Open Access

Mental distress among Liberian medical staff working at the China Ebola Treatment Unit: a cross sectional study

Contributed equally
Health and Quality of Life Outcomes201513:156

https://doi.org/10.1186/s12955-015-0341-2

Received: 7 May 2015

Accepted: 9 September 2015

Published: 26 September 2015

Abstract

Background

Ebola virus outbreak in West Africa not only triggered a grave public health crisis, but also exerted and induced huge mental distress on medical staff, which would negatively influence epidemic control and social rebuilt furthermore. We chose the local medical staff working at the China Ebola Treatment Unit (ETU) to explore the severity of potential mental distress and involved potential causes.

Methods

A descriptive study using the Symptom Check List 90 - Revised (SCL90-R) questionnaire to assess psychological health status was conducted among 52 Liberian medical staff. Global indices, including Global Severity Index (GSI), Positive Symptom Total (PST) and Positive Symptom Distress Index (PSDI), and nine subscales based on 90 inquiry items were compared among gender, work duty and other subgroups. Data were analyzed using Graphpad Prism and SPSS software.

Results

Mental distress among participants was not very serious; only PSDI, paranoid ideation and interpersonal sensitivity numerically increased relative to changes in other categories. While male medics and those responsible for cleaning and disinfection showed significant increases in scores for psychological dimensions, such as obsessive-compulsive, anxiety, phobic anxiety, interpersonal sensitivity, paranoid ideation and positive symptom total.

Conclusions

Data of this study implies that the psychological health status of medical staff within the special social environment of an Ebola treatment unit should warrant more attention.

Background

Beginning in March 2014, the Ebola virus outbreak in West Africa triggered a grave public health crisis that hit Guinea, Liberia and Sierra Leone particularly hard. Case count doubled every 4 weeks [1] as a reflection of slow global response and outbreak underestimation [2].

Although the crisis has already passed, what could we learn from it and are we ready for the further public crisis? In addition to well-known undermined readiness of local public health systems caused by long-term poverty, human rights abuses and civil, fear and misinformation about Ebola significantly hampered epidemic control efforts and accelerated viral spread. According to data from several studies, the last contributing factor is often overlooked and common not only in affected regions but in far-away countries such as the United Kingdom and the United States [3, 4]. As documented early in Ebola outbreaks in tropical African countries, medical staff shortages are exacerbated by the mental distress that medics experience as targets of fear by the affected community [5, 6].

Because severity of mental distress among local medical staff has been inadequately defined previously in similar crisis, the present cross-sectional study was done to evaluate Liberian medical peers under such circumstance, which will provide the first-hand data and help to prepare furthermore regional or global public crisis. These Liberian medical peers worked in China Ebola Treatment Unit (ETU) that were swiftly organized and deployed by the Chinese government in an international collaboration effort to aid West Africa combat Ebola [7]. Located at Samuel Kanyon Doe Sports Stadium in Monrovia, Liberia, the ETU counts with a team that has been in place and in full operation since setup in October 2014 and could be used as a representative sample of local medical staff fighting against Ebola.

Methods

Study design and participants

Liberian medics working at the China Ebola Treatment Unit (SKD stadium, Monrovia, Liberia) were enrolled from March 1 to 10, 2015 if aged >18 years, willing to complete the study questionnaire, and without mental disorders. Other inclusion criterion for the participants was the ability to understand, speak, and write English, which could approve the completion of mental distress evaluation without difficulty. Since such study was done during the prevailing period of Ebola, it was very dangerous and not possible for us to go to other ETUs in Liberia to enroll more participants, the snow sampling strategy was used and we enrolled all the Liberian medics in our ETUs only according with the above inclusion criteria. All study participants provided written informed consent, and the study protocol was approved by the Biomedical Ethics Committee in the second batch of the Medical Team of the Chinese People’s Liberation Army to Liberia.

Participant evaluation

Demographics and psychological health status data, including age, gender, education level, marital status, and whether any family member had died of Ebola within 6 months were collected from study participants. The SCL-90-R questionnaire was used as in a previous report [8], and two trained experts in the ETU mainly responsible for psychological support and fluent spoken English separately evaluated the participants’ psychological health status for about 20–25 min. English was chosen to do all the evaluation, which was widely used among the participants during the routine work in the ETU and could avoid potential information loss. Results of the 90-item SCL90-R questionnaire were classified according to 9 psychological dimensions: 1) somatization (SOM); 2) obsessive-compulsive (O-C); 3) interpersonal sensitivity (I-S); 4) depression (DEP); 5) anxiety (ANX); 6) anger-hostility (HOS); 7) phobic anxiety (PHOB); 8) paranoid ideation (PAR); and 9) psychoticism (PSY); and according to 3 global scales: the Global Severity Index (GSI), Positive Symptom Total (PST) and Positive Symptom Distress Index (PSDI). While the answers to each question included “not at all” (0) to “a little bit” (1),”moderately” (2),”quite a bit” (3) and “extremely” (4), the corresponding severity of psychological discomfort was graded as normal, mild, moderate, severe, or very severe, respectively.

Other possible independent variables considered in the analysis were working positions, occupation type and sex. And other factors were also collected such as marital status, education, religion, age and whether lost one of family member or not. Working positions included observation, treatment and cleaning. Occupations were divided into nurses and hygienists. Marital status was classified as “Unmarried”, or “Married”, and religious belief as “Christian” or “others”. Lost one of family member was defined as “Yes” or “No” following the question: “Have you lose one of your family member during the outbreak of Ebola?” Education level was classified as elementary school, middle school, high school, or college graduate and the latter two were regarded as receiving higher education. Age was classified into < 32 and ≥32-years-old.

Definitions and scores

The validity and reliability of the SCL90-R test has been confirmed previously in studies around the world [914]. Overall psychological health status was evaluated using the GSI score, a global scale; average level of distress was determined as the mean scores for PST and PSDI and compared among group categories. The former PST is a count of all the items with non-zero responses, and PSDI is calculated by dividing the sum of the values of items with non-zero responses by PST [15].

Statistical analysis

All data are expressed as mean ± standard derivation. Group means were compared by one-way or two-way analysis of variance (ANOVA) followed by a Student-Newman-Keuls test. Analysis of all data was performed using GraphPad Prism 4 and SPSS for Windows 7.0; p < 0.05 was considered statistically significant. In order to elucidate the potential influence of factors such as work duty, gender and job type on the psychological health status among such participants, subgroup analysis was done later.

Results

Demographics

Demographic characteristics of the 52 study participants are shown in Table 1. Mean age was 32.3 ± 6.7 (range, 24–50) years and 24 (46.2 %) were male, respectively; 65.4 % had higher education. Average time working at the ETU was 5.5 ± 2.0 (range, 3–10) months.
Table 1

Demographic characteristics of the participants (n = 52)

Demographic items

Status

Frequency

%

Gender

Male

24

46.2

Female

28

53.8

Ages (years)

<32

29

55.8

≥32

23

44.2

Working positions

Observation

19

36.5

Treatment

22

42.3

Cleaning

11

21.2

Job

Nurse

16

30.8

Hygienist

36

69.2

Marriage status

Married

18

34.6

Unmarried

34

65.4

Religious belief

Christian

34

65.4

Others

18

34.6

Lost one of family member

Yes

11

21.2

No

41

78.8

Psychological dimensions among participants overall

Among participants overall, mean GSI, PST and PSDI was 0.42 ± 0.42, 24.15 ± 18.27, and 1.31 ± 0.51, respectively, and among the 9 dimension subscale categories mean scores were: SOM, 0.21 ± 0.32; O-C, 0.34 ± 0.48; I-S, 0.59 ± 0.62; HOS, 0.24 ± 0.45; PAR, 0.61 ± 0.65; DEP, 0.48 ± 0.46; ANX, 0.27 ± 0.42; PHOB, 0.59 ± 0.69; and PSY, 0.41 ± 0.48. Among the latter, PSDI, PAR and I-C showed numerical increases relative to changes in other categories (Table 2).
Table 2

Psychological dimensions of SCL90-R among the participants (n = 52)

Clinical diagnosis

Mean Score

Standard Deviation

95 % CI

Lower

Upper

GSI

0.42

0.42

0.31

0.53

PST

24.15

18.27

19.19

29.12

PSDI

1.31

0.51

1.17

1.45

SOM

0.21

0.51

0.13

0.30

O-C

0.34

0.48

0.21

0.47

I-S

0.59

0.62

0.42

0.76

DEP

0.48

0.46

0.36

0.60

ANX

0.27

0.42

0.16

0.39

HOS

0.24

0.45

0.12

0.36

PHOB

0.59

0.69

0.40

0.78

PAR

0.61

0.65

0.43

0.79

PSY

0.41

0.48

0.28

0.54

CI: Confidence interval, GSI: Global Severity Index, PST: Positive Symptom Total, PSDI: Positive Symptom Distress Index, SOM: somatization, O-C: obsessive-compulsive, I-S: interpersonal sensitivity, DEP: depression, ANX: anxiety, HOS: anger-hostility, PHOB: phobic anxiety, PAR: paranoid ideation, PSY: psychoticism

Subgroup analysis of psychological dimensions

Because of heterogeneity among participants, analysis was also done among subgroups such as by work duty, gender and job type.

Among the work duty subgroups, local medical staff responsible for cleaning and disinfection showed significantly higher levels of obsessive-compulsive (1.68 ± 1.03 versus 1.24 ± 0.78, p < 0.05), anxiety (1.65 ± 0.99 versus 1.16 ± 0.52, p < 0.05), phobic anxiety (1.94 ± 1.19 versus 1.47 ± 1.05, p < 0.05) and PST categories (38.64 ± 16.61 versus 18.73 ± 17.89, p < 0.05) than treatment ward staff, and of anxiety level (1.68 ± 1.03 versus 1.19 ± 0.61, p < 0.05) and PST (38.64 ± 16.61 versus 22.05 ± 15.83, p < 0.05) than observation ward staff (Fig. 1a, b).
Fig. 1

Dimensions of SCL90-R among 3 subgroups of participants working in observation and treatment ward or responsible for cleaning and disinfection. Concerning different working position, participants responsible for cleaning and disinfection showed significantly higher levels of obsessive-compulsive, anxiety, phobic anxiety (a) and Positive Symptom Total scales (b) than those in treatment ward (p < 0.05), while similar higher level of anxiety than those in observation ward (p < 0.05)

In terms of gender differences, male participants showed significantly more severe interpersonal sensitivity (0.81 ± 0.70 versus 0.40 ± 0.48, p < 0.05), paranoid ideation (0.88 ± 0.75 versus 0.39 ± 0.47, p < 0.05) and PST (31.17 ± 19.44 versus 18.14 ± 15.08, p < 0.05) as compared to female ones (Fig. 2a, b).
Fig. 2

Dimensions of SCL90-R between male and female participants. More severity of interpersonal sensitivity, paranoid ideation (a) and Positive Symptom Total (b) was shown in male participants compared with female ones (p < 0.05)

No significant differences were apparent between nurses and hygienists for all analyzed psychological dimensions (p > 0.05) (Fig. 3a, b).
Fig. 3

Dimensions of SCL90-R between nurses and hygienists. No difference of all the analyzed psychological dimensions was found between nurses and hygienists among neither psychological dimensions (a) nor positive symptom total (b) (p > 0.05)

Discussion

With significant support from the international community, the fight against the recent Ebola outbreak in West Africa primarily focused on promptly bringing the underestimated epidemic under control. Despite said efforts, the Ebola epidemic reached crisis levels with toll mounting by April 2015 according to WHO [16] to 25,178 cumulative case counts and 10,445 case deaths.

Prominent among the reasons cited for the Ebola virus spread across West Africa and into other continents was insufficient medical staff not only stemming from impoverished health systems in affected African countries but also fueled by severe mental stress during the epidemic [17]. Previous Ebola outbreaks in Africa had attested to the great sacrifices endured by medical staff [1821]. The frontline staff facing infected patients has been not only at great peril of becoming themselves infected because of inadequate availability of protective gear, but also subjected to intense stigmatization by family, coworkers, and the community [22]. Effective intervention unfortunately remains elusive despite recognition of these problems and formulation of pertinent recommendations by the World Health Organization and Médecins Sans Frontières et al. [17]. The present cross-sectional study therefore was conducted among local medical staff in an attempt to gain further insight into this unmet medical need.

Data from the present study showed that mental distress among local medical staff in an ETU was not very serious. Possible reasons include: 1. At assessment time, local medical staff had worked at the ETU from 3 to 10 months, and some had even worked at an Island Clinic Centre for a while before being employed by our ETU, which made them be very familiar with Ebola virus and decreased fear about it; 2. the study was implemented from March 1 to 10, when vigilance already had been implemented without any newly lab-confirmed Ebola cases in Liberia after March 1 [16], which might significantly relieve their distress; and 3. close cooperation and early psychosocial support by our medical team and other organizations also might have contributed to mitigation of emotional distress consequences among Liberian medics. Nonetheless, subgroup analyses revealed that scores for psychological dimensions such as obsessive-compulsive, anxiety, phobic anxiety, interpersonal sensitivity, paranoid ideation and Positive Symptom Total significantly increased among male medical staff and those responsible for cleaning and disinfection. At our ETU, the cleaning and disinfection section was responsible for disinfection of recycled protective gear, garbage collection out of isolated wards, and incineration. Although personnel was not directly in contact with suspected or confirmed Ebola patients as were those at observation and treatment wards, the garbage handled was hazardous and high risk even under the protection of personal protective equipment (PPE). Furthermore, heat and smoke during incineration was not without hazards related to heat stress and dehydration, as evinced by fainting occurrences during work.

As for the male medical staff, abnormal levels of interpersonal sensitivity, paranoid ideation and PST relative to females might be derived from relative differences in workload which was physically more demanding for males, who were mainly in charge of garbage collection and cleaning within the wards. The possibility of greater negative influence by communal stigmatization against male medical staff could not be excluded.

No significant difference was apparent in mental distress despite the difference in education level between nurses and hygienists (100 % vs. nearly 50 % had higher education, respectively) possibly because: 1. Both nurses and hygienists had been intensively trained for 2 weeks at our ETU on donning, doffing, use and disposal of PPE and dealing with infected patients according to WHO recommendations, which might have changed their attitudes toward Ebola overall; and 2. As shown by studies of intensive care units [23], the abundant information exchange during dinners and night duties among staff might have fostered prompt identification and correction of potential flaws, and possibly effectively alleviated tense attitudes towards working in isolated wards with many infected patients.

Attention should be paid to increased levels of obsessive-compulsive, anxiety, phobic anxiety, interpersonal sensitivity, and paranoid ideation among local medical staff seen in the present study because of the very prevailing social stigma in Ebola affected areas. Stigmatization against medical staff working against Ebola had already fueled viral spread and hampered efficient infection control during the alert management phase not only in Africa but also in other affected countries [2427]. To offset such stigma, Ebola infection survivors were encouraged to engage in the fight against Ebola as burial team members, contact tracers, and community educators, which benefitted affected communities [26, 28, 29]. However, despite several plans proposed by WHO and its partners aimed at resolving the problem [30], stigma against local medical staff has not received adequate attention, which might further undermine the already fragile public health system infrastructure against further possible infectious outbreaks in Africa.

The present study was limited by its observational design; the lack of a suitable reference for SCL-90R psychological dimension norms for the Liberian population; and the small study sample size which might have precluded finding significant associations among variables. Further research with normal controls and larger sample sizes is warranted.

Conclusions

Findings of this study implied that within the specific social environment of the fight against Ebola, the psychological health status of the medical staff warrants more attention and intervention particularly among male medical staff responsible for cleaning and disinfection. As brave fighters against Ebola, local medical staffs are susceptible to being infected and they deserve and should be relieved from unnecessary mental distress stemming from social stigmatization and work related stress, both physical and mental.

Notes

Abbreviations

ETU: 

Ebola Treatment Unit

SCL90-R: 

Symptom Check List 90 – Revised

GSI: 

Global Severity Index

PST: 

Positive Symptom Total

PSDI: 

Positive Symptom Distress Index

SOM: 

Somatization

O-C: 

Obsessive-compulsive

I-S: 

Interpersonal sensitivity

DEP: 

Depression

ANX: 

Anxiety

HOS: 

Anger-hostility

PHOB: 

Phobic anxiety

PAR: 

Paranoid ideation

PSY: 

Psychoticism (PSY)

ANOVA: 

Analysis of variance

PPE: 

Personal protective equipment

Declarations

Acknowledgements

We extend our best regards and wishes to all the medics in ETUs around Africa fighting Ebola.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Nursing, Eastern Hepatobiliary Surgery Hospital, Second Military Medical University
(2)
Department of Orthopaedic Surgery, Shanghai Changzheng Hospital, Second Military Medical University
(3)
Department of Anesthesiology, Shanghai Changhai Hospital, Second Military Medical University
(4)
Outpatient Department, Shanghai Changhai Hospital, Second Military Medical University
(5)
Department of Cardiology, Shanghai Changzheng Hospital, Second Military Medical University
(6)
Department of Infectious Diseases, Shanghai Changhai Hospital, Second Military Medical University
(7)
Second patch of Medical Team of the Chinese People’s Liberation Army to Liberia

References

  1. Meltzer MI, Atkins CY, Santibanez S, Knust B, Petersen BW, Ervin ED, et al. Estimating the future number of cases in the Ebola epidemic--Liberia and Sierra Leone, 2014–2015. MMWR Surveill Summ. 2014;63 Suppl 3:1–14.PubMedGoogle Scholar
  2. Team WHOER. Ebola virus disease in West Africa--the first 9 months of the epidemic and forward projections. N Engl J Med. 2014;371:1481–95.View ArticleGoogle Scholar
  3. Turtle L, McGill F, Bettridge J, Matata C, Christley R, Solomon T. A Survey of UK Healthcare Workers’ Attitudes on Volunteering to Help with the Ebola Outbreak in West Africa. PLoS One. 2015;10:e0120013.PubMed CentralView ArticlePubMedGoogle Scholar
  4. Matlock AM, Gutierrez D, Wallen G, Hastings C. Providing nursing care to Ebola patients on the national stage: the National Institutes of Health experience. Nurs Outlook. 2015;63:21–4.PubMed CentralView ArticlePubMedGoogle Scholar
  5. Heymann DL, Weisfeld JS, Webb PA, Johnson KM, Cairns T, Berquist H. Ebola hemorrhagic fever: Tandala, Zaire, 1977–1978. J Infect Dis. 1980;142:372–6.View ArticlePubMedGoogle Scholar
  6. Ulrich CM. Ebola is causing mental distress among African healthcare workers. BMJ. 2014;349:g6672.View ArticlePubMedGoogle Scholar
  7. Zhang B, Gao GF. A new chapter for China’s public health security--aids offered to Africa to combat Ebola. Sci China Life Sci. 2015;58:114–6.View ArticlePubMedGoogle Scholar
  8. Lopez Seco F, Aguado-Gracia J, Mundo-Cid P, Acosta-Garcia S, Marti-Serrano S, Gaviria AM, et al. Maternal psychiatric history is associated with the symptom severity of ADHD in offspring. Psychiatry Res. 2015;226:507–12.View ArticlePubMedGoogle Scholar
  9. Xie H, Li B, Li L, Zou XL, Zhu CR, Li Y, et al. Association of increased circulating catecholamine and glucocorticoid levels with risk of psychological problems in oral neoplasm patients. PLoS One. 2014;9:e99179.PubMed CentralView ArticlePubMedGoogle Scholar
  10. Ringqvist A, Bech P, Glenthoj B, Petersen E. Acute and long-term psychiatric side effects of mefloquine: a follow-up on Danish adverse event reports. Travel Med Infect Dis. 2015;13:80–8.View ArticlePubMedGoogle Scholar
  11. Palmieri VO, Santovito D, Margari F, Lozupone M, Minerva F, Di Gennaro C, et al. Psychopathological profile and health-related quality of life (HRQOL) in patients with hepatocellular carcinoma (HCC) and cirrhosis. Clin Exp Med. 2015;15:65–72.View ArticlePubMedGoogle Scholar
  12. Loesch DZ, Bui MQ, Hammersley E, Schneider A, Storey E, Stimpson P, et al. Psychological status in female carriers of premutation FMR1 allele showing a complex relationship with the size of CGG expansion. Clin Genet. 2015;87:173–8.View ArticlePubMedGoogle Scholar
  13. Kontoangelos K, Papageorgiou CC, Raptis AE, Tsiotra P, Lambadiari V, Papadimitriou GN, et al. Homocysteine, cortisol, diabetes mellitus, and psychopathology. J Diabetes Res. 2015;2015:354923.PubMed CentralView ArticlePubMedGoogle Scholar
  14. Gul AI, Colgecen E. Personality traits and common psychiatric conditions in adult patients with acne vulgaris. Ann Dermatol. 2015;27:48–52.PubMed CentralView ArticlePubMedGoogle Scholar
  15. Derogatis LR, Melisaratos N. The Brief Symptom Inventory: an introductory report. Psychol Med. 1983;13:595–605.View ArticlePubMedGoogle Scholar
  16. Ebola Situation Report [http://apps.who.int/ebola/current-situation/ebola-situation-report-11-march-2015]
  17. Shultz JM, Baingana F, Neria Y. The 2014 Ebola outbreak and mental health: current status and recommended response. JAMA. 2015;313:567–8.View ArticlePubMedGoogle Scholar
  18. Arthur RR. Ebola in Africa--discoveries in the past decade. Euro Surveill. 2002;7:33–6.PubMedGoogle Scholar
  19. Lahm SA, Kombila M, Swanepoel R, Barnes RF. Morbidity and mortality of wild animals in relation to outbreaks of Ebola haemorrhagic fever in Gabon, 1994–2003. Trans R Soc Trop Med Hyg. 2007;101:64–78.View ArticlePubMedGoogle Scholar
  20. Nkoghe D, Kone ML, Yada A, Leroy E. A limited outbreak of Ebola haemorrhagic fever in Etoumbi, Republic of Congo, 2005. Trans R Soc Trop Med Hyg. 2011;105:466–72.View ArticlePubMedGoogle Scholar
  21. Muyembe-Tamfum JJ, Mulangu S, Masumu J, Kayembe JM, Kemp A, Paweska JT. Ebola virus outbreaks in Africa: past and present. Onderstepoort J Vet Res. 2012;79:451.View ArticlePubMedGoogle Scholar
  22. Hewlett BL, Hewlett BS. Providing care and facing death: nursing during Ebola outbreaks in central Africa. J Transcult Nurs. 2005;16:289–97.View ArticlePubMedGoogle Scholar
  23. Edwards MP, McClement SE, Read LR. Nurses’ responses to initial mental distress in long-term care. J Bioeth Inq. 2013;10:325–36.View ArticlePubMedGoogle Scholar
  24. Okware SI, Omaswa FG, Zaramba S, Opio A, Lutwama JJ, Kamugisha J, et al. An outbreak of Ebola in Uganda. Trop Med Int Health. 2002;7:1068–75.View ArticlePubMedGoogle Scholar
  25. Kinsman J. “A time of fear”: local, national, and international responses to a large Ebola outbreak in Uganda. Global Health. 2012;8:15.PubMed CentralView ArticlePubMedGoogle Scholar
  26. Davtyan M, Brown B, Folayan MO. Addressing Ebola-related stigma: lessons learned from HIV/AIDS. Glob Health Action. 2014;7:26058.PubMedGoogle Scholar
  27. Lin L, Hall BJ, Khoe LC, Bodomo AB. Ebola Outbreak: From the Perspective of African Migrants in China. Am J Public Health. 2015;105:e1.View ArticleGoogle Scholar
  28. Lee-Kwan SH, DeLuca N, Adams M, Dalling M, Drevlow E, Gassama G, et al. Support services for survivors of ebola virus disease - Sierra Leone, 2014. MMWR Morb Mortal Wkly Rep. 2014;63:1205–6.PubMedGoogle Scholar
  29. Epstein JM, Sauer LM, Chelen J, Hatna E, Parker J, Rothman RE, et al. Infectious disease: Mobilizing Ebola survivors to curb the epidemic. Nature. 2014;516:323–5.View ArticlePubMedGoogle Scholar
  30. Reardon S. Ebola’s mental-health wounds linger in Africa. Nature. 2015;519:13–4.View ArticlePubMedGoogle Scholar

Copyright

© Li et al. 2015

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