J Arthropod-Borne Dis, September 2016, 10(3): 394–404 H Banneheke et al.: Perceived Risk of … 394 http://jad.tums.ac.ir Published Online: January 06, 2016 Original Article Perceived Risk of Dengue in Ones’ Living Environment as a Determinant of Behavior Change through Social Mobilization and Communication: Evidence from a High Risk area in Sri Lanka *Hasini Banneheke 1, 2, Sarath Paranavitane 3, Vathsala Jayasuriya 4, Sarath Banneheka 5 1Specialist in Medical Parasitology, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka 2International Medical University, Kuala Lumpur, Malaysia 3Central Medical Centre (Pvt) Ltd, Nugegoda, Sri Lanka 4Specialist in Community Medicine, Faculty of Medical Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka 5Department of statistics, Faculty of Applied Sciences, University of Sri Jayewardenepura, Nugegoda, Sri Lanka (Received 8 Feb 2014; accepted 30 Nov 2014) Abstract Background: The aim of this study was to assess community knowledge and behavioral impact of the social mobili- zation and communication strategy applied in a dengue high-risk area in Sri Lanka. Methods: A group of adults visiting selected primary care facilities in Colombo district were interviewed to collect socio-demographic data, attributes of knowledge regarding dengue and the responsive behaviors adopted by them following the dengue control program though the media and social marketing campaigns. These attributes were clas- sified as `good ', `fair,' or `poor' by developing a composite scale for analysis and interpretation of data. Results: The primary source of information was television in the majority. The overall knowledge of the disease, vector and control methods was poor. The overall level of contribution to dengue control activities was good. Conclusion: Awareness of the disease and its complications had not contributed to favorable behavior changes. While the social mobilization and behavior change campaign in Sri Lanka had low impact on knowledge and be- haviors, a better understating of community perceptions of DF and how these perceptions are formulated within the social and cultural context; would be useful to improve uptake. This knowledge would be valuable for program plan- ners to strengthen dengue control activities in SL and other similar settings across the region. Keywords: Dengue control, Social mobilization, Behavior change, Sri Lanka Introduction Dengue ranks as the most important mos- quito borne viral disease in the world en- demic in over 100 countries in the world af- fecting 40% of the world population. Ac- cording to WHO estimates, 50–100 million cases of dengue infections with 500000 cas- es of dengue hemorrhagic fever (DHF) and 22,000 deaths occur annually in the world (WHO 2011).. In Asian countries, DHF is a leading cause of serious illness and death among children (WHO 2011) and case fatal- ity rates vary between 0.5 and 3.5%. Dengue fever (DF) has now become the most dread- ed and significant communicable disease affecting the South Asian tropical island of Sri Lanka (SL) characterized by cyclical ep- idemics in urban centers, spread to rural are- as and presence of multiple circulating virus serotypes. Despite extensive efforts by the government of SL strengthening the dengue management, surveillance and control activi- ties through a national plan of action (Kyu et *Corresponding authors: Dr Hasini Banneheke, E-mail: hasini.banneheke@gmail.com J Arthropod-Borne Dis, September 2016, 10(3): 394–404 H Banneheke et al.: Perceived Risk of … 395 http://jad.tums.ac.ir Published Online: January 06, 2016 al. 2005), there had been a steady increase in the incidence of dengue in the country (Annual Health Bulletine 2012, National Plan of Action for Prevention and Control of Dengue Fever 2005). In 2014 (up to No- vember), there were 39521 cases of suspect- ed cases of dengue reported to the national surveillance system. Out of this 56.40% were reported from the Western province which includes Colombo district (Quarterly Epidemiology Bulletin 2014). These epi- demics cause significant morbidity and mor- tality and its control and management con- straints an already over-burdened medical and financial resources. Traditional programs for dengue control and vector control used vertical approaches to reduce the source of transmission includ- ing physical (e.g. destruction or other physi- cal manipulation of water-holding contain- ers), biological (e.g. use of bacteria), and chemical (e.g. use of larvicides, spraying with systemic insecticides) control methods. However, these efforts have only resulted in short-term control as the areas become re- infested in a short period. One of the recent strategies initiated in SL was ‘behavioral changes through effective communication (social mobilization)’ as recommended by WHO for dengue control. During this cam- paign, public awareness activities were car- ried out to disseminate messages regarding the spread of the disease and the responsi- bility of the community with special empha- sis on removal of mosquito breeding sites and environmental management. Electronic media coordinated the broadcasting of mes- sages with the aim of improving knowledge, attitude, skills and practices towards eradi- cating dengue and to obtain community sup- port towards control activities. Despite being in effect for over 5 years, these strategies have not been examined from the user’s per- spective to determine if they have received the intended messages and or adapted the desired behaviors. In the absence of an ef- fective vaccine for disease control, control of the disease transmitting vectors Aedes ae- gypti and Ae. alobopictus mosquitoes is the mainstay of control with regards to this ma- jor public health problem in many parts of the world (Erlanger et al. 2008). Vector control is effective in reducing mosquito populations, when interventions use a community-based, integrated approach (Er- langer et al. 2008). However, as vector control is highly de- pendent on human behavior and actions, a major obstacle to effective implementation of vector control has been the inability to mobilize and coordinate the resources need- ed to achieve and sustain behavioral impact among populations at risk of DF/DHF (Parks et al. 2004). Social mobilization and communication strategies have been used for a number of years in an effort to achieve such behavioral changes among communities. Social mobili- zation is the process of bringing together all feasible and practical inter-sectoral social allies to raise people’s awareness of and de- mand for dengue prevention and control, to assist in the delivery of resources and ser- vices, and to strengthen community partici- pation for sustainability and self-reliance. Social marketing is based on an appeal to the individual through mass media and other methods. Evidence from other settings such as Co- lombia, Honduras, and Indonesia has demonstrated the usefulness of this method in Dengue control. In Columbia when high school students were trained to assist as community-based health educators, a steady decline was reported in the number of hous- es with Ae. aegypti larvae (Kroeger et al. 1995) and in Honduras, a method for clean- ing large cement washbasins and metal drums was shown to have a significant im- pact on Aedes larval populations (Fernandez et al. 1998). Moreover, in Malaysia, (Crab- tree et al. 2001) an integrated social mo- J Arthropod-Borne Dis, September 2016, 10(3): 394–404 H Banneheke et al.: Perceived Risk of … 396 http://jad.tums.ac.ir Published Online: January 06, 2016 bilization and communication campaign mo- tivated householders in Johor Bahru District to seek prompt treatment, to destroy larval breeding sites, and to organize voluntary teams to inspect and control larval breeding sites in public spaces. Other methods that have been effective include a participatory action research project involving community meetings, community-based production of communication materials, and door-to-door education aimed at household behaviors, particularly in the disposal of non- essential containers. For dengue control in Sri Lanka, National Dengue Control unit (NDCU) established in 2005 under the Ministry of Health, takes the lead in providing technical guidance for so- cial mobilization focusing on health issues in DF/DHF control activities in collaboration with the Epidemiological Unit and other special units such as Anti Malaria Campaign and Anti Filariasis Campaign at central lev- el. The national action plan set up centrally is executed at district level by regional ma- laria officers, medical officers, entomolo- gists and their teams in the Ministry of Health (Epidemiological Bulletine Sri Lanka 2008). According to the 2009 national action plan, a media campaign was developed with the objective of achieving sustained commu- nity action for prevention and control of dengue. The strategies employed include, dissemination of comprehensive, accurate, clear and consistent messages co-ordinated through print media, television (TV) and ra- dio regarding characteristics of the disease and the vector, spread of the disease, respon- sibility of community for prevention and control. Specific tasks such as declaration of mosquito control weeks, cleaning of schools and work environments are done with media seminars and mass media publicity activi- ties. Health education message to the parents through schoolchildren. Health education in the form of seminars, distribution of leaflets, display of billboards by the road side and ad- vertisements in electronic and printed media were used to deliver the messages. Red no- tices were displayed on publicly visible places at premises that tested positive for dengue larva as another health education message. Health care workers and volunteers were also being deployed for periodical in- spection for mosquito larva and to provide health education for residents on a house-to- house basis. Proper disposal of refuse and reduction of sources of refuse were the main emphasis of the social mobilization cam- paign. Electronic and print media were used to reinforce the messages and obtain public support before or during outbreaks. NDCU provides funds and technical assistance di- rectly or through non-governmental organi- zations such as WHO, especially to those areas at high risk of dengue, and also re- views the control programmes at grass root level while continuing surveillance at the national level. The objective of this study was to assess community knowledge and behavioral im- pact of the social mobilization and commu- nication strategy applied in a dengue high- risk area in Sri Lanka. Materials and Methods This descriptive cross-sectional study was carried out in 2013 in a dengue high-risk ar- ea within the capital province of the country; the Colombo district. Although mass media approaches used by the national dengue con- trol program is expected to reach all parts of the country, the extent to which it reaches rural areas which have less access to and coverage of radios/TV’s and electricity. Thus to increase the likelihood of the health messages reaching all of the target popula- tion and to obtain a more homogenous pop- ulation with regards to socio-economic sta- tus. Three hundred and forty nine randomly selected adults over 18 years visiting se- J Arthropod-Borne Dis, September 2016, 10(3): 394–404 H Banneheke et al.: Perceived Risk of … 397 http://jad.tums.ac.ir Published Online: January 06, 2016 lected primary care facilities were recruited. A pre-tested interviewer-administered struc- tured questionnaire was used to collect so- cio-demographic data, attributes of knowledge regarding dengue (as dissemi- nated by the dengue control program though the media and social marketing campaigns) and the responsive behaviors adopted by participants. Questions collected responses about awareness of disease characteristics, epidemiology, symptomatology, spread of the disease and their perceived responsibility for prevention, actions and measures adopt- ed for vector control. The extent to which the attributes were internalized by the partic- ipants was determined by assessing their perception of morbidity and mortality of the condition as well as the perceived risks of dengue in their own living environments. These attributes were classified as `good ', `fair,' or `poor' by developing a composite scale using several aspects of each assessed element. EpiData 3.0 software was used for the da- ta entry and error detection. Descriptive sta- tistics were derived using SPSS 16.0 soft- ware program. Ethical clearance was ob- tained from the Ethics Review Committee of Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka. Results Socio-demographic characteristics of the 349 participants are given in Table 1 showing the almost equal representation of both sexes and married and unmarried adults. Respond- ents were asked to list their sources of infor- mation regarding DF/DHF as different strat- egies were used for dissemination of health messages, and results are shown in Table 2. Table 3 summarizes the respondents’ aware- ness of characteristics of DF/DHF and its symptomology. When messages are disseminated, the ef- fectiveness of them can be measured by the translation of knowledge into practice. In- formation regarding the vector, its habits, and measures taken up by individuals was assessed during the survey (Table 4). Only 20% of the study participants knew the biting times (dusk and dawn) of dengue mosquitoes. Elimination of breeding places is one of the main strategies promoted to control vector density in this high-risk area. Although the respondents adopted a range of these strategies, the proportion that used each of these methods was varied. Regular inspection of surroundings and removal of breeding sites was rarely or never adhered to by 20%. Less effective methods to prevent mosquito-human contact such as use of bed nets at night and insecticide sprays were re- ported as strategies used to prevent dengue by most respondents. The composite varia- ble created by amalgamating responses to dengue control activities are also shown in Table 4. Participants’ knowledge regarding the ep- idemiological characteristics of DF and DHF, perceptions of its significance in their own living environment and its symptomol- ogy were assessed and the results are given in Table 5. Perceptions regarding seriousness of DF and DHF (in terms of morbidity and mortal- ity caused by them) and level of impact on one’s participants’ living area are given in Table 5. The overall knowledge regarding epidemiological significance of DF in living environment was derived by amalgamating responses to the above questions (Table 5). Comparison of knowledge and practices The composite variables created for knowledge and contribution to dengue con- trol activities were compared to determine the extent to which knowledge is translated to practice by this community. As shown in Table 6 and 7, higher proportions of those with good knowledge and average knowledge of DF, had relatively good and fair contribu- J Arthropod-Borne Dis, September 2016, 10(3): 394–404 H Banneheke et al.: Perceived Risk of … 398 http://jad.tums.ac.ir Published Online: January 06, 2016 tions to Dengue control activities. However, a larger proportion of those with poor knowledge of DF, contributed poorly to the control activities. A similar trend was seen when knowledge of DHF and contribution to dengue control activities were compared. Perceived significance of dengue in one’s own living environment was considered an important factor in respondents’ contribution to control activities (Table 8) and it was seen that a larger proportion of those who perceived dengue as highly significant or somewhat significant made good and fair contributions to control activities. Significantly, 69 % of those who considered DF to be of low risk contributed poorly to the control activities compared to 7.5% of those who considered it highly significant and 11.7% of those who perceived it to be somewhat significant. Table 1. Socio-demographic characteristics of the participants Variable Number (n=349) Per- centage (%) Age group (range 18–72 yr) < 30 169 48.4 31–65 155 44.4 > 65 25 7.2 Gender Male 181 51.9 Female 168 48.1 Civil status Unmarried 163 46.7 Married 186 53.3 Educational level Primary or less 31 8.9 Primary to ordinary level 98 28.1 Advanced level (A/L) quali- fied 176 50.4 Higher education 44 12.6 Standard of living Low 109 31.2 Middle 159 45.6 High 81 23.2 Employment status Student 60 17.2 House wife 34 9.7 Employed/ retired 182 52.2 Currently unemployed 73 20.9 Table 2. Primary source of information Source Number (n=349) Percentage (%) Television 178 51.0 Newspapers/ magazines 85 24.4 Radio 29 8.3 Family and friends 27 7.7 Health staff 5 1.4 Other (web/public lectures etc) 25 7.2 Table 3. Knowledge of characteristics and symptoms of DDF/DHF (n= 349) Characteristics /symptom Number (%)* Characteristics /symptom Number (%)* Cause of dengue fever virus parasite bacteria fungus 218 (62.5) 93 (26.6) 32 (9.2) 6 (1.7) Life threatening symptoms Breathing difficulty Cold extremities Signs of dehydration Do not know 161 (46.1) 107 (30.7) 92 (26.4) 109 (31.2) J Arthropod-Borne Dis, September 2016, 10(3): 394–404 H Banneheke et al.: Perceived Risk of … 399 http://jad.tums.ac.ir Published Online: January 06, 2016 Symptoms of DF High Fever Headache Muscle or joint pain Skin rash Pain behind the eyes Nausea/vomiting Abdominal pain Do not know 292 (83.7) 187 (53.6) 125 (35.8) 113 (32.4) 101 (28.9) 97 (27.8) 63 (18.1) 22 (6.3) Symptoms of DHF High fever Skin bruising/bleeding patches Flushed appearance Nose/gum bleeding Vomiting blood Dark stools Abdominal pain Do not know 226 (64.8) 194 (55.6) 149 (42.7) 131 (37.5) 110 (31.5) 97 (27.8) 62 (17.8) 47 (13.5) Overall knowledge of DF Good Average Poor 106 (30.4) 63 (18.1) 180 (51.5) Overall knowledge of DHF Good Average Poor 112 (32.1) 41 (11.7) 196 (56.2) *Total does not add up to 349 (or 100%) as multiple responses are given Table 4. Knowledge and practices on vector and vector control activities (n=349) Responses of the participants Number (%) Knowledge Type of mosquito Aedes species Anopheles species Culex species 190 (54.4) 101 (28.9) 58 (16.6) Biting habits Day time Dawn and dusk Night time 242 (69.3) 70 (20.1) 37 (10.6) Possible preventive measures Avoid mosquito bites (human-vector contact) Avoid contact with dengue patients (human-human contact) Getting a vaccine for dengue 254 (72.8) 66 (18.9) 29 (8.3) Practices Personal protective measures (human-vector contact) Use of mosquito repellents Mosquito nets when sleeping during the day Clothes to cover extremities Avoid areas with high vector density None 215 (61.6) 165 (47.3) 133 (38.1) 119 (34.1) 14 (4.0) Eliminate breeding places Inspect surroundings Remove clean water collections Keep surroundings clean, remove potential breeding sties Clean surroundings-schools Change water collections (tanks, vases) Clean surroundings-workplace Destroy /remove possible water collectors Cover water collections/containers Change water in bird baths Add salt to water containers Other measures 284 (81.4) 240 (68.8) 223 (63.9) 205 (58.7) 187 (53.6) 148 (42.4) 141 (40.4) 140 (40.1) 123 (35.2) 69 (19.8) 4 (1.1) Table 3. Continued… J Arthropod-Borne Dis, September 2016, 10(3): 394–404 H Banneheke et al.: Perceived Risk of … 400 http://jad.tums.ac.ir Published Online: January 06, 2016 Destroy breeding places Often Sometimes Rarely Never 150 (43.0) 130 (37.2) 57 (16.3) 12 (3.4) Sleep under mosquito net (night time) often sometimes rarely never 205 (58.7) 87 (24.9) 30 (8.6) 27 (7.7) Use insecticide sprays Often Sometimes Rarely Never 86 (24.6) 123 (35.2) 77 (22.1) 63 (18.1) Contribution to dengue control activities (composite variable) Good Fair Poor 80 (22.9) 207 (59.3) 62 (17.8) *Total does not add up to 349 (or 100%) as multiple responses are given Table 5. Knowledge regarding epidemiology and significance of the disease Epidemiology and significance of the disease Number (%) (n= 349) Morbidity and mortality of Dengue fever Very high Somewhat high Moderate Low Do not know 167 (47.9) 107 (30.7) 60 (17.2) 8 (2.3) 7 (2.0) Morbidity and mortality of Dengue Hemorrhagic Fever Very high Somewhat high Moderate Low Do not know 256 (73.4) 66 (18.9) 10 (2.9) 6 (1.7) 11 (3.2) Significance of the disease in own residential area Highly significant Somewhat significant Moderate and low level of significance Do not know 54 (15.5) 244 (69.9) 19 (5.4) 32 (9.2) Overall rating of epidemiological significance of DF in living environ- ment (composite variable) Highly significant Somewhat significant Not significant 187 (53.6 ) 111 (31.8) 51 (14.6) *Total does not add up to 349 (or 100%) as multiple responses are given Table 4. Continued… J Arthropod-Borne Dis, September 2016, 10(3): 394–404 H Banneheke et al.: Perceived Risk of … 401 http://jad.tums.ac.ir Published Online: January 06, 2016 Table 6. Contribution to dengue control activities compared to overall knowledge of DF Contribution to dengue control activities Overall knowledge of DF Number (%) Good Average Poor Good 32 (30.2) 32 (50.8) 16 (8.9) Fair 72 (67.9) 30 (47.6) 105 (58.3) Poor 2 (1.9) 1 (1.6) 59 (32.8) Total 106 (100.0) 63 (100.0) 180 (100.0) Chi= 84.16, df= 4, P< 0.001 Table 7. Contribution to dengue control activities compared to overall knowledge of DHF Contribution to dengue control activities (composite variable) Overall knowledge of DHF Number (%) Good Average Poor Good 55 (49.1) 14 (34.1) 11 (5.6) Fair 52 (46.4) 24 (58.5) 131 (66.8) Poor 5 (4.5) 3 (7.3) 54 (27.6) Total 112 (100.0) 41 (100.0) 196 (100.0) Chi- 90.6, df= 4, P< 0.001 Table 8. Contribution to dengue control activities by epidemiological significance of dengue in the living environ- ment Contribution to dengue control activities Overall rating of epidemiological significance of DF in living environment Number (%) Highly significant Somewhat Not significant Good 68 (36.4) 9 (8.1) 3 (5.9) Fair 105 (56.1) 89 (80.2) 13 (25.5) Poor 14 (7.5) 13 (11.7) 35 (68.6) Total 187 (100.0) 111 (100.0) 51 (100.0) Chi- 137.8, df= 4, P< 0.001 Discussion In the absence of an effective treatment and/or a vaccine for dengue, for the time be- ing, the only methods for preventing and controlling are prompt diagnosis of cases of fever, appropriate clinical management, re- ducing human-vector contact, and control- ling larval habitats. The WHO recommends social mobilization and communication for behavioral impact based on the COMBI (Communication-for Behavioral-Impact) mod- el (WHO 2005) and this has been adopted in the Sri Lankan National plan of action for dengue prevention and control since 2009 (National Plan of Action for Prevention and Control of Dengue Fever 2005). According to the results of our survey, it was seen that J Arthropod-Borne Dis, September 2016, 10(3): 394–404 H Banneheke et al.: Perceived Risk of … 402 http://jad.tums.ac.ir Published Online: January 06, 2016 common knowledge regarding DF/DHF has reached majority of this community through television, radio and newspapers, similar to the effect of such social marketing programs in other countries (Hairi et al. 2003, Pérez- Guerra et al. 2005, Matta et al. 2006, Itrat et al. 2008). Considering the life style of urban Sri Lankans who watch television as the major if not sole leisure activity, this medium could be utilized better to deliver the health education massages. However, it is important to maximize the way it is being done by uti- lizing peak hours and by using short mes- sages. Meanwhile residents living in remote areas with no access to television, would re- quire alternative modes for delivery of health education messages. The participants overall knowledge of the disease, vector and control methods were low and respondents continued to use meth- ods that are not effective for the dengue mosquito vector control including, use of mosquito nets at night and smoke to drive them away. Significantly, a proportion of this community completely lacked awareness of some aspects of the disease and failed to take any personal protective measures or participate in any of the control activities. One of the reasons may be due to fact that health messages had not been done in a re- ceptive manner with clear ‘dos’ and ‘don’t’ messages. Since there is no ‘one for all’ type of health education process for dengue, ef- fectiveness can be based on the characteris- tics of the educator and method of delivery per se. A uniform massage which is simpli- fied to suit the educational level and age of the recipients, can be effective health educa- tional material. Overall, improvement of the quality of presentation may enhance the ac- cessibility to a larger target group. Although many of the respondents par- ticipated in activities aimed at eliminating breeding sites, a proportion of them contin- ued to have a nonchalant approach to this essential dengue control activity despite the social marketing and community mobiliza- tion campaign. When the overall level of contribution to dengue control activities were assessed here, a significant proportion showed a poor response similar to findings from other studies. As previously acknowl- edged by the WHO and others, an informed and educated individual did not necessarily create a behaviorally responsive community member concerning dengue control activities. The study setting, Colombo district is a high-risk area in SL where dengue is endem- ic with frequent outbreaks, and majority of respondents considered DF to be of high morbidity and mortality and recognized its significance in their own residential area. However, majority (69.9%) thought it is on- ly somewhat significant and 15% of them did not consider it significant in their own residential area, or did not know of its sig- nificance. Short message services (SMS) and social media have become important and effective modes of communication in many societies across world. As most telecommu- nication services have the access to a large pool of customers SMS and Social media can be used to alert or alarm the communi- ties at risk when the cases of dengue are ris- ing or an epidemic is impending. Effective and sensitive videos shared via social media could also be used to create awareness and sensitization. Often research into KAP re- garding dengue fails to assess the respond- ents’ perceived personal risk, which is im- portant for developing an effective behavior- al change communication package. As we have shown here, despite the overt risks in this setting, a significant proportion believed their own personal risks to be low. This highlights the need for dengue control pro- grams to be informed by formative research. Also local social and cultural contexts may be important in determining individuals’ up- take and responses to messages. Therefore, periodical reviews existing programs and health education strategies are an urgent J Arthropod-Borne Dis, September 2016, 10(3): 394–404 H Banneheke et al.: Perceived Risk of … 403 http://jad.tums.ac.ir Published Online: January 06, 2016 need in Dengue high risk areas. The web and social media can also be used to gather pub- lic perceptions about exiting strategies and programs. Most respondents were aware of the basic facts regarding the dengue vector, life- threatening symptoms of DF and were able to list a few common symptoms of DF and DHF as demonstrated in previous similar studies in this setting. Although it was pre- viously believed that awareness of the dis- ease and its complications would encourage communities to adapt responsive behaviors, it is evident from this study that such knowledge does not necessarily lead to fa- vorable behavior changes. In our study, although the community was aware of the principals of prevention, the level of involvement in control activities were low. It was demonstrated that the per- ceived risk of DF in their own living envi- ronment was important, as almost 70% of those who considered it to be of low risk contributed poorly to the control activities. Conclusion This study demonstrated for the first time the importance of assessing the community perceived risk of the disease in their own living environment as a determinant of be- havior changes concerning dengue control activities in Colombo district, a high-risk area for DF/DHF in Sri Lanka. Although this study was based on respondents’ self-as- sessments, self-reported behaviors, and prob- ably an over-reporting of acceptable behav- iors, it nonetheless reveals the importance of their own perceptions about personal risks and this is likely to be accurate. 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