Hrev_master Healthcare in Low-resource Settings 2025; volume 13:13370 Prevalence of physical activity and its associated sociodemographic factors among schoolchildren in Albania Brizida Refatllari,1 Jonida Stefa,1 Migena Gega,1 Grejd Hyska,2 Gentiana Qirjako,3,4 Genc Burazeri3,5 1Faculty of Technical Medical Sciences, University of Medicine, Tirana, Albania; 2Global Studies Institute, University of Geneva, Geneva, Switzerland; 3Faculty of Medicine, University of Medicine, Tirana, Albania; 4Institute of Public Health, Tirana, Albania; 5Department of International Health, CAPHRI (Care and Public Health Research Institute), Maastricht University, Maastricht, The Netherlands Abstract Physical Activity (PA) promotes health and wellbeing of chil- dren. Our objective was to assess the prevalence and the associat- ed sociodemographic factors of PA among schoolchildren in a Southeastern European country. This was a cross-sectional study conducted in Albania in 2022 including a nationwide representa- tive sample of 5454 schoolchildren aged 11-15 years (≈52% girls; ≈96% response). Data on children’s PA and their sociodemograph- ic factors were collected. Daily moderate-to-vigorous PA was more prevalent in boys, younger children and those from wealthier families (overall: ≈29%). Conversely, sedentary behaviour (mod- erate-to-vigorous PA ≤2 days/week) was more prevalent in girls, older children, rural children, those with unemployed parents and children from less affluent families (overall: ≈26%). Frequent vig- orous PA (≥3 days/week) was more prevalent in boys, younger children and those from better-off families (overall: ≈64%). Our findings highlight potential advantages of PA engagement linked to both male gender and a higher socioeconomic status. This study underscores the need for targeted interventions to promote active lifestyles in children, particularly among groups at higher risk of sedentary behaviour which correspond to girls and disadvantaged socioeconomic categories. Introduction Engagement in regular physical activity (PA) promotes physi- cal health, as well as social and emotional development in children and adolescents.1 PA supports healthy growth, strengthens bones and muscles, enhances cognitive abilities, and fosters psycho- emotional well-being in children.2-4 Additionally, PA helps reduce anxiety and depression, supporting better mental health and well- being in adolescents.5 Also, regular PA improves concentration and fosters a range of positive social health outcomes,6 as well as prevents child obesity and reduces body weight.7 According to the World Health Organization (WHO), children and young people aged 5-17 years should engage every day in at least 60 minutes of Moderate-to-Vigorous PA (MVPA).7 The majority of these activities should be aerobic.2 In addition, WHO recommends that children should engage at least three days a week in Vigorous PA (VPA), consisting of aerobic and/or activi- ties that strengthen bones and muscles.2 However, most adolescents in the European Region do not meet the recommended PA guidelines.8 Instead, MVPA levels remain steadily low, tend to decrease with age during adolescence, and have shown little improvement over the past two decades.9,10 Conversely, engagement in VPA is relatively high among children in many European countries and seems to have remained steady between 2002 and 2014, with a modest upward trend in girls,9 and among adolescents from families with moderate to high socioeco- nomic status.11 The Health Behaviour in Schol-aged Children (HBSC) study is a well-structured school-based survey conducted every four years across multiple countries (including Europe, Central Asia and Canada).1,12 The HBSC survey gathers essential data on vari- ous health behavioural characteristics and health status of schoolchildren aged 11, 13 and 15 years.1,12 The last round of Correspondence: Genc Burazeri, University of Medicine, Rr. “Dibres”, No. 371, Tirana, Albania. Tel.: +355674077260 E-mail: genc.burazeri@maastrichtuniversity.nl Key words: Albania, children, Health Behaviour in School-aged Children (HBSC), physical activity, schoolchildren. Funding: this study was funded by the following agencies: the United Nations Population Fund (UNFPA) Office in Albania, the United Nations Children’s Fund (UNICEF) Office in Albania, and the Swiss Development and Cooperation (SDC) Agency through the project “Schools for Health” implemented in Albania. Acknowledgment: this study was conducted by the Faculty of Medicine, University of Medicine, Tirana, Albania. Conflicts of interest: none declared. Ethical approval: this study was approved by the Ethics Committee of Tirana Medical University (approval ID: No.700/1, date: 05-04-2022). Availability of data and material: the data presented in this study are available upon request from the corresponding author. Contributions: BR, GQ and GB contributed to the study conceptualiza- tion and design, analysis and interpretation of the data and writing of the article. JS, MG and GH commented comprehensively on the manuscript. All authors have read and approved the submitted manuscript. Received: 11 November 2024. Accepted: 11 November 2024. Early access: 17 January 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13:13370 doi:10.4081/hls.2025.13370 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 86] [Healthcare in Low-resource Settings 2025;13:13370] HBSC survey was carried out during 2021-2022 in 44 countries including Albania.1,12,1 Alongside numerous health outcomes and behavioural factors, the survey included also questions assessing engagement in PA among schoolchildren aged 11-15 years.1,12 Albania, a post-communist country in Southeastern Europe, has been characterized in the past three decades by a rapid political and socioeconomic transition which has been also associated with behavioural changes.14 Nevertheless, according to the most recent estimates available from the Global Burden of Disease Study,15 the age-standardized mortality rate attributed to low levels of PA has remained almost unchanged in the past three decades (with about 6 deaths per 100,000 population). Regarding children, a recent study from Albania has shown that almost 1/3rd of schoolchildren aged 12-15 years (N=7831) do not exhibit the best attitudes toward health promotion, a composite indicator including also children’s attitudes toward PA (16). According to this study, significant inde- pendent sociodemographic correlates of poorer attitudes toward health promotion (ability to maintain and improve health) consist- ed of older age, a lower maternal education, and a lower family income.16 Within this context, the aim of our analysis was to assess the prevalence of PA and its associated sociodemographic factors among schoolchildren, based on the last HBSC round carried out in Albania in 2022.13 Based on the findings from previous HBSC rounds, we hypothesized a higher prevalence of PA among boys and younger children.1,12 Materials and Methods A cross-sectional study (corresponding to the last round of HBSC survey) was conducted in Albania in 2022.13 Participants included a nationwide representative sample of 5454 schoolchildren aged 11, 13 and 15 years (2844 girls, ≈52% of the sample). The overall response rate was ≈96%.13 The survey instrument consisted of an internationally standard- ized self-administered questionnaire which included information on a wide range of behavioural factors and sociodemographic fac- tors of schoolchildren.1,12 Measurement of PA consisted of assessment of the frequency of moderate-to-vigorous PA (MVPA) and vigorous PA (VPA). MVPA was measured based on the following question: “Over the past seven days, on how many days were you physically active for a total of at least 60 minutes per day?”. Possible answers ranged from 0 (zero days) to 7 (seven days). In the analysis, MVPA was also dichotomized into: “7 days/week” (referred to as “daily MVPA”) vs. “≤6 days/week”, as well as into: “0-2 days/week” (referred to as “sedentary lifestyle/behaviour”) vs. “≥3 days/week”.1,12 VPA was measured based on the following ques- tion: “How often do you usually exercise in your free time, outside of school hours, so much that you get out of breath or sweat?”. Possible answers ranged from 1 (every day) to 8 (never). In the analysis, VPA was also dichotomized into: “≥3 days/week” (referred to as “frequent VPA”) vs. “≤2 days/week”.1,12 Sociodemographic factors consisted of children’s gender (boys vs. girls), age (11, 13, and 15 years), place of residence (urban vs. rural areas), mother’s and father’s current employment status (for each: yes vs. no), and family affluence scale (less affluent vs. more affluent families).12 The Ethics Committee of Tirana Medical University endorsed the study (approval ID: No.700/1). All schoolchildren were informed about the objectives and procedures of the survey, with a focus on the aspects related to the survey anonymity and the aggre- gated statistical analysis. General linear model was used to compare the mean values of PA variables (expressed as numerical terms) by sociodemographic factors of schoolchildren. Crude (unadjusted) mean values and their respective 95% confidence intervals (95%CIs) and p-values were calculated (Table 1). On the other hand, binary logistic regression was employed to assess the associations of PA indices (introduced as categorial terms) with sociodemographic factors of schoolchildren. Crude (unadjusted) models were run (Table 2). Odds ratios (ORs) and their respective 95%CIs and p-values were calculated for each PA index (daily MVPA, sedentary behaviour, and frequent VPA). In all cases, P≤0.05 was considered as statistically significant. All the statistical analyses were conducted by use of the Statistical Package for the Social Sciences (SPSS, version 19.0). Results Table 1 presents the distribution of scores of PA variables by sociodemographic factors of schoolchildren included in this study. Overall, mean score of MVPA was about 4.3 [range from 0 (zero days) to 7 (seven days)]. It was significantly higher in boys than in girls (4.7 vs. 3.9, respectively; P<0.01). There was evidence of a graded inverse relationship with age (overall P<0.01), with the youngest children exhibiting considerably higher mean MVPA scores compared to their oldest counterparts (4.8 vs. 3.8, respec- tively). Furthermore, mean MVPA scores were somehow higher among schoolchildren whose fathers and/or mothers were employed (4.3 for both) than among those whose parents were unemployed (3.9 for father’s unemployment and 4.2 for mother’s unemployment). Also, mean MVPA score was higher among chil- dren pertinent to more affluent families than in those from less affluent families (4.5 vs. 4.1, respectively; P<0.01). Overall, mean score of VPA was around 3.2 [range from 1 (every day) to 8 (never)]. It was lower in boys than in girls (2.8 vs. 3.6, respective- ly; P<0.01). There was a positive linear relationship with age (overall P<0.01), with older children displaying the highest mean VPA scores and the youngest children exhibiting the lowest VPA scores (3.6 vs. 2.8, respectively). Additionally, mean VPA scores were lower among children with employed fathers compared with those with unemployed fathers (3.2 vs. 3.5, respectively; P<0.01) and in children belonging to more affluent families than in those with a lower family wealth (3.0 vs. 3.4, respectively; P<0.01). The overall prevalence of daily MVPA was about 29% (Table 3). Daily MVPA was substantially more prevalent in boys than in girls (36% vs. 22%, respectively); among the youngest children compared to their oldest counterparts (37% vs. 21%, respectively); among children whose fathers were employed than in those with unemployed fathers (29% vs. 24%, respectively); and in children from more affluent families than in those with a lower family wealth (31% vs. 27%, respectively). On the whole, the prevalence of a sedentary lifestyle (MVPA: 0-2 days/week) was around 26%. Sedentary behaviour was much more prevalent in girls than in boys (33% vs. 19%, respectively); among the oldest children than their youngest counterparts (32% vs. 20%, respectively); among children whose fathers were unemployed compared to those with employed fathers (33% vs. 25%, respectively); among children with unemployed mothers than in those whose mothers were employed (28% vs. 25%, respectively); and among children perti- nent to less affluent families than in those from better-off families (31% vs. 22%, respectively). Overall, the prevalence of frequent Article [Healthcare in Low-resource Settings 2025;13:13370] [page 87] VPA (at least three days a week) was approximately 64%. Frequent VPA was considerably higher in boys than in girls (74% vs. 54%, respectively); among the youngest children than in the oldest indi- viduals (72% vs. 54%, respectively); among children with employed fathers than in those whose fathers were unemployed (64% vs. 58%, respectively); and in children from more affluent families than in those from poorer families (68% vs. 59%, respec- tively). Table 2 presents binary logistic regression results of the associations between PA indices (categorial terms) and sociodemo- graphic factors of schoolchildren. There was evidence of positive and significant associations of daily MVPA with male gender (OR=1.9, 95%CI=1.7-2.2), a younger age (OR=2.3, 95%CI=2.0- 2.7), father’s employment (OR=1.3, 95%CI=1.1-1.7), and family affluence (OR=1.3, 95%CI=1.1-1.4). Conversely, sedentary behaviour (MVPA: 0-2 days) was inversely related to male gender (OR=0.5, 95%CI=0.4-0.5), a younger age (OR=0.5, 95%CI=0.5- 0.6), urban residence (OR=0.9, 95%CI=0.8-1.0), father’s employ- ment (OR=0.7, 95%CI=0.6-0.9), mother’s employment (OR=0.8, 95%CI=0.7-1.0), and family affluence (OR=0.6, 95%CI=0.6-0.7). On the other hand, frequent VPA (≥3 days/week) was positively associated with male gender (OR=2.5, 95%CI=2.2-2.8), a younger age (OR=2.2, 95%CI=1.9-2.5), father’s employment (OR=1.3, 95%CI=1.1-1.6), and family wealth (OR=1.5, 95%CI=1.3-1.7). Discussion Main findings of our study conducted in Albania indicate that demographic and socioeconomic factors play a significant role in children’s PA patterns. Our analysis provided evidence of consis- tent positive links between male gender, younger age and family wealth with higher levels of both MVPA and VPA. In contrast, sedentary behaviour (MVPA: 0-2 days per week) was more com- mon among girls, older children, and those from a lower socioeco- nomic background. A pretty recent report informing about PA levels among all 44 participating countries in the last HBSC survey round conducted in 2021-221 and employing the same measuring instrument1,12 indi- cated that the average proportion of adolescents across countries and regions reporting daily 60 minutes of MVPA was 25% for boys and 15% for girls, which is lower than our findings pertinent to Albanian children (36% in boys and 22% in girls). In most coun- tries and regions included in the last HBSC survey round caried out in 2021-22, and across all age groups, girls had a significantly lower prevalence of daily MVPA compared to boys,1 which is in line with our findings. Girls in several countries have reported a low prevalence of daily MVPA (≤10%), including Italy, Greece, France, Greenland (Denmark) and Lithuania (1). Of note, the prevalence of daily MVPA was the lowest among Italian girls aged 15 years (only 3%) and the highest among Serbian boys aged 11 years (49%).1 Our findings on a positive link between daily MVPA and fam- ily wealth are in line with the multi-country HBSC 2021-22 report.1 Hence, among all 44 participating countries,1 the preva- lence of daily MVPA among boys pertinent to more affluent fami- lies was 32% compared to 20% among those from lower affluent families (in our study: 38% vs. 33%, respectively; data not shown in the tables). In girls, these estimates were 19% and 13%, respec- tively1 – in our study: 24% vs. 21%, respectively (not shown). On the whole, there were no considerable changes in the levels of daily MVPA between 2018 and 2022 which consist of the two last rounds conducted in the HBSC participating countries,1 where- as in Albania there is evidence of 10% increase in boys and 5% increase in girls (data not shown). Conversely, there are countries Article Table 1. Distribution of scores of physical activity variables by sociodemographic factors in a nationwide sample of Albanian schoolchild- ren, HBSC 2022 survey. Sociodemographic factors Moderate-to-vigorous Vigorous physical activity (VPA) physical activity (MVPA) Mean (95%CI)* P* Mean (95%CI) P Total sample (n=5454) 4.32 (4.26-4.38) - 3.18 (3.12-3.23) - Gender <0.001 <0.001 Boys (n=2610) 4.74 (4.66-4.83) 2.74 (2.66-2.82) Girls (n=2844) 3.89 (3.81-3.97) 3.61 (3.53-3.69) Age <0.001 (2)† <0.001 (2) 11 years (n=1784) 4.76 (4.66-4.87) <0.001 2.82 (2.72-2.91) <0.001 13 years (n=1785) 4.32 (4.21-4.43) <0.001 3.12 (3.02-3.21) <0.001 15 years (n=1877) 3.82 (3.72-3.93) - 3.63 (3.53-3.72) - Residence 0.617 0.490 Urban areas (n=3648) 4.31 (4.23-4.38) 3.21 (3.14-3.28) Rural areas (n=1806) 4.27 (4.17-4.38) 3.17 (3.07-3.27) Father’s employment <0.001 0.004 Yes (n=4928) 4.34 (4.27-4.40) 3.17 (3.11-3.23) No (n=479) 3.90 (3.97-4.11) 3.46 (3.27-3.65) Mother’s employment 0.031 0.732 Yes (n=3676) 4.34 (4.27-4.41) 3.19 (3.12-3.26) No (n=1710) 4.20 (4.09-4.30) 3.21 (3.11-3.31) Family affluence <0.001 <0.001 Less affluent (n=2600) 4.06 (3.97-4.15) 3.41 (3.33-3.49) More affluent (n=2715) 4.51 (4.42-4.60) 3.00 (2.92-3.08) * Mean values and their respective 95% confidence intervals and p-values from the General Linear Models. Range of scores for MVPA: from 0 (0 days) to 7 (seven days); hence, higher MVPA scores denote a higher frequency of physical activity. Range of scores for VPA: from 1 (every day) to 8 (never); thus, higher VPA scores indicate less frequent vigorous physical activity. †Overall p-value and degrees of freedom (in parentheses). [page 88] [Healthcare in Low-resource Settings 2025;13:13370] which exhibit a decrease in the prevalence of daily MVPA such as Lithuania, Armenia, Greenland (Denmark) and North Macedonia.1 Regarding VPA, 60% of adolescents in the 44 HBSC partici- pating countries met the WHO recommendation for engaging in VPA at least three times a week,1 which is slightly lower than our findings pertinent to Albanian children (about 64%). In most coun- tries, boys reported higher levels of VPA than girls across all age groups,1 which is in line with our findings from Albania. Of 44 countries included in the multi-country analysis, frequent VPA decreased significantly with age in 37 countries and regions for girls and 21 for boys.1 Likewise daily MVPA, there was evidence of a positive rela- tionship of frequent VPA with family affluence in most HBSC par- ticipating countries,1 which is compatible with our findings from Albania. According to the multi-country HBSC report,1 the preva- lence of frequent VPA among children from more affluent families was 77% in boys and 61% in girls, whereas among children from less affluent families it was 61% in boys and 42% in girls (in our study: 77% in boys and 58% in girls from more affluent families, and 70% in boys and 49% in girls from less affluent families – data not shown). As for the sedentary lifestyle, on average, 24% of adolescents from 44 participating HBSC countries were highly inactive (MVPA≤2 days/week),1 which is quite similar with our findings (26%). The prevalence of sedentary lifestyle was the highest (60%) in Greenland (Denmark) and the lowest (<10%) in Slovenia, Finland and Ireland.1 There was evidence of an inverse association with socioeconomic status, with children from high-affluence fam- Article [Healthcare in Low-resource Settings 2025;13:13370] [page 89] Table 2. Associations of physical activity indices with sociodemographic factors of schoolchildren; results from binary logistic regression models Physical activity indices Demographic factors Male Age 11† OR (95%CI) * P * OR (95%CI) P MVPA: 7 days/week 1.93 (1.71-2.18) <0.001 2.29 (1.97-2.66) <0.001 MVPA: 0-2 days/week 0.47 (0.42-0.54) <0.001 0.54 (0.46-0.63) <0.001 VPA≥3 days/week 2.46 (2.19-2.76) <0.001 2.17 (1.89-2.49) <0.001 Physical activity indices Socioeconomic factors Father employed Mother employed OR (95%CI) * P * OR (95%CI) P MVPA: 7 days/week 1.32 (1.06-1.65) 0.014 1.07 (0.94-1.22) 0.297 MVPA: 0-2 days/week 0.70 (0.57-0.86) <0.001 0.84 (0.74-0.96) 0.009 VPA≥3 days/week 1.29 (1.06-1.56) <0.001 1.01 (0.89-1.13) 0.925 * Odds ratios and their respective 95% confidence intervals (in parentheses), as well as p-values from crude (unadjusted) binary logistic regression models. †Compared to age 15. Table 3. Distribution of physical activity categories by sociodemographic factors of schoolchildren included in the HBSC 2022 survey in Albania. Sociodemographic factors Moderate-to-vigorous physical activity (MVPA). Vigorous physical activity (VPA) 7 days/week 0-2 days/week VPA≥3 days/week Total sample (n=5454) 1535 (28.8)* 1381 (25.9) 3416 (63.5) Gender Boys (n=2610) 908 (35.8) 470 (18.6) 1900 (74.1) Girls (n=2844) 627 (22.4) 911 (32.6) 1516 (53.8) Age 11 years (n=1784) 650 (37.2) 355 (20.3) 1262 (71.9) 13 years (n=1785) 505 (29.0) 436 (25.0) 1142 (65.1) 15 years (n=1877) 377 (20.6) 588 (32.1) 1007 (54.1) Residence Urban areas (n=3648) 1012 (28.4) 892 (25.1) 2284 (63.6) Rural areas (n=1806) 523 (29.6) 489 (27.6) 1132 (63.3) Father’s employment: Yes (n=4928) 1415 (29.4) 1218 (25.3) 3112 (64.0) No (n=479) 112 (23.9) 152 (32.5) 274 (57.9) Mother’s employment: Yes (n=3676) 1050 (29.2) 893 (24.8) 2308 (63.5) No (n=1710) 464 (27.8) 471 (28.2) 1067 (63.4) Family affluence Less affluent (n=2600) 674 (26.5) 776 (30.5) 1507 (58.6) More affluent (n=2715) 822 (30.9) 573 (21.6) 1825 (67.9) *Absolute numbers and their respective percentages (in parentheses). For the physical activity variables, there were the following missing values: MVPA (n=125); and VPA (n=72). In addi- tion, there were the following missing values for sociodemographic factors: age of schoolchildren (n=8), father’s employment status (n=47); mother’s employment status (n=68); and family affluence score (n=139). ilies exhibiting lower levels of physical inactivity compared to their low-affluence counterparts,1 which is in line with our findings from Albania. According to the multi-country HBSC report,1 the prevalence of sedentary lifestyle was higher among girls (29%) than boys (20%), a gender-difference which is compatible with our findings too (33% vs. 19%, respectively). Gender differences in the preva- lence of sedentary lifestyle range from 3% in Norway to 20% in Italy,1 whereas in our study the gender gap was 14%. Lack of PA and sedentary behaviours are significant public health issues that contribute to the onset of obesity and various chronic diseases later in life, including cardiovascular diseases, diabetes, some types of cancers and hypertension.17-19 The shift from adolescence to adulthood involves numerous life changes that impact lifestyle habits17,20,21 of which, physical inactivity is an important risk factor for ill-health and premature mortality.22 Hence, regardless of the proven health benefits of PA, most of the studies have revealed that it decreases during the transition from adolescence to adulthood and is replaced by increased time spent on sedentary activities.17,23,24 Our study included a large nationwide representative sample of schoolchildren and employed an internationally standardized instrument.12 Nevertheless, lack of generalizability to out-of- school Albanian children aged 11-15 years may be a potential lim- itation of this study. Additionally, there is a potential for informa- tion bias, particularly social desirability bias (overreporting PA fre- quency) or intentional misreporting. Also, the cross-sectional design of the study may represent another limitation, as it prevents the determination of causal relationships. Nonetheless, our study provides useful evidence on the preva- lence and sociodemographic factors associated with PA among schoolchildren in Albania. Policymakers and decisionmakers in Albania and in other countries should consider effective measures and implementation of cost-effective programs which increase engagement in PH among children and adolescents. Such pro- grams should be implemented in school settings, as an umbrella systematic review25 has persuasively indicated that the availability of PA programs and equipment within schools are positively asso- ciated with PA levels in children and adolescents.25-27 At the same time, there is need for interventions at community level, as such neighbourhood characteristics as pedestrian and cyclist safety structure has been also convincingly linked to increased PA levels among children and adolescents.25,26 Therefore, it has been sug- gested that, considering that PA practices among children are influ- enced by factors at different levels including home, school and neighbourhood environment,27 interventions should target all these levels and also consider elements of the macro environment in order to effectively address the problem of physical inactivity among children and adolescents.2527 Conclusions In conclusion, our study caried out in post-communist Albania highlights significant disparities in PA patterns among children based on gender, age and socioeconomic status (operationalized through parental employment status and family affluence scale). Boys, younger children, and those from wealthier families consis- tently exhibited higher levels of MVPA and VPA, suggesting that access to resources and social support in Albania may play a criti- cal role in encouraging active lifestyles. Conversely, girls, older children, rural children, and especially those from less affluent families seem more prone to sedentary behaviour, potentially plac- ing them at higher risk for health issues associated with physical inactivity. Addressing these disparities in Albania requires targeted inter- ventions that promote equitable access to PA opportunities, espe- cially for vulnerable groups, to foster healthier lifestyles across all sociodemographic population categories. On an international scale, our findings underscore the need for globally coordinated efforts to reduce disparities in PA among children, as inequities in access to active lifestyles may contribute to broader health and development inequalities across countries worldwide. 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