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Knowledge Level of Health Care Providers about Complicated Grief
during the COVID-19 Pandemic
Sareh Dashti1, Tahereh Fathi Najafi1, Fatemeh Mohammadzadeh2, Afsaneh Rezaei Kalat3, Narjes
Bahri4*
Abstract
Objective: The coronavirus 2019 (COVID -19) pandemic had great psychological impact on COVID-19 patients and their
families. Relatives of the deceased COVID-19 patients are at risk for complicated grief. Healthcare providers (HCPs)
should be able to identify complicated grief cases. The aim of this study was to assess HCP knowledge regarding
complicated grief during the COVID-19 pandemic.
Method: This cross-sectional study was conducted using an online researcher-made questionnaire. The questionnaire
was designed and validated before being used in this study. The questionnaire included demographic questions as well
as knowledge about complicated grief and its symptoms, risk factors and management. The link to the questionnaire
website was sent to HCP governmental and private sectors. Data was analyzed using the ordinal regression model by
the SPSS 16 software.
Results: A total of 887 HCPs (69% female and 31% male) participated in this study. Majority of the participants (594,
70%) had fair overall knowledge about complicated grief while 206 (23.2%) participants had poor knowledge. Poor
knowledge level about risk factors for complicated grief was observed in 44.3% of the participants. Fair or poor
knowledge about prevention and management of complicate grief was observed in 39.2% of participants. Knowledge
about complicated grief had a significant positive relationship with female gender (OR: 1.55; 95% CI: 1.15-2.08) and
higher education level (OR: 1.86; 95% CI: 1.37-2.54).
Conclusion: Knowledge of HCPs about complicated grief was low. There is need for HCP knowledge improvement
regarding complicated grief by appropriate education.
Key words: Adjustment Disorder; COVID-19;
Grief; Health Personnel; Knowledge
Iran J Psychiatry 2022; 17: 2: 154-161
Original Article
1. Department of Midwifery, Faculty of Nursing and Midwifery, Mashhad Medical Sciences, Islamic Azad University, Mashhad,
Iran.
2. Department of Epidemiology & Biostatistics, School of Health, Social Development & Health Promotion Research Center,
Gonabad University of Medical Sciences, Gonabad, Iran.
3. Psychiatry and Behavioral Sciences Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
4. Department of Midwifery, Faculty of Medicine, Social Determinants of Health Research Center, Gonabad University of Medical
Sciences, Gonabad, Iran.
*Corresponding Author:
Address: Khorasan Razavi, Gonabad, Imam Khomeini Avenue, Gonabad University of Medical Sciences, Gonabad, Iran, Postal
Code: 969179371.
Tel: 98-51 57223513, Fax: 98-51 57223814, Email: nargesbahri@yahoo.com
Article Information:
Received Date: 2020/09/26, Revised Date: 2021/07/11, Accepted Date: 2021/10/05
COVID-19 and Complicated Grief
Iranian J Psychiatry 17: 2, April 2022 ijps.tums.ac.ir
155
COVID-19 is a severe acute respiratory syndrome
caused by the coronavirus family. The disease, which
began in late December 2019 in Wuhan, China, spread
rapidly and soon became a global pandemic (1). The
disease symptoms include fever, dry cough, sore throat,
shortness of breath, diarrhea, fatigue, and myalgia,
which can lead to severe respiratory distress and death
(2).
In addition to the great financial and physical burden
COVID-19 has inflicted on the people and governments
globally, the new Coronavirus also has had
psychological impacts on people (3). The rapid rise in
the number of deaths, followed by lack of diagnostic and
treatment facilities, shortage in personal protective
equipment, and lack of definitive treatment or vaccines
have restricted disease prevention to advice on social
distancing and personal hygiene, including hand
washing (3).
Psychological disorders currently observed in
communities due to this pandemic include fear of
contamination and anxiety and paranoia about attending
mass ceremonies. Furthermore, students, employees and
travelers who have been deprived of their life, study,
work and living facilities due to COVID-19 suffer from
mental disorders. The mental disorders are caused by
stress, reduced autonomy due to job, financial and
security concerns (4-6). COVID-19 pandemic is
predicted to have long-term psychological consequences
including fear and panic in society, which are predicted
to be far more damaging to societies than the disease
itself (7). One of the major challenges associated with
COVID-19 is the relatively high incidence of morbidity
and mortality. The current crisis and the growing
number of patients who unfortunately die during the
epidemic have sounded the alarm about the need for
intervention in families with deceased members due to
COVID-19.
Grief is an inevitable experience in every person's life (8,
9). However, people's ability to accept grief extends in a
wide spectrum from acceptance to serious consequences.
In many cases, the grief process goes through naturally
life events (9, 10). Loss of a loved one is a painful
experience that has mental, psychological, and social
consequences for family members. Duration of these
symptoms and how they are expressed vary widely
within and between different cultural groups. Eventually,
these symptoms improve within 2 to 4 months or a
maximum of 6 months, and the person gradually returns
to normal life. Grief may include a wide range of
emotional experiences including the perception that life
would be difficult in future, but, in most cases, relief and
reduction of symptoms will occur gradually (11).
Meanwhile, social support from friends and relatives and
participation of family members in mourning ceremonies
help to alleviate suffering in mourners and helps them
better adapt to the natural grief process (12).
On the other side of the spectrum of the grief
phenomenon is abnormal or complicated grief. In some
cases, grief symptoms persist and symptoms, including
depression and severe helplessness, can deviate
individuals from normal life (13). In general, abnormal
or complicated grief is more likely to occur when a
person does not go through the normal grief process.
Other risk factors include lack of social support,
elongated grief duration, person’s inability to return to
routine function or serious interference with the course
of life in oneself or relatives (13). In other words,
complicated grief occurs when the mourning is
incomplete and the person has not attended or prevented
from attending the funeral, when the phenomenon of
loss is not accepted or denied, unexpected death of
relative, or loss of several people at the same time (14-
16).
The reported prevalence of complicated grief ranges
from 24 to 44 percent (17), but it seems that the
prevalence of complicated grief has increased
significantly in the current context following the
COVID-19 pandemic crisis. In fact, one of the most
important issues in dealing with grieving families at an
epidemic is holding funerals safely and at the same time
respecting the human rights of the deceased and their
families. Death of a patient in quarantine and burial by
people other than the family effectively deprives the
patient's family of contact with the missing person,
seeing and touching and saying goodbye to him/her in
the moments after death. In fact, relatives do not have
the opportunity to mourn and express their emotions at
time of burial. Another important point is that not only
the patients who died from the disease, but also their
families are exposed to stigma. COVID-19 stigma
results in rejection of the family by society and reduced
desire of friends and relatives to participate in the
deceased house, both due to fear of spreading the disease
and stigma. These consequences can lead to intensified
isolation, loneliness, and experience of loss without
adequate emotional support and empathy from others.
Lack of social support from friends and relatives result
in unexpressed emotions during the grief period. The
risk factors for complicated grief have been evaluated
before but there is inconsistency in terms of risk factors
between the studies. In a study conducted in Taiwan, the
risk factors for complicated grief in care givers of
terminally ill patients were spousal or parent-child
relationship between the care giver and the patient, lack
of religious beliefs, lack of family support, and history
of other comorbidities in the patient (18). On the other
hand, the mentioned study showed that longer duration
of disease, medical history of disease in the patient and
admission to the hospice ward were the preventive
factors against complicated grief (18). In another study
conducted on the general population in Japan, risk
factors for complicated grief were close relationship
with the deceased, short duration of disease or
unexpected loss, admission to hospice, and
Dashti, Fathi Najafi, Mohammadzadeh, et al.
Iranian J Psychiatry 17: 2, April 2022 ijps.tums.ac.ir
156
accompanying the deceased in the last week of life (19).
On the other hand, there is not enough evidence
regarding risk factors for complicated grief and results of
the currently available articles are controversial. To the
best of our knowledge, prevalence and risk factors for
complicated grief have not been reported in HCPs who
care for severe COVID-19 patients.
Timely and appropriate psychological interventions are
very important in these cases. The first step in
performing these interventions is to accurately diagnose
complicated grief. Health care providers (HCPs) in
private and public health sectors can play an important
role in identification, intervention, and referral of
complicated grief cases, as they have close contact with
patient families. Therefore, it is necessary for HCPs to
have sufficient knowledge about recognizing this
disorder.
Considering the short duration of COVID-19 and lack of
facilities that fulfill the needs of patients especially in
disease peaks, it was hypothesized that risk of
complicated grief may increase with increase in death
due to COVID-19. Furthermore, it is hypothesized that
demographic variables including gender, education level
and work experience might play a role in susceptibility
of HCPs to complicated grief. Therefore, the primary
objective of this study was to investigate HCPs’
knowledge level about complicated grief in families of
deceased patients due to COVID-19. The second
objective of this study was to identify demographic risk
factors for complicated grief among HCPs. These risk
factors provide the opportunity to rapidly identify
complicated grief risk in HCPs working in a health care
facility and to predict the required interventions and
support to prevent and manage complicated grief among
HCPs.
Materials and Methods
Study design, procedure, and sampling
This online cross-sectional study was conducted from
May 1/ 2020 to June 1/ 2020, coinciding with the first
wave of COVID-19 in Iran, among Iranian HCPs
employed by both the public and private sectors. The
participants entered the study based on the convenience
sampling strategy. The online questionnaire was
designed using Google forms. The first page of the form
provided detailed information on the design and the aim
of our research. The next page was the consent form for
participation in the study and the questionnaire was
presented in subsequent pages. To prevent respondents
from leaving questions blank, completion before
submission, and to avoid missing data, the "Required"
box was checked for all questions. Link to the
questionnaire website was sent to all national HCPs in
governmental and private sectors through social media
(Telegram, WhatsApp, and Instagram) and SMS.
The inclusion criterion in this study was working as an
HCP team member, including healthcare staff,
midwives, health educators, physicians, or dentists in
public or private sectors. In order to determine
knowledge status of HCPs about complicated grief in
families of the deceased patients due to COVID-19, the
minimum sample size was determined to be 869 subjects
based on the formula ((Z_(1-α/2)+Z_(1-β))/E )^2 with a
confidence interval of 95%, a test power of 0.8, a small
effect size E = 0.1 according to Cohen's guidelines (20),
and a drop-out rate of 10%.
Measures
Questions were divided into three parts. The first part
included demographic information, including gender,
age, marital status, occupation, and level of education.
The second part included questions about information on
COVID-19 before its spread in Iran, source of
information about COVID-19, history of COVID-19
infection in family and close friends, history of
providing care to COVID-19 patients, COVID-19
mortality in patients or clients, self-assessment of
knowledge status to manage complicated grief in people
who have lost relatives due to COVID-19, and having
access to grief management protocols. The third part was
a researcher-made questionnaire about HCPs’
knowledge status about complicated grief during the
COVID-19 outbreak. For this purpose, a meticulous
literature review was conducted to discover available
resources on knowledge about complicated grief. In the
second stage, 39 items were designed in three domains.
The first domain was about the signs and symptoms of
completed grief. The second domain was about risk
factors and the third domain was about management and
preventative behaviors. The questionnaire items were
scored based on a 3-point Likert scale (correct, incorrect
and I do not now). Incorrect answers or "I do not know"
response were assigned a score of 0, and the correct
answer was given a score of one. The total score was
calculated by summing up all the scores on questions.
The higher the total score, the higher the knowledge
level.
Validity and reliability
The content validity of the questionnaire was assessed
by a panel of 19 experts including 12 psychiatrists, 6
psychologists, and one consultant. Two indices including
content validity ratio (CVR), and content validity index
(CVI) were used to evaluate content validity. Thirty-five
items, including 23 items in domain 1, 6 items in domain
2, and 6 items in domain 3 had a CVR higher than 0.44
(ranging from 0.44 to 0.88) based on the Lawshe’s
critical value for CVR. The CVI for accepted items was
also higher than 0.79 (ranging from 0.79 to 1.00) (21).
The reliability of the questionnaire was also assessed
using the Kuder-Richardson coefficient of reliability
(KR-20) in a study on 30 individuals. The KR-20
coefficient of variation was 0.94, which indicated a good
reliability (22).
Ethical considerations
The Ethics Committee of the Gonabad University of
Medical Sciences approved the study design (Code: IR.
GMU.REC.1399.23). Participants who were willing to
COVID-19 and Complicated Grief
Iranian J Psychiatry 17: 2, April 2022 ijps.tums.ac.ir
157
participate in the study filled the online questionnaire
anonymously.
Statistical analysis
The obtained data were analyzed by the statistical
package for social sciences (SPSS) software version 16.
Descriptive statistics for quantitative variables were
presented using mean and standard deviation.
Frequency, percentage, and confidence interval (CI)
were used for qualitative variables. To assess the
relationship between knowledge score (dependent) and
gender, work experience, and educational level
(independent variables), the ordinal regression models
were used. For this purpose, the variables that had P <
0.2 in simple ordinal regression were entered into the
multiple ordinal regression model and their relationships
were assessed in presence of other variables (potential
confounding variables). The results were presented using
raw and adjusted odds ratio (OR). Level of statistical
significance was considered as P < 0.05.
Results
Demographic characteristics
Data of 887 HCPs were collected and analyzed. The
mean age of the participants was 36.5 ± 7.9 (range: 20-
75) years old. The mean work experience was 10.6 ± 7.7
years. Other characteristics of the participants were
shown in Table 1.
Knowledge of HCPs about complicated grief due to
COVID-19 disease
The mean total score for knowledge about complicated
grief was 20.5 ± 5.4. The findings showed that
knowledge level was generally poor to fair among 206
(23.2%; 95% CI: 20.4%-26.1%) and 594 (70.0%; 95%
CI: 63.7%-70.1%) of the participants, respectively. Only
87 (9.8%; 95% CI: 7.9%-11.9%) of the participants had
good knowledge about complicated grief (Table 2).
Results demonstrated that the level of general
information about symptoms of complicated grief was
poor in 44.3% (95% CI: 41.0%-47.6%) and fair in
51.0% (95% CI: 47.6%-54.3%) of the participants. The
mean score of knowledge about risk factors for
complicated grief during COVID-19 outbreak was 4.3 ±
1.4. Good knowledge about the risk factors for
complicated grief during COVID-19 outbreak was
observed in 451 (50.8%; 95% CI: 47.5%-54.1%)
respondents. The mean knowledge score regarding
management and preventive behaviors towards
complicated grief during COVID-19 outbreak was 4.4 ±
1.3. Level of knowledge about management and
preventive behaviors towards complicated grief during
COVID-19 outbreak was poor or fair in 348 (39.2%;
95% CI: 36.0%-42.5%) participants.
Relationships between level of knowledge about
complicated grief during COVID-19 outbreak and
gender, educational level, and work experience
Simple ordinal regression results revealed that gender
(OR raw: 1.55; 95% CI: 1.15-2.08) and education level
(OR raw: 1.86; 95% CI: 1.37-2.54) were significantly
related to knowledge about complicated grief. No
significant difference was observed between knowledge
about complicated grief and work experience (OR raw:
1.00; 95% CI: 0.98-1.02). Based on the multivariable
ordinal regression results, women had higher levels of
knowledge than men (OR adjusted: 1.53; 95% CI: 1.14-
2.06). Furthermore, participants with Master’s degree or
above had higher level of knowledge compared to
participants with Bachelor’s degree or below (OR
adjusted: 1.85; 95% CI: 1.35-2.52) (Table 3).
Table 1. Demographic Characteristics, COVID-19 History, and Knowledge of the Study Participants
Characteristics
N (%)
Gender
Female
612 (69.0)
Male
275 (31.0)
Marital status
Married
582 (65.6)
Single/widowed/divorced
305 (34.4)
Educational level
Bachelor's degree or below
617 (69.6)
Master's degree or above
270 (30.4)
Job
Physician/Nurse/Dentist
383 (43.2)
Allied health professionals
504 (56.8)
Previous information about COVID 19 before its spread in Iran
Yes
357 (40.2)
No
530 (59.8)
Source of information about COVID-19
Dashti, Fathi Najafi, Mohammadzadeh, et al.
Iranian J Psychiatry 17: 2, April 2022 ijps.tums.ac.ir
158
Scientific journals
156 (17.6)
Ministry guidelines
382 (43.1)
Social media
197 (22.2)
Family and friends
5 (0.5)
Television
146 (16.5)
Newspapers
1 (0.1)
COVID 19 infection in family and close friends
Yes
380 (42.8)
No
507 (57.2)
COVID 19 patient care history
Yes
493 (55.6)
No
394 (44.4)
COVID 19 mortality in patients or clients
Yes
601 (67.8)
No
286 (32.2)
Amount of information to manage complicated grief in people who have lost relatives due to COVID-19
Very high
8 (0.9)
High
126 (14.2)
Low
472 (53.2)
Very low
281 (31.7)
Access to grief management protocols
Yes
119 (13.4)
No
768 (86.6)
Table 2. Mean Scores for Complicated Grief Knowledge among Study Participants
Knowledge Level
N (%)
General information about symptoms of complicated grief (differentiating it from natural grief and depression).
Poor
393 (44.3)
Fair
452 (51.0)
Good
42 (4.7)
Score (Mean ± SD)
12.6 ± 3.7
Risk factors for complicated grief during COVID-19 outbreak
Poor
102 (11.5)
Fair
334 (37.7)
Good
451 (50.8)
Score (Mean ± SD)
4.3 ± 1.4
Management and Preventative behaviors towards complicated grief during COVID-19 outbreak
Poor
77 (8.7)
Fair
271 (30.6)
Good
539 (60.8)
Score (Mean ± SD)
4.4 ± 1.3
Total knowledge towards complicated grief
Poor
206 (23.2)
Fair
594 (67.0)
Good
87 (9.8)
Score (Mean ± SD)
20.5 ± 5.4
COVID-19 and Complicated Grief
Iranian J Psychiatry 17: 2, April 2022 ijps.tums.ac.ir
159
Table 3. Relationships between Gender, Education Level, and Work Experience with Knowledge Level
about Complicated Grief during the COVID-19 Outbreak
Predictors
Ordinal Logistic Regression Analysis
Simple
Multiple
OR Raw (95% CI)
P-value
OR Adjusted (95% CI)
P-value
Gender
Female
1.55 (1.15-2.08)
0.004
1.53 (1.14-2.06)
0.005
Male
1
Educational level
Master's degree or above
1.86 (1.37-2.54)
< 0.001
1.85 (1.35-2.52)
< 0.001
Bachelor's degree or below
1
1
Work experience
1.00(0.98-1.02)
0.707
Note: OR, Odds ratio; CI, Confidence Interval.
Discussion
The present study demonstrated that more than half of
the studied HCPs had poor knowledge about
complicated grief during COVID-19 pandemic and only
9.8% of the patients had good knowledge. According to
the results of the present study, gender and education
level were significantly related to knowledge about
management of complicated grief.
COVID-19 had various effects on different populations.
During the recent outbreak, many individuals
experienced various degrees of physical or mental health
problems due to being quarantined for a long time (23).
Moreover, many people experienced different levels of
emotional strain and many people lost their family
members or close friends. Grief after losing a family
member or close friend is one of the most intense
psychological distresses during life (24). Acute grief is
an intense emotion and individuals experiencing acute
grief deal with thoughts and memories of the deceased
patients (24). Most of the individuals adapt themselves
with the grief but some may experience chronic and
complicated grief. Many situations may provoke
development of complicated grief. Traumatic events and
disease outbreaks are considered as conditions that
negatively affect grief. Many factors may affect
complicated grief during pandemics. Mental, physical
and social aspects of isolation and long term social
distancing are among the important factors that have a
negative effect on complicated grief during the COVID-
19 pandemic (23). Important risk factors for complicated
grief include low social support and sudden death (25).
Both of these risk factors are common during disease
outbreaks. The physical condition of COVID-19 patients
may rapidly shift from a healthy individual to an ill and
end stage patient (23). Moreover, because of social
distancing, many individuals may experience lack of
social support and dissociation from family or even
community (25). During the COVID-19 outbreak,
prevalence of many psychological disorders increased
alongside the complicated grief. HCPs face individuals
with the mentioned psychological complications daily
(26).
Despite lack of unique terminology and diagnostic
criteria for complicated grief, there is agreement on
importance of managing complicated grief (27). A recent
systematic review about knowledge and attitudes of
mental health professionals toward complicated grief
demonstrated an urgent need for translating research
findings into clinical practice (27). There is no doubt that
individuals who deal with complicated grief are more
susceptible to developing negative health sequelae (24).
These individuals require professional support as
untreated complicated grief correlates with prolonged
debility and susceptibility to other psychological
disorders, including depression and even suicidal
behaviors (24).
The present study demonstrated that healthcare providers
have fair knowledge about complicated grief. Most
HCPs including physicians, nurses as well as healthcare
workers are not involved in assessment of families
coping with traumatic grief and most of them refer these
families to pastoral care. Ladoris et al. demonstrated that
many physicians seek medical education on traumatic
grief as they are not familiar with this psychological
problem (28). A qualitative study on 30 HCPs showed
that due to low level of knowledge about complicated
grief, HCPs were concerned about misdiagnosing natural
grief for complicated grief and performing false referrals
(29). The present study also found that female HCPs
were more likely to have higher knowledge about
complicated grief. To the best of our knowledge, no
study has yet assessed gender differences in knowledge
about complicated grief in HCPs. It was previously
shown that no gender differences were observed in
knowledge and attitude toward providing care to
mentally ill patients among nurses in South Africa (30).
The reason for this difference might be due to the higher
number of female HCPs as well as inclusion of
participants from a variety of health care professions in
the current study. Moreover, the findings of the current
study revealed that HCPs with higher education level
Dashti, Fathi Najafi, Mohammadzadeh, et al.
Iranian J Psychiatry 17: 2, April 2022 ijps.tums.ac.ir
160
were more likely to have higher level of knowledge
regarding complicated grief. To the best of our
knowledge, no study has yet assessed the difference in
knowledge status regarding complicated grief between
HCPs with different levels of education. It was
previously shown that professional level health workers
had higher knowledge about medical conditions and
patient illness (31).
It is noteworthy to mention that not all individuals
experience complicated grief during the COVID-19
outbreak and healthcare providers should differentiate
complicated grief from other psychological disorders
and provide appropriate management to prevent further
psychological problems (23). The first important issue
regarding management of complicated grief is
considering the possible differential diagnoses, including
major depressive disorder (MDD) and post-traumatic
stress disorder (PTSD). It should be noted that although
MDD, PTSD and complicated grief may share similar
manifestation, concomitant presence of these
psychological disorders should always be considered
(24). Symptoms including sorrow and yearning for the
deceased individual and difficulty in accepting the
reality of death are not usually present during MDD and
PTSD (24). Individuals with previous history of
depression, anxiety and mood disorders, as well as drug
and alcohol addiction are more likely to develop
complicated grief (24).
Various questionnaires have been developed for
screening and diagnosis of complicated grief (24). By
using these questionnaires, HCPs can diagnose
complicated grief and facilitate screening of patients
during COVID-19. In the present study, we developed a
questionnaire to evaluate knowledge level of HCPs
about complicated grief.
As far as we know, this was the first study to evaluate
knowledge of Iranian HCPs about complicated grief in
families of deceased patients due to COVID-19. A
further strength of this research was the large sample
size. There were also some limitations to this study.
First, the design of this study was cross-sectional;
therefore, it was not possible to assess causal
relationships. Second, to avoid the possibility of
COVID-19 infection transmission, we conducted an
online survey using non-random sampling, which can
lead to selection bias and poor generalizability. Third,
self-reported questionnaires may be a further source of
bias in this study.
Limitation
One of the limitations of this study was related to the
study design. As the data was gathered through
questionnaires, there is a possibility of bias due to the
self-report nature of this study design. As the study was
conducted in the time when healthcare workers had long
shifts and work overload due to the primary waves of
COVID-19, interview was not applicable for data
collection. Therefore, it is recommended that further
studies evaluate the knowledge of the healthcare
providers through questionnaire and interviews. Another
limitation of this study was related to its online design,
which might have neglected the healthcare workers who
did not have access to internet. However, considering the
high internet penetration rate in Iran, it can be
hypothesized that the study sample could still be a
representative of the healthcare worker population in
Iran.
Conclusion
According to the results of the current study, level of
knowledge in HCPs about complicated grief was low. We
suggest that healthcare authorities provide educational
courses, workshops, guidelines, and pamphlets to HCPs. We
also suggest that HCPs be familiarized with using
complicated grief diagnostic questionnaires during disease
outbreaks in order to provide better management services to
individuals with complicated grief.
Acknowledgment
We hereby wish to express our gratitude to the Research
Council of the Gonabad University of Medical Sciences
for funding this project (Grant no.: A-10-1269-9).
Conflict of Interest
None.
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