Onsline Survey - Patient 18 yr 6-month Follow-Up English

Monitoring & Evaluation for the Zika Contraception Access Network (Z-CAN)

Att R-1 Patient Survey_6 mo_12 mo vA (Eng)

Online Survey - 6 month Follow-Up - Patients 18 years or older

OMB: 0920-1164

Document [docx]
Download: docx | pdf


Attachment R-1. Online follow-up survey for Z-CAN patients (6-month survey and 12-month survey version a – for respondents to the 6-month survey)







Note to Reviewers: This is a web-based survey. The patient’s Z-CAN ID will be embedded in the backend of the survey (not visible to the participant) to allow for linking of 6 month and 12 month survey results and programmatic data from the same participant. All skip patterns will be programmed into the survey which will minimize survey completion time.


Online No.

No.

Question

Coding

Skip to No.

1

1

What is your current relationship status?

Single/never married 1

Partner (not cohabiting) 2

Cohabiting (not married) 3

Married 4

Separated/Divorced 5

Widowed 6


2

2

During the past 12 months, have you had trouble paying for any of the following? (check all that apply)

Transportation 1

Housing 2

Medical care or medicine 3

Food 4

None of the above 5


3

3

Do you want to prevent pregnancy now?

No 1

Yes 2

15


4

4

What is the main reason you want to prevent pregnancy now? (Select one)


I cannot afford to have a baby (or another baby) now 1

I don’t want to have a baby now 2

I don’t want to get pregnant now because I am worried about Zika virus 3

Other___________________ 4


5

5

In the past 6 months, have you been pregnant?

No 1

Yes 2

Don’t know 3

111



311

6

6

How many times in the past 6 months have you been pregnant?

----- times


7

7

Are you pregnant right now?

No 1

Yes 2

Don’t know 3




The next few questions ask about pregnancies you have had in the past 6 months. If you were pregnant more than once in the past 6 months, please respond about your most recent pregnancy.

8

8

Thinking back to just before you got pregnant, how did you feel about becoming pregnant?

I wanted to be pregnant later 1

I wanted to be pregnant sooner 2

I wanted to be pregnant then 3

I didn’t want to be pregnant then or at any time in the future 4

I wasn’t sure what I wanted 5


9

9

When you got pregnant, were you or your husband or partner doing anything to keep from getting pregnant? Some things people do to keep from getting pregnant include having their using birth control pills, implants, condoms, withdrawal, or natural family planning.

No 1

Yes 2

111


10

10

What method of birth control were you using when you got pregnant? Check ALL that apply

IUD (Mirena, ParaGard, Liletta, or Skyla ) 1

Contraceptive implant (Nexplanon) 2

Shots or injections (Depo-Provera) 3

Birth control pills 4

Contraceptive patch (Xulane) or vaginal ring (NuvaRing) 5

Condoms 6

Natural family planning (including rhythm method) 7

Withdrawal (pulling out) 8

Other______________________ 9










11

11

In the next 6 months, how would you feel if you got pregnant?

Very upset 1

Somewhat upset 2

Indifferent or don’t care 3

Somewhat pleased 4

Very pleased 5

Don’t know 6




The next questions ask about birth control methods you are using now or used in the past 6 months, even if it was for a short time.

12

12

Are you using any of these methods of birth control now? (Select one)



Note-survey will skip to appropriate ‘current’ section for methods marked ‘yes’

Hormonal IUD (Mirena, Skyla, Liletta)

No 1

Yes 2

Copper IUD (ParaGard)

No 1

Yes 2

Implant (Nexplanon)

No 1

Yes 2

Contraceptive shot (DepoProvera)

No 1

Yes 2

Birth control pills

No 1

Yes 2

Contraceptive ring (Nuvaring)

No 1

Yes 2

Contraceptive patch (Xulane)

No 1

Yes 2



2LNG-IUD current



2Cu-IUD current



2Implant current





2Depo current



2Pills current



2Ring current



2Patch current

52





61





70





77





83





92







100

13

Did you use any of these methods of birth control during the past 6 months, but you are not using it now? (select all that apply)



Note- Survey will skip to section for each methods marked ‘yes’. After those sections are completed, will skip to ‘Condom’ section

























Note- if no to all methods, will skip to ‘Condom’ section.

Hormonal IUD (Mirena, Skyla, Liletta)

No 1

Yes 2

Copper IUD (ParaGard)

No 1

Yes 2

Implant (Nexplanon)

No 1

Yes 2

Contraceptive shot (DepoProvera)

No 1

Yes 2

Birth control pills

No 1

Yes 2

Contraceptive ring (Nuvaring)

No 1

Yes 2

Contraceptive patch (Xulane)

No 1

Yes 2



2LNG-IUD past



2Cu-IUD past



2Implant past





2Depo past



2Pills past



2Ring past



2Patch past



If 1 to ALL

Condom


LNG-IUD--Current (Note- These headings will not be visible to the participant)

13

14

When did you start using the hormonal IUD (Mirena, Skyla, Liletta)?

MM / YYYY


14

15

In the past 6 months, how satisfied have you been with your hormonal IUD?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3


117


15

16

What are the main reasons you have not been very satisfied with your hormonal IUD? (check all that apply)

I experienced bleeding changes 1

I experienced side effects 2

It caused me pain 3

It was too expensive for me 4

My partner does not want me to use it 5

I want to get pregnant 6

I do not believe it is effective for birth control 7

Other reason (specify): ­­____ 8


16

17

In the past 6 months, did your hormonal IUD ever completely fall out?

No 1

Yes 2



221

17

18

In the past 6 months, was your hormonal IUD removed?

No 1

Yes 2

1next applicable section

18

19

Did you pay a Z-CAN provider to have your IUD removed?

No 1

Yes 2

if yes, show pop-up screen:

You should not have been asked to pay for your IUD removal. If you were asked to pay for a Z-CAN service, you may contact the Z-CAN program at [email protected]         


19

20

Why did you have your hormonal IUD removed? (check all that apply)

It was in the wrong place 1

It was falling out 2

I had an infection (e.g. chlamydia, gonorrhea, pelvic inflammatory disease (PID)) ..3

I experienced bleeding changes…...…..4

I experienced side effects……………….5

It caused me pain 6

I wanted to get pregnant………………...7

Other____________________ 8


20

21

When did you have a new hormonal IUD inserted?

MM / YYYY

next applicable section



LNG-IUD Past

53

22

When did you start using the hormonal IUD (Mirena, Skyla, Liletta)?

MM / YYYY


54

23

In the past 6 months, how satisfied were you with your hormonal IUD (Mirena, Skyla, Liletta)?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3


125


55

24

What are the main reasons you were not very satisfied with your hormonal IUD? (check all that apply)

I experienced bleeding changes 1

I experienced side effects 2

It caused me pain 3

It was too expensive for me 4

My partner did not want me to use it 5

I wanted to get pregnant 6

I do not believe it is effective for birth control 7

Other reason (specify): ­­__________ 8


56

25

In the past 6 months, did your hormonal IUD ever completely fall out?

No 1

Yes 2

2next applicable section

57

26

In the past 6 months, was your hormonal IUD removed?

No 1

Yes 2


58

27

Did you pay a Z-CAN provider to have your IUD removed?

No 1

Yes 2

if yes, show pop-up screen:

You should not have been asked to pay for your IUD removal. If you were asked to pay for a Z-CAN service, you may contact the Z-CAN program at [email protected]         


59

28

Did you talk with a Z-CAN provider before you stopped using your hormonal IUD (or had it removed)?

No 1

Yes 2


60

29

Why did you stop using your hormonal IUD (or have it removed)? (check all that apply)

It was in the wrong place………………..1

It was falling out………………………..2

I had an infection (e.g. chlamydia, gonorrhea, pelvic inflammatory disease (PID)) 3

I experienced bleeding changes 4

I experienced side effects 5

It caused me pain 6

It was too expensive for me 7

My partner did not want me to use it 8

I wanted to get pregnant 9

I do not believe it is effective for birth control 10

Healthcare provider recommended I stop using it 11

Other reason (specify): ­­_______ 12

next applicable section



Cu-IUD Current

21

30

When did you start using the copper IUD (ParaGard)?

MM / YYYY


22

31

In the past 6 months, how satisfied have you been with your copper IUD?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3

133


23

32

What are the main reasons you have not been very satisfied with your copper IUD? (check all that apply)

I experienced bleeding changes 1

I experienced side effects 2

It caused me pain 3

It was too expensive for me 4

My partner does not want me to use it 5

I want to get pregnant 6

I do not believe it is effective for birth control 7

Other reason (specify): ­­____ 8


24

33

In the past 6 months, did your copper IUD ever completely fall out?

No 1

Yes 2



237

25

34

In the past 6 months, was your copper IUD removed?

No 1

Yes 2

1next applicable section

26

35

Did you pay a Z-CAN provider to have your IUD removed?

No 1

Yes 2

if yes, show pop-up screen:

You should not have been asked to pay for your IUD removal. If you were asked to pay for a Z-CAN service, you may contact the Z-CAN program at [email protected]         


27

36

Why did you have your copper IUD removed? (check all that apply)

It was in the wrong place 1

It was falling out 2

I had an infection (e.g. chlamydia, gonorrhea, pelvic inflammatory disease (PID)) 3



I experienced bleeding changes …...….4

I experienced side effects……………….5

It caused me pain……...……………...…6

I wanted to get pregnant………………..7

Other____________________ 8


28

37

When did you have a new copper IUD inserted?

MM / YYYY

next applicable section


CU-IUD Past

62

38

When did you start using the copper IUD (ParaGard)?

MM / YYYY


63

39

In the past 6 months, how satisfied were you with your copper IUD?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3

138


64

40

What are the main reasons you were not very satisfied with your copper IUD? (check all that apply)

I experienced bleeding changes 1

I experienced side effects 2

It caused me pain 3

It was too expensive for me 4

My partner did not want me to use it 5

I wanted to get pregnant 6

I do not believe it is effective for birth control 7

Other reason (specify): ­­____ 8


65

41

In the past 6 months, did your copper IUD ever completely fall out?

No 1

Yes 2


2next applicable section

66

42

In the past 6 months, was your copper IUD removed?

No 1

Yes 2


67

43

Did you pay a Z-CAN provider to have your IUD removed?

No 1

Yes 2

if yes, show pop-up screen:

You should not have been asked to pay for your IUD removal. If you were asked to pay for a Z-CAN service, you may contact the Z-CAN program at [email protected]         


68

44

Did you talk with a Z-CAN provider before you stopped using your copper IUD (or had it removed)?

No 1

Yes 2


69

45

Why did you stop using your copper IUD (or have it removed)? (check all that apply)

It was in the wrong place………………..1

It was falling out………………………….2

I had an infection (e.g. chlamydia, gonorrhea, pelvic inflammatory disease (PID)) 3

I experienced bleeding changes 4

I experienced side effects 5

It caused me pain 6

It was too expensive for me 7

My partner did not want me to use it 8

I want to get pregnant 9

I do not believe it is effective for birth control 10

Healthcare provider recommended I stop using it 11

Other reason (specify): ­­_______ 12

next applicable section



Implant-current

29

46

When did you start using the implant (Nexplanon)?

MM / YYYY


30

47

In the past 6 months, how satisfied have you been with your implant?



Note- 1,2 will skip to either other methods (past use) or condom section

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3


1,2next appropriate section


31

48

What are the main reasons you have not been very satisfied with your implant? (check all that apply)

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner does not want me to use it 6

I want to get pregnant 7

I do not believe it is effective for birth control 8

Other reason (specify): ­­____ 9

next applicable section



Implant-past

71

49

When did you start using the implant (Nexplanon)?

MM / YYYY


72

50

In the past 6 months, how satisfied were you with the implant?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3

152

73

51

What are the main reasons you were not very satisfied with your implant? (check all that apply)

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner did not want me to use it 6

I wanted to get pregnant 7

I do not believe it is effective for birth control 8

Other reason (specify): ­­____ 9


74

52

Did you pay a Z-CAN provider to have your implant removed?

No 1

Yes 2

if yes, show pop-up screen:

You should not have been asked to pay for your implant removal. If you were asked to pay for a Z-CAN service, you may contact the Z-CAN program at [email protected]         


75

53

Did you talk with a Z-CAN provider before you had your implant removed?

No 1

Yes 2



76

54

Why did you have your implant removed? (check all that apply)

I experienced bleeding changes 1

I experienced side effects 2

It caused me pain 3

It was too expensive for me 4

My partner did not want me to use it 5

I wanted to get pregnant 6

I do not believe it is effective for birth control 7

Healthcare provider recommended I stop using it 8

Other reason (specify): ­­_________ 9

next applicable section



Depo-Current

32

55

When did you start using the contraceptive shot (Depo Provera)?

MM / YYYY


33

56

What was the date of your most recent shot?

If you do not know the exact date, please provide month and year.

MM / DD / YYYY


34

57

In the past 6 months, how satisfied have you been with the contraceptive shot?

Note- 1,2 will skip to either other methods (past use) or condom section

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3


1,2next appropriate section

35

58

What are the main reasons you have not been very satisfied with contraceptive shot? (check all that apply)

It is not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner does not want me to use it 6

I want to get pregnant 7

I do not believe it is effective for birth control 8

Other reason (specify): ­­____ 9

next applicable section



Depo-past

78

59

When did you start using the contraceptive shot (Depo Provera)?

MM / YYYY


79

60

In the past 6 months, how satisfied were you with the contraceptive shot (Depo Provera)?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3

162

80

61

What are the main reasons you were not very satisfied with the contraceptive shot? (check all that apply)

It was not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner did not want me to use it 6

I wanted to get pregnant 7

I do not believe it is effective for birth control 8

Other reason (specify): ­­____ 9


81

62

Did you talk with a Z-CAN provider before you stopped using the contraceptive shot?

No 1

Yes 2


82

63

Why did you stop using the contraceptive shot? (check all that apply)

It was not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner did not want me to use it 6

I wanted to get pregnant 7

I do not believe it is effective for birth control 8

Healthcare provider recommended I stop using it 9

I had trouble getting to a Z-CAN clinic for shots 10

Other reason (specify): ­­_______ 11

next applicable section



Pill-Current

36

64

When did you start using the birth control pill?

MM / YYYY


37

65

In the past 6 months, how satisfied have you been with the using the birth control pill?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3

167

38

66

What are the main reasons you have not been very satisfied using the birth control pill? (check all that apply)

It is not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner does not want me to use it 6

I want to get pregnant 7

I do not believe it is effective for birth control 8

Other reason (specify): ­­____ 9


39

67

The last time that you got birth control pills from a Z-CAN provider, how many packs of pills did you receive?

1 pack 1

2 packs 2

3 packs 3

4-6 packs 4

7-9 packs 5

10-12 packs 6

13 packs 7


40

68

During the past 6 months, how difficult has it been for you to get more pills when you need them?

Not difficult 1

Somewhat difficult 2

Very difficult 3

1next applicable section

41

69

Why was it was difficult for you to get more pills when you needed them?

Select all that apply

Distance to the Z-CAN clinic 1

Hard to get to the Z-CAN clinic 2

Remembering to go to the Z-CAN clinic 3

Finding the time to go to the Z-CAN clinic 4

Pills were too expensive 5

Other reason____________ 6

next applicable section



Pill-Past

84

70

When did you start using the birth control pill?

MM / YYYY


85

71

In the past 6 months, how satisfied were you with the using the birth control pill?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3


173


86

72

What are the main reasons you were not very satisfied using the birth control pill? (check all that apply)

It was not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner did not want me to use it 6

I wanted to get pregnant 7

I do not believe it is effective for birth control 8

Other reason (specify): ­­____ 10


87

73

The last time that you got birth control pills from a Z-CAN provider, how many packs of pills did you receive?

1 pack 1

2 packs 2

3 packs 3

4-6 packs 4

7-9 packs 5

10-12 packs 6

13 packs 7


88

74

During the past 6 months, how difficult was it for you to get more pills when you need them?

Not difficult 1

Somewhat difficult 2

Very difficult 3


176


89

75

Why was it was difficult for you to get more pills when you needed them?

Select all that apply

Distance to the Z-CAN clinic 1

Hard to get to the Z-CAN clinic 2

Remembering to go to the Z-CAN clinic 3

Finding the time to go to the Z-CAN clinic 4

Pills were too expensive 5

Other reason____________ 6


90

76

Did you talk with a Z-CAN provider before you stopped using the pill?

No 1

Yes 2


91

77

Why did you stop using the birth control pill? (check all that apply)

It was not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner did not want me to use it 6

I wanted to get pregnant 7

I do not believe it is effective for birth control 8

Healthcare provider recommended I stop using it 9

Too hard to remember to take a pill every day 10

Too hard to get pills from Z-CAN clinic 11

Other reason (specify): ____ 12

next applicable section



Ring-Current

42

78

When did you start using the ring (Nuvaring)?

MM / YYYY


43

79

In the past 6 months, how satisfied have you been with the ring?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3

181




44

80

What are the main reasons you have not been very satisfied with the ring? (check all that apply)

It is not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner does not want me to use it 6

I want to get pregnant 7

I do not believe it is effective for birth control 8

Other reason (specify): ­­____ 9


45

81

During the past 6 months, how hard has it been for you to get more rings when you need them?

Note- 1 will skip to either other methods (past use) or condom section

Not difficult 1

Somewhat difficult 2

Very difficult 3


1next appropriate section

46

82

Why has it been was difficult for you to get more rings when you needed them?

Select all that apply

Distance to the Z-CAN clinic 1

Hard to get to the Z-CAN clinic 2

Remembering to go to the Z-CAN clinic 3

Finding the time to go to the Z-CAN clinic 4

The ring is too expensive 5

Other reason____________ 6

next applicable section



Ring-Past

93

83

When did you start using the ring (Nuvaring)?

MM / YYYY


94

84

In the past 6 months, how satisfied were you with the ring?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3


186




95

85

What are the main reasons you were not very satisfied with the ring? (check all that apply)

It was not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner did not want me to use it 6

I wanted to get pregnant 7

I do not believe it is effective for birth control 8

Other reason (specify): ­­____ 9


96

86

During the past 6 months, how hard was it for you to get more rings when you need them?

Not difficult 1

Somewhat difficult 2

Very difficult 3

188


97

87

Why was it difficult for you to get more rings when you needed them?

Select all that apply

Distance to the Z-CAN clinic 1

Hard to get to the Z-CAN clinic 2

Remembering to go to the Z-CAN clinic 3

Finding the time to go to the Z-CAN clinic 4

The ring is too expensive 5

Other reason____________ 6


98

88

Did you talk with a Z-CAN provider before you stopped using the ring?

No 1

Yes 2


99

89

Why did you stop using the ring? (check all that apply)

It was not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner did not want me to use it 6

I wanted to get pregnant 7

I do not believe it is effective for birth control 8

Healthcare provider recommended I stop using it 9

It was difficult to use/insert 10

Too hard to get rings from Z-CAN clinic 11

Other reason (specify): ____ 12

next applicable section



Patch-Current

47

90

When did you start using the patch?

MM / YYYY


48

91

In the past 6 months, how satisfied have you been with the patch?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3

193




49

92

What are the main reasons you have not been very satisfied with the patch? (check all that apply)

It is not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner does not want me to use it 6

I want to get pregnant 7

I do not believe it is effective for birth control 8

Other reason (specify): ­­____ 9


50

93

During the past 6 months, how hard has it been for you to get more patches when you need them?

Note- 1 will skip to either other methods (past use) or condom section

Not difficult 1

Somewhat difficult 2

Very difficult 3


1next appropriate section

51

94

Why has it been difficult for you to get more patches when you needed them?

Select all that apply

Distance to the Z-CAN clinic 1

Hard to get to the Z-CAN clinic 2

Remembering to go to the Z-CAN clinic 3

Finding the time to go to the Z-CAN clinic 4

The patch is too expensive 5

Other reason____________ 6

next applicable section



Patch-Past

101

95

When did you start using the patch?

MM / YYYY


102

96

In the past 6 months, how satisfied were you with the patch?

Very satisfied 1

Somewhat satisfied 2

Not satisfied 3

198




103

97

What are the main reasons you were not very satisfied with the patch? (check all that apply)

It was not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner did not want me to use it 6

I wanted to get pregnant 7

I do not believe it is effective for birth control 8

Other reason (specify): ­­____ 9


104

98

During the past 6 months, how hard was it for you to get more patches when you need them?

Not difficult 1

Somewhat difficult 2

Very difficult 3


105

99

Why was it was difficult for you to get more patches when you needed them?

Select all that apply

Distance to the Z-CAN clinic 1

Hard to get to the Z-CAN clinic 2

Remembering to go to the Z-CAN clinic 3

Finding the time to go to the Z-CAN clinic 4

The patch is too expensive 5

Other reason____________ 6


106

100

Did you talk with a Z-CAN provider before you stopped using the patch?

No 1

Yes 2



101

Why did you stop using the patch? (check all that apply)

It was not convenient for me 1

I experienced bleeding changes 2

I experienced side effects 3

It caused me pain 4

It was too expensive for me 5

My partner did not want me to use it 6

I wanted to get pregnant 7

I do not believe it is effective for birth control 8

Healthcare provider recommended I stop using it 9

It was difficult to use 10

Too hard to get patches from Z-CAN clinic 11

Other reason (specify): ____ 12

next applicable section



Condoms

108

102

During the past 6 months, how often do you and your partner(s) use condoms?

Never 1

Sometimes 2

Most of the time 3

Always 4

1104

109

103

Why do you and your partner(s) use condoms? (select all that apply )

To prevent sexually transmitted infections (Chlamydia, gonorrhea, HIV, etc) 1

To prevent pregnancy 2

To prevent Zika virus infection 3

Other__________________ 4



Other

110

104

During the past 6 months, did you use any of these other birth control methods?

Withdrawal (pulling out)

No 1

Yes 2

Tubal sterilization (female)

No 1

Yes 2

Vasectomy (male sterilization)

No 1

Yes 2

Rhythm method or fertility awareness

No 1

Yes 2

Other_________________

No 1

Yes 2



Thank you very much for participating in this survey. The information you provide will help the Z-CAN program improve contraception services in Puerto Rico.



File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorWhiteman, Maura (CDC/ONDIEH/NCCDPHP)
File Modified0000-00-00
File Created2021-01-22

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