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Building Bridges to Cultural Competency. Center for Public Health Education Stony Brook University. Who We Are: A Cultural Perspective. Module I. Welcome. Introductions CPHE RTC COE HRSA Cell Phones and Pagers Housekeeping Postcards. Introductions. Name Agency Position

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Building Bridges to Cultural Competency

Center for Public Health Education

Stony Brook University

The Center for Public Health Education


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Who We Are: A Cultural Perspective

Module I

The Center for Public Health Education


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Welcome

  • Introductions

  • CPHE

    • RTC

    • COE

    • HRSA

  • Cell Phones and Pagers

  • Housekeeping

  • Postcards

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Introductions

  • Name

  • Agency

  • Position

  • What do you expect to get out of this training?

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Notes . . . .

  • Three basic goals

    • To increase knowledge about the impact of culture on the delivery and accessing of health and human services

    • To increase knowledge about the impact of power and privilege on the delivery and accessing of health and human services

    • Assist providers in their attempt to become culturally competent

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Training Objectives

  • Define culture

  • Define power and privilege

  • Examine the cultural competency continuum

  • Examine how cultural personal, social and family experiences influence assumptions and perceptions

  • Review the effects of perceptions, assumptions and stereotypes on health and human service delivery

  • Examine the relationship between culture and privilege

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Training Objectives

  • Explore the effects of privilege on accessing healthcare

  • Define cultural competency

  • Demonstrate the need for cultural competency in the health and human service setting

  • Review the cultural values of western medicine in a multi-ethnic and multi-cultural society

  • Describe the impact of culture on accessing and delivering health and human services

  • Review strategies for enhancing cultural competence

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Ground Rules . . . .

  • What are some ground rules we should establish?

  • Does the group agree on the suggestion?

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Ground Rules . . . .

  • It’s okay to pass

  • Listen actively-respect others while they are talking

  • Respect each others right to have an opinion other than you own

  • Speak from your own experience instead of generalizing (Use I statements)

  • Refrain from personal attacks

  • Keep an open mind to explore other ideas, values and opinions

  • Allow yourself to examine personal beliefs and attitudes

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Definitions . . .

How would you define culture?

Culture – the total way of life of a group of people, including their beliefs, institutions, and technology.

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Definitions . . .

  • Culture- “ a system of shared values, beliefs, ideas and learned patterns of behavior, explicit and implicit, which a people use to interpret the world. Art, literature and history of a society, but also less tangible aspects such as language, attitudes, prejudices and folklore can impact a persons’ culture. Cultural identity influences how a person behaves and acts, what they believe and what they actually know . . .”

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Definitions . . . .

  • Historical Underpinnings – Events that occurred in the past which may affect how a particular individual or community perceives events or reacts to specific issues

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Definitions . . . .

  • External Factors – Issues/events occurring around the world which may affect an individual.

  • Access Barriers – Prevent individuals from using existing services. These barriers may be cultural, individual, physical, financial or structural.

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Points to Consider

  • Culture is a very broad concept

  • Perceiving, assuming and stereotyping are part of the “human condition”

  • Providers need to be aware so this “human condition” does not interfere with the delivery of services

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Cultural Postcard

  • Review your list of your own cultures and subcultures.

  • I.- Can you add any other cultures or subcultures based on the lecture?

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A Look Inward: Examining Personal Experiences

Module II

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Cultural Competence

  • Gaining cultural competence is a process

  • In order to achieve higher levels of competence, it is helpful to engage in self assessment

  • Self assessment provides direction for improvement

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Cultural Competence Model

Cultural Blindness

Cultural Incapacity

Cultural Proficiency

Cultural Destruction

Cultural Competence

Cultural Pre-Competence

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Cultural Competence Continuum

  • Cultural Destructiveness

    • The negative end of the spectrum

    • Refers to the blatant attempts to destroy the culture of a given group

    • Assumes that one group is superior over another

    • Acknowledges only one way of being and purposefully denies or outlaws any other cultural approach

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Cultural Competence Continuum

  • Cultural Incapacity

    • The capacity is lacking to be responsive to different groups, though not intentional

    • Ignorance and unfounded fear is often the underpinning of the problem

    • Failure to recognize when mistreatment is due to cultural differences and there by perpetuating its occurrence

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Cultural Competence Continuum

  • Cultural Blindness

    • Blindness or ignorance of cultural differences

    • Perceives of themselves as “unbiased”

    • The believe that culture makes no difference in the way a person or group acts or reacts

    • Fosters the assumption that we are all basically alike so what works with members of one group will work with members of all other cultures

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Cultural Competence Continuum

  • Cultural Pre-Competence

    • Movement toward cultural sensitivity

    • Actively pursues knowledge about differences and attempts to integrate this information into delivery of services

    • Recognizes that cultural differences exist but those differences are acknowledged as “differences” and nothing more

    • Learning and understanding of new ideas is encouraged along with solutions to improve performances or services

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Cultural Competence Continuum

  • Cultural Competence

    • The capacity to function in an effective manner within the context of the targeted group

    • Acceptance and respect of differences

    • Continual expansion of knowledge about the target group

    • Actively seeks advice and consultation

    • Committed to incorporating new knowledge and experiences into a wider range of practice

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Cultural Competence Continuum

  • Cultural Proficiency

    • The positive end of the spectrum

    • Proactively regards cultural differences

    • Promotes improved cultural relations among diverse groups

    • Holds culture in very high esteem

    • Regarded as a specialist in developing culturally sensitive practices

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Cultural Postcard

  • II-A. Where do you fall on the Cultural Competence Continuum?

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Cultural Competence Model

Cultural Blindness

Cultural Incapacity

Cultural Proficiency

Cultural Destruction

Cultural Competence

Cultural Pre-Competence

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Eight Questions: Personal Memories Activity

  • Choose one culture that has had the most influence on you

  • You will have the opportunity to be the interviewer and the person interviewed

  • Obtain the answers to questions 1-7

  • You will use the information to formulate an answer to question 8

  • Switch roles

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Eight Questions: Personal Memories Activity

  • Human beings are complex

  • Beliefs, values and traditions come from cultural and life experiences

  • Cultures we are born into and cultures we embrace shape who we have become

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Eight Questions: Personal Memories Activity

  • Individuals may belong to the same culture, but may not share the same experiences

  • There may be greater differences within a culture than between cultures

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Power and Privilege: Making Privilege Visible

Module III

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What is Power?

The ability to achieve aims or further the interests you hold even when opposed by others; or as the ability to impose one’s will on others, even if those others resist in some way.

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What is Privilege?

An unearned right, advantage or immunity granted to or enjoyed beyond the common advantages of all others; an exemption in many certain cases from burdens of liabilities.

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What is Privilege

Those with privilege rarely understand it’s full impact on those who do not have privilege

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The “I” Statements

  • The “I” statements reflect privileges enjoyed by different groups or cultures in our society.

  • The lists are not inclusive of all privileges, but provide a basic overview and help to identify some unearned privileges.

  • Privileged groups are usually unaware of their privilege

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The “I” Statements

  • Having privileges is not always a negative

  • Privileges should not taken away, but shared with all members of society

  • When only certain members of society enjoy privileges, it creates inequities

  • Once all members of a society enjoy the same privilege, it no longer is a privilege but has become an equal right for all members of society

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White Privilege

  • I can move wherever I want to move

  • I can do well in a challenging situation without being called a credit to my race

  • I can go into a supermarket and find the staple foods which fit my cultural traditions

  • I can take a job without my coworkers suspecting I got it because of my race

  • My medical provider will be aware of cultural values and traditions related to my healthcare

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Male Privilege

  • When competing against a female for a job, the odds are probably in my favor

  • My odds of being raped are low

  • I can be assertive without being called a bitch

  • If I have sex with a lot of people, it will not make me an object of contempt or stereotyping

  • I am not expect to spend my entire life 20-40 pounds underweight

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Heterosexual Privilege

  • When I talk about my intimate relationships I will not be accused of pushing my sexual orientation onto others

  • People do not ask me when I decided to be heterosexual

  • I can marry and enjoy all the legal benefits associated with marriage

  • I can hold hands in public with my significant other

  • I can count on finding a health and human service provider willing and able to talk about my sexuality

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Non-Trans Privilege

  • My validity as a man/woman/human is not based upon how much surgery I’ve had

  • I am not expected to constantly defend my medical decisions

  • Strangers do not ask me what my “real name” is

  • People do not disrespect me by using incorrect pronouns

  • I do not have to worry about whether I will be able to find a bathroom to use or whether I will be safe changing in a locker room

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Able-bodied Privilege

  • If I need to move, I can be assured of purchasing a home I can get access to easily

  • I can be assured that my entire neighborhood will be accessible to me

  • I can be assured that assumptions about my mental capabilities will not be based on my physical limitations

  • I can take a job without someone suspecting I got my job because of my physical status

  • I can turn on the TV or open the newspaper and see people of my physical ability represented

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The Effect of Privilege on Accessing Health and Human Services

  • Presenting western medicine as superior to all other medical beliefs

  • Having a health and human service provider that only sees the physical challenge and not the whole person

  • Providers who ignore the need to be culturally competent

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Effect of Privilege on Accessing Health and Human Services

  • Providers who refuse to provide health and human services within a neighborhood

  • Providers that exclude individuals from clinical trails based on gender or using information from clinical trails based on other races.

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Addressing Privilege

  • Inequities and discrimination occur when power and privilege are not equally shared by all members of society

  • Legislative attempts to level the playing field have not always been successful

    • Inequities that are part of a society’s structure or system are not always adequately addressed by laws

    • Laws have no power when addressing invisible privilege

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Addressing Privilege

  • Lawmakers have attempted to address imbalance

  • This is often met with resistance

    • Women’s suffrage movement was met with great resistance and required a constitutional amendment to allow women to vote

    • Current debate allowing gays and lesbians the right to marry has met with opposition, including an attempt to pass an amendment banning gay marriage

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Making the Connection

  • Membership in multiple privilege groups result in additional invisible privileges.

  • Members with the most privileges tend to have the most power in society.

  • White, heterosexual, able-bodied, males typically have the most privileges in our society.

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Making the Connection

  • When privilege remains invisible it is difficult to see how it effects the privileged and the unprivileged.

  • Becoming aware of privilege can lead to feelings of guilt for some

    • It is important not to let guilt paralyze

    • Guilt can politicize

  • Recognizing privilege may help to address inequity

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Cultural Postcard

  • III. List any privileged groups or cultures you belong to.

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Bowling for Privilege

  • Choose ten privileges that are most desirable

  • As a group pick the most important privilege

  • Arrange privileges like bowling pins with the most desirable as the first bowling pin.

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Bowling for Privilege

In your groups, answer the following question:

  • What privilege was most important?

  • Which groups commonly have this privilege?

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Bowling for Privilege

  • Two members from each group will have one chance each at knocking down the pins

  • After one member goes, reset the pins

  • Each group must keep score of how many pins were knocked down.

  • The group that knocks down the most pins wins

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When Culture and Health and Human Services Collide

Module IV

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When Culture and Healthcare Collide

  • By the year 2010, the US minority population will increase by 32%

  • More that 31million Americans are unable to speak the same language as their health care providers

  • There is a direct correlation between health care disparities and culturally incompetent health care

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When Culture and Healthcare Collide

  • Human service providers need to identify cross-cultural differences between their clients, themselves and other providers

  • It is important to identify potential cultural obstacles and barriers early in the provider-client/patient relationship

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When Culture and Healthcare Collide

  • Everyone has a culture and cultural background that shapes one’s view about health, illness, mental health and human services

  • It is impractical, if not possible, to learn every aspect of every culture and subculture

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When Culture and Healthcare Collide

  • Providers should explore the various types of challenges that are likely to occur in cross-cultural encounters

  • Misunderstandings often reflects differences in culturally determined values

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The Spirit Catches You and You Fall Down

  • Read the case study on page 4.

  • Given this information, what would your next course of action be in working with this family?

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Points to Consider

  • Country of Origin

  • Preferred Language

  • Communication Style

  • Views on Health

  • Family and Community Relationships

  • Religion

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The Spirit Catches You and You Fall Down

  • In your groups read the full case study on page 6

  • Choose a recorder and a reporter

    • Group 1: Questions 1,4,7

    • Group 2: Questions 2,5,8

    • Group 3: Questions 3,6,9

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The Spirit Catches You and You Fall Down

  • How do Hmong and Western views of illness and health differ?

  • What do you think of the Hmong cultural practices?

  • How do you feel about the Lee’s refusal to give Lia her medicine? Do you empathize with it?

  • How is this story similar to treatment recommendation regarding ART for the prevention and treatment of perinatal transmission? What issues are similar?

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The Spirit Catches You and You Fall Down

  • How do providers generally react if a patient/client declines treatment because of cultural values and beliefs?

  • It is clear that many of Lia’s doctors tried to help Lia and that her parents cared for her deeply, yet this tragedy still occurred. List three strategies you think might have prevented it.

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The Spirit Catches You and You Fall Down

  • What was the rationale for involving Child Protective Services?

  • What examples of power and privilege can be gleamed from this case study?

  • What can providers do to increase their understanding of patient’s/client’s culture?

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Where do you think Lia Lee’s health care providers fall on the Cultural Competency Continuum?

Cultural Blindness

Cultural Incapacity

Cultural Proficiency

Cultural Destruction

Cultural Competence

Cultural Pre-Competence

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The Eight Questions of Cross Cultural Medicine

  • Dr. Arthur Kleinman from Harvard Medical School developed a set of 8 questions designed to elicit a patient’s “explanatory model.”

  • An explanatory model is an individual’s ideas about the origin of illness and treatment.

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The Eight Questions

  • What do you call the problem?

  • What do you think caused the problem?

  • Why do you think it started when it did?

  • What do you think the illness does? How does it work?

  • How severe is the sickness? Will it have a short or long course?

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The Eight Questions

  • What kind of treatment do you want to receive? What are the most important results you hope to receive from this treatment?

  • What are the chief problems this sickness has caused?

  • What do you fear most about this sickness?

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The Spirit Catches You and You Fall Down Revisited

  • How may have Lia’s situation been different if Dr. Kleinman’s suggestions been implemented?

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Impact of Historical Events on Healthcare Delivery

  • Tuskegee Syphilis Study

  • Japanese-American Internment Camps

  • Sterilization of Puerto Rican Women

  • Los Angeles Vaccine Study

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Cultural Postcard

  • IV. Has your culture ever collided with accessing healthcare? How?

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Building Bridges to Cultural Competence

Module V

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Building Bridges to Cultural Competence

  • Culture greatly influences behavior, attitudes, values and beliefs about health and human services

  • Understanding these influences will help providers to develop cultural competency

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Building Bridges to Cultural Competence

  • The Culturally Competent person:

    • Knows that competency involves a deeper commitment to the people for whom we provide services

    • Recognizes and learns to work within the context of different languages, customs, worldviews, religions, spiritual views, health beliefs, gender roles, sexuality and family relationships when interacting with clients/patients

    • Develops specific practice skills

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Building Bridges to Cultural Competency

  • Practice Skills

    • Has an awareness and acceptance of difference whereby diversity is valued

    • Understands how one’s own culture influences how one thinks, acts and delivers services

    • Understands the dynamics of difference and is conscious of those dynamics inherent when cultures interact

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Building Bridges to Cultural Competency

  • Becomes familiar with the different aspects of various cultures in target areas and institutionalizes cultural knowledge within an agency, institution or system

  • Has the ability to adapt practice skills that fit the cultural context of the patient/client

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THE LEARN MODEL

  • Listen with empathy and understanding of the patient/clients perception of the problem

  • Explain your perceptions of the problem

  • Acknowledge and discuss the differences and similarities

  • Recommend a course of action or treatment

  • Negotiate an agreement

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Role Plays

  • Break into dyads

  • You will have the opportunity to play both the client and the provider

  • Remember to use the LEARN model

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Wrap Up!

Module VI

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Cultural Competence includes:

Self-examination

Understanding the effects of power and privilege

Actively engaging clients/patients

An ongoing process and determined effort

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The achievement of cultural competence assures that clients/patients are treated with dignity and that cultural traditions and values that can impact healthcare are identified and treated respectfully.

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ACKNOWLEDGMENTS

  • This curriculum was originally developed and written by Center for Public Health Education (CPHE), at Stony Brook University under contract with the NYSDOH AIDS Institute (AI) Case Management Unit.

  • This training is intended for health and human service providers. Staff, supervisors and administrators are encouraged to attend.

  • Our appreciation and thanks is extended to our consultant, Lisa Skill of PDP, SUNY at Albany for assistance in the development of this curriculum. Her creative input was invaluable.

  • Much thanks to the AIDS Institute (AI) staff who served as an Advisory Workgroup. The workgroup included: Richard Cotroneo, Rachel Iverson, Heather Duell, Sally Perryman, Dina M. Williams, Barry D. Watson, Bethsabet Justiniano and Mary Lou Del Rio.

  • Lastly, we would like to thank staff from the following agencies for their helpful suggestions and encouragement: NDRI, Inc., PDP, Latino Commission on AIDS, Inc., Cicatelli Associates, Inc., and Erie County Health Department.

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QUESTIONS?

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Evaluations

Letters of Attendance

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