By Chipchase, Lucy S; Williams, Marie T; Robertson, Val J
Decisions about auricular content in entry-level health professional programs are influenced by a variety of external and internal factors. However, little is known about how lecturers make decisions about the curricular content to be included or excluded from entry-level programs. This study aimed to explore the factors influencing such decision making regarding curricular content in entry-level Australian and New Zealand programs for physiotherapy, as well as how evidence-based practice (EBP) is integrated into the teaching and learning framework. Thirteen lecturers from 13 institutions (100% response rate) responsible for teaching a core part of physiotherapy practice, electrophysical agents, participated in a semistructured telephone interview. Decision making for curricular content involved an overall democratic process with the program team, but the day-to-day content was determined by the lecturer. Factors that lecturers reported as impacting on the choice of curriculum were current clinical practice, evidence, and accreditation or registration requirements. Thematic analysis of open-ended questions identified four main themes relating to the integration of the EBP paradigm within teaching: resource materials, use of broad definitions of evidence, inclusion of specific instructional strategies, and context of curriculum. Lecturers used a variety of research methodologies as a backdrop for the presentation of techniques and interventions that are used commonly in clinical practice despite limitations in the evidence base. The results highlighted tensions that exist when designing entry-level curricula with the need to prepare competent and safe practitioners while working within an EBP paradigm. J Allied Health 2007; 36:17- 23.
ENTRY-LEVEL PROGRAMS for the health professions must ensure that beginning practitioners are competent and safe to practice within the scope of their discipline and that they are aware of the current dominating paradigms within health care.1,2 The move away from apprenticeshipbased education models for allied health care professions toward university-based degrees provided for the need for predictable and standardized training and also implicitly encouraged health professions to explore, innovate, and experiment while providing students with new and sometimes controversial material within the curricula.3 At the same time, however, lecturers involved in health care education have to respond to local and international trends in clinical practice, the demands of accreditation and registration authorities, and workload and time constraints.4,5
Accreditation systems for physiotherapy (known as physical therapy in some countries) such as the Australian Council of Physiotherapy Regulating Authorities Ltd. in Australia and the Commission on Accreditation in Physical Therapy Education in the United States offer limits and guidance but do not provide an hour- by-hour description of required curricular content. Specific decisions concerning curricula (such as what should be included, removed, and excluded; the mode of teaching and nature; and type and scheduling of assessments) are the responsibility of the lecturers. Little is known about how lecturers make decisions and the factors that impact on choice of curricula.
Competence with electrophysical agents is a core requirement of beginning physiotherapy practitioners. Consistent with this, subjects on electrophysical agents have been included in entry- level physiotherapy curricula since the inception of the profession.6,7 Electrophysical agents consist of three main energy forms (thermal, sound, and electric and electromagnetic energy) that can be applied for therapeutic (and sometimes diagnostic) purposes and biofeedback.8-10 Table 1 summarizes the variety of electrophysical agents currently used by physiotherapists in Australia and New Zealand.
Over the past decade, evidence-based health care has become a global philosophy underpinning the decisionmaking process in the clinical management of health care consumers. Evidence-based practice (EBP) has been defined as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.”11 EBP is the integration of individual clinical expertise with the best available external evidence from systematically conducted research.11 While debate continues as to what is acceptable as best available evidence, professional health care programs must provide beginning practitioners with the skills and knowledge to practice safely and effectively within the current health care climate. In addition, health care curricula must also integrate other factors such as the cost of the treatment, the availability of a range of treatments, and the patients’ preferences.
To assist with the preparation of beginning health care practitioners, subjects (courses, units, or modules) on EBP, critical appraisal, statistics, and research methods have become incorporated as standard into health professional entry-level programs.12-14 These subjects commonly emphasize the development of skills associated with information literacy, evidence retrieval, and critical evaluation of the literature.13,15-17 The few studies that have reported how EBP is integrated into entry-level curricula have described the use of assignments or case studies that require students to access current best practice or explore the evidence supporting specific clinical practices.2,18-20 No studies have documented how well current curricula reflect best practice, the evidence base underpinning the content covered within subjects, or how lecturers integrate EBP into the teaching of core professional subjects in allied health disciplines.
This report presents the results of a qualitative exploration concerning how lecturers employed within a core area of physiotherapy education (electrophysical agents) made decisions concerning curricula content choices, factors impacting on these decisions, and how EBP was integrated into the teaching of entry- level physiotherapy programs in Australia and New Zealand.
Methods
Ethics approval was granted by the University of South Australia Human Research Ethics Committee. All universities that were running or were due to start entry-level physiotherapy programs in 2004 in Australia and New Zealand were included in the study. Universities that indicated that they were in the process of developing a physiotherapy program but did not have an intake of students proposed for 2004 were excluded.
Eighteen physiotherapy programs in 13 universities in Australia and New Zealand were identified at the beginning of 2004 via access to university Web sites. Five universities ran two entry-level degrees: a four-year bachelor’s degree and a two-year master’s degree, resulting in a total of 10 separate curricula on electrophysical agents. The other eight universities conducted only one entry-level physiotherapy program and hence one curriculum on electrophysical agents each. The discipline leader, either head of school or program director, for each physiotherapy program was identified and then mailed an information sheet outlining the aims and objectives of the study, a consent form, and a stamped addressed envelope. The discipline leader was formally invited to accept the invitation for his or her program to participate in this study, approve the process, and identify the lecturer(s) responsible for developing and coordinating the teaching of electrophysical agents in their entry-level program.
Once the lecturer responsible was identified, a letter that included information about the study and a consent form were sent directly to him or her. A stamped addressed envelope was enclosed so that lecturers could mail the consent form back to the chief investigator. If the consent form was not returned by the specified date, a follow-up letter and e-mail were sent. Once the consent form was received, a mutually convenient time was determined by e-mail communication for a telephone interview.
A semistructured telephone interview was selected as the data collection instrument to address the wide geographical distances with lecturers from all Australian and New Zealand physiotherapy programs.
The data collection instrument was developed following an extensive literature review, two independently moderated focus groups, and a pilot test.21 This established both the content and the face validity of the data collection instrument. Figure 1 provides a summary of the design process. The semistructured interview included both open- and closed-ended questions. The closed- ended questions collected information on curricular content and process. The results from this part of the interview and a copy of the data collection instrument have been reported previously.21 Open- ended questions were used to ascertain how lecturers incorporated evidence related to practice into their teaching, how decisions about curricular content were made, and the factors that impacted on these decisions. Groups of open-ended questions were used to elicit information about three key areas: how EBP was integrated into the teaching of electrophysical agents in their programs, who made the decisions about curricular content regardingelectrophysical agents, and what factors were perceived to impact on the choice of content.
During design of the data collection instrument, an interview schedule was developed to ensure that the interviewer followed a consistent sequenced format. The semistructured interview included a standard introduction and summary. With respect to open-ended questions, several extra “probing” questions were included. These extra questions were similar to the opening question but worded slightly differently to facilitate cross-checking, prompting, and clarification as needed.22
A copy of the interview format was sent to each lecturer before the interview to allow time to collect any relevant data or material and to become familiar with the questions. The chief investigator (L.S.C.) performed all interviews using the interview schedule to complete the data collection instrument. All telephone interviews were conducted using the speakerphone feature on a standard telephone, allowing the investigator to tape the interview with a standard microcassette recorder (RN-502, Panasonic, Osaka, Japan). The interview was recorded and transcribed within two days of the interview date by the chief investigator. The written transcripts were then cross-checked against each audiotape for accuracy of transcription. The transcribed data from the semistructured interview were then returned via e-mail to all lecturers to confirm the accuracy of the data. Lecturers were asked to check the transcription for accuracy, add any details that they had been unable to provide, and e-mail the transcript back with changes. All but two lecturers (three programs) responded to this e-mail, providing further detail and confirming the accuracy of the interview data. Data collection occurred over a two-month period during 2005.
DATA ANALYSIS
Results from the open-ended survey items were analyzed using an iterative approach involving a preliminary and then thematic analysis.23 An inductive approach was used to identify the broad conceptual frameworks and key themes. The aim of this analysis was to identify any trends and patterns within the discussion.
To assist coding, the validated transcribed data were copied onto single-sided A4 paper, with generous margins, page numbers, double spacing, and the main questions highlighted in bold to demarcate possible headings. The thematic analysis started with a reading and rereading of all the transcripts. The sources and selection of categories, themes, and subthemes were influenced by literature reviews, local commonsense constructs, the richness of the data, and the lead researcher’s values and experiences. Codes were derived from each unit of analysis having a word, phrase, or concept requiring attention.24 These categories, themes, and subthemes were added and refined as the researcher became more familiar with the data and were noted in the margin of the transcripts. Highlighters were used to color code themes for ease of identification. Most of the three open-ended survey questions resulted in 0.5- to 1.5-typed pages of double-spaced notes. This relative brevity of response facilitated this form of analysis.
Results
The discipline leaders from each of the 13 universities with an entry-level physiotherapy program consented to involvement in the study and nominated the lecturer responsible for the curriculum on electrophysical agents to be approached to participate in the interview. Of the 13 universities, five offered both bachelor’s (four-year) and master’s (two-year) entry-level programs. In these cases, the same lecturer was responsible for the curriculum on electrophysical agents. Consequently, one lecturer from each of these institutions was interviewed. Thus, a total of 13 lecturers consented to participate in the study.
At the time of data collection, two universities were recruiting a lecturer to teach and oversee their curriculum on electrophysical agents. In these instances, the program director (entry-level program coordinator) was nominated by the discipline leader to participate in the study. One was unable to answer the open-ended questions in the semistructured interview and gave permission for the previous lecturer to be contacted regarding them. The same recruitment and consent procedure was undertaken for this additional subject.
The chief investigator of the present study was one of the 13 lecturers at one of the universities. In this case, an independent person was recruited and trained to conduct that particular telephone interview.
On average, each interview lasted for one hour. The data provided from the open-ended questions ranged from 0.3 to 1.5 pages.
Of the 13 lecturers responsible for curriculum on electrophysical agents, eight were women and five were men. All 13 lecturers held an entry-level physiotherapy degree, and all had postgraduate qualifications. The highest degrees among the lecturers teaching about electrophysical agents in Australia and New Zealand at the time of data collection were three PhDs, five with master’s degrees by research, and five with master’s degrees by coursework.
INTEGRATION OF EBP INTO TEACHING ABOUT ELECTROPHYSICAL AGENTS
Thematic analysis of the transcripts identified four main themes in the responses to the question “How is EBP integrated into teaching electrophysical agents?” These themes were as follows:
1. Resource materials: the type of materials given and presented to students
2. Use of broad definitions of evidence: the types of evidence that lecturers used when presenting information to students
3. Inclusion of specific instructional strategy: how EBP is integrated into teaching about electrophysical agents
4. Context of curriculum: when teaching about electrophysical agents occurred in the overall sequencing of the two- or four-year curriculum.
The first identified theme was resource materials. Lecturers indicated that the research base supporting the use of specific electrophysical agents was included within formal resource materials provided during lectures and practical teaching sessions and informally through verbal discussions associated with teaching sessions. As lecturer 3 commented:
And its (EBP) basically on the direct use of descriptions and discussion within the class about the evidence base. So in the theory lectures there will be discussion in there and again it will be added to in the discussion in the prac(ticd) class.
Other lecturers commented that reading material and recent references were provided to students. As lecturer 7 commented:
We spend a lot of time actually discussing literature in ekctrophysical agents (sic). We work through with the published research for each modality. They have reading lists that relate to each modality in terms of what is the evidence for and against, if you like.
The second theme, use of broad definitions of evidence, represents the wide variety of types of evidence reported as used to support the clinical use of electrophysical agents. Lecturers commented that the types of evidence they use to justify the clinical use of a modality are based on different types of research. The different types of research included randomized control trials and systematic reviews, accepted as the highest levels of evidence within experimental designs hierarchies. They also included evidence obtained from experimental approaches classed as providing a lower level of evidence, such as histologic and physiologic studies, case studies, and qualitative explorations. This approach is summarized in the following response:
Lecturer 5: What we tend to say is ‘evidence supported practice.’ Which means the evidence comes from their pathology lecture notes, their anatomy lecture notes. So they need to know for example with functional electrical stimulation, they need to know what the muscle does, what innervates that muscle and where the nerve runs . . . they can support it from animal studies . . . from clinical trials and evidence . . . from case studies.
Responses to this question indicate that lecturers perceived difficulties with the incorporation of the evidencebased paradigm, particularly the experimental design hierarchical ranking model. A number of lecturers questioned whether a hierarchy of evidence, based on experimental designs, was the appropriate model to determine the evidence base of electrophysical agent modalities in order to educate entry-level physiotherapy students. This issue also identified some concerns with the current lack of highlevel evidence for some electrophysical agents and the methodological quality of existing high-level evidence and the preparation of graduates for a professional working environment where electrophysical agents without highlevel evidence continue to be used. Examples of responses raising these concerns included the following:
Lecturer 3: Whilst we focus on it (evidence) and encourage students to search for it and certainty use it as a guide; one of the problems of electrophysical agents is the dearth of evidence or good evidence in relation to their use. We don’t actually say to students, don’t use something because there is no evidence. Because ultimately that may well be counterproductive. So its looking for… making the most appropriate choices based on the evidence available. And then the other thing that we do with students is to get them to prove or disprove the use of that modality in their current clinical practice. So basically, if you chose ultrasound, in this situation, you need to prove that it’s having an effect. And if it’s not, then you need to think about using a different modality or (a) different way of approaching your problem.
Lecturer 11 : Look 1 think, one tries whenever one is presenting it, to refer to research that provides evidence. And as I say, because there isn’t a great deal, and you can turn around and say why is one still teaching this, that or the other. I think its partly because students are stil\l going to be exposed to it clinically. So one talks about the lack of evidence quite a lot.
The third of the four themes, inclusion of specific instructional strategy, represents responses on how EBP is integrated within the curriculum on electrophysical agents. It also concerns the use of instructional strategies designed to develop skills in accessing and reviewing evidence related to modalities. Four lecturers directly assessed their students’ ability to critically appraise the evidence supporting the use of specific modalities. Examples of assessment included group presentations, set examination questions, and written assignments. However, the focus in these examples was more on understanding the evidence underpinning a particular electrophysical agent, not the ability of students to access or review evidence. Examples of relevant comments included the following:
Lecturer 9: We actively provide an assessment item that shows they have actually looked at providing an argument to support an intervention that they are recommending for a particular case study. And they will be given guidelines to begin that process of critically overviewing the evidence base that they might have access to. The students do this in an assignment sense for one (a modality) of their choosing.
Lecturer 2: In one subject, they need to look at… (developing a topic) but basically it might be on something like laser. They could pick laser even though we haven’t covered it. And discuss the efficacy for laser for wound healing. They will be assessed on the currency and relevance of the research and hopefully how critical they can be given that they are only year 2 students.
The fourth theme identified related to how and when both EBP and electrophysical agents were taught in the context of the overall curriculum. Several lecturers indicated that EBP and critical appraisal of literature were integrated throughout the entire curriculum.
Lecturer 7: One of the big themes that runs through out our entire program is critical appraisal of literature. It is stressed from first semester in first year so in EPA in one of the tutorial sessions, they do a formal tutorial on critical appraisal of electrotherapy literature in which they have articles that they have pre-read.
Other lecturers indicated that teaching about electrophysical agents occurred at a point in the curriculum when students had not completed subjects in statistics or EBP. Because most teaching about electrophysical agents occurred in the early years of the program, several lecturers highlighted the difficulties students had with their limited understanding of the concepts of EBP and knowledge of statistics. This limited their ability to read and review research papers. Thus, there appeared to be limits imposed by curricular sequencing of subjects that affected how EBP was integrated into the teaching of core professional courses.
Lecturer 9: Our biggest evidence-based practice component comes in, unfortunately after the formal teaching of electrophysical agents. But we are trying to begin the process of thinking along the lines of developing a support for treatment based on an assay of relevant literature right from that stage.
Lecturer 2: At the same time they are doing dus (year 2), they are doing a subject on research methods and stat(istics)s so they should be learning how to critically review the literature. But at year two, it’s difficult to say that they are anything more than beginners. The reality is that at the end of it, I can’t believe it, but at the end of it, they come out cheerfully saying nothing works. So I suppose that shows that they know how to be critical. . , . That’s as far as they can go.
DECISION MAKING AND CURRICULAR CONTENT
Textual analysis identified two main responses to the question, “Who makes the decisions as to which electrophysical agents are included or excluded in a curriculum?” The decisions regarding which electrophysical agents are included or excluded in the curriculum, in most instances, appeared to occur at two levels. Many lecturers indicated that the overarching decisions were made in a democratic manner at a teaching and learning committee. As lecturer 8 offered:
We have a teaching and learning committee. As I mentioned at the beginning, we are kind of undergoing a bit of a change at the moment. And that sort of… everyone from each of the courses comes and says, well, I’d like this sort of modality introduced. And so, although I tend to drive it, I get input from everybody else who are (sic) the coordinators of those other courses about what they like in it. It’s a democratic sort of thing.
However, other lecturers indicated that the minutiae and detail of what might be taught or the level to which material was taught depends largely on the actual lecturer. That person is perceived as the content expert in the field and ultimately has the final say on the day-to-day teaching of material. Lecturer 12 commented:
Well me, as the … lecturer has the final say. We have basically decided that across the areas that if each of the staff members was providing the sort of expert background in those areas then they would be responsible for that.
FACTORS AFFECTING CHOICE OF CURRICULAR CONTENT
Using an open-ended question, lecturers were asked what factors they perceived impacted on their choices of content in the curriculum. The range of factors cited included current clinical practice (within Australia and New Zealand), the research or evidence base for electrophysical agents, registration or accreditation requirements, safety, time available within the curriculum, access to equipment, tradition, legislation, and personal clinical practice.
Each lecturer was then asked to rank each factor they had identified in terms of its impact when deciding on the curricular content (1, greatest impact). Table 2 illustrates that most responses related to clinical practice and research/evidence (64- 1%). These were reported as the most or second most important reasons for selecting curricular content in 56.4% of all responses. This was a consistent finding, with 11 of the 13 lecturers ranking these two factors as either the highest or second highest factor. Registration or accreditation requirements were also reported as affecting the decisions. For two respondents, this factor had the greatest impact; for five respondents, it was the third most important factor.
Discussion
Graduates from health professional programs must be work fit, competent, and safe using interventions, such as electrophysical agents, that are commonly accepted and used in clinical practice. When determining curricular content, entry-level programs and their curricula have to be responsive to changes in practice patterns, evidence, and a range of other external and internal factors. The findings of the present study provide valuable insights into how decisions regarding curricula are made and the factors that impact on these decisions. In addition, the study demonstrates how EBP is integrated into the teaching and learning framework. While the results cannot be generalized to other international entry-level professional programs, they provide an interesting and useful picture of how curricular content and professional expectations are currently reconciled by lecturers when preparing core discipline subjects.
The decisions about choice of curricular content were shown to operate at two levels. First, decisions regarding overviews of curricular content were generally made by program teams, yet the actual day-to-day teaching choice was usually the choice of the academic content expert. This suggests that there is a level of autonomy and academic freedom within the teaching of professional subjects but that this is moderated by a democratic team approach to the overall curriculum. In Australia and New Zealand, there is no national examination for students graduating from entry-level physiotherapy programs, and while there are competency standards by which each program is accredited, these do not delineate specific curricular content. This may be one factor that allows this relative autonomy in determining curricular content.
Despite this academic freedom, there are a wide variety of factors that impact on choice of curricula. The key factors that lecturers reported as guiding curricular choices were research or evidence base and current clinical practice. The nexus between clinical practice and evidence base suggests the need for the development of clearer educational guidelines from accreditation and registration authorities to assist lecturers in their choice of curricula such that graduates can be prepared to be safe, effective, and efficacious practitioners. This is particularly necessary because registration and accreditation authorities appear to also exert influence on the choice of academic content. Safety was seen as a relatively low priority by lecturers compared with the previously mentioned factors. This is a surprising result given that electrophysical agents are potentially harmful if applied incorrectly. The results indicate that other factors such as evidence and current clinical practice are more important than safety as a standalone factor.
The results of the second aim of this study indicate that lecturers use a range of knowledge sources in an effort to conform to the principles of evidence-supported practice in their teaching area. These include research using a variety of methodologies, ranging from case reports to randomized controlled trials, which lecturers included in their course materials and reading lists.
The teaching of EBP is accepted as a core requirement of students graduating from entry-level physiotherapy programs, yet educating students in EBP also requires integration with preclinical teaching and clinical education.13,14 The views of the interviewees indicated that educators face a “balancing act” when prepari\ng professional curricula. Lecturers noted the incongruity in developing and teaching curricular material in a program that seeks to use an EBP approach while also having to ensure that they teach core professional subjects that may lack high-level evidence of efficacy yet are still used commonly in contemporary clinical practice. Lecturers reportedly do not shy away from telling students when there is limited or conflicting evidence to support the use of modalities; at the same time, students need to be able to use electrophysical agents safely and independently on graduation.
This study illustrates the dilemmas that lecturers face when preparing a curriculum in an environment where the dominant ideology surrounding EBP is of a hierarchical and quantitative nature. There is little room within this ideology for the use of cellular research and animal-based studies and even less room for practice-based experiential evidence. Despite this, lecturers report using this type of research to substantiate the clinical use of electrophysical interventions in the face of limited availability of randomized controlled trails and systematic reviews. Furthermore, they encourage students to build up their own experiential evidence from clinical practice and to access the wider sources of evidence, both scientific and clinical, than is usually acceptable with a strict interpretation of “best research evidence.”
The findings also highlight how the principles of EBP need to permeate vertically and horizontally throughout the entire curriculum. Lecturers in this study acknowledged the difficulty of teaching core clinical subjects early in a professional course when students may not have had an introduction to the concepts of underpinning knowledge, such as statistics and research methods. This suggests that concepts such as EBP and foundation subjects such as statistics and research methods need to be introduced early in a program and integrated throughout professional courses. However, to do this, program teams must make decisions regarding the EBP paradigm and any limits it might have in a clinical discipline with a rapidly developing research profile but still limited research availability.
The present study has several limitations. While it had a 100% response rate, telephone interviews have the potential for investigator bias, are time limited, and do not allow for visual feedback between the lecturer and the investigator. Face-to-face interviews would have been the ideal, but this was precluded by issues of time and distance. The potential for investigator bias is acknowledged, but processes to reduce the impact of any potential bias were included (development and consistent interview schedule). Similarly, the inclusion of data from the lead researcher, who was responsible for not only the development of the data collection instrument but also completion of the phone interviews and thematic analysis of the response to open-ended questions, is potentially problematic. The lead researcher is an experienced lecturer with primary responsibility for the development and maintenance of the curricula on electrophysical agents within a bachelor’s- and master’s-degree physiotherapy program. The possibility that individual views may have been introduced or skewed the interpretations of data exists, but on review of the openended question responses, the data from the lead researcher reflected similar themes and content to other interviews and were therefore retained. A perhaps more important limitation of this study was the lack of exploration of the underpinning educational philosophy of each program. This may have yielded valuable information regarding the decisions related to content and EBP.
Another possible limitation is the effect that sending questionnaires in advance to each lecturer may have had. This provided time for consultation by the lecturer and may have impacted on the data. Alternatively, this strategy may have resulted in a more thoughtful response from interviewees, increasing the richness of the data, an important consideration in a qualitative study.
In summary, this investigation provides a snapshot of the factors affecting curricular content and how the principles of EBP are amalgamated into the teaching and learning framework of core professional subjects. Lecturers use a variety of research methodologies as a backdrop for the presentation of techniques and interventions that are used commonly in clinical practice despite limitations in the evidence base. This study also highlights the tensions that exist when designing entry-level curricula with the need to prepare competent, safe, and registrable practitioners while working within an EBP paradigm.
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Lucy S. Chipchase, M App Sc
Marie T. Williams, PhD
Val J. Robertson, PhD
Ms. Chipchasc is Program Director and Dr. Williams is Associate Professor, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia; and Dr. Robertson is Professor of Allied Health, CCH Teaching & Research Unit, University of Newcastle, Gosford Hospital, Gosford, New South Wales, Australia.
Received August 29, 2005; revision accepted April 19, 2006.
Address correspondence and reprint requests to: Lucy S. Chipchase, M App Sc, School of Health Sciences, University of South Australia, Adelaide, SA 5000, Australia. Tel (61) 8-8302-2553; fax (61) 8-8302-2766; e-mail [email protected]
Copyright Association of Schools of Allied Health Professions Spring 2007
(c) 2007 Journal of Allied Health. Provided by ProQuest Information and Learning. All rights Reserved.
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