Perspectives on Sexual and Reproductive Health最新文献

{"title":"Imagining Coat-Hangers and Pills: A Qualitative Exploration of Abortion Beliefs and Attitudes in Hostile Policy Contexts in the United States.","authors":"Rosalyn Schroeder, Lori R Freedman, Andréa Becker, Chris Ahlbach, M Antonia Biggs","doi":"10.1111/psrh.12289","DOIUrl":"10.1111/psrh.12289","url":null,"abstract":"<p><strong>Objective: </strong>We explored awareness of and attitudes about the safety of various methods people use to attempt to end a pregnancy without medical assistance, which we refer to in this study collectively as self-managed abortion (SMA).</p><p><strong>Methods: </strong>In 2020, we invited individuals living in eight United States (US) states considered \"hostile\" to abortion rights or with a history of criminalizing abortions performed outside the formal healthcare system to participate in semi-structured telephone interviews regarding their attitudes toward these practices. We analyzed coded transcripts for content and themes.</p><p><strong>Results: </strong>We interviewed 54 individuals. Participants perceived methods of ending a pregnancy on one's own to have a high potential for complications, often evoking \"coat hanger\" abortions. Participants also frequently referenced methods such as physical trauma, herbs, teas, alcohol, or other drugs. Very few participants reported awareness of medication abortion pills. When asked about the safety of SMA in the context of self-sourcing these medications, participants considered pills safer and more acceptable than other SMA methods, while still fearing incorrect use and complications. Others believed that SMA could offer greater reproductive autonomy, less stigma, and a safer physical and psychological experience than facility-based abortion care.</p><p><strong>Conclusion: </strong>In 2020, most participants perceived SMA as involving unsafe practices and did not include use of medication abortion pills. Future research should document how beliefs and attitudes have been influenced by the expansion in telemedicine provision of medication abortion, the implementation of new state abortion bans, and the promulgation of Shield Laws.</p>","PeriodicalId":47632,"journal":{"name":"Perspectives on Sexual and Reproductive Health","volume":" ","pages":"25-35"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11936864/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142956673","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"An Affective-Sexual Education Program for People With Moderate Intellectual Disabilities: Analysis of Its Effectiveness in the Spanish Context.","authors":"Verónica Estruch-García, María Dolores Gil-Llario, Olga Fernández-García, Rafael Ballester-Arnal","doi":"10.1111/psrh.12291","DOIUrl":"10.1111/psrh.12291","url":null,"abstract":"<p><strong>Introduction: </strong>Affective-sexual education is essential for all people, regardless of their intellectual capacity. However, people with intellectual disabilities, and especially those with conceptual, social, and practical limitations, may face additional challenges. In this study, we evaluate the effectiveness of the Saludiversex-M affective-sexual education program for people with moderate intellectual disabilities using a controlled trial design.</p><p><strong>Methodology: </strong>A total of 99 Spanish participants with moderate intellectual disabilities completed a battery of instruments before and after the intervention. Overall, 30 support staff professionals hetero-evaluated participants before and after the program.</p><p><strong>Results: </strong>Multilevel analyses showed that knowledge about sexuality significantly increased among those who received the intervention compared to those who did not. Support staff observed an increase in knowledge about sexuality and reported decreased concern about uninhibited behaviors among those who participated in the program.</p><p><strong>Discussion: </strong>The Saludiversex-M program is effective in improving knowledge about sexuality, which is essential for promoting behavioral change. The program is a pioneering and effective educational strategy for sexual health promotion for people with moderate intellectual disabilities and empowers support staff working with these populations.</p>","PeriodicalId":47632,"journal":{"name":"Perspectives on Sexual and Reproductive Health","volume":" ","pages":"95-103"},"PeriodicalIF":3.4,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11936861/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142956745","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Brief of over 300 reproductive health researchers as Amici Curiae in FDA v. Alliance for Hippocratic Medicine.","authors":"Amanda Barrow, Cathren Cohen, Jaclyn Serpico, Melissa Goodman, Daniel Grossman, Sarah Raifman, Ushma Upadhyay","doi":"10.1111/psrh.12281","DOIUrl":"10.1111/psrh.12281","url":null,"abstract":"<p><p>On January 30, 2024, over 300 researchers filed an amicus brief in FDA v. Alliance for Hippocratic Medicine, a United States (US) Supreme Court case that could have severely impacted access to mifepristone, one of the two drugs commonly used in medication abortion. The researchers summarize the legal challenges to the US Food and Drug Administration's (FDA's) original approval of mifepristone in 2000 and its 2016 and 2021 decisions modifying mifepristone's Risk Evaluation and Mitigation Strategy (REMS) Program and label, the responses from the FDA and drug manufacturer to the challenges, and the potential implications of the Court's decision on access to mifepristone in the US. The researchers detail how the FDA relied on a robust scientific record analyzing tens of thousands of patient experiences that conclusively demonstrated the safety and effectiveness of the changes to the mifepristone REMS Program and label and urge the Supreme Court to rely on the clear scientific record and preserve access to mifepristone without reimposing restrictions. What follows is a reprint of this brief.</p>","PeriodicalId":47632,"journal":{"name":"Perspectives on Sexual and Reproductive Health","volume":" ","pages":"320-328"},"PeriodicalIF":3.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141793773","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"\"It definitely changed me\": Exploring sexual and gender diverse people's experiences with intimate partner violence in Ontario, Canada.","authors":"Kyle J Drouillard, Angel M Foster","doi":"10.1111/psrh.12276","DOIUrl":"10.1111/psrh.12276","url":null,"abstract":"<p><strong>Introduction: </strong>Intimate partner violence (IPV) involves an individual committing acts intended to harm or intimidate a current or former romantic partner. The COVID-19 pandemic and subsequent stay-at-home orders often trapped victims with perpetrators and intensified IPV. Although sexual and gender diverse people disproportionately experience IPV compared to cisgender, heterosexual people, their experiences are not well documented in the Canadian context. This study aimed to explore the experiences of Two-Spirit, lesbian, gay, bisexual, transgender, queer, intersex, asexual, and other sexual and gender diverse (2S/LGBTQIA+) people with IPV in Ontario and how the COVID-19 pandemic affected their IPV experiences.</p><p><strong>Methods: </strong>We conducted in-depth, semi-structured interviews with self-identified 2S/LGBTQIA+ people who experienced IPV on/after March 15, 2020. We audio-recorded and transcribed all interviews and coded the transcripts for content and themes using inductive and deductive techniques.</p><p><strong>Results: </strong>Our 20 participants experienced physical, psychological, sexual, and financial abuse. Technology-facilitated violence extended abuse geographically and temporally. IPV experiences were associated with negative mental health outcomes that were intensified by the COVID-19 pandemic. Participants struggled to see themselves as legitimate victims of IPV. Although participants regretted being victims of violence, many saw their abusive relationship(s) as a learning experience to inform future relationships.</p><p><strong>Discussion: </strong>Our findings suggest that 2S/LGBTQIA+ people may experience unique forms of identity abuse and may have difficulty recognizing their IPV experiences as abuse. Ensuring that comprehensive sexual health education is trauma-informed, anti-oppressive, and includes information about healthy relationship dynamics, 2S/LGBTQIA+ relationships, and IPV is critical.</p>","PeriodicalId":47632,"journal":{"name":"Perspectives on Sexual and Reproductive Health","volume":" ","pages":"368-377"},"PeriodicalIF":3.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11646827/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141263080","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Patient experiences switching from in-clinic to self-administration of injectable contraception in two Western US states.","authors":"Rebecca L Newmark, Caroline C Hodge, Grace Shih, Jennifer Karlin","doi":"10.1111/psrh.12278","DOIUrl":"10.1111/psrh.12278","url":null,"abstract":"<p><strong>Objective: </strong>We describe the experiences and preferences of women who switched from clinic-administered intramuscular depot medroxyprogesterone acetate (DMPA-IM) to self-administered subcutaneous DMPA (DMPA-SC) in the context of the COVID-19 pandemic.</p><p><strong>Methods: </strong>We conducted interviews with women in California and Washington about their experiences with self-administered DMPA-SC. We interviewed women after their first or second self-administered DMPA-SC injection and conducted follow-up interviews after their third or fourth injection. We performed both thematic and descriptive content analyses.</p><p><strong>Results: </strong>We completed 29 interviews with 15 women. Most participants (n = 10) were between the ages of 20 and 39 and the majority (n = 12) used DMPA primarily for contraception. Most (n = 13) described self-administered DMPA-SC as \"very easy\" or \"somewhat easy\" to use and reported greater convenience, decreased pain, fewer logistical and financial challenges, increased privacy, and improved comfort with injection compared to DMPA-IM. Participants identified difficulties obtaining DMPA-SC from pharmacies and safe needle disposal as barriers. Most (n = 13) would recommend DMPA-SC to a friend and desired to continue self-administration beyond the COVID-19 pandemic. Participants recommended counseling all patients about this option alongside other contraceptive methods, and offering clinician supervision, if desired.</p><p><strong>Conclusion: </strong>Women who switched from in-clinic DMPA-IM to self-administered DMPA-SC during the COVID-19 pandemic preferred the latter and intended to continue self-administration. Self-administration of DMPA-SC should be routinely offered and easily accessible to patients.</p>","PeriodicalId":47632,"journal":{"name":"Perspectives on Sexual and Reproductive Health","volume":" ","pages":"347-357"},"PeriodicalIF":3.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11646826/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141535669","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"\"It shouldn't be just hush-hush\": A qualitative community-based study of menstrual health communication among women in Philadelphia.","authors":"Allison R Casola, Lynette Medley, Brianna C Kunes, Nya McGlone, Alexis Silverio","doi":"10.1111/psrh.12277","DOIUrl":"10.1111/psrh.12277","url":null,"abstract":"<p><strong>Introduction: </strong>Although menstruation is a natural biological process, many people feel embarrassed of their menses and struggle to discuss it. To mitigate menstrual communication stigma, it is necessary to first elucidate communication experiences and perceptions. Thus, we qualitatively explore menstrual communication among cisgender women who menstruate and their family, friends, healthcare providers, and community.</p><p><strong>Methodology: </strong>In partnership with No More Secrets (NMS), a Philadelphia menstrual health non-profit, we conducted a community-based participatory research (CBPR) project in Fall 2020. Cisgender, menstruating individuals ages 18-45 recruited from NMS' catchment in Philadelphia participated in semi-structured interviews about their menstrual experiences and communication (N = 20). A deductive, theory-driven approached based on the social-ecological model was used to analyze the data.</p><p><strong>Results: </strong>Varying emotional responses arose across social-ecological levels: communication was awkward and simplistic with family; positive and supportive with friends and community members; and uncomfortable and frustrating with healthcare providers. Participants echoed the importance of menstrual communication as a means of sharing information, feeling less alone, and decreasing menstrual stigma.</p><p><strong>Discussion: </strong>Findings can inform future CBPR workshops that address stigma in familial, healthcare, and community-based discussions to improve menstrual health and experiences for cisgender girls and women, transgender men, and gender non-binary individuals who menstruate.</p>","PeriodicalId":47632,"journal":{"name":"Perspectives on Sexual and Reproductive Health","volume":" ","pages":"378-388"},"PeriodicalIF":3.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11646828/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141789476","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Exploring adolescent-facing US clinicians' perceptions of their contraceptive counseling and use of shared decision-making: A qualitative study.","authors":"Madeline Thornton, Emily S Mann, Brooke W Bullington, Joline Hartheimer, Kavita Shah Arora, Bianca A Allison","doi":"10.1111/psrh.12283","DOIUrl":"10.1111/psrh.12283","url":null,"abstract":"<p><strong>Background: </strong>Adolescent contraceptive decision-making is influenced by a number of patient and clinician-driven factors. Although the AAP continues to endorse an efficacy-based model of contraceptive counseling, many professional organizations are shifting to a shared decision-making model as the optimal approach for providing unbiased and patient-driven contraceptive counseling. While SDM is intended to reduce the influence of clinician bias, it can exacerbate inequity if a clinician tailors a conversation based on their assumptions of a patient's goals or preferences. In this qualitative study, we explored self-reported contraceptive counseling practices among US-based clinicians who see adolescent patients to assess how these practices create barriers or facilitators to SDM and person-centered contraceptive care.</p><p><strong>Methods: </strong>We interviewed 16 clinicians at the 2022 AAP Annual Meeting who counsel adolescent patients about contraception. We used thematic content analysis to analyze interview transcripts using Dedoose.</p><p><strong>Results: </strong>We identified six aspects of contraceptive counseling that clinicians commonly employed with adolescent patients. These were: (1) sociodemographic characteristics driving counseling, (2) reliance on tiered effectiveness counseling, (3) initiating counseling conversations using \"ask then explain\" or \"explain then ask\" approaches, (4) emphasis on teen pregnancy prevention, (5) the influence of method accessibility on counseling, and (6) parental involvement in decision-making and patient confidentiality. We describe how these themes align with or diverge from each component of the SDM framework.</p><p><strong>Conclusion: </strong>Clinicians in this study frequently engaged in non-patient-centered techniques during contraceptive counseling with adolescents. These findings can inform practice recommendations to support clinicians in providing high-quality contraceptive counseling using shared decision-making.</p>","PeriodicalId":47632,"journal":{"name":"Perspectives on Sexual and Reproductive Health","volume":" ","pages":"337-346"},"PeriodicalIF":3.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11649482/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142037348","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sexual choking/strangulation and its association with condom and contraceptive use: Findings from a survey of students at a university in the Midwestern United States.","authors":"Debby Herbenick, Tsung-Chieh Fu, Callie Patterson Perry, Lucia Guerra-Reyes, Heather Eastman-Mueller, Dubravka Svetina Valdivia","doi":"10.1111/psrh.12285","DOIUrl":"10.1111/psrh.12285","url":null,"abstract":"<p><strong>Introduction: </strong>Consensual sexual choking has become prevalent among young United States (US) adults. In sex between women and men, women are overwhelmingly the ones choked, perhaps reproducing traditional heteronormative power dynamics. No research has examined the relationship between being choked during consensual sex and the use of external condoms and other contraceptives.</p><p><strong>Methods: </strong>We administered a cross-sectional campus-representative survey to 4989 undergraduate students at a large public Midwestern US university.</p><p><strong>Results: </strong>Half of respondents (n = 1803) had ever been choked during sex. Having been choked was associated with a significantly lower likelihood of event-level condom use (OR = 0.32 [0.19, 0.54] for >5 times lifetime choking among men and OR = 0.35 [0.27, 0.45] for >5 times lifetime choking among women compared to those with no choking experiences) and in the past 6 months (OR = 0.42 [0.24, 0.72] for >5 times lifetime choking among men and OR = 0.59 [0.43, 0.81] for >5 times lifetime choking among women compared to those with no choking experiences). Also, having ever been choked was associated with a significantly greater likelihood of having used an implant/intra-uterine device in the past 6 months (OR = 1.85 [1.28, 2.68] for >5 times lifetime choking compared to those with no choking experiences).</p><p><strong>Conclusion: </strong>Recognition that sexual choking is prevalent among young people has only recently emerged and educational programs are lacking. Study findings could be used to engage people in discussions about choking in relation to gender, power, and reproductive health agency.</p>","PeriodicalId":47632,"journal":{"name":"Perspectives on Sexual and Reproductive Health","volume":" ","pages":"358-367"},"PeriodicalIF":3.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11646831/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142336939","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Amicus brief of over 300 reproductive health researchers supports mifepristone's safety and effectiveness.","authors":"Amanda Barrow, Cathren Cohen, Jaclyn Serpico, Melissa Goodman, Daniel Grossman, Sarah Raifman, Ushma Upadhyay","doi":"10.1111/psrh.12282","DOIUrl":"10.1111/psrh.12282","url":null,"abstract":"<p><p>On January 30, 2024, over 300 researchers filed an amicus brief in FDA v. Alliance for Hippocratic Medicine, a United States (US) Supreme Court case concerning the regulatory status of mifepristone, one of two drugs used in medication abortion. In this Comment we summarize the legal challenge, responses from the FDA and drug manufacturer to these challenges, oral arguments presented before the Court, and the implications of the Court's decision on access to mifepristone in the US. We also summarize the content of the accompanying amicus brief.</p>","PeriodicalId":47632,"journal":{"name":"Perspectives on Sexual and Reproductive Health","volume":" ","pages":"317-319"},"PeriodicalIF":3.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141793772","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Understanding abortion legality and trimester of abortion care in Ohio, West Virginia and Kentucky, three abortion‐restrictive states","authors":"Annamarie L. Beckmeyer, Jeremy A. Brenner‐Levoy, B. Jessie Hill, Tamika C. Odum, Abigail Norris Turner, Alison H. Norris, Danielle Bessett, Katherine L. Rivlin","doi":"10.1111/psrh.12284","DOIUrl":"https://doi.org/10.1111/psrh.12284","url":null,"abstract":"IntroductionIn the era of Dobbs, legality of abortion care in the United States depends upon state law. Even before Dobbs, while abortion remained legal mounting restrictions and debate surrounding legal abortion could have led to confusion about abortion legality and discouraged patients from accessing legal abortion. We hypothesized an association between believing abortion is illegal or uncertainty about legality with later timing of abortion care.MethodsWe surveyed patients seeking abortion care in Ohio, West Virginia, and Kentucky from April 2020 to April 2021. We asked about their understanding of abortion legality at the time they were first deciding to have an abortion. Using unconditional logistic regression models, we examined associations between beliefs about abortion legality (measured as belief that abortion is legal or sometimes legal versus. illegal or unsure) and timing of abortion care (measured as trimester of abortion).ResultsOver half (57%) of the 1,479 patients who met eligibility criteria and completed the survey believed abortion was always legal, 21% thought abortion was sometimes legal, 12% believed abortion was illegal, and 10% did not know. Most (92%) had a first trimester abortion (&lt;14 weeks gestation). Belief that abortion was illegal, or uncertainty about abortion legality, was not significantly associated with second trimester abortion care (unadjusted odds ratio [uOR]: 0.78, 95% confidence interval [CI]: 0.50–1.20). This association did not change meaningfully after adjusting for demographic and clinical variables (adjusted OR [aOR]: 0.83, 95% CI: 0.51–1.33).DiscussionMore than one in five patients presenting for abortion care in three abortion‐restrictive states prior to Dobbs erroneously believed that abortion was illegal or were unsure. Understanding of legality was not significantly associated with timing of abortion care. These misunderstandings could escalate under Dobbs.","PeriodicalId":47632,"journal":{"name":"Perspectives on Sexual and Reproductive Health","volume":"24 1","pages":""},"PeriodicalIF":5.8,"publicationDate":"2024-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142251054","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}