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Domestic elder abuse in Yazd, Iran: a cross-sectional study

Health Promotion Perspectives

eISSN: 2228-6497

Health Promotion Perspectives, 6(2), 104-110; DOI: 10.15171/hpp.2016.18

Original Article

Domestic elder abuse in Yazd, Iran: a cross-sectional study

Mohammad Ali Morowatisharifabad1, Hassan Rezaeipandari2,*, Ali Dehghani3, Ahmad Zeinali4


1 Department of Ageing Health, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
2 Elderly Health Research Center, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
3 Department of Biostatistics and Epidemiology, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran
4 Department of Neurology, School of Medicine, Shahid Sadoughi University of Medical Sciences, Yazd, Iran

*Corresponding Author: Hassan Rezaeipandari; Tell: +98 9103090966; Email: hrezaeipandari@yahoo.com


© 2016 The Author(s). This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Background: Social changes due to urbanism, acculturation, and fading of values have led to some challenges in family relationships, including domestic elder abuse. This study was conducted to determine elder abuse status in Yazd, Iran.

Methods: This cross-sectional study was conducted on 250 elderly people over 60 years in Yazd in 2014-2015. Clustered random sampling was used to recruit the participants from 10 clusters in Yazd (25 individuals from each cluster). The data were gathered by the 49-item,Iranian Domestic Elder Abuse Questionnaire which was filled out through private interviews with the participants.

Results: Mean score of elder abuse was 11.84 (SD: 12.70) of total 100. Of the participants,79.6% (95% CI: 74.5-84.6) experienced at least one type of abuse. Emotional neglect was the most reported abuse and physical abuse was the least reported. Abuse score was associated with age, education level, living status, and insurance status of elders. Further, those who reported history of gastrointestinal problems, dyslipidemia, respiratory diseases, sleep disorders,audiovisual problems, joints pain, hypertension, dental/oral problems, cardiovascular disease,urinary incontinence and disability, reported a statistically significant higher abuse score.

Conclusion: Despite overall low rate of domestic elder abuse, its high prevalence indicates that some interventions are necessary to decrease domestic elder abuse. Emotional neglect of elders should be addressed more than other abuse types.


Keywords: Elder Abuse, Prevalence, Yazd, Iran

Citation: Morowatisharifabad MA, Rezaeipandari H, Dehghani A, Zeinali A. Domestic elder abuse in Yazd, Iran: a cross-sectional study.Health Promot Perspect. 2016;6(2):104-110. doi: 10.15171/hpp.2016.18.

Introduction

There is scant evidence on elder abuse, one of the most hidden and frequent forms of family violence. According to the Centers for Disease Control and Prevention (CDC), elder abuse is an intentional act, or failure to act, by a caregiver or another person in a relationship involving an expectation of trust that causes or creates a risk of harm to an older adult.1

Social changes due to urbanism, acculturation, and fading of values and traditional beliefs have led to some challenges in family relationships, including domestic elder abuse. Elder abuse is not a new issue, but it has recently been raised as a main public health and a widespread, growing social problem worldwide. Elder abuse is targeted intentionally or unintentionally at the elderly and making them injured and annoyed.2

The World Health Organization (WHO) has reported the rate of elder abuse in domestic settings in developed countries to be 4%-6% if physical, psychological and financial abuse, and neglect are all included.3

A recently published paper reported an aggregate prevalence of 4.6% of elder abuse in New York state households, the United States in 2009.4 A systematic review of prevalence and risk factors for elder abuse in Asia reported the prevalence ranging from 0.22 per 1000 to 62%, across Asia.5 Despite the WHO’s emphasis on international awareness of detection and prevention of elder abuse incidence, unfortunately developing countries have not yet taken necessary measures to systematically gather the relevant data. However, there is much evidence on elder abuse incidence in these countries.6 A study on the prevalence of elder abuse in Gorgan and Aq-Qala cities, northern Iran in 2013 reported the total frequency of elder abuse to be 63.3%.7

Some studies, however, have indicated that many cases of elder abuse are not detected and only 1/10 cases of elder abuse is reported.3 Newton reported that actual figures show 67% of the abuse occurs in the elders’ own homes.8 Because abuses in the homes are usually not reported, the rate of hidden elder abuse is likely to be higher than the reported figures. This problem is under-reported in many communities because the victims rarely report or seek out assistance.

Several abuse type patterns have been reported in different studies. In a study by Buka and Sookhoo,9 psychological abuse was the highest at 38.9% with sexual and societal types at the lowest level, 1.9% and 1.5%, respectively. In Manoochehri et al10 study, emotional abuse was the most prevalent (84.8%) subscale followed by neglect (68.3%), financial abuse (40.1%), and sexual abuse (35.2%). Furthermore, Heravi-Karimoei et al11 study on different types of elder abuse reported that most of the elderly were victims of emotional neglect, psychological abuse, and care neglect and the least number of them were victims of rejection and physical abuse.

Elder abuse can lead to declined self-esteem, hopelessness, insufficiency, mental problems, and inability.12 Abuse at any degrees may decline the elderly health and safety.13 Regarding the significance of elder abuse and the elderly’s health as well as inconsistent findings of different studies and no large study of elder abuse in Iran, the present study was conducted to determine the status of elder abuse in the elderly population of Yazd in 2014-2015.

Materials and Methods

Participants and procedures

This cross-sectional study was conducted on 250 elders (60 years and older) in Yazd in 2014-2015. The required sample size was estimated 250 people considering 95% CI, elder abuse ratio of 0.7,14 and the design effect equal to 1.1. A clustered random sampling was used to select the participants. For this purpose, 10 geographic clusters were selected in Yazd and 25 people from each cluster were enrolled into the study. The questionnaires were filled out through 20 to 30-minute private interviews with the participants at their own homes. Interviews were carried out by two trained interviewers. The elders who were able to answer the questions were considered eligible to enter the study.

Measure

Data collection tool was a questionnaire including demographic information and a question about the history of disease and chronic conditions, and Iranian Domestic Elder Abuse Questionnaire.15 Demographic information included age, gender (male, female), marital status (married, dead spouse, divorced), house ownership status (owner, rented house), education level (illiterate, elementary, secondary, high school completion, academic), number of children, retirement status (yes, no), current occupational status (employed, housewife, unemployed), living status (with spouse, with single children, with married children, alone) and income source (current occupation, retirement, children support, institutional support, renting property). Iranian Domestic Elder Abuse Questionnaire consists of 49 items divided into eight subscales including care neglect (11 items), psychological abuse (eight items), physical abuse (four items), financial abuse (six items), authority deprivation (10 items), rejection (four items), financial neglect (four items), and emotional neglect (two items). The choices to answer the questions were “Yes”, “No,” and “No relevance.” The choice “No relevance” applies when the item has no relevance to the respondent’s living conditions. The score range is from 0 to 100 and higher scores represent more symptoms of abuse. The psychometric indices of the instrument have been reported by the developers of the scale, found to have face, content, and construct validity. They also reported a Cronbach alpha of 0.9 to 0.975 for the subscales.15

This instrument is appropriate for investigating family elder abuse in Iran because of some characteristics such as being developed based on the perceptions and conceptions of abuse and abuse-related life experiences among Iran’s elderly population, explanation of a wide variety of family elder abuse, easy scoring, acceptable reliability and validity, and application in different situations.15

Statistical analysis

The SPSS was used for data analysis. Frequency distribution tables were used to show descriptive results and Mann-Whitney U test to compare the abuse scores by two-level independent variables. Also, Kruskal-Wallis H test was used to compare the abuse scores by multi-level independent variables. The level of significance was 0.05.

Results

Demographic characteristics of the participants

Overall, 250 elders with mean age of 73.93 (SD: 8.20) years participated in this study. Of the participants, 49.6% were women and most of them were married. Regarding education level, most of the participants were illiterate. Over 35% of the participants were retired and 88% lived in their own homes. Complete demographic information of the participants is presented in Table 1.

Table 1. Frequency distribution of demographic information in the studied elderly
Variable Number %
Age (year)
60-69 82 32.8
70-79 91 36.4
≥80 77 30.8
Gender
Male 126 50.4
Female 124 49.6
Marital status
Married 169 67.6
Dead spouse 73 29.2
Divorced 5 02.0
House ownership
Owner 222 88.8
Rented 8 03.2
Children’s home 19 07.6
Education level
Illiterate 127 50.8
Elementary 80 32.0
Secondary 26 10.4
High School completion 14 05.6
Academic 3 01.2
Number of children
1-3 59 23.6
4-6 123 49.2
≥7 68 27.2
Retired
Yes 89 35.7
No 160 64.3
Current occupational status
Employed 44 07.7
Housewife 114 46.0
Unemployed 90 36.3
Living status
With spouse 168 67.2
With single children 6 02.4
With married children 28 11.2
Alone 48 19.2
Income source
Current occupation 52 20.9
Retirement 128 51.4
Children support 45 18.1
Institutional Support 9 06.3
Renting property 5 06.0

Descriptive features of elder abuse

The most frequently reported abuse was family members’ indifference (52.8%) followed by no visit or call by family members (51.6%) in emotional neglect subscale. Forced sexual activity and touching sensitive parts of the body in deprivation subscale and abandoning elderly in nursing home in rejection subscale did not reported by any of the elders (Table 2).

Of the subscales, emotional neglect and physical abuse were the most and least reported subscales of abuse, respectively (Table 3).

Table 2. Distribution of participants’ responses to questionnaire items
Subscale Item Yes No No relevance
n % n % n %
Emotional neglect Family members indifference 130 52.8 116 47.2 ‏- ‏-
No visit or call by family members 127 51.6 119 48.4 ‏- ‏-
Care neglect No help for movement 110 44.7 115 46.7 21 8.5
No help for eating and drinking 84 34.1 115 46.7 47 19.1
No help for visiting physician 88 35.8 119 48.4 39 15.9
No help for providing and/or taking medications 80 32.5 117 47.6 49 19.9
No help for personal hygiene and bathing 51 20.7 73 29.7 122 46.6
No help for toilet and cleanliness 38 15.4 74 30.1 134 54.5
Failure to buy medical equipment such as eyeglasses 55 22.4 72 29.3 119 48.4
Failure to give food or water and fluids on time 41 16.7 153 62.2 52 21.1
No adherence to diet despite privilege 30 12.2 171 69.5 45 18.3
Failure to do outdoor activities such as shopping and paying bills 40 16.3 156 63.4 50 20.3
Failure to do home activities such as cleaning and maintenance 44 17.9 158 64.2 44 17.9
Financial neglect Failure to provide the needed money to supply basic life needs 35 14.2 159 64.6 52 21.1
Disrespectfully paying money in case of urgent need 22 8.9 164 66.7 60 24.4
No payment of money to provide prize or pay votive despite privilege 16 6.5 166 67.5 64 26.0
Failure to provide the required comfort appropriate for the elderly dignity 21 8.6 224 91.4 ‏- ‏-
Authority Deprivation Interdiction of social activities such as offering voluntary services 15 6.1 231 93.9 ‏- ‏-
Interdiction of traveling with friends and relatives 13 5.3 233 94.7 ‏- ‏-
Depriving grandchildren visit 9 3.7 131 53.3 106 43.1
Interdiction of the elderly awareness of important news about themselves 10 4.1 236 95.9 ‏- ‏-
Dictation of the ideas regarding choice of spouse, remarriage, or residence 5 2 125 50.8 116 47.2
No permission to use assets based on their own desire 17 6.9 229 93.1 ‏- ‏-
Interdiction of access to life equipment such as telephone and TV 11 4.5 235 95.5 ‏- ‏-
Changing appearance like cutting hairs without the elderly consent 12 4.9 234 95.1 ‏- ‏-
Forced sexual activity 0 0 247 100 ‏- ‏-
Forced touching sensitive parts of the body 0 0 247 100 ‏- ‏-
Psychological abuse Threatening such as threats of beating, imprisonment, deprivation of assistance 4 1.6 234 98.4 ‏- ‏-
Terrifying by breaking or ruining home appliances 10 4 237 96 ‏- ‏-
Revealing the secrets of the elderly with others 83 33.6 164 66.4 ‏- ‏-
Failure to give importance to personality, knowledge, ability, and experience of the elderly 41 16.7 205 83.3 ‏- ‏-
Blaming for no reason 44 17.8 203 82.2 ‏- ‏-
Addressing by means of impolite names, inappropriate tone and/or offensive language 33 13.4 214 86.6 ‏- ‏-
Shouting 30 12.1 217 87.9 ‏- ‏-
Doing offensive gestures 15 6.1 232 93.9 ‏- ‏-
Physical abuse Attempt to beat 6 2.4 241 97.6 ‏- ‏-
Throwing objects and furniture to the elderly 5 2 242 98 ‏- ‏-
Attempt to strangle the elderly 0 0 247 100 ‏- ‏-
Prescription of hypnotics or sedatives for no reason 5 2 242 98 ‏- ‏-
Financial abuse Borrowing money from others on behalf of and without the awareness of the elderly 18 7.3 229 92.7 ‏- ‏-
Failure to repay money borrowed from the elderly 101 40.9 146 59.1 ‏- ‏-
Imposing living costs on the elderly without their consent 12 4.8 235 95.1 ‏- ‏-
Obtaining possession of salary, money, equipment, home or property without the elderly consent 8 3.2 238 96.7 ‏- ‏-
No payment of inheritance 6 2.4 241 97.6 ‏- ‏-
Obtaining power of attorney by force or changing will without elderly consent 6 2.4 241 97.6 ‏- ‏-
Rejection Being driven from the homes of family members 3 1.2 244 98.8 ‏- ‏-
Being driven from his/her own home 5 2 242 98 ‏- ‏-
Abandoning the elderly in hospital 17 6.9 230 93.1 ‏- ‏-
Abandoning elderly in nursing home 0 0 247 100 ‏- ‏-

Table 3. Min, max, median and mean (standard deviation) of elder abuse subscales scores in the studied elderly
Subscales Min Max Median Mean SD
Emotional neglect 0 100 50 51.40 47.71
Care neglect 0 100 7.14 21.85 29.93
Financial neglect 0 100 0 09.10 24.89
Authority deprivation 0 80 0 03.51 11.49
Psychological abuse 0 100 0 13.00 20.55
Physical abuse 0 50 0 01.60 07.91
Financial abuse 0 83.3 0 10.06 14.00
Rejection 0 50 0 02.50 08.74
Total abuse score 0 75.51 8.16 11.84 12.70

Correlates of elder abuse

Examining the elder abuse score by some demographic characteristics showed that elder abuse increased by age increase and those who had a higher education level were less likely to be abused. Also, the uninsured elderly reported higher scores of abuse than those reported by the insured (P < 0.05; Table 4).

Table 4. Distribution of min, max, median and mean (standard deviation) of elder abuse scores by some demographic characteristics of the studied elderly
Variable Labels Mean SD Min Max Median Pa
Age (year) 60-69 8.02 9.94 0 59.18 5.76 0.004
70-79 11.80 11.61 0 49.06 10.34
≥80 15.96 15.18 0 75.51 12.24
Gender Male 12.33 12.34 0 54.90 9.00 0.33
Female 11.34 13.09 0 75.51 8.08
Education Level Illiterate 14.26 13.46 0 75.51 11.76 0.012
Elementary 10.40 11.59 0 54.90 7.54
Secondary 8.27 13.19 0 59.18 3.38
High school completion 5.95 5.71 0 20.41 4.61
Living status With Spouse 9.50 10.30 0 59.18 6.15 0.001
Without spouse 16.72 15.60 0 75.51 15.09
Current occupational Employed 12.13 14.66 0 54.90 5.96 0.39
Housewife 11.23 12.58 0 75.51 8.24
Unemployed 12.72 11.92 0 53.85 9.44
Insurance Yes 11.05 12.01 0 75.51 8.16 0.009
No 19.77 16.06 0 51.02 19.60
Income source Current occupation 12.94 14.19 0 54. 90 7.40 0.071
Retirement 10.23 12.57 0 75.51 6.34
Children 15.03 11.95 0 51.02 16.39
Support institute 13.06 11.64 0 34.69 15.09
Renting property 12.16 9.70 0 28.30 11.54
House ownership Owner 11.90 12.70 0 75.51 8.16 0.87
Rented 14.82 19.50 0 49.06 3.73
Children’s home 10.03 9.47 0 32.65 9.54
aMann-Whitney U test for 2-level variables; Krukal-Wallis H test for multi-level variables.

Regarding the diseases and problems, the elders who had the history of gastrointestinal problems, dyslipidemia, respiratory diseases, sleep disorders, audiovisual problems, joints pain, hypertension, dental/oral problems, cardiovascular disease, urinary incontinence and disability, reported a statistically significant higher abuse scores (P < 0.05; Table 5).

Table 5. Distribution of min, max and median of abuse scores by some diseases and problems in the studied elderly
Diseases and Problems Yes No Pa
Min Max Median Min Max Median
Gastrointestinal problems 0 75.51 10.81 0 53.85 5.66 0.004
Depression 0 75.51 8.33 0 54.90 8.16 0.920
Dyslipidemia 0 75.51 10.00 0 54.90 6.34 0.028
Respiratory diseases 0 59.18 9.80 0 75.51 7.47 0.042
Sleep disorders 0 75.51 11.53 0 54.90 6.15 0.001
Audiovisual problems 0 75.51 11.33 0 53.85 4.68 0.001
Joints pain 0 75.51 10.00 0 23.53 1.88 0.001
Osteoporosis/ arthritis 0 75.51 10.17 0 54.90 7.47 0.093
Hypertension 0 75.51 11.53 0 54.90 4.08 0.001
Hypotension 0 54.90 9.09 0 75.51 8.16 0.861
Dental/oral problems 0 75.51 10.90 0 21.43 3.88 0.001
Anorexia 0 75.51 10.67 0 54.90 8.16 0.138
Cardiovascular disease 0 75.51 12.24 0 53.85 4.34 0.001
Cancer 0 51.02 12.30 0 75.51 8.16 0.089
Diabetes 0 59.18 7.69 0 75.51 8.92 0.483
Urinary incontinence 0 75.51 12.24 0 54.90 5.76 0.001
Disability 0 51.02 18.36 0 75.51 8.16 0.017
aMann-Whitney U test.

Discussion

In the present study, the mean score of elder abuse was obtained 11. 84 (SD: 12.70) of a total score of 100, representing the low level of domestic elder abuse, but 79.6% of the studied elderly experienced at least on type of abuse. Manoochehri et al10 study in 2008 indicated that the prevalence of at least one type of family elder abuse as 87. 8 %. It was reported 25. 9 % in Heravi-Karimoei et al14 study in Tehran and 10.5%-25% in Karimi and Elahi study in Ahwaz.16 The prevalence of abuse has been obtained 4%-10% in the United States,17 14% in India,18 36% in China,19 3%-5% in Ireland,20 and 3%-10% in Australia, Canada, and England.21 Pillemer and Finkelhor22 estimated the prevalence of elder abuse in Boston, the United States to be 32/1000 people and Cooper et al23 reported the total prevalence of domestic elder abuse to be 6%. The data on elder abuse are inconsistent because of differences in methods of the studies, non-probability sampling, no consensus on elder abuse concept, use of inappropriate instruments, and the problems related to gathering of reliable data. Therefore, it is difficult to compare the findings of different studies.24 However, if we cannot say that the elder abuse is more prevalent in the studied community, we may easily say that the problem is as common as other communities.

Of the subscales of elder abuse, emotional neglect (mean: 40.51) and physical abuse (mean: 1.60) were the most and least reported abuse type. Similarly, Heravi-Karimoei et al11 found emotional abuse to be the most reported subscale and physical abuse the least reported subscale. Manoochehri et al10 study on the rate and types of domestic elder abuse in the elderly going to parks in Tehran demonstrated that most of the elderly were victims of emotional abuse and neglect and least of them victims of physical abuse. In Zandi and Fadaei25 study on the abused elderly referring police stations, prosecutors, courts, and offices of lawyers and consultants for criminal complaint, financial abuse was reported to be the most prevalent subscale. Nowrouzi26 study on elder abuse rate and associated family factors among the elderly admitted to Tehran nursing houses found emotional neglect and physical abuse to be the most and least frequent abuse in the studied population. Karimi and Elahi16 found neglect followed by financial abuse and psychological abuse to be the most frequent types of abuse in the elderly living in Ahwaz including those in nursing houses. Some other studies27-36 also reported similar findings in elder abuse types. All these studies highlight the significance of emotional domain for the elderly. Clearly, emotional abuse is more common elder abuse type and emotional support which comprises sympathy, attention, kindness, and interest, could play an important role in improving the quality of life and health among the elderly.

Abuse scores were significantly related to elder’s age, education level, living status and insurance status. In Keyghobadi et al28 study no significant relation was observed between abuse and education level, living conditions, income source, and suffering from chronic diseases. Heravi-Karimoei et al11 demonstrated that abuse was significantly associated with gender, insurance, occupation, adequate financial sources, age, and number of children. In Nori et al27 study there was a significant association of elder abuse with income level and marital status. Karimi and Elahi16 derived a significant association between abuse and age in the elderly. More clearly, older participants were more predisposed to abuse.

In the present study, regarding gender, there was no difference in elder abuse between men and women, which is consistent with Heravi-Karimoei et al11 and inconsistent with Gil et al.37 According to National Center on elder abuse report, most abused elderly in the United States are women.38 The inconsistency of the findings could be explained by the culture, customs, and religion in Yazd community by which women and men are treated equally and women are not considered subservient.

Regarding education level, abuse score was lower in educated people than the illiterate and those with elementary school education, consistent with Gil et al.37 This finding represents that education contributes positively to living a healthy life in the elderly. High educated people develop mental disorders and chronic diseases less frequently39 and hence are less predisposed to abuse, because acquisition of chronic and mental diseases and dementia could be one of the risk factors for being abused.

Regarding living status, mean abuse score was lower in elderly who were living with their spouses than those who were not, which is consistent with Nori et al.27 As one of the potential risks to the elderly health is loneliness and seclusion, it is necessary to provide a supporting living environment and even rehabilitation services for them. The married elderly enjoy a strong support, spouse, which contributes considerably to preventing abuse in them. In most cases of abuse, the abused people are single. Losing spouse means losing emotional, mental, caring, and also financial support. The single elderly tend to face abuse in one of the subscales, particularly emotional, authority deprivation, and financial.

Regarding insurance, the findings, as expected, indicated that the elder abuse was lower in the insured elders. Since the educated, independent elders are usually insured, they are less likely to be abused.

As expected, consistent with some other studies,16,32,40,41 a significant association was seen between elder abuse and acquisition of some diseases and problems. In other words, the elderly with chronic diseases had a lower quality of life than healthy elderly and hence were dependent on relatives’ help most of the time, making them more predisposed to abuse. These diseases may lead to elder abuse per se.

The limitations of this study include using self-reported questionnaire that are subject to response bias. Moreover, the study was conducted in Yazd province, Iran, which is famous as a traditional and religious community that respects the elders much more strictly than people in other provinces and the results cannot be generalized to the whole country. This study also was limited to urban areas and the results cannot be generalized to rural areas. Finally‏, due to non-experimental nature of the study, no causal inferences may be drawn.

Conclusion

Despite a low rate of domestic elder abuse, a large proportion of the elders experience some type(s) of abuse. Emotional neglect is the most frequently seen elder abuse type despite emphasis on respect for the elderly in Iran. Regarding the significance of affective domain in healthy ageing, raising the awareness and sensitivity of people and the related organizations is recommended to take effective measures to prevent elder abuse.

Ethical approval

The study was approved by the institutional review board at Shahid Sadoughi University of Medical Sciences. Moreover, participation in the study was voluntary and oral informed consent was taken from the participants for participation in the study after the study aims were explained for them before the interviews.

Competing interests

Authors declare that they have no competing interest.

Authors contributions

MSHMA and RP H, designed and implemented the study and wrote the paper. DA, participated in data analysis and ZA, participated in the study design.

Acknowledgments

The authors thank all respectful elders who participated in this study and their families. This paper was derived from a research project (grant no. 3415) funded by the Elderly Health Research Center, School of Public Health, Shahid Sadoughi University of Medical Sciences, Yazd, Iran.

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Submitted: 28 Feb 2016
Accepted: 09 May 2016
First published online: 11 Jun 2016
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