning that your living room is just not smelling very fresh when you’ve smoked.” They also had less pronounced motives to implement an SFH. These motives included their own health and that of others, as well as the smell of smoke and a lower frequency of smoking.“Yes, actually I want to [have an SFH]. […] Because it’s just better and healthier for my environment. […] Maybe I’ll be smoking less, that would be nice too.” Parents with a partial SFH were much more likely to violate their home smoking rules. This mostly happened when the children were away or asleep.“Especially when my son goes to his father every other weekend, and then he’s not here and then I tend […] to open all windows and doors and then I can smoke in the living room. That’s of course not what was intended. But that happens sometimes. Then I think, well, it’s easy, he’s not there, as if suddenly I’m doing it [only smoking in kitchen] just for him.”  The many exceptions and violations were partly the result of having unclear rules. This lack of clarity made it difficult to enforce the rules. In addition, both smoking and non-smoking parents felt that they were not in a position to initiate, communicate, reinforce, or strengthen home smoking rules.“Obviously, having a smoke-free house would be nice. But I’m not the one who smokes. So then it’s difficult to set the rules. I can’t decide for him [partner who smokes] and say to him: ‘From now on you go outside or you quit smoking’. You just can’t say that.” “It’s a bit of a concession [having a partial SFH]. […] For me as an occasional smoker […] I find it a little bit hypocritical to make the rules even stricter.” Characteristic was the parents’ struggle to change their habit of smoking anywhere in the home to a habit of smoking only in the kitchen. This habit change was perceived as a big step, since compared to the living room, the kitchen was seen as a much less comfortable place to smoke. Still, most parents viewed an SFH as the next step, albeit a difficult one.“I’m not in my kitchen for nothing, otherwise I would have sat on the couch. You know it’s not good. So why not take that step further? […] I also find that very difficult.” Perceived barriers to realizing a complete SFH were especially related to the built environment: having no outdoor space , having no comfortable or safe outdoor place to smoke, and bad weather.“And then in the evening, [...] it also feels a bit scary to smoke in the garden as a single parent. […] I think it’s just uncomfortable to smoke outside in the evening.” Perceived facilitators related to social support , skills and self-efficacy , and the built environment .“If I had such a shelter, so you’re dry outside, that would of course help a lot [to implement an SFH]. I’m indeed thinking about the evening hours.” At the same time, implementing an SFH was perceived as unrealistic, because changing the habit of smoking indoors, e.g., to relax or socialize, to smoking outdoors would be even more uncomfortable than smoking only in the kitchen. Therefore, most parents thought they could just as well quit smoking.“Because then it [implementing an SFH] would be the same as if he would quit smoking. We live in an upstairs apartment. […] We don’t have a balcony or a garden, so we really have to go downstairs and then smoke in front of the front door. That also looks a bit weird. But no, that’s just not convenient, so we never actually talked about it.” Most parents with a partial SFH saw a substantial role for their children in the implementation of an SFH, such as confronting parents with their smoking behavior, reminding parents of rules, determining a reward for implementing an SFH, and supporting parents in smoking cessation. This is what some children actually already do.“I’ve been told by my son that I must smoke outside. […] And then I will consider it. […] He says: ‘You’re going to die of smoking and if you want to smoke that’s your own concern. But I don’t want it in my presence’, so could I just go outside.” However, not every parent agreed with giving children such a role, as they thought it was the smokers themselves who were responsible.In our qualitative study among lower SES parents, we noticed three levels of SFH implementation: complete SFH, flexible SFH, and partial SFH. In addition, we found that the factors influencing the process of creating an SFH were likely to be related to the level to which the household had currently implemented home smoking rules. Between these three implementation levels, parents essentially differed regarding: (1) the role of child-related moral considerations in their motivation for an SFH; (2) whether they felt they were in the position to set and enforce home smoking rules; (3) the difficulties they experienced in changing their habit from smoking indoors to smoking outdoors. Finally, we saw differences in the parents’ opinions about the role children could play in facilitating the process of change leading to an SFH.The factors we identified largely correspond to those reported in a recent review study . HoweverIn our study, parents who differed in the level to which they had implemented home smoking rules also differed in their moral considerations regarding an SFH. For parents who had realized a complete SFH, the primary motivation had been their parental duty to protect the child’s health and wellbeing. In line with the self-determination theory (SDT) ,35, thisNotably, most SFH interventions we know of have tended to focus on the parent’s attitudinal motivation in terms of increased awareness, knowledge, and commitment regarding the risks and prevention of child exposure to secondhand smoke ,15,16,17In our study, parents without a complete SFH often felt they were not in a position to set and enforce home smoking rules. This may relate to the concept of personal agency, meaning that “people bring their influence to bear on their own functioning and on environmental events” . The parSo far, most interventions to support parents in the implementation of an SFH have aimed at strengthening the children’s, rather than the parents’, self-efficacy and skills, although we are aware of some exceptions ,21,22,23Whether children should indeed have a role in strengthening parental agency, as was also suggested by parents in our study, seems questionable. Although previous studies illustrated the feasibility of such a role ,14,15, mOur results confirm the earlier finding that the habit of smoking inside the home is hard to break ,27,44. THowever, just as in other studies ,27,44, wIf an acceptable outdoor space is lacking, our findings indicate that parents may feel they could just as well quit rather than set more restrictive home smoking rules. Although quitting is very difficult for lower SES smokers , our resOur study was subject to some limitations. First, it was a cross-sectional qualitative study . Our resSecond, due to our small sample size, we may not have reached data saturation for all three levels of SFH implementation . Also, tThird, our sample is presumably a selected group, that is not representative in every respect. For instance, most respondents were women. Also, the sample did not include parents without home smoking rules , nor didIf we want to prevent children from being exposed to secondhand smoke, interventions to support parents in creating a smoke-free home (SFH) could start from the current level to which households have already implemented home smoking rules. Factors influencing the process of parental change toward a complete SFH differed between implementation levels, which provides opportunities for tailored intervention development. Such tailored interventions should most probably take a different approach than the awareness–knowledge–commitment SFH interventions commonly used so far.


Various establishments exist in which animals are held for a variety of reasons. Historically, the management and inspection of animals in commerce and in private keeping have involved a considerable degree of arbitrary evaluation based on the personal experience of the vendor, keeper, advisor, or inspector. Accordingly, relevant protocols and standards are subject to considerable variation. Relatedly, diversity of traded and privately kept species generates significant challenges for those responsible for facility management and inspection alike. Animal welfare and public health and safety are constant and major concerns that require objective methodologies to monitor and control. This report focuses on establishments concerned with the boarding, breeding, storage, vending or handover of animals intended for human “companions” or “pets”, and aims to provide universal objective information for essential husbandry, inspection protocols and an allied inspection assessment tool for scoring establishments. In the UK alone, there are estimated to be ~5,000 dog breeding centers and 4,500 pet stores . At leasHistorically, the management and inspection of animal establishments, both in commerce and in private keeping, have involved a considerable degree of arbitrary evaluation based on the personal experience of the vendor, keeper, advisor, and inspector. Relevant protocols and standards are subject to wide variation, both locally and internationally . In addiRelatedly, scientific reviews and allied provision of tools for assessing the suitability of species are also available –35. NoneThis report focuses on establishments concerned with the boarding, storage, breeding, vending or handover of animals intended as human “companions” or “pets”, and aims to provide universal objective information for both inspection protocols and essential husbandry. In order to enhance objectivity for any inspection process, we have proposed a novel scoring system. Using this scoring system, a “traffic light,” “star rating” or simple 0–3 number ranking can be utilized to “flag” or grade the facility in a manner not dissimilar to that adopted for restaurants and other establishments.prima facie relevance were identified and reviewed for content that included combined guidance on animal husbandry and facility inspection, together with provision of an allied inspection assessment tool. Fifteen articles and reports were considered to be cogent. None of the identified items achieved the “three-asset” resource target. Essentially, the most welfare generous recommendations were selected from any reviewed publication. In addition, a working consultation group of independent experts familiar with animal husbandry and inspection provided input and also conducted reviews of the present guidelines thereby allowing high-level impartial experiential contributions in all relevant areas. Accordingly, this review primarily utilized literature-based evidence, and secondarily expert-led, experiential-based information, particularly in respect of the specific guidance sections.We conducted an online literature search using Google Scholar, EMBASE, MEDLINE, Royal Society of Medicine, VetMed Resource, and Murdoch University and used the following key terms: animal, establishment, inspection, guidelines, companion, pet, best practice, husbandry, boarding, breeding, storage, wholesale, retail, vending, enforcement, licensing; with a key objective being to identify items that fulfilled our “three-asset” resource target—namely resources that addressed guidance regarding animal husbandry, inspection, and provision of a relevant assessment tool to aid the guidance. Twenty three publications of Our research and review found several areas, for example those of relevance to establishment layout and quarantine protocols, where significant information was unavailable. However, these areas are important aspects of animal husbandry. Therefore, in areas of such information deficiency we have drawn on group consensus, some of which arguably is also “common sense,” for example avoidance of unnecessary environmental disturbances and other rational approaches to management.Terms used in this document are not intended to offer legal definitions, but are descriptions intended to clarify relevance and focus for both animal establishment managers and inspectors. Accordingly, meanings of the terms used herein are as follows:“Animal establishment”: any operation or premises including pet stores, boarding facilities, breeders, and rescue shelters or “sanctuaries” in which “companion” or “pet” animals are kept or intended to be kept for any period whether for commercial or other reasons, and that may be required to undergo inspection.“Companion” or “pet”: any animal kept or intended for personal, pleasure, or ornamental use rather than for agricultural food, sport, public exhibition, or research and experimental purposes.“Handover”: the passing of an animal from an establishment to a recipient, whether the recipient is another establishment or individual for any reason including sale, donation, and post-boarding release.Laws and regulations vary considerably across different nations and regions, therefore, it is essential that users of these guidelines independently ascertain any relevant legal requirements. It is beyond the scope of this article to attempt to present and discuss international regulations, laws, and cultural issues. Our aim is that, regardless of whether or not legal and cultural issues are well defined in a region or country, these guidelines may become aspirational and assist at some level to augment any structure or intention to determine or improve relevant issues. Animal establishment inspectors and managers have a legal or moral “duty of care” toward animals and the public, and should take reasonable steps in all circumstances to meet the welfare needs of the animals and to safeguard public health and safety to the extent required by good (preferably best) practice . WhetherFor example, in respect of animal welfare, The UK Farm Animal Welfare Council established the Five Freedoms for animal well-being , which aFive Freedoms:Freedom from hunger and thirst—by ready access to fresh water and a diet to maintain full health and vigor;Freedom from discomfort—by providing an appropriate environment including shelter and a comfortable resting area;Freedom from pain, injury or disease—by preventing them from getting ill or injured and by making sure animals are diagnosed and treated rapidly if they do;added: where appropriate);Freedom to express normal behavior—by providing sufficient space, proper facilities and company of the animal's own kind  should be established for inspection .The layout of the establishment must be assessed with the primary principle being the welfare of the animals. The atmosphere should be calm and quiet. The ambient lighting should be soft. Included in the assessment should be the ease of access for monitoring of the animals and cleaning of facilities.General positioning of cages should avoid undesirable potentially stressful situations where the presence of relevant predatory species may lead to stress in relevant prey species . AccordiCage stacking should be such that it avoids the risk of cross contamination, for example, feces, food, water, or substrate dropping into a cage from above. Animals must not be situated “too low down” where they may experience fright and stress from visitors or passers-by  . Cages sStaff should be sufficient in number and adequately qualified or experienced to maintain good supervision of both the premises and all animals . Where qInspection will assess the cleaning protocols and general hygiene conditions for the facility itself. This is separate and distinct from the individual cage cleaning and should be recognized as such by the facility.The overall assessment will firstly consider general odor. This should be fresh and free from any obvious noxious or foul smell , 48. Equcleanliness—should be assessed by establishing the absence of foul or atypical odors, infrequency or absence of “smears” and other overt debris on walls and furnishings, absence of “compacted” and thus likely old and soiled substrata, absence of “pest” invertebrates such as mites, flies, fly larvae, and specific feeder invertebrates such as crickets where these are ubiquitous and/or free-running from cage to cage , and the wider environment should always be considered potentially contaminated with both animal and human pathogens .Signage: Clear signage should be in place cautioning the public with regards to zoonotic infections  must be recorded in order to allow for contact tracing in the event of an epidemiological outbreak .All reasonable precautions must be taken to prevent the outbreak and spread of disease. No animal that is suffering from  any infectious disease or which is infested with parasites, shall be brought into or kept on the premises unless effectively isolated and quarantined , 53. SpeInspection will assess the length of quarantine given to each new batch of animals. Quarantine periods may vary according to the source and the species. Where animals are acquired from reliable distributors, quarantine may reasonably involve a minimum of 7 days. Where the reliability of supply sources is less well known or unknown, generally longer quarantine periods, for example, 30 days minimum , 55 are Animal foodstuffs should be stored in pest-proof closable/sealable containers to ensure that food does not unduly spoil. Where refrigeration or freezing of food is necessary, facilities should be inspected for both cleanliness and operation . Where lPreparation areas must be away from the public and managed so as to avoid cross contamination. Areas used for cleaning, for example, washing of food bowls, should be separate from food preparation areas. Food or drink for human consumption should never be kept in areas intended for storage or preparation of animal feed.All animals must be under regular supervision , 47, whiWhere dangerous wild animals are held at an establishment, all enclosures must be both structurally secure and lockable, and animals as well as enclosure locks must be inaccessible to the public. Accordingly, no enclosures should open directly into the public area.The local authority should be requested to determine suitable waste disposal for the establishment; a list of wastes must be drawn up by the licensee and their disposal agreed with the local authority .A list of wastes may include: soiled animal bedding including feces, urine, and vomit; foods that may have been contaminated; cadavers (dead bodies) of licensed animals, or feed animals; discarded, used animal items such as beds, hides, and toys.Staff must demonstrate to the satisfaction of the fire service or other relevant organization that they are at all times capable of safely evacuating all animals  from the facilities in a manner and time frame as determined by the fire service .A fire risk assessment document should be available for inspection, which will be prepared by the licensee and will list the areas of highest risk, as well as how these risks are mitigated. The fire risk assessment document must include a floor plan and details about fire monitoring equipment, fire fighting equipment, and escape routes. The risk assessment may need to be agreed on by the local fire service if not determined by them. Fire fighting and monitoring equipment must be appropriately serviced and maintained.All major electrical systems and fixtures should be installed by registered qualified professionals and certified as being safe on a regular basis. Documentary evidence of installation should be available to the satisfaction of inspectors.New electrical installations or portable equipment must have installation certification available. It is advised that equipment is regularly inspected and is compliant with all relevant local and national regulations.Establishments should publicly display a valid operational license, including on their websites .An inspection of protocols concerning animal movement, handover and veterinary records is essential along with assessment of the environment and health and welfare of all animals kept at the establishment.Establishments must maintain a comprehensive and regularly updated register of animals “in” and “out,” together with contact information concerning both the supplier of animals to the establishment as well as recipients to whom animals are handed over by the establishment. This process is intended to assist with the potential requirement for contact-tracing in the event of outbreak of disease .Veterinary records must be maintained for all animals that are under veterinary care and treatment . New acqAll transportation (and handling) of animals under the control of the establishment, including where handed over to acquirers, must be subject to independently approved (for example by a veterinarian) procedures and compliant with relevant legislation.Impulse buying of animals by the public should be discouraged . AnimalsAnimals should be discharged from the premises only when they are in a healthy state. Details of the animal must be provided to the new owner, including the source of the animal, the duration that the animal was held at the establishment, and any historical health or problematic behavioral issues noted and/or treated whilst in the care of the licensee . AnimalsInformation provided to new acquirers of animals must be scientific, evidence-based and independently prepared by relevant recognized experts with no conflict of interest in the nature of the business of the establishment . The useGuiding principles must be that the animal to be handed over meets all legal requirements and is capable of self-feeding, drinking, defecating, urinating, moving independently, and appropriately socialized . The aniTo be especially meaningful and relevant, guidance ought to be structured on a species-specific basis. However, the diversity of species currently available, as well as the variability of their biological needs and an associated dearth of species-specific information, prohibits highly detailed guidance . Also, eIn captive situations, “proper care” is impossible, but responsible management is feasible ;Species-specific information is essential , althougThere are no complete biological and behavioral profiles for any species ;Animals are probably living under conditions of controlled deprivation, even where the best species-specific information is available .Accordingly, although it is impossible to provide useful detailed species-specific information for the diversity of animals involved, this does not negate the potential benefit of providing broad concepts and principles of care that may at least provide some form of standardized recognition of biological needs, welfare and inspection. It is for all these reasons that this guidance exists. However, this guidance is not a “how to care for animals” instructional, nor is it an animal keeping promotional. Animal establishments exist, and these facilities require better-informed structure and inspection. This guidance is intended to assist those with responsibility for such inspections, as well as those managing establishments that are being inspected, by providing an information framework to enable better-informed decision-making and “safety-net” practices to help alleviate especially poor husbandry standards and to promote some fundamental universal management and welfare considerations.All animals ought to be able to express a natural range of behaviors including free movement, locomotion, climbing, play, and burrowing where appropriate for the species , 60–65. all animals to easily use any facility  at any one time, and allow for all normal behavior and exercise, and adequate escape from conspecifics and the public . Where very small species and individuals are involved see “absolute minimum enclosure size.” The diagram also intentionally does not include furnishings because it is a spatial reference only.Example A. tortoise: shell diameter  15 cm; X 10 = 150 cm minimum main linear dimension.Example B. snake: straight-line length 120 cm; coiled  diameter = 15 cm; X 10 = 150 cm minimum main linear dimension.Example C. lizard: total length 50 cm; coiled  diameter = 15 cm; X 10 = 150 cm minimum main linear dimension.Example D. bird: total length 20 cm; “rolled-up”  diameter = 15 cm; X 10 = 150 cm minimum main linear dimension.Example E. kitten: total length 35 cm; “rolled-up”  diameter = 15 cm; X 10 = 150 cm minimum main linear dimension.Example F. fish: total length 30 cm diameter  = 15 cm; X 10 = 150 cm minimum main linear dimension.Note: the tortoise (A), the kitten (E), and the fish (F) images provide examples of animals that are already “ball-like” in image/anatomy, thus these are represented using a single illustration each.Figure Where very small species and individuals are involved one must apply the principle of “absolute minimum” enclosure size to prevent, for example, animals measuring only a few centimeters being confined to “micro-environments,” which should be discouraged.Save as for short-term transportation, no enclosure should be <100 cm at its main linear dimension –85, withThe spatial minimum system above Figure  should bOvercrowding can be considered as having two “forms” “overt overcrowding” and “covert (or “crypto”) overcrowding” . The numNote: Summary principles for spatial issues and enclosure size.Estimate animal's body-size diameter in centimeters; multiply diameter by 10 to determine minimum required primary enclosure dimension . All other dimensions to be reasonably proportionate to primary dimension . No enclosure to have primary dimension <100 cm.Stocking density: Apply “crypto-overcrowding” principle . Where an enclosure meets this principle its stocking density has not been breached.In the following sections we have adopted deliberately broad criteria utilizing objective data pertaining to heat, light and humidity observed in the natural environment on a “zone-by-zone” basis—an approach used as broad guidance in reviewed literature The levels of, for example, heat and ultraviolet light, in nature may be extreme and avoided by animals at certain times. At other times, suboptimal levels of heat and light may result in deficiencies that cause animals to adopt compensation strategies when environmental resources are more abundant . Few detaccessible, but not imposed conditions, causing animals to have the ability to voluntarily choose both thermal and UV gradation as much as possible.Accordingly, considerable caution must be applied when using thermal and UVI maximums, because these are unlikely to represent species optimal levels . TherefoLighting must be appropriate to the species and this should include both appropriate periodicity of lighting as well as take account of diurnal and nocturnal habits , 58, 89.For many species, light (in its various forms) is an important component of health , 92. Lig“Open habitat” (such as grassland/prairie and desert) species are naturally exposed to high intensity UV light. These raised levels of UV light are frequently important to these species, and typically these animals possess physiological mechanisms to regulate their condition under such exposure.“Closed habitat”  species are naturally exposed to lower intensity UV light, and intensive UV exposure may result in eye injuries and otherwise compromise health. High-level exposure to cage-based UV can also harm the human observer's eyes.Essential UV light requirements may not correspond with the number of daylight hours. In nature, some animals, while active during the day, may not be directly exposed to strong or significant sunlight during this entire period whether due to habitat cover or deliberate heat or light avoidance . Relatedly, captive animal management (according to species) may involve deliberate UV exposure for only a portion of any single day.Diurnal species requiring UVB lighting should have appropriate UVB emitting lamps. These should be replaced according to manufacturer's recommendations. Mercury vapor or metal halide UVB emitting lamps may also be used to provide a daytime heat source. UV light sources must not be screened by non-UV transmitting glass or plastic . The distance from the UV radiation source must not be so close as to expose animals to excessive radiation, nor should it be for excessive periods. Animals should have areas of shade so that they can escape from the light if desired. No species should be subject to persistent invasive light . A day/night time period of (50% light/50 dark) is a broad guide, although crepuscular and nocturnal species' habits should be carefully considered.It is vital that lighting needs according to species are carefully managed. For example, nocturnal, crepuscular (twilight) and subterranean species should not be exposed to excessive levels or periods of light. Nocturnal species in particular, should not be exposed to invasive light on the basis of any display needs of the establishment. While it is important to position enclosures for light-sensitive species in less-invasive areas, this should not be taken to imply merely positioning cages in “dark” areas of a facility. Nocturnal and crepuscular species should have limited light sources dedicated to primarily low-level lighting that includes some UV component. Brighter areas and “warm” basking spots are acceptable, as long as these facilities are not major components of the environment. Significant specific welfare considerations arise in relation to nocturnal and crepuscular species because human activities frequently involve risk of disturbance and stress to animals, and also because keepers are commonly resting during animals' activity period this means that reasonable opportunities for observing normal health and welfare may be confounded.Optimum temperatures, normal ranges and critical thermal maximums vary considerably with species. Also, constant uniform temperatures  are not consistent with good practice in most cases and may result in stress and harm to animals. Therefore, a reasonable variation of temperature within each enclosure may be important for animal health and welfare. Accordingly, these guidelines adopt a precautionary approach. Inspector and establishment manager familiarity with species natural history is an important component of assessment and management.Humidity is a feature of air-quality and can be important to animal health and welfare , 67, 90.It is important that basking animals are able to warm their bodies across their entire length as would occur from sunlight in nature, whether in relation to warmth or ultraviolet light acquisition as appropriate . For exaPoorly conceived or instituted conditions relating to temperatures, ultraviolet light, basking options, humidity, and ventilation can be harmful or lethal to animals , 58. SimTemperatures, UV levels, and humidity should be recorded in the establishment and assessed against acceptable ranges. The housing of any relevant species outside the given range of temperatures should “red-flag” conditions as imminently potentially dangerous. The principle for assessing a minimum standard adequate thermal range should be determined by evidence-based species thermal preferences and/or natural geographic and thermal ranges of species derived from relevant climate map data for regions. Enclosures should possess a thermal gradient (warmer and cooler areas) appropriate to the species.Care should be taken regarding both the period of exposure and the placement of light sources to avoid over-exposure and thermal burns , 44. ForElectric UV bulbs should be checked regularly for their output because the level of UV output will decrease over time. Furthermore, all lighting equipment must be kept free of dust; this is particularly important for UV lighting where accumulated dust will act to absorb the UV and convert it to heat. Hand-held UV-monitoring devices are available to establish bulb and environment UV intensity. Table Daytime-to-night-time transitions (and vice-versa) that are gradual (such as a progressed by dimmer/control switching) are preferable to sudden “on-off” transitions.Sounds or noises may be gross or subtle elements in an environment that should be carefully assessed for their invasive potential . Road trGiven the diversity of species in trade and keeping along with respective varying audio sensitivities (as well as information deficits), it is not possible to provide detailed guidance on acceptable sound or “noise” levels. However, broadly speaking, Table Ventilation involves the process (or management) of the medium of air as it affects an animal , 113. VeIn essence, air can be thought of as a mixture of gasses and a very light “fluid” environment—almost as if living in very “thin” water. Just as water quality is important to organisms that occupy the aquatic environment, so too air quality is important to animals that occupy the terrestrial and arboreal environments. While many animals, such as domesticated species comfortably share air qualities that match human preferences, others such as some amphibians and reptiles may require highly specific air qualities that differ from typical human preferences. For example, humid, very warm and “static” air environments may be stressful to species adapted to occupying elevated “breezy” arboreal sites. In addition, temperature change, excitement, activity, and processes such as skin-shedding can produce marked respiratory changes in animals that must be accommodated by adequate environmental ventilation. Knowledge of species-specific natural history is important to providing adequate ventilation and to its assessment.The starting point for adequate ventilation is the general environment of the establishment itself. Unless enclosures are externally ventilated (which is unlikely) then the establishment's ambient air must be of both sufficient quality and throughput. As indicated under “Hygiene,” the presence of odors  usually is an indicator of poor hygiene and poor facility ventilation. Further, enclosures or other items should not be in positions as to negatively compromise the airflow. As a very basic guide, species with possibly greater thermal and humidity sensitivities, while still being well ventilated, should be maintained in areas that are especially well protected from door drafts, and no species should be subject to “cold air bursts”. Fewer enclosures promote better general ventilation. No smoking of tobacco should occur within the vicinity of indoor animals on the precautionary basis that “passive” inhalation may impact on animal health.Little species-specific information is available concerning recommended ventilation levels for the wide variety of animals kept in captivity. However, information regarding laboratory animals (rodents and lagomorphs) held in relatively large numbers in open cages  indicates that general room ventilation should involve 15–20 air exchanges per hour . BecauseFurnishings must reflect the habitat and behavioral needs of animals, for example in respect of: terrestrial, burrowing, subterranean, arboreal, climbing, postural-positional, semi-aquatic, aquatic characteristics . AccordiThe issue of space and spatial needs are addressed more specifically elsewhere in this document. However, although spatial issues and exercise are clearly conjoined subjects in certain respects, in some circumstances they may be more distinct. Therefore, exercise facilities will be dependent on the species held and may or may not be sufficient as part of the enclosure.Many wild animal species naturally occupy large home ranges  that mayCertain species, for example hamsters, in the closed environment may arguably be considered to exercise reasonably using running wheels. Fish are able to exercise in their aquarium, but consideration for size of aquarium will be dictated by the needs of the species. Obviously sedentary and reclusive species such as coral fish may require less space than most freshwater river species, but this does not imply that restrictive minimalist environments are justified.Details of frequency and time of exercise must be recorded. Inspection of exercise areas will be included and evidence of staff exercise rosters and individual exercise logs must be kept.Substrates or “beddings” are important or vital for many species as a medium for appropriate behavior, such as hiding and burrowing, as well as for the avoidance of injury when “diving” to the ground from elevated positions, and also for the absorption of waste , 119. UnGravel, hemp, wood chips, along with numerous commercial product substrates present highly problematic potentially ingestible materials that should not be used. In addition, certain materials, e.g., cedar wood and certain barks can be toxic. Although some of these do occur under natural conditions for many species, captive animals often ingest harmful substrate incidentally or develop eating disorders termed “pica” and may consume small stones and other items resulting in illness and death.Sleep and rest are fundamental biological needs for all animals and an essential requirement to health , 90. GooTransparent boundaries (such as glass) commonly result in psychological stress and behavioral and physical problems for certain animals, for example, reptiles , 69. WheWritten protocols for food and water provision for each species must be available , 58. ThiFood must be prepared in a clean and hygienic area dedicated for that purpose. Hot and cold water must be available. Contamination to and from other cleaning activities and other food preparation areas (for example staff facilities) must be avoided. Water must be fresh. Where tap water is used it should preferably be filtered or have been left to stand for 24 h to reduce possible chlorine products. Food and water vessels must be cleansed with appropriate cleaning agents at least several times weekly.Food and water should always be clean and obviously fresh. Considerable diversity exists for feeding habits, and diet must be suitable for the species and provided at sufficient frequency , 58. AltWater quality for aquatic and semi-aquatic species is important and requires regular monitoring, and a regular water testing protocol should be in place to test for basic parameters of pH, nitrite, nitrate, free-ammonium, and dissolved oxygen . Where aAppropriate food and water provisions should be made available for all live invertebrates intended as food .Establishment staff should remain constantly and proactively alert for early onset of problems, including injury, ill-health, behavioral, and general environmental problems. The number of animals in an establishment should be proportionate to the ability of the staff to identify emerging problems. Animal welfare may be assessed in different ways, including: behavioral signs ; physical signs ; physiological signs ; and physical examination . Over 13,000 animal species  are keptTables The tables Tables –F providInspection may apply a “star” or a “traffic light” scoring system to both general and individual sections of an establishment based on 14 categories and 27 subcategories to deliver the relevant “checklist” scores .The use of a points and stars system also enables establishments to be rated according to a quick-view color standard for public assurance. Establishments obtaining a zero score involve poor facilities that constitute “poor/fail” and in a traffic lights system Figure  would beAnimal welfare as well as human health and safety considerations conjoin across a diversity of animal establishments. Overseeing these establishments, however regulated, requires onsite inspection by suitably qualified, impartial, and competent personnel. Standardization of modern inspection methodology provides a “safety net” level for management protocols aimed at delivering reasonable protections both for animals and people. Mandatory minimum standards of husbandry and inspection may be augmented by incentivization of establishments to voluntarily further raise operating conditions to achieve recognized distinctions, which also offer elevated public assurance. We believe that this is the first impartial resource that meets the “three-asset” target for providing guidance regarding animal husbandry for diverse establishments, inspection protocols, and the provision of a relevant assessment tool to aid the guidance.All authors contributed equally to the concept and design of the paper. CW prepared the first draft. CW, MJ, PA, AP, and CS provided additional research and writing input to the final manuscript.CW, CS, and MJ have acted as professional consultants to the Animal Protection Agency. The Animal Protection Agency contributed financially to the literature search and review by CW and CS, whilst having no design, research, data collection, analysis, interpretation, writing, decision-making, or other directional role in this report. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


End-user input is critical to inform development of multipurpose prevention technology (MPT) products that prevent HIV and pregnancy. The TRIO Study, conducted in Kenya and South Africa, enrolled 277 HIV-negative women aged 18–30 in a randomized cross-over study to use each placebo MPT  for one month. At the end of each month, participants rated how much they liked using the product on a 5-point Likert scale (5 = liked very much). We compared mean ratings using paired t-tests and examined sociodemographic-, attribute-, and behavior-related characteristics associated with ratings using multivariable linear regression and data from in-depth interviews. After use, mean ratings were significantly higher for injections [4.3 (SD = 1.0)] compared with tablets [3.0 (SD = 1.3)] and rings [3.3 (SD = 1.4)] (p < 0.001); mean ratings for rings were significantly higher than for tablets (p = 0.013). Mean ratings of a hypothetical active MPT increased for all products after the one-month period of use, with the greatest increase for rings, the least familiar product. In multivariable analysis, acceptability of key product attributes  were associated with a significant increase of ≥ 1 point in the mean rating across all three products (p ≤ 0.001). Perceived ability to use the product without partner knowledge was associated with a higher mean rating for rings . The acceptability of product attributes contributed significantly to the rating of all products, highlighting the value of choice in pregnancy and HIV prevention to accommodate diverse users. Preventing HIV and unintended pregnancy are health priorities for women globally. In sub-Saharan Africa, nearly one in four married or in-union women are estimated to have an unmet need for contraception, with use of modern contraceptives varying across geographic settings and population groups . Even inAlthough MPTs already exist in the form of male and female condoms, acceptability of these products is low due to both product attributes and contextual factors. Men and women report that condoms interfere with sexual pleasure, and their use is associated with mistrust and infidelity –9. New MPlacing end-users at the center of product development is now recognized as critical to the design of products that ultimately will meet the needs of target users –13. End-We conducted the TRIO Study to examine acceptability and preferences among three placebo MPT forms for prevention of HIV and unintended pregnancy among young women in Kenya and South Africa. The overall goal of this research was to obtain information that would inform decisions regarding further development of MPTs to optimize the likelihood of end-user adoption. This analysis assesses ratings of product use experiences for three delivery forms currently available for either HIV or pregnancy prevention that are candidates for an MPT product: oral tablets, injections, and vaginal rings. In addition, we used quantitative and qualitative data to examine the acceptability of product attributes and factors associated with product ratings.The TRIO Study was a randomized, mixed-methods cross-over study with two stages: a three-month cross-over period in which young women used each product for one month, followed by a two-month period in which women could choose which product to use.The goal of TRIO was to investigate acceptability and preferences among the delivery forms; therefore, all three MPTs were placebos without any active pharmaceutical agent so we could uncouple the attributes of each delivery form from potential side effects or effectiveness. The delivery forms and use protocols are described in detail elsewhere . BrieflyThe study was conducted at two sites: Impact Research and Development Organization (IRDO) in Kisumu, Kenya and Setshaba Research Centre (SRC) in Soshanguve, South Africa. We selected two well-established research sites where a potential MPT product would be of interest to young women—where HIV rates are high and use of modern contraceptive methods is at least moderate. To inform future MPT product development, we aimed to examine the research questions in two diverse geographic areas within sub-Saharan Africa to evaluate the consistency of findings. All study procedures received ethics and regulatory approvals prior to implementation. Participants were recruited from communities in the geographic areas served by the research sites using community mobilization and sensitization meetings, street recruitment from shopping areas, and (in South Africa only) outreach at family planning clinics and voluntary HIV counseling and testing centers . EnrollmAt enrollment, participants were randomized in equal numbers to one of six product-use sequences representing all possible orders of the three products . RandomiAt enrollment, participants completed an interviewer-administered sociodemographic and product acceptability questionnaire after being introduced briefly to the products by viewing an animated educational video. At the end of the visit, they were given their first product (based on randomization sequence) with instructions for use. The site pharmacist dispensed tablets directly to participants and observed the first dose. Injections and rings were dispensed by the site pharmacist to the clinicians who then provided them to participants. Injections were administered by study clinicians. The vaginal ring was inserted by the participant at the research sites with guided instruction by study clinicians.Each month during the cross-over period, participants completed a follow-up study visit that included an acceptability and product use questionnaire that asked about the product they had been given at their previous study visit. At follow-up visits one and two, they were given the next product in their randomization sequence. At the end of stage one (follow-up visit 3), participants were asked to choose which product they would like to use for the next two months, with an option to switch after one month. In addition, at this visit, a random sub-sample of 46 participants  completed an in-depth interview that explored product use experiences for each of the three products.The primary outcome for this analysis was the participant’s rating of how much she liked the product after use during the previous month. The 5-point Likert scale (5 = high) corresponded to the following labeled options: dislike very much, dislike, neither like nor dislike, like, and like very much. For this analysis, the response scale was analyzed as a continuous variable. To assess changes in opinions before and after use, we compared responses to a question asked at baseline and monthly follow-up visits that assessed how much the participant would like using a hypothetical active version of each product for both pregnancy and HIV prevention, rated on the same 5-point Likert scale.We evaluated three categories of factors as potential predictors of product ratings: sociodemographic characteristics, sexual behavior, and the acceptability of product attributes. Sociodemographic characteristics included age, marital status, parity, household composition, contraceptive history and several socioeconomic indicators . Sexual behaviors focused on recent behaviors in the past month (during the period of product use) and included number of partners and frequency of sexual intercourse. Product attributes assessed in common across all three products included: product look, ease of use, interference with normal activities, and discreteness. In addition, we evaluated product-specific attributes that included factors such as tablet color, dosing regimens, and ring size and thickness. Participants were asked to classify most product attributes as very unacceptable, unacceptable, acceptable, or very acceptable, and responses were collapsed into binary variables for analysis (unacceptable or acceptable). For the discreteness attribute, they were asked whether they believed the product could be used without their partner knowing and without their friends or family knowing. See Tables t test.Our analysis focused on the 3-month crossover period that comprised the first stage of the study. Data from each visit were analyzed according to which product the participant had used over the past month. We compared ratings of actual use between products using paired t-tests. We also examined ratings for hypothetical active versions of each product at baseline and after one month of use and assessed whether this rating changed between these two time points using a one-sample To estimate the association of each predictor with the rating outcome, we used linear regression models with robust standard errors. Each product  was modeled separately. We examined each of the sociodemographic, sexual behavior, and attribute-related characteristics separately in bivariate models and in models adjusting for age, study site, and randomization sequence as potential confounders. We report results from the adjusted models only as there were no meaningful differences between the unadjusted and adjusted estimates.For analysis of attribute-related characteristics associated with product ratings, we considered whether ratings were clustered . To evaluate this, we calculated pairwise correlations among attributes and the total number rated as acceptable. Most product attribute ratings were not collinear or highly clustered. Only two sets of attributes had correlations > 0.5: the acceptability of the number of injections received at a given time and of having had 2 injections in a month (rho = 0.53) and the acceptability of how the ring felt during sex to the participant and to her partner (rho = 0.79).We coded in-depth interview transcripts using a codebook informed by our team’s past work in similar studies  and a coThe study enrolled 277 participants; our analytical sample consists of the 258 participants 93.1%) who completed at least one follow-up visit during the cross-over period: 255 participants reported on tablet use and 254 reported on injection and ring use. As presented in Table % who comProduct ratings after one month of use were highest for injections , followed by rings  and then tablets . The mean rating for injections was significantly higher than those for rings and tablets (p < 0.001); the mean rating for rings was also significantly higher than that for tablets (p = 0.015).Mean ratings, at enrollment, of a hypothetical active version of each product were highest for injections , followed by tablets , and then ring   that, at first, they disliked or even found “shocking.” One woman’s comments about the tablet echoed remarks made by others, “I was scared the first time I saw the tablets. I was just—wow, this tablet is big, but the swallowing was not a problem.”  In discussing injections, past experience with injectable contraceptives typically allayed negative opinions at the outset. For those women who did express negative reactions to the injection, they discussed being afraid of pain with the injections when they first saw the needle; however, these feelings subsided after receiving them, with comments from multiple participants that this product was “a once-off thing” and “nothing to worry about.” Many women described the opportunity to try the ring and gain familiarity with it as critical to improved acceptability. This participant illustrates this shift when describing how she felt the first time saw the ring and how swiftly her opinion changed after trying the product: “I was like wow!! This aah circle thing, ring vaginal is going to enter my vagina?! I was like argh!! Like I was thinking about pains and what…. I thought I won’t be comfortable but I was comfortable you know. After one day, aah!! I was like wow, I don’t feel nothing. It’s like normal.” .Few sociodemographic or behavioral characteristics were significantly associated with product ratings. Women in Kenya rated tablets higher and rings lower than women in South Africa , while site was not associated with injection ratings Tables , 3, 4. PProduct attributes were more strongly associated with product ratings than sociodemographic or behavioral factors. The overall acceptability of the attributes assessed in common varied across the three products, with, for example, 61.8% of women finding the “look” of the tablet acceptable, compared with 88.2% for the injection and 66.5% for the ring Tables , 4. LikeFor all three products, multiple product-specific attributes were associated with product rating after use. Of those assessed for tablets, the least acceptable were how it felt to swallow tablets (50.2%), daily tablet taking (51.8%) and tablet size 38.8%). The magnitude of the estimated increase in tablet rating for each tablet-specific attribute ranged from 0.64 to 1.32 points . For injections, in general, the level of acceptability of product-specific attributes was higher than for the other products . However, this aversion was primarily described as a visual reaction rather related to the experience of receiving the injection itself. Among women who found that physical attributes of the ring were acceptable, the most commonly discussed physical attribute was its size. In general, these participants seemed to react to the diameter more than the thickness of the ring—for those who thought the ring was too large, the size seemed to be primarily a visual or psychological barrier rather than an experiential one. Even though a number of these participants indicated that once they inserted the ring they did not feel it, they nonetheless suggested that it be made smaller because the “idea” of keeping such a large thing inside their bodies was disconcerting. As one participant described, “I think that if some people see the ring then they see the size and say that this thing is so big that I cannot use. So what I would want to tell them [product developers] is that they reduce the size” .Participants who found products acceptable based on several dimensions of use attributes—ease of use, interference with normal activities and discreetness—offered reflections on product characteristics that affected use experiences and perceived burden. TRIO participants who reported the tablets’ ease of use as acceptable, for example, still maintained reservations about the tablets when discussing them during in-depth interviews. They described persistent barriers to easy use of the tablets, including negative sensations when swallowing tablets, challenges with discreetness and difficulty with adhering to a daily dosing regimen. As one woman who resided in a one-room house noted, “It is difficult to take the drug in front of the visitor because they might go saying things that you don’t know” . Women who indicated the injection’s attributes tied to use were acceptable very consistently expressed positive views of the product, valuing the fact that it “saved time” and offered discreetness. One participant described, “after being injected, you are done and [do] not keep using it every day. You just leave because it’s not like other drugs that you have to go home with. It’s something that you get injected and it’s over. You just leave the clinic the way you came.” . Participants who indicated that ease of use of the ring was “acceptable” defined this in several ways, including whether they could detect it once inserted; whether it caused physical discomfort, particularly during insertion or removal; and whether they experienced difficulty with ring insertion. One South African woman described that she liked that “when [the ring is] already inside you, it stays leveled. It doesn’t move, it doesn’t do anything. It just stays where you put it” . Others, as reflected in this comment by a Kenyan woman, conceptualized ease of use as discreetness, “I liked it because once you have inserted it, you are just okay. No one knows that you have inserted something in you…no one knows, it is private” . Though many women expressed that they had initial concerns that their partners might feel the ring during sex, few actually noted that their partner did, in fact, detect the ring.We found that when given the opportunity to try three placebo MPT products, after using the products for one month, women in the TRIO study rated injections most highly, followed by rings, and then tablets. The mean rating for injections fell between “like” and “like very much” on the 5-point Likert scale, while the ratings for rings and tablets were slightly above and below the “neither like nor dislike” category, respectively. With an opportunity to use the products for one month each, for all products, the rating of a hypothetical active MPT product increased from enrollment. This was particularly the case for the ring, a product with which women had no familiarity.These findings highlight the varying experiences young women had with the three delivery forms examined in the TRIO Study, and point to an overall desire for longer-acting products, with injections emerging as a clear favorite at both time points. Product rating findings align with the preferences indicated through product choice by participants for use during stage two of the study, though, despite the ring being rated higher than tablets in this analysis, product choice for use during stage two of the study did not differ significantly between the two . The incProduct attributes were most influential on product ratings. Attributes related to user burden, such as ease of use and dosing regimen, had the greatest effects on mean ratings. Several social factors we hypothesized to be important, such as partner characteristics and household structure, were not associated with product rating. The ability to use the ring without a partner’s knowledge was an important predictor of ring rating, echoing findings from other vaginal ring studies in sub-Saharan African populations . Ring acSeveral factors related to study design should be considered when interpreting the findings. TRIO was designed with placebo products to permit examination of preferences among delivery forms, first and foremost, without consideration of side effects and adverse events that might result from use of active products. Side effects do constitute an important contributor to contraceptive and PrEP discontinuation , 26 and The TRIO Study offers a unique examination of potential MPTs for HIV and pregnancy prevention based on young women’s actual use of three placebo products. The study engaged women as “co-designers” who reported on product use and acceptability, informed by having tried each product. Information about modifiable product attributes that are most influential to acceptability is valuable during product development to maximize the chance that a new product ultimately will be liked and adopted by women. The importance of product attributes to product ratings and acceptability, more than sociodemographic and contextual factors, suggests that physical features of the products themselves as well as low burden assume key roles in shaping acceptability . As evid