Health Literacy A Prescription to End Confusion (2004) / Chapter Skim
Currently Skimming:
3 Extent and Associations of Limited Health Literacy
3 Extent and Associations of Limited Health Literacy
Pages 59-107
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From page 59... ...
Everyone -- not just those with limited literacy skills -- is increasingly faced with difficult and confusing text at work, at home, in institutional settings such as schools, banks, social service organizations, and within health-care settings. People of all literacy levels might be able to manage texts that they frequently encounter 59
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From page 60... ...
Directions for operating a particle accelerator, filing income tax returns, or choosing between health insurance plans may be similarly indecipherable for most adults, regardless of literacy skills in other contexts. As discussed in detail in Chapter 2, current measures of health literacy rely primarily on print in the health context and not on the broad array of skills needed for true health literacy.
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From page 61... ...
Of the 90 million adults with limited literacy skills, about 42 million demonstrated skills in NALS Level 1. Of these, a small percentage had such limited English literacy skills that they were unable to respond to much of the survey.
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Over half of the people with NALS Level 1 skills are Caucasians, and about 57 million Caucasian Americans have limited literacy skills (NALS Levels 1 and 2) (Kirsch et al., 1993)
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. Table 3-1 displays the percentage of persons overall and various demographic groups that have NALS Level 1 or 2 literacy skills, the lowest of five skill levels.
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08 years of education prior to arrival in US 60 31 9 9+ years of education prior to arrival in US 44 27 29 Disability Any mental or emotional condition 48 26 27 Learning disability 59 22 19 Hearing difficulty 35 34 32 Speech disability 54 27 19 Visual difficulty 55 26 19 SOURCE: Unadjusted averages of prose and document literacy scores on the NALS as reported on Tables 1.1A, 1.1B, 1.2A, 1.2B, 1.8, and Figure 1.10 in Kirsch et al.
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From page 65... ...
. THE EPIDEMIOLOGY OF LIMITED HEALTH LITERACY Ninety million people -- approximately one-half of our adult population -- lack the basic literacy skills required for full participation in Ameri
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. Recognizing that basic literacy skills are required for health literacy, it is reasonable to conclude that individuals with limited literacy -- the 90 million individuals that scored in Levels 1 and 2 of NALS -- probably also have limited health literacy.
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From page 67... ...
Literacy levels are lower among the elderly, those who have lower educational levels, those who are poor, minority populations, and groups with limited English proficiency such as recent immigrants. Studies of Limited Health Literacy In this section, we examine the extent of limited health literacy by examining peer-reviewed studies that provide evidence about the epidemiology, or relative rates, of health literacy skills using currently available measures in different demographic groups.
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From page 68... ...
Table 3-2 also identifies the reported demographic characteristics of the study participants that were reported to be associated with limited health literacy. Studies noted in Table 3-2 document the prevalence of limited healthliteracy skills as measured by the REALM or TOFHLA among patients in general medical and pediatric clinics; specialty care clinics including those for asthma, HIV, family planning, obstetrics, and oncology; and community-based sites including retirement homes and social service agencies.
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From page 69... ...
The prevalence of inadequate and marginal health literacy scores on the STOFHLA among English speakers was 23.5 percent and 10.4 percent, respectively, while among Spanish speakers prevalence rates were 34.2 percent and 19.7 percent. Results varied by city, with the participants in Cleveland showing the highest rate of inadequate health literacy scores among English speakers at 34.1 percent, and those in Tampa showing the lowest rate at 16.6 percent.
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From page 70... ...
70 HEALTH LITERACY TABLE 3-2 The Epidemiology of Health Literacy Skills Among Various Populations Participation Citation Population Rate Study Design Setting Arnold N = 600 96% Convenience Obstetric clinics, et al., 2001 Pregnant women sample Louisiana 296 African American 303 Caucasian Mean age: 23 years Beers et al., N = 1805 -- -- Primary care 2003. 58% African clinics, VA Published American medical center Abstract 66% male and university (Health Literacy hospital and Patient Satisfaction Study)
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From page 71... ...
EXTENT AND ASSOCIATIONS 71 Reported Demographic Associations with Measure Low Health Literacy Prevalence of Literacy Levels REALM African American race African American women 3rd and below: 9% 4th6th: 19% 7th8th: 41% 9th and above: 31% Caucasian women 3rd and below: 4% 4th6th: 5% 7th8th: 26% 9th and above: 66% REALM African American race REALM Older age 3rd and below: 2% Lower education level 4th6th: 8% Association with age 7th8th: 31% was no longer 9th and above: 59% significant when stratified by education level Association with race remained significant when stratified by education level REALM African American race African American men Geographic location 6th and below: 52.3% (Louisiana site) Caucasian men: 6th and below: 8.7% Chicago, IL: 6th and below: 12.3% Shreveport, LA: 6th and below: 38.1% TOFHLA Older age 74% or less Fewer years of on TOFHLA: 30% education Continued
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72 HEALTH LITERACY TABLE 3-2 Continued Participation Citation Population Rate Study Design Setting Davis et al., N = 396 96% -- Pediatric clinic 1994 Parents or other in a public caretakers hospital, accompanying Louisiana pediatric outpatients Mean age: 30 years Fortenberry N = 1035 78% -- Clinics, et al., 2001 Mean age: community 26.36 based organizations, and by street intercept in 4 sites (CO, IN, NY, and AL) Gazmararian N = 3260 39% Cohort Prudential et al., 1999b New Medicare 3,260 Medicare enrollees participated Managed 2,956 English out of 8,409 Care Study speakers, identified 4 sites: 304 Spanish for study Cleveland, speakers OH, Age distribution: Houston, TX, 6569 years: south Florida, 37% and Tampa, 7074 years: Florida 27.3% 7579 years: 19.3% 8084 years: 11% 85 years: 5.4%
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From page 73... ...
EXTENT AND ASSOCIATIONS 73 Reported Demographic Associations with Measure Low Health Literacy Prevalence of Literacy Levels REALM and -- REALM WRAT-R 3rd and below: 11% 4th6th: 16% 7th8th: 37% 9th and above: 35% WRAT Less than 4th: 31% Less than 7th: 55% Less than 9th: 73% REALM -- 8th and below: 35% 9th and above: 65% S-TOFHLA African American race Total Older age English Spanish Fewer years of school Inadequate: 23.5% Inadequate: 34.2% completed Marginal: 10.4% Marginal: 19.7% History of blue collar Adequate: 66.1% Adequate: 46.1% occupations Older age was Cleveland, OH strongly associated English with lower health Inadequate: 34.1% literacy, and this Marginal: 9.9% association Adequate: 56.0% remained after adjusting for years Houston, TX of school completed English Spanish and cognitive Inadequate: 28.0% Inadequate: 21.2% impairment Marginal: 9.4% Marginal: 19.2% Adequate: 62.6% Adequate: 59.6% Continued
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From page 74... ...
74 HEALTH LITERACY TABLE 3-2 Continued Participation Citation Population Rate Study Design Setting Gazmararian N = 406 19% Cohort Medicaid managed et al., 1999a Women enrolled 406 care plan in in a Medicaid participated Memphis, managed care out of 2,197 Tennessee plan identified Age distribution: for study 1924 years: 144 2529 years: 86 30 years: 175 Kalichman N = 228 -- Convenience HIV clinics, AIDS et al., HIV-infected sample service 2000 adults organizations, Mean age: social service 39.7 years agencies Kalichman N = 182 -- Convenience HIV clinics, AIDS et al., 1999 HIV-infected sample service adults organizations, Mean age: social service 39.1 years agencies
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EXTENT AND ASSOCIATIONS 75 Reported Demographic Associations with Measure Low Health Literacy Prevalence of Literacy Levels South Florida English Spanish Inadequate: 17.3% Inadequate: 34.3% Marginal: 11.6% Marginal: 20.3% Adequate: 71.1% Adequate: 45.4% Tampa, FL English Spanish Inadequate: 16.6% Inadequate: 60.0% Marginal: 10.2% Marginal: 16.0% Adequate: 73.2% Adequate: 24.0% TOFHLA Lower education level 9.6% scored less than 80% on the (abbreviated Health literacy levels TOFHLA version) were not significantly associated with age, race, marital status, employment status, and poverty status TOFHLA Fewer years of TOFHLA Scores: education 0%20%: 2% Ethnic/minority status 21%40%: 2% Health literacy level 41%60%: 3% was not related to 61%80%: 11% age, income level, 81%90%: 23% gender, or sexual 91%100%: 59% orientation TOFHLA 41% scored below 85% on the TOFHLA Continued
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From page 76... ...
76 HEALTH LITERACY TABLE 3-2 Continued Participation Citation Population Rate Study Design Setting Kaufman N = 61 -- Convenience Public health et al., 2001 First-time sample clinic, mothers aged Albuquerque, 18 years or NM older who had an infant between 2 and 12 months Li et al., N = 55 (REALM 71% Convenience Clinic in the 2000 scores 39 patients sample rural south available on participated 39) in REALM Women with testing out early-stage of 55 breast cancer identified by retrospective chart review Lindau N = 529 91% Prospective Ambulatory et al., 2002 English-speaking Cohort Obstetrics patients older and Gynecology than 18 years clinic and a Median age: 27 women's HIV clinic Montalto and N = 70 38.% Rural community Spiegler, 2001 Female: health center Mean age: 45 Male: Mean age: 55 Schillinger N = 408 91% Cross-sectional Two primary care et al., 2002 English- and clinics, public Spanish- hospital, San speaking Francisco, CA type-2 diabetes patients older than 30 years (San Francisco General Diabetic Patients with Low Health Literacy Study)
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EXTENT AND ASSOCIATIONS 77 Reported Demographic Associations with Measure Low Health Literacy Prevalence of Literacy Levels REALM -- 3rd and below: 0% 4th6th: 0% 7th8th: 36% 9th and above: 64% REALM -- 3rd and below: 0% 4th6th: 12.8% 7th8th: 12.8% 9th and above: 74.4% REALM Non-white participant 6th and below: nearly 10% Those with no or 7th8th: 33% public health 9th and above: 61% insurance TOFHLA Inadequate: 2.86% Marginal: 11.43% Adequate: 85.71% S-TOFHLA Older age English Spanish Female gender Inadequate: 27.7% Inadequate: 56.8% Non-white Marginal: 12.7% Marginal: 14.2% Spanish-speakers Adequate: 59.6% Adequate: 29.9% Lower education level Medicare coverage Longer time with diabetes Continued
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From page 78... ...
Weiss et al., N = 402 75% Cohort University Family 1994 Medicaid Care, a health enrollees, care organization 21.6% Male, in Tucson, AZ 78.4% Female 45.8% Hispanic 42.8% Caucasian 5.5% African American Mean age: 49.0 Williams N = 483 ED = 79% Cohort ED and AC at et al., 273 from AC = 90% urban public 1998a emergency hospital, department Atlanta, GA (ED) 210 from asthma clinic (AC)
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From page 79... ...
EXTENT AND ASSOCIATIONS 79 Reported Demographic Associations with Measure Low Health Literacy Prevalence of Literacy Levels S-TOFHLA -- Inadequate: 25% Marginal: 11% Adequate: 65% Instrument for Spanish-speaking 0: 8.7% the 1st: 4.7% Diagnosis 2nd: 5.1% of Reading/ 3rd: 5.6% Instrumento 4th: 4.2% Para 5th: 5.2% Diagnosticar 6th: 13.7% Lecturas 7th: 14.2% (IDL) 8th and above: 38.6% REALM Older age 3rd and below: 13% 4th6th: 27% 7th8th: 33% 9th and above: 27% TOFHLA Older age Diabetes patients*
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From page 80... ...
. While older individuals have some of the highest rates of limited health literacy scores and limited functional literacy scores, they also have some of the most demanding health-care needs.
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. Finding 3-2 On the basis of limited studies, public testimony, and committee members' experience the committee concludes that the shame and stigma associated with limited literacy skills are major barriers to improving health literacy.
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. Examination of health literacy scores and health-care management found that patients with limited health literacy as determined by current measures have a decreased ability to share in decision making about prostate cancer treatment (Kim et al., 2001)
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From page 83... ...
found no relationship between parental literacy levels, as measured by the REALM, and use of preventive health services for pediatric patients. Finding 3-3 Adults with limited health literacy, as measured by reading and numeracy skills, have less knowledge of disease management and of health-promoting behaviors, report poorer health status, and are less likely to use preventive services.
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speakers 304 Spanish speakers Baker et al., N = 979 -- Prospective Large public 1998 (Literacy in cohort hospital Health Care emergency Study) department; Atlanta
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From page 85... ...
Spanish-speaking individuals at all literacy levels had a lower risk of admission than English speakers. TOFHLA Patients with inadequate literacy were Structured interview significantly more likely to be Grady Memorial Hospital information hospitalized one or more times than those system with marginal or adequate literacy.
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From page 86... ...
86 HEALTH LITERACY TABLE 3-3 Continued Participation Citation Population Rate Study Design Setting Baker et al., N = 2,659 81% Prospective Two large public 1997 979 Atlanta cohort hospitals: Los Angeles Atlanta and 913 English Los Angeles speakers 767 Spanish speakers (Literacy in Health Care Study) Bennett N = 212 96% Convenience Prostate clinics in et al., 1998 Low-income men sample Shreveport, LA 109 African and Chicago, IL American 103 Caucasian Mean age: 70.8 Fortenberry N = 1,035 78% Convenience Clinics, et al., 2001 Mean age: 26 sample community based organizations, and by street intercept (4 states: CO, IN, NY, and AL)
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From page 87... ...
, patients with inadequate literacy were more likely to have been hospitalized in the year preceding the study, and this relationship remained after controlling for age, gender, race, socioeconomic indicators, and self-reported health. REALM Participants with literacy levels below the Medical record review sixth grade were significantly more likely Pathology reports to present with Stage D cancer than those with higher literacy levels.
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From page 88... ...
speakers 304 Spanish speakers 76% Caucasian Gordon N = 123 96.8% Cross-sectional Arthritis clinic et al., 2002 Patients with rheumatoid arthritis Median age: 56 years Range: 1977 years
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From page 89... ...
There was no relationship between health literacy levels and either pregnancy intendedness or current use of contraception. S-TOFHLA Participants with inadequate health literacy Geriatric Depression Scale skills were significantly more likely to Interview report depressive symptoms than those with adequate health literacy skills.
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From page 90... ...
Kalichman N = 228 Convenience HIV clinics, AIDS et al., 2000a HIV-positive sample service adults organizations, Mean age: 40 social service agencies
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From page 91... ...
TOFHLA Participants with lower health literacy were Questionnaire or interview significantly less likely than those with higher health literacy: to report an undetectable HIV viral load, to indicate that they understand the meaning of viral load and CD4 cell counts, to state that their doctors ask their opinions about treatment, and to state that their doctors explain things to them so they understand. Participants with lower health literacy were significantly more likely than those with higher health literacy: to visit a doctor at least once per month, to believe that HIV medications reduce HIV-transmission risk, to believe that it is safe to have sex if an HIV+ person has an undetectable viral load, to state that new HIV treatments make it easier to relax about unsafe sex, and to state that they practice more unsafe sex because of new treatments.
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From page 92... ...
92 HEALTH LITERACY TABLE 3-3 Continued Participation Citation Population Rate Study Design Setting Kalichman N = 339 -- Convenience HIV clinics, AIDS and Rompa, HIV-positive sample service 2000 adults organizations, Mean age: 40 social service agencies Kalichman N = 182 -- Convenience HIV clinics, AIDS et al., 1999 HIV-positive sample service adults organizations, Mean age: 39.1 social service agencies Kaufman N = 61 -- Convenience Public health et al., 2001 First-time sample clinic mothers aged 18 years or older who spoke English as their first language and had an infant between 2 and 12 months
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From page 93... ...
After adjusting for years of formal education, lower health literacy was associated with poorer knowledge of one's HIV-related health status, poorer AIDS-related disease and treatment knowledge, and more negative health-care perceptions and experiences. Adapted reading comprehension Participants with fewer years of education section of TOFHLA (lower literacy and lower health literacy were defined as scoring 85% or below, significantly more likely to be non higher literacy as scoring above adherent in the past 2 days than those 85%)
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From page 94... ...
94 HEALTH LITERACY TABLE 3-3 Continued Participation Citation Population Rate Study Design Setting Lindau N = 529 91% Prospective Ambulatory et al., 2002 English-speaking cohort OBGYN clinic patients older and a women's than 18 years HIV clinic Median age: 27 58% African American 18% Hispanic Moon et al., N = 543 85.8% Prospective Pediatric acute 1998 Parents cohort care clinic accompanying children to clinic Mean age: 32 Parikh et al., N = 202 65% Cohort Emergency 1996 Patients from department and Literacy in walk-in clinic, Health Care Atlanta, GA Study Mean age: 41 92% African American
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From page 95... ...
Participants with inadequate and marginal health literacy were significantly more likely than those with adequate health literacy to: state that they would seek care for an illness in an emergency department or acute care facility (11% vs.
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From page 96... ...
Scott et al., N = 2,722 36% Cohort Prudential 2002 New Medicare Medicare enrollees managed care between 65 (4 sites) and 80 years Cleveland, old Houston, Mean age: 71 Tampa, or South Florida
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From page 97... ...
Patients with inadequate health literacy were less likely than those with adequate health literacy to achieve tight glycemic control and were more likely to have to report having retinopathy. S-TOFHLA Inadequate health literacy was Interview independently associated with lower use of preventive health services including receiving the influenza and pneumococcal vaccinations, mammogram, or a Pap smear.
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From page 98... ...
98 HEALTH LITERACY TABLE 3-3 Continued Participation Citation Population Rate Study Design Setting Shea et al., N = 2,494 -- Cohort Urban 2003 62% Hispanic communityPublished 78% female based practices Abstract 50% younger than 40 (Health Literacy and Patient Satisfaction Study) Weiss et al., N = 402 75% Cohort University Family 1994 Adult Medicaid Care, a health enrollees care organization 78.% Female Tucson, AZ 46% Hispanic 43% Caucasian Mean age: 49 Williams et al., 1998a N = 483 90% Cohort Emergency 273 from department and emergency asthma clinic at department urban public Mean age: 37 hospital, 210 from Atlanta, GA asthma clinic Mean age: 47 Williams et al., 1998b N = 516 94% (Los Cohort Two urban public 402 patients Angeles)
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From page 99... ...
telephone survey Instrument for the Diagnosis of There was no significant relationship Reading between literacy and health-care costs. University Famili Care Records REALM Reading level was the strongest predictor of Interview asthma knowledge score in a multivariate Observation of Metered dose inhaler analysis.
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From page 100... ...
Differences in health-care spending were estimated by comparing health-care utilization by people with a lower probability of having functional literacy skills to health-care utilization by people those with a higher probability of having functional literacy skills. Friedland suggested that the additional health-care resource attributable to inadequate health literacy (NALS Level 1)
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From page 101... ...
Of 979 patients seen in the emergency department of Grady Memorial Hospital (Atlanta) in 19941995, logistic regression showed that those with inadequate health literacy, as measured by the TOFHLA, were more likely to be hospitalized (31.5 percent)
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From page 102... ...
Literacy levels are lower among the elderly, those who have lower edu cational levels, those who are poor, minority populations, and groups with limited English proficiency such as recent immigrants. Finding 3-2 On the basis of limited studies, public testimony, and committee members' experience, the committee concludes that the shame and stigma asso ciated with limited literacy skills are major barriers to improving health literacy.
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From page 103... ...
The Department of Health and Human Services, especially the National Institutes of Health, the Agency for Healthcare Research and Quality, the Health Resources and Services Administrations, and the Centers for Disease Control and Prevention; the Department of Defense; the Veterans Administration; and other public and private funding agencies should support multidisciplinary research on the extent, associations, and consequences of limited health literacy, including studies on health service utilization and expen ditures. REFERENCES Arnold CL, Davis TC, Berkel HJ, Jackson RH, Nandy I, London S
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From page 104... ...
1996. Teaching Patients with Low Literacy Skills.
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From page 105... ...
2001. The International Adult Literacy Survey (IALS)
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From page 106... ...
1995. The Test of Functional Health Lit eracy in Adults: A new instrument for measuring patients' literacy skills.
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From page 107... ...
1995. Inadequate functional health literacy among patients at two public hospitals.
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