PEDIATRICS Vol. 120 No. 5 November 2007, pp. 1036-1043 (doi:10.1542/peds.2007-0842)
ARTICLE |
Pediatricians’ Perspectives Regarding Community Child Health: Training, Involvement, and Expectations According to Age
a Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
b Division of Health Services Research, American Academy of Pediatrics, Elk Grove Village, Illinois
c Department of General Pediatrics, Children's Hospital Boston, Boston, Massachusetts
d Rand Corporation, Arlington, Virginia
e Boys Town National Research Hospital, Omaha, Nebraska
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ABSTRACT |
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OBJECTIVE. There are increasing opportunities for pediatricians to promote children's health through community involvement during and after residency training. Little is known about whether younger relative to established pediatricians have different experiences regarding community activities. In this study we examined whether pediatricians’ training, perspectives, and involvement in community activities vary by age.
METHODS. Eight hundred seventy-six pediatricians participated in a national, random-sample, mailed periodic survey of US members of the American Academy of Pediatrics in 2004 (response rate: 58%). 
2 statistics and median tests were used to measure associations of age (
34, 35–39, 40–50, and 
51 years) with training, perspectives, and involvement.
RESULTS. Younger pediatricians reported more training in community child health during and before residency but were less likely to be involved currently (37.9% for 34 years, 44.4% for 35–39 years, 46.2% for 40–50 years, 48.3% for 51 years). They were more likely to report that their current involvement was too little versus just right or too much (81.3%, 73.5%, 60.7%, and 47.1%, respectively). Younger pediatricians were more willing to spend 1 hour/month on community child health activities (95.0%, 91.2%, 89.7%, and 85.4%, respectively). Younger versus older pediatricians were more likely to sense moderate or greater responsibility for improving children's health in their community (83.6%, 77.2%, 76.7%, and 70.2%, respectively) and expected their community work to increase during the next 5 years (80.0%, 67.5%, 59.7%, and 40.1%, respectively). Age findings persisted when adjusted for gender.
CONCLUSIONS. Although practice constraints may limit community involvement, younger pediatricians anticipated growing participation in community activities. Longitudinal studies are needed to determine whether such expectations are realized.
Key Words: community pediatrics • workforce • age
Abbreviations: AAP—American Academy of Pediatrics • PS—periodic survey
Many pediatric residency programs now provide didactic and experiential training in community pediatrics. Solomon et al1 reported that in 2002, 28% of programs provided training in 0 to 3 community settings, 41% in 4 to 6 settings, and 31% in 7 activities. In addition, many provided didactic education on various community health topics and exposed residents to communicating with elected officials, participating on longitudinal projects, conducting research in the community, and, to a lesser degree, providing legislative testimony.
Although the pediatric Residency Review Committee mandated training in child advocacy in 1991, core competencies in community pediatrics have not been adopted universally. Wright et al2 used a modified Delphi process to develop a set of objectives for a resident advocacy curriculum. Rezet et al3 identified community pediatrics competencies and learning objectives, cross-referenced to the Accreditation Council for Graduate Medical Education competencies, that residents are expected to achieve. Despite lack of consensus on curricular content, most residency programs offer related community pediatrics training1; however, it is unclear whether pediatricians who were trained more recently have more skills or more favorable perspectives than more established pediatricians.
The objective of this study was to examine whether pediatricians’ training, perspectives, and involvement in community activities vary by age. We hypothesized that younger physicians relative to older physicians would report more training during residency, less current involvement, and comparable senses of responsibility for improving child health in their communities. These assumptions are based on the growing emphasis of community pediatrics in residency training, conflicting demands of family responsibilities and of establishing practices and/or completing training in the early years after completing residency, and a shared sense of responsibility for children's health, regardless of age.
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METHODS |
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Periodic Survey
The American Academy of Pediatrics (AAP) conducts periodic surveys (PSs) 3 to 4 times per year on topics of importance to pediatricians. Each survey uses a unique random sample of members of the AAP. The 2004 PS (PS 60) included questions on involvement in community child health, including a global question asking participants to indicate whether in the past 12 months they "participated in a professional capacity in any activities that promote child health" in their community. The surveys also included a separate question inquiring about involvement in 19 individual activities (and other category) and whether participation was volunteer or paid. All participants further identified their use of 8 strategies to influence children's health in their home and practice communities, including serving on community boards; participating on child health committees; working with a coalition; educating legislators; communicating with media; addressing parent, teacher, or other community groups; working with the local AAP chapter; and voting in state/local elections. All respondents additionally reported on their perspectives regarding community involvement and their use in the past 12 months of 6 skills related to community health activities: locating community resources for individual children, identifying community needs, using population-level data to understand the determinants of children's health, working as a member of an interdisciplinary team to promote children's health in the community, speaking publicly on behalf of children's health, and using computers/Internet to find information about child health policy and related activities. Respondents also described the timing of their participation and training in community activities (eg, before medical school, during medical school, during residency, during fellowship training, since completing training).
Survey content was informed by a national advisory group with expertise in community pediatrics, by review by members of the AAP Community Pediatrics Action Group and the Council on Community Pediatrics, and review of similar PS questions asked in 1989 and 1993. This survey was an 8-page self-administered questionnaire sent to 1829 active members. The original mailing and 5 follow-up mailings to nonrespondents were conducted from April through October 2004. After the first and fifth mailings, an e-mail reminder was sent to nonrespondents with e-mail addresses, and a postcard reminder was sent to those without (68% and 32% of nonrespondents, respectively). We received a total of 1053 completed questionnaires for a response rate of 57.6%.
Data Analysis
Data analysis was conducted to examine the relationship between age and involvement in community child health activities. Analysis included postresidency pediatricians and excluded residents (n = 160) and pediatricians with a Specialty Fellow designation (n = 12) in the AAP membership database as well as 5 respondents who did not provide age information. The final sample included 876 pediatricians (83.2% of respondents).
2 statistics were used to assess differences according to age in demographic and practice characteristics, community child health perspectives, and participation in community child health activities. Median test analyses (Kruskal-Wallis) also were used to compare skill level in community child health activities according to age category. Age analyses were adjusted for the effect of gender. For the purposes of analysis, 4 age categories were constructed: 34, 35 to 39, 40 to 50, and 51 years). The age range for the youngest category (34 years) was identified, as a proxy, to capture the experiences of pediatricians within their first 5 years out of residency. This is consistent with graduating residents’ mean age being 32 years4–6 and 88% of residents in the United States completing residency training at 34 years (K.G.O., unpublished data). In general, 5 to 10 years are required after residency to become established in pediatric practice and to develop relationships in the community.7
For assessing potential response bias in 2004, comparisons between respondents and nonrespondents were conducted for several demographic variables. No significant differences were found between respondents and nonrespondents for mean age (43.7 years) and region of country (24.5% Northeast, 21.5% Midwest, 33.4% South, and 20.7% West). More respondents were female (53.9% vs 46.6%; P < .05).
Analyses were conducted by using SPSS 11.5 (SPSS Inc, Chicago, IL). Human-subjects approval was obtained from the AAP Institutional Review Board and the Committee on Human Research at Johns Hopkins Bloomberg School of Public Health.
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RESULTS |
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Respondent Characteristics
Demographic and practice characteristics of respondents were compared according to age (Table 1). A greater percentage of respondents who were
50 years were female, whereas more male respondents were represented among those who were 51 years. There were no age differences in racial/ethnic distribution. Approximately half of respondents were working in pediatric group or health maintenance organization practices, and more than half were located in urban settings. Older pediatricians were more commonly in solo or 2-physician practices compared with young pediatricians. More than one quarter of all respondents spent less than half of their time in general pediatrics, and pediatricians in the youngest (through 34 years) and oldest (51 years) age categories more frequently indicated this time distribution.
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Participation in Community Child Health
Table 2 highlights involvement in community child health activities by the 4 age categories. Participation in community child health tended to be least frequent in the youngest age group (37.9% for
34 years, 44.4% for 35–39 years, 46.2% for 40–50 years, and 48.3% for 51 years; P = .51). The majority of respondents indicated that their community involvement is only on a volunteer basis, with the youngest begin most likely to volunteer (86.8% for 34 years, 79.7% for 35–39 years, 85.1% for 40–50 years, and 71.1% for 51 years; P < .05).
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There were age differences in the timing of participation in community child health activities during the course of medical training. More young pediatricians compared with older pediatricians indicated involvement in the early part of their career, including before (68.2%, 59.3%, 43.0%, and 26.9%, respectively; P < .01) and during medical school (80.3%, 71.1%, 46.5%, and 36.8%, respectively; P < .01). In addition, a greater percentage of young pediatricians participated in community child health training in residency programs (74.2% for
34 years, 58.5% for 35–39 years, 51.3% for 40–50 years, and 38.3% for 51 years; P < .001); however, pediatricians in the older age groups reported more involvement since completing residency than young pediatricians (36.4% for 34 years, 56.3% for 35–39 years, 78.1% for 40–50 years, and 87.6% for 51 years). Age differences in the timing of training persisted when analyses were adjusted for gender.
Pediatricians chose varying strategies in their community child health promotion activities. Overall, most respondents used voting in state and local elections (69.7%) and addressing community groups (48.7%) as their more common strategies rather than working as a coalition member (8.4%) or serving on a community organization board (17.0%). Pediatricians in the oldest and youngest age groups educated legislators (26.9% for 34 years, 11.5% for 35–39 years, 19.9% for 40–50 years, and 33.3% for 51 years; P < .01) and worked with their local AAP chapters (21.2% for 34 years, 10.7% for 35–39 years, 14.5% for 40–50 years, and 23.1% for 51 years; P < .01). Conversely, more pediatricians between 35 and 50 years of age focused on addressing parent, teacher, or other community groups (46.2% for 34 years, 59.5% for 35–39 years, 52.0% for 40–50 years, and 40.0% for 51 years; P < .01).
The community child health settings where pediatricians were engaged (health, school, government, or nonprofit) did not vary by age, with 1 exception. Older pediatricians were more involved with nonprofit organizations (eg, Children's Defense Fund, March of Dimes) than younger pediatricians (11.3% for 34 years, 11.6% for 35–39 years, 16.3% for 40–50 years, and 20.7% for 51 years; P < .05).
Community Child Health Perspectives
There were key age differences in perspectives toward involvement in community child health activities (Table 3). A greater percentage of young pediatricians reported that their current level of participation is too little, whereas more than half of pediatricians in the oldest age category (51 years) believed that their involvement was "just right." Young pediatricians also expected an increase in their community work in the next 5 years, whereas fewer pediatricians who were older than 40 years anticipated an increase (81.3% for 34 years, 73.5% for 35–39 years, 60.7% for 40–50 years, and 47.1% for 51 years; P < .01). Younger versus older pediatricians were more likely to sense moderate or greater responsibility for improving the health of children in their community (83.6% for 34 years, 77.2% for 35–39 years, 76.7% for 40–50 years, and 70.2% for 51 years; P < .05). Age differences persisted after adjustment for gender.
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Skills and Training in Community Child Health
Tables 4 and 5 describe use of 6 skills in participating in community health activities and reported skill levels according to age. Using the Internet to find information about child health policy was more common among younger pediatricians, whereas working to identify community health needs was cited less commonly. Median test analyses revealed that younger pediatricians reported a higher skill level in using the computers/Internet to find information about child health policy (P < .01), whereas older pediatricians noted more skill in locating resources for children (P < .01), speaking publicly on behalf of child health (P < .05), and identifying community needs (P < .05). Age differences in skills with regard to computers, local resources, and identifying community needs persisted when adjusted for gender.
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Training in community child health also differed according to age. Many (44%) respondents had never received formal training at any point in their medical career, and the most common time for training was during residency (39.1%). Formal training during medical school (43.0% for
34 years, 52.6% for 35–39 years, 32.0% for 40–50 years, and 22.4% for 51 years; P < .01) and residency (63.4% for 34 years, 54.7% for 35–39 years, 29.9% for 40–50 years, and 20.0% for 51 years; P < .01) was more frequently cited among younger pediatricians, whereas older pediatricians indicated receipt of training after residency (5.4% for 34 years, 7.4% for 35–39 years, 25.9% for 40–50 years, and 36.0% for 51 years; P < .01). Again, findings of differences in training according to age were independent of gender. |
DISCUSSION |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Traditionally, work in the community and particularly work that is aimed at policy change at a systems level generally has been done by more established physicians, based on their years of experience in the community and their increasing understanding of the complex interplay of systems, community, and family factors on the lives of children.8 In recent years, there has been a growing interest among young physicians and among the faculty in residency training programs to introduce the knowledge, skills, and attitudes necessary to address community- and systems-level problems earlier in the careers of physicians.5, 9–12 A driving force for the creation of the Dyson Community Pediatrics Initiative was the notion that advocacy in pediatrics at the community level would be far more effective if it were an integral part of a pediatrician's work throughout his or her career than if it were engaged in only at the culmination of the career.13
In these analyses, pediatricians reported more training during medical school and residency, greater expectations for increased future involvement, and less involvement in the past year by the youngest pediatricians. The observed differences in perspectives regarding and engagement in community activities suggest a need to develop age-specific strategies for encouraging increased participation in community child health.7 For example, younger pediatricians may benefit from senior colleagues’ introducing them to community leaders, highlighting local resources, identifying community needs, and providing networking opportunities. More established pediatricians may benefit from training in specific skills to which they have not been previously exposed, such as computer-related activities and the additional human resources of younger pediatricians who also are committed to improving the lives of children.
Although all pediatricians balance work and personal commitments with community involvement, opportunities for younger pediatricians may need to recognize places and organizations with which young parents come into contact to facilitate their involvement in ways that are particularly meaningful to the needs of their own families. Organizations that are interested in promoting involvement of those in the middle age group may find that a mix of strategies is needed. For all groups, it is likely that pediatricians will continue to select multiple venues in which to be engaged, based on life experiences, personal preferences, and political climate.
Differences observed according to age also may reflect generational differences with those in the youngest age group, a product of generation X, more concerned about work-life balance14 and perhaps, in combination with challenges of establishing careers and families, being less willing to engage at the current time in community activities. More established pediatricians, born during the baby boomer and traditional eras,14 may be more willing to work longer hours without enhanced remuneration and be more service oriented. To address this possibility, we assessed participation in community activities among those aged 40 to 50 years in this survey, aged 29 to 39 years in the 1993 survey, and aged 29 to 35 years in the 1989 survey and found comparable percentages of 42%, 49%, and 46%, respectively, suggesting stable levels of involvement among the cohort over time; however, within each PS, we also observed increasing involvement in community activities with increasing age, suggesting that generational differences alone do not account for the observed findings; rather, younger pediatricians likely require time to establish themselves professionally and gain credibility in their local communities before engaging in community activities.4, 15 In both the 2004 and 1993 surveys, greater percentages of younger pediatricians reported that their current level of involvement was too little, recognizing a desire for increasing involvement.
Several limitations should be noted. First, self-report may lead to overestimations of community involvement, although we have no reason to suspect that this varies by age. It is possible that younger pediatricians, with more training in residency and not having entered the work world beyond training, inflate their anticipated future involvement. Second, enhanced exposure to community pediatrics may increase social desirability bias, with younger pediatricians reporting but not truly believing that they have greater responsibility than their older colleagues. Third, we focused on population-based rather than individual patient-level skills in this national survey of pediatricians; however, other assessment tools assess quality of care with regard to medical home attributes and primary care. Fourth, it is possible that older pediatricians do not report receipt of formal training during residency because of recall bias; however, our finding of increased training for those who more recently completed residency is consistent with increased exposures to community pediatrics reported by third-year residents surveyed from 1997 to 2002.5 Finally, the survey response rate was 58%, although this level of participation is consistent with other national surveys of physicians, and respondent bias has not been observed in other PSs.16
Whether generational perspectives ultimately influence pediatricians’ involvement in community activities is unclear. From 1997 to 2002, third-year pediatric residents reported enhanced quality of training regarding child advocacy and assessing the needs of their community as they increasingly were exposed to community sites, including schools, child care centers, public health departments, and community health centers.5 It is possible that increased skills and exposures will overcome potential generational tendencies for less involvement; however, with younger physicians increasingly working in salaried positions in group practices, ability to participate in community activities may require engagement outside work responsibilities if such activities are not supported and valued by employers or paid for by other sources. Although there is decreased involvement by younger pediatricians, this largely reflects a decline in paid activities. A separate article (C.S.M., K.G.O., H.G., A.C., C. A. Aligne, MD, MPH, M. D. Kogan, PhD, and D. Tayloe, MD, unpublished data) discussed time trends with regard to community child health activities and documented that during the past 2 decades, there was a decline in pediatrician involvement in government and philanthropically sponsored paid opportunities for community activities.
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CONCLUSIONS |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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Pediatricians’ training, perspectives, and involvement in community child health activities vary by age. Although younger pediatricians report less current involvement, they also report receiving more training during and before residency and believe that their current level of involvement is insufficient. Prospective longitudinal studies, such as that being conducted as part of the national evaluation of the Dyson Community Pediatrics Training Initiative, are needed to address whether greater exposures to community training during residency and expectations for greater involvement translate into enhanced involvement once pediatricians are established in their careers.
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ACKNOWLEDGMENTS |
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This study was funded by the Maternal and Child Health Bureau, Health Resources and Services Administration, and supported by the American Academy of Pediatrics.
These analyses were conducted as part of the Dyson Initiative National Evaluation and informed by the AAP PS 60 Workgroup: C. Andrew Aligne, MD, MPH (University of Rochester School of Medicine and Dentistry, Rochester, NY); Holly Grason, MA (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD); David E. Heppel, MD (Maternal and Child Health Bureau/Health Resources and Services Administration, Rockville, MD); Michael D. Kogan, PhD (Maternal and Child Health Bureau/Health Resources and Services Administration, Rockville, MD); Cynthia S. Minkovitz, MD, MPP (Johns Hopkins Bloomberg School of Public Health, Baltimore, MD); Karen G. O'Connor (American Academy of Pediatrics, Elk Grove Village, IL); Judith S. Palfrey, MD (Children's Hospital, Boston, MA); David Tayloe, MD (Goldsboro Pediatrics, Goldsboro, NC), and Thomas F. Tonniges, MD (Boys Town National Research Hospital, Omaha, Nebraska).
We gratefully acknowledge thoughtful review by Lynn Olson, PhD.
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FOOTNOTES |
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Accepted May 22, 2007.
Address correspondence to Cynthia S. Minkovitz, MD, MPP, Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe St, E4636, Baltimore, MD 21205. E-mail cminkovi{at}jhsph.edu
The views expressed in this article are those of the authors and do not represent policies of the American Academy of Pediatrics.
The authors have indicated they have no financial relationships relevant to this article to disclose.
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REFERENCES |
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TOPABSTRACTMETHODSRESULTSDISCUSSIONCONCLUSIONSREFERENCES |
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- Solomon B, Minkovitz CS, Mettrick JE, Carraccio C, Dyson Initiative National Evaluation Team. Training in community pediatrics: a national survey of program directors. Ambul Pediatr. 2004;4 :476 –481[CrossRef][Web of Science][Medline]
- Wright CJ, Katcher ML, Blatt SD, et al. Toward the development of advocacy training curricula for pediatric residents: a national Delphi study. Ambul Pediatr. 2005;5 :165 –171[CrossRef][Web of Science][Medline]
- Rezet B, Risko W, Blaschke GS; Dyson Community Pediatric Training Initiative Curriculum Committee. Competency in community pediatrics: consensus statement of the Dyson Initiative Curriculum Committee.
Pediatrics. 2005;115
:1172
–1183
[Free Full Text] - Cull WL, Chang C, Goodman DC. Where do graduating pediatric residents seek practice positions? Ambul Pediatr. 2005;5 :228 –234[CrossRef][Web of Science][Medline]
- Cull WL, Yudkowsky BK, Shipman SZ, Pan RJ. Pediatric training and job market trends: results from the American Academy of Pediatrics third-year resident survey, 1997–2002.
Pediatrics. 2003;112
:787
–792
[Abstract/Free Full Text] - Pan RJ, Cull WL, Brotherton SE. Pediatric residents’ career intentions: data from the leading edge of the pediatrician workforce.
Pediatrics. 2002;109
:182
–188
[Abstract/Free Full Text] - Guyer B. Promoting community pediatrics: recommendations from the Community Access to Child Health Evaluation. Pediatrics. 1999;103(6 pt 3) :1370 –1372
- Grason H, Aliza B, Hutchins VL, Guyer B, Minkovitz C. Pediatrician-led community child health initiatives: case summaries from the evaluation of the community access to child health program. Pediatrics. 1999;103(6 pt 3) :1394 –1419
- Shipley LJ, Stelzner SM, Zenni EA, et al. Teaching community pediatrics to pediatric residents: strategic approaches and successful models for education in community health and child advocacy. Pediatrics. 2005;115(4 suppl) :1150 –1157
- Chamberlain LJ, Sanders LM, Takayama JI. Child advocacy training: curriculum outcomes and resident satisfaction.
Arch Pediatr Adolesc Med. 2005;159
:842
–847
[Abstract/Free Full Text] - Palfrey JS. Child Health in America: Making a Difference Through Advocacy. Baltimore, MD: Johns Hopkins University Press; 2006
- Bright Futures Health Promotion Workgroup. Pediatrics in practice: a center for teaching and learning health promotion. Available at: www.pediatricsinpractice.org. Accessed April 26, 2007
- Palfrey JS, Hametz P, Grason H, McGaskill QE, Scott G, Chi GW. Educating the next generation of pediatricians in urban health care: the Anne E. Dyson Community Pediatrics Training Initiative. Acad Med. 2004;79 :1184 –1191[CrossRef][Web of Science][Medline]
- Howell LP, Servis G, Bonham A. Multigenerational challenges in academic medicine: UC Davis's responses. Acad Med. 2005;80 :527 –532[CrossRef][Web of Science][Medline]
- Berman S. Training pediatricians to become child advocates.
Pediatrics. 1998;102
:632
–636
[Free Full Text] - Cull WL, O'Connor KG, Sharp S, Tang SS. Response rates and response bias for 50 surveys of pediatricians. Health Serv Res. 2005;40 :213 –226[CrossRef][Web of Science][Medline]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics
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