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Van Hout MC, Akugizibwe M, Shayo EH, Namulundu M, Kasujja FX, Namakoola I, Birungi J, Okebe J, Murdoch J, Mfinanga SG, Jaffar S. Decentralising chronic disease management in sub-Saharan Africa: a protocol for the qualitative process evaluation of community-based integrated management of HIV, diabetes and hypertension in Tanzania and Uganda. BMJ Open 2024; 14:e078044. [PMID: 38508649 PMCID: PMC10961519 DOI: 10.1136/bmjopen-2023-078044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
INTRODUCTION Sub-Saharan Africa continues to experience a syndemic of HIV and non-communicable diseases (NCDs). Vertical (stand-alone) HIV programming has provided high-quality care in the region, with almost 80% of people living with HIV in regular care and 90% virally suppressed. While integrated health education and concurrent management of HIV, hypertension and diabetes are being scaled up in clinics, innovative, more efficient and cost-effective interventions that include decentralisation into the community are required to respond to the increased burden of comorbid HIV/NCD disease. METHODS AND ANALYSIS This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomised trial (INTE-COMM) in Tanzania and Uganda that will compare community-based integrated care (HIV, diabetes and hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension and diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet and exercise) provided by community nurses and trained lay workers, as well as the devolvement of NCD drug dispensing to the community level. Based on Bronfenbrenner's ecological systems theory, the process evaluation will use qualitative methods to investigate sociostructural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multistakeholder interviews (patients, community health workers and volunteers, healthcare providers, policymakers, clinical researchers and international and non-governmental organisations), focus group discussions (community leaders and members) and non-participant observations (community meetings and drug dispensing) will explore implementation from diverse perspectives at three timepoints in the trial implementation. Iterative sampling and analysis, moving between data collection points and data analysis to test emerging theories, will continue until saturation is reached. This process of analytic reflexivity and triangulation across methods and sources will provide findings to explain the main trial findings and offer clear directions for future efforts to sustain and scale up community-integrated care for HIV, diabetes and hypertension. ETHICS AND DISSEMINATION The protocol has been approved by the University College of London (UK), the London School of Hygiene and Tropical Medicine Ethics Committee (UK), the Uganda National Council for Science and Technology and the Uganda Virus Research Institute Research and Ethics Committee (Uganda) and the Medical Research Coordinating Committee of the National Institute for Medical Research (Tanzania). The University College of London is the trial sponsor. Dissemination of findings will be done through journal publications and stakeholder meetings (with study participants, healthcare providers, policymakers and other stakeholders), local and international conferences, policy briefs, peer-reviewed journal articles and publications. TRIAL REGISTRATION NUMBER ISRCTN15319595.
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Affiliation(s)
| | | | - Elizabeth Henry Shayo
- Health Systems, Policy and Translational Reseach Section, National Institute for Medical Research, Dar es Salaam, Tanzania, United Republic
| | - Moreen Namulundu
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | | | - Ivan Namakoola
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Wakiso, Uganda
| | | | - Joseph Okebe
- Institute for Global Health, University College London, London, UK
| | - Jamie Murdoch
- School of Life Course and Population Sciences, King's College London, London, London, UK
| | - Sayoki Godfrey Mfinanga
- Muhimbili Medical Research Centre, National Institute for Medical Research Tanzania, Dar es Salaam, Tanzania, United Republic of
| | - Shabbar Jaffar
- Institute for Global Health, University College London, London, UK
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Seward N, Hanlon C, Hinrichs-Kraples S, Lund C, Murdoch J, Taylor Salisbury T, Verhey R, Shidhaye R, Thornicroft G, Araya R, Sevdalis N. A guide to systems-level, participatory, theory-informed implementation research in global health. BMJ Glob Health 2021; 6:e005365. [PMID: 34969685 PMCID: PMC8718460 DOI: 10.1136/bmjgh-2021-005365] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 12/03/2021] [Indexed: 12/17/2022] Open
Abstract
Implementation research is a multidisciplinary field that addresses the complex phenomenon of how context influences our ability to deliver evidence-informed healthcare. There is increasing realisation of the importance of applying robust implementation research to scale-up life-saving interventions that meet health-related sustainable development goals. However, the lack of high-quality implementation research is impeding our ability to meet these targets, globally. Within implementation research, theory refers to the proposed hypothesis and/or explanation of how an intervention is expected to interact with the local context and actors to bring about change. Although there is increasing interest in applying theory to understand how and why implementation programmes work in real-world settings, global health actors still tend to favour impact evaluations conducted in controlled environments. This may, in part, be due to the relative novelty as well as methodological complexity of implementation research and the need to draw on divergent disciplines, including epidemiology, implementation science and social sciences. Because of this, implementation research is faced with a particular set of challenges about how to reconcile different ways of thinking and constructing knowledge about healthcare interventions. To help translate some of the ambiguity surrounding how divergent theoretical approaches and methods contribute to implementation research, we draw on our multidisciplinary expertise in the field, particularly in global health. We offer an overview of the different theoretical approaches and describe how they are applied to continuously select, monitor and evaluate implementation strategies throughout the different phases of implementation research. In doing so, we offer a relatively brief, user-focused guide to help global health actors implement and report on evaluation of evidence-based and scalable interventions, programmes and practices.
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Affiliation(s)
- Nadine Seward
- Centre for Implementation Science, Department of Health Service and Population Research, King's College London, London, UK
| | - Charlotte Hanlon
- Institute of Psychiatry, Psychology and Neuroscience, Health Service and Population Research Department, Centre for Global Mental Health, King's College London, London, UK
- Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia
| | | | - Crick Lund
- King's College London, London, UK
- University of Cape Town, Rondebosch, South Africa
| | - Jamie Murdoch
- University of East Anglia Faculty of Medicine and Health Sciences, Norwich, UK
| | | | - Ruth Verhey
- Research Support Centre, College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Rahul Shidhaye
- Pravara Institute of Medical Sciences, Loni, Maharashtra, India
| | | | | | - Nick Sevdalis
- Health Service & Population Research Department, King's College London, London, UK
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Van Hout MC, Bachmann M, Lazarus JV, Shayo EH, Bukenya D, Picchio CA, Nyirenda M, Mfinanga SG, Birungi J, Okebe J, Jaffar S. Strengthening integration of chronic care in Africa: protocol for the qualitative process evaluation of integrated HIV, diabetes and hypertension care in a cluster randomised controlled trial in Tanzania and Uganda. BMJ Open 2020; 10:e039237. [PMID: 33033029 PMCID: PMC7542920 DOI: 10.1136/bmjopen-2020-039237] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION In sub-Saharan Africa, the burden of non-communicable diseases (NCDs), particularly diabetes mellitus (DM) and hypertension, has increased rapidly in recent years, although HIV infection remains a leading cause of death among young-middle-aged adults. Health service coverage for NCDs remains very low in contrast to HIV, despite the increasing prevalence of comorbidity of NCDs with HIV. There is an urgent need to expand healthcare capacity to provide integrated services to address these chronic conditions. METHODS AND ANALYSIS This protocol describes procedures for a qualitative process evaluation of INTE-AFRICA, a cluster randomised trial comparing integrated health service provision for HIV infection, DM and hypertension, to the current stand-alone vertical care. Interviews, focus group discussions and observations of consultations and other care processes in two clinics (in Tanzania, Uganda) will be used to explore the experiences of stakeholders. These stakeholders will include health service users, policy-makers, healthcare providers, community leaders and members, researchers, non-governmental and international organisations. The exploration will be carried out during the implementation of the project, alongside an understanding of the impact of broader structural and contextual factors. ETHICS AND DISSEMINATION Ethical approval was granted by the Liverpool School of Tropical Medicine (UK), the National Institute of Medical Research (Tanzania) and TASO Research Ethics Committee (Uganda) in 2020. The evaluation will provide the opportunity to document the implementation of integration over several timepoints (6, 12 and 18 months) and refine integrated service provision prior to scale up. This synergistic approach to evaluate, understand and respond will support service integration and inform monitoring, policy and practice development efforts to involve and educate communities in Tanzania and Uganda. It will create a model of care and a platform of good practices and lessons learnt for other countries implementing integrated and decentralised community health services. TRIAL REGISTRATION NUMBER ISRCTN43896688; Pre-results.
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Affiliation(s)
- Marie-Claire Van Hout
- Public Health Institute, Liverpool John Moores University, Liverpool, Merseyside, UK
| | - Max Bachmann
- Norwich Medical School, University of East Anglia Faculty of Medicine and Health Sciences, Norwich, UK
| | - Jeffrey V Lazarus
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Catalunya, Spain
| | - Elizabeth Henry Shayo
- Muhimbili Centre, National Institute for Medical Research, Dar es Salaam, Dar es Salaam, Tanzania, United Republic of
| | - Dominic Bukenya
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Camila A Picchio
- Barcelona Institute for Global Health (ISGlobal), Hospital Clinic, University of Barcelona, Barcelona, Catalunya, Spain
| | - Moffat Nyirenda
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Sayoki Godfrey Mfinanga
- Muhimbili Centre, National Institute for Medical Research, Dar es Salaam, Dar es Salaam, Tanzania, United Republic of
| | - Josephine Birungi
- MRC/UVRI/LSHTM Uganda Research Unit, Medical Research Council Uganda, Entebbe, Uganda
| | - Joseph Okebe
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
| | - Shabbar Jaffar
- Department of International Public Health, Liverpool School of Tropical Medicine, Liverpool, Liverpool, UK
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D'Mello-Guyett L, Greenland K, Bonneville S, D'hondt R, Mashako M, Gorski A, Verheyen D, Van den Bergh R, Maes P, Checchi F, Cumming O. Distribution of hygiene kits during a cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo: a process evaluation. Confl Health 2020; 14:51. [PMID: 32760439 PMCID: PMC7379792 DOI: 10.1186/s13031-020-00294-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Accepted: 07/15/2020] [Indexed: 12/30/2022] Open
Abstract
Background Cholera remains a leading cause of infectious disease outbreaks globally, and a major public health threat in complex emergencies. Hygiene kits distributed to cholera case-households have previously shown an effect in reducing cholera incidence and are recommended by Médecins Sans Frontières (MSF) for distribution to admitted patients and accompanying household members upon admission to health care facilities (HCFs). Methods This process evaluation documented the implementation, participant response and context of hygiene kit distribution by MSF during a 2018 cholera outbreak in Kasaï-Oriental, Democratic Republic of Congo (DRC). The study population comprised key informant interviews with seven MSF staff, 17 staff from other organisations and a random sample of 27 hygiene kit recipients. Structured observations were conducted of hygiene kit demonstrations and health promotion, and programme reports were analysed to triangulate data. Results and conclusions Between Week (W) 28-48 of the 2018 cholera outbreak in Kasaï-Oriental, there were 667 suspected cholera cases with a 5% case fatality rate (CFR). Across seven HCFs supported by MSF, 196 patients were admitted with suspected cholera between W43-W47 and hygiene kit were provided to patients upon admission and health promotion at the HCF was conducted to accompanying household contacts 5-6 times per day. Distribution of hygiene kits was limited and only 52% of admitted suspected cholera cases received a hygiene kit. The delay of the overall response, delayed supply and insufficient quantities of hygiene kits available limited the coverage and utility of the hygiene kits, and may have diminished the effectiveness of the intervention. The integration of a WASH intervention for cholera control at the point of patient admission is a growing trend and promising intervention for case-targeted cholera responses. However, the barriers identified in this study warrant consideration in subsequent cholera responses and further research is required to identify ways to improve implementation and delivery of this intervention.
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Affiliation(s)
- Lauren D'Mello-Guyett
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.,Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Katie Greenland
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Rob D'hondt
- Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Maria Mashako
- Médecins Sans Frontières, Kinshasa, Democratic Republic of Congo
| | - Alexandre Gorski
- Médecins Sans Frontières, Kinshasa, Democratic Republic of Congo
| | - Dorien Verheyen
- Médecins Sans Frontières, Kinshasa, Democratic Republic of Congo
| | - Rafael Van den Bergh
- LuxOR, Luxembourg Operational Research Unit, Médecins Sans Frontières, Luxembourg City, Luxembourg
| | - Peter Maes
- Environmental Health Unit, Médecins Sans Frontières, Brussels, Belgium
| | - Francesco Checchi
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Oliver Cumming
- Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
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Fairall L, Cornick R, Bateman E. Empowering frontline providers to deliver universal primary healthcare using the Practical and Approach to care kit. BMJ Glob Health 2018; 3:bmjgh-2018-k4451rep. [PMID: 30538824 PMCID: PMC6266967 DOI: 10.1136/bmjgh-2018-k4451rep] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Affiliation(s)
- Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Cape Town, South Africa
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Fairall L, Cornick R, Bateman E. Empowering frontline providers to deliver universal primary healthcare using the Practical Approach to Care Kit. BMJ 2018; 363:k4451. [PMID: 30355721 PMCID: PMC6200083 DOI: 10.1136/bmj.k4451] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, South Africa
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, South Africa
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Picken S, Hannington J, Fairall L, Doherty T, Bateman E, Richards M, Wattrus C, Cornick R. PACK Child: the development of a practical guide to extend the scope of integrated primary care for children and young adolescents. BMJ Glob Health 2018; 3:e000957. [PMID: 30397519 PMCID: PMC6203049 DOI: 10.1136/bmjgh-2018-000957] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Revised: 09/21/2018] [Accepted: 09/22/2018] [Indexed: 02/03/2023] Open
Abstract
Pioneering strategies like WHO's Integrated Management of Childhood Illness (IMCI) have resulted in substantial progress in addressing infant and child mortality. However, large inequalities exist in access to and the quality of care provided in different regions of the world. In many low-income and middle-income countries, childhood mortality remains a major concern, and the needs of children present a large burden upon primary care services. The capacity of services and quality of care offered require greater support to address these needs and extend integrated curative and preventive care, specifically, for the well child, the child with a long-term health need and the child older than 5 years, not currently included in IMCI. In response to these needs, we have developed an innovative method, based on experience with a similar approach in adults, that expands the scope and reach of integrated management and training programmes for paediatric primary care. This paper describes the development and key features of the PACK Child clinical decision support tool for the care of children up to 13 years, and lessons learnt during its development.
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Affiliation(s)
- Sandy Picken
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Juliet Hannington
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Mowbray, South Africa
| | - Tanya Doherty
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- South African Medical Research Council, Cape Town, South Africa
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Mark Richards
- Department of Paediatrics and Child Health, Somerset Hospital, University of Cape Town, Green Point, South Africa
| | - Camilla Wattrus
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
- Department of Medicine, University of Cape Town, Mowbray, South Africa
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Cornick R, Picken S, Wattrus C, Awotiwon A, Carkeek E, Hannington J, Spiller P, Bateman E, Doherty T, Zwarenstein M, Fairall L. The Practical Approach to Care Kit (PACK) guide: developing a clinical decision support tool to simplify, standardise and strengthen primary healthcare delivery. BMJ Glob Health 2018; 3:e000962. [PMID: 30364419 PMCID: PMC6195147 DOI: 10.1136/bmjgh-2018-000962] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/17/2018] [Accepted: 08/20/2018] [Indexed: 12/17/2022] Open
Abstract
For the primary health worker in a low/middle-income country (LMIC) setting, delivering quality primary care is challenging. This is often complicated by clinical guidance that is out of date, inconsistent and informed by evidence from high-income countries that ignores LMIC resource constraints and burden of disease. The Knowledge Translation Unit (KTU) of the University of Cape Town Lung Institute has developed, implemented and evaluated a health systems intervention in South Africa, and localised it to Botswana, Nigeria, Ethiopia and Brazil, that simplifies and standardises the care delivered by primary health workers while strengthening the system in which they work. At the core of this intervention, called Practical Approach to Care Kit (PACK), is a clinical decision support tool, the PACK guide. This paper describes the development of the guide over an 18-year period and explains the design features that have addressed what the patient, the clinician and the health system need from clinical guidance, and have made it, in the words of a South African primary care nurse, 'A tool for every day for every patient'. It describes the lessons learnt during the development process that the KTU now applies to further development, maintenance and in-country localisation of the guide: develop clinical decision support in context first, involve local stakeholders in all stages, leverage others' evidence databases to remain up to date and ensure content development, updating and localisation articulate with implementation.
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Affiliation(s)
- Ruth Cornick
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Sandy Picken
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Camilla Wattrus
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Ajibola Awotiwon
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Emma Carkeek
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Juliet Hannington
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Pearl Spiller
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Eric Bateman
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
| | - Tanya Doherty
- South African Medical Research Council, Cape Town, South Africa
| | - Merrick Zwarenstein
- Centre for Studies in Family Medicine, Schulich School of Medicine & Dentistry, Western University, London, Ontario, Canada
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town Lung Institute, Cape Town, South Africa
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