EXERCISE CONSULTATION PROGRAM ON EXERCISE BEHAVIORAL CHANGES IN PATIENTS OF TYPE 2 DIABETES MELLITUS WITH OVERWEIGHT: TRANSTHEORETICAL MODEL APPROACH Program Konsultasi Latihan Fisik dengan Pendekatan Transtheoretical Model terhadap Perubahan Perilaku Latihan Fisik pada Pasien Diabetes Mellitus Tipe 2 dengan Overweight Rinco Siregar, Karnirius Harefa, Eva Kartika Faculty of Nursing and Midwifery Sari Mutiara Indonesia University Email:
[email protected] ABSTRAK Pendahuluan. Diabetes mellitus merupakan salah satu masalah kesehatan yang paling menantang dan terus meningkat di seluruh dunia. Tujuan dari studi ini adalah untuk mengetahui pengaruh program konsultasi latihan fisik dengan pendekatan Transtheoretical Model (TTM) terhadap perubahan perilaku latihan fisik, kadar glukosa darah dan indeks massa tubuh (IMT) pada pasien DMT2 dengan kelebihan berat badan. Metode. Dengan kelompok pembanding, studi kuasieksperimental dengan rancangan pre-test/post-test; 61 pasien DM Tipe 2 dialokasikan ke dalam kelompok eksperimen (31pasien) dan kelompok kontrol (30 pasien). Sementara kelompok eksperimen menerima konsultasi latihan fisik selama 12 minggu, kelompok kontrol menerima perawatan rutin. Data dianalisis menggunakan uji Chi square dan t-test. Hasil. Proporsi perubahan perilaku latihan fisik ini antara kelompok secara statistik signifikan berbeda (Chi-Square = 000, p < 0,05). Glukosa darah secara signifikan menurun pada kelompok eksperimen (t = -4,926, p = 0,000 < 0,05), namun tidak ada perbedaan yang signifi kan dalam kelompok kontrol. Tidak ada perbedaan yang signifikan dari skor rata-rata IMT peserta antara kelompok eksperimen dan kelompok kontrol setelah diberikan program konsultasi latihan fisik (p > 0,05). Diskusi. Program konsultasi latihan fisik bisa mempromosikan perilaku latihan fisik. Ini juga dapat meningkatkan kesehatan pasien dengan menurunkan glukosa darah pasien DMT2. Kata kunci: transtheoretical model, latihan fisik, diabetes tipe 2 ABSTRACT Introduction. Diabetes mellitus is one of the most challenging and escalating health problems worldwide.The purpose of this study was to determine the effect of exercise consultation program based on Transtheoretical Model (TTM) approach on exercise behavioral change, blood glucose and body mass index (BMI) in patients of Type 2DM with overweight. Methods. This study was quasi-experimental study with pre-test/post-test procedures; 61 patients of Type 2DM allocated into the experimental (31 patients) and the control (30 patients) groups. While the experimental group received the exercise consultation for 12 weeks, the control group received routine care. Data were analyzed with Chi-Square test and t-test. Results. This proportion of exercise behavior change between the groups was significantly statistical different (Chi-Square = 000, p < 0.05). Blood glucose significantly decreased in the experimental group (p < .05), but there was no significant difference in the control group. No significant difference of mean scores of BMI of participants between the experimental group and the control group post-intervention of exercise consultation program (p > .05). Discussion. The exercise consultation program could promote the exercise behaviors. This also improves health outcome on blood glucose among patients of T2DM who. Keywords: transtheoretical model, physical exercise, type 2 diabetes
Organization (WHO) predicts that DM will become the fourth or fifth leading cause of death in the world by the year 2030 (WHO 2011). In Indonesia, diabetes mellitus has affected 7.6 million (8.6%) of total adult Indonesian populations in 2010, and the figures will rise to 21.3 million by 2030 (Pramono et al., 2010). On this basis, it was estimated that within the next 20 years, Indonesia would have become the fourth rank among nations with
INTRODUCTION Diabetes mellitus is one of the most challenging and escalating health problems worldwide. International Diabetes Federation (IDF) reports that, in 2011, diabetes mellitus (DM) affected more than 371 million (8.3%) adults globally. Diabetes will dramatically increase to 552 million by 2030 (IDF 2013), which is equivalent to approximately 3 new cases every 10 seconds or nearly 10 million per year (IDF 2013). The World Health 24
Exercise Consultation Program on Exercise Behavioral Changes (Rinco Siregar, dkk.) The interventions for physical exercise in patients of T2DM have often been based on the Transtheoretical Model (TTM) in western countries, for example exercise consultation. The exercise consultation intervention based on TTM is effective for short-term, as well as longterm, in promoting exercise behavior among patients of T2DM, in comparison with merely giving standard exercise information (Kirk et al., 2003; Jackson et al. 2007; Plotnikoff et al. 2011). Those exercise consultation for patients of T2DM has been formulated on the basis of physical activity counseling based on the TTM and cognitive behavioral approach to promote physical exercise (Kirk et al., 2007). This has never been used in Indonesia. This is the first study that used the exercise consultation based on TTM approach to promote physical exercise .With regard to raising the number of participants among the patients of T2DM previously failed to meet their required level of participation in diabetes exercise (Unairawati and Soetjiatie, 2011), especially in Medan, Indonesia (Sinaga et al., 2011; Khairunnisa 2012), and with the support of literature of TTM approach, which, together, have provided the researcher the interest to attempt to improve physical exercise behavior among patients of T2DM through exercise consultation while focusing on promoting Diabetes exercise. Therefore, this study has proposed to examine the effect of exercise consultation programs to induce exercise behavioral change with the subsequent benefits of lowering blood glucose levels and body mass index (BMI) in patients of T2DM.
the highest diabetes cases in the worldwide after India, China, and America, if there was no effective prevention program implemented. The Basic Health Research of Indonesia [BHR] (2013) found that for population of age group 45–59 years in urban areas, the proportion of deaths due to diabetes was ranked second, representing 14.7% of the total population of the group, after stroke disease which accounted for 15.9%. People of type 2 diabetes mellitus (T2DM) are at higher risk by two to four times of cardio-vascular disease, it then follows that their life expectancy is lower than the rest of the population (Januszewska et al. 2011). Fifty percent (50%) of patients of T2DM died of cardio-vascular disease (primarily heart disease and stroke), 10–20% of patients of T2DM died of kidney failure (WHO 2011). T2DM has evolved in association with increasing physical inactivity and other unhealthy lifestyle and behavioral pattern (Sincree et al., 2010; IDF, 2011). Based on this phenomenon that is increasing constantly, it is very important to provide the necessary intervention to reduce incidence of these diseases stemming from diabetes, such as providing information to the public to promote healthy behaviors and to prevent complications in patients of T2DM by diet control and taking up regular exercise. In spite of numerous evidence from previous studies suggesting that exercise of Diabetes was excellent in managing diabetes in patients of T2DM, but others studies had shown that a high proportion of T2DM patients were still physically inactive, failed to engage themselves with Diabetes exercise (Unairawati and Soetjiatie, 2011). According to Khairunisa (2012) it was reported that 73% of patients of T2DM living in Medan, North Sumatra, Indonesia, had failed to participate in Diabetes exercise to a required level. Therefore, a major challenge to community nurse and health care providers is to promote the Diabetes exercise program among patients of T2DM so as to encourage them to become active participants of the physical exercise program on a regular basis and thereafter, to maintain their active participations.
METHODS A quasi-experimental study design with two groups, and both pre-test/post-test, was adopted in this study with the aim of examining what effect the exercise consultation program would have on exercise behavioral change, and changes in body mass index and blood glucose level in patients of T2DM with overweight. The target populations in this study were patients of T2DM as having been diagnosed by a medical doctor. The participants were recruited at Darussalam’s Community Health 25
Jurnal INJEC Vol. 1 No. 1 Juni 2016: 24–33 stage of behavioral change has reflected the kappa index reliability of.78 (Fischer et al. 2008). Body Mass Index or BMI of patient was assessed by using Electronic scales ‘Transcell Technology T1500’ (Manufactured by Standard Prodia Laboratory, USA). Blood Glucose Tests were administered on patients using biochemical analyzer - Blood Glucose Test Meter ‘ One Touch BASIC Plus Life Scan 2000 ‘ (Manufactured by Standard Prodia Laboratory, USA). Exercise consultation program was developed by Kirk et al. (2007) based on Transtheorethical Model (Prochaska and Velicer, 1997) and has been adopted for use in this study with certain modifications to meet the goals of motivating and enhancing confidence to change. The difference of the participant’s characteristic between the groups was tested by Chi-Square test and independent t-test. Data were tested for normal distribution using Shapiro-Wilk Test (p >.05). The differences of means scores of blood glucose levels and BMI taken both before and after intervention of participants within the same group were analyzed using dependent t-test. While the differences of means scores of blood glucose levels and BMI between the two groups was analyzed using independent t-test. Difference on exercise behavioral change between experimental group and control group was tested using Chi square test at the confidence level Alpha 0.05.
Center in Medan, Indonesia, which provides medical services to diabetics. The total samples were 66 participants. Initially, 33 patients of type 2 diabetes were assigned to the experimental group with 2 participants subsequently dropped out due to personal reason. Therefore, only 31 patients of type 2 diabetes remained in the experimental group. Similarly with the control group, 3 participants were considered dropouts as they failed to return the questionnaire and also failed to come to the community health center because of personal reason. Therefore, only 30 patients of type 2 diabetes remained in the control group. The primary objective of the participants recruitment exercise was to ensure full compliance to the inclusion criteria which were: 1) Individuals diagnosed with T2DM by physician at Rantang’s Community Health Center in Medan. 2) Participants were in either a contemplation or preparation stage of exercise behavior change, (i.e., they were not meeting current physical activity guidelines but intended to become more active). 3) Adults of age between 40 to 59 years. 4) Capable to read and speak Indonesian. 5) Blood glucose level indication ranging of 140–250 mg/dl as per physical check-up. And 6) be willing to participate in this study. The Exercise Stage of Change Questionnaires developed by Marcus et al., (1992) was used to measure exercise behavioral change. Reliability of the exercise
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Exercise Consultation Program on Exercise Behavioral Changes (Rinco Siregar, dkk.) RESULT Table 1. Statistics and Percentages of Participants’ Demographic Characteristics in Both The Experimental and The Control Groups (N = 61) Participants’ characteristics
Experimental Group (n = 31) n(%) (63.12,3.61)
Control Group (n = 30) n(%) (62.70,3.91)
p-value
0.658a Age, (M, SD), Years Gender 13 (41.9) 11 (36.70) Male 0.674b 19 (63.30) Female 18 (58.1) Marital Status Married 24 (77.40) 23 (76.70) 0.944b 7 (22.60) 7 (23.30) Widow Religion 14 (45.20) 19 (63.30) Muslim 0.354b Christian 10 (32.30) 6 (20.0) 5 (16.70) Chatolic 7 (22.60) Educational Level 2 (6.70) Elementary School 2 (6.50) 0.876c 12 (38.70) 14 (46.70) Junior High Sch 11 (36.70) Senior Sch 12 (38.70) 3 (10.0) 5 (16.10) University a = independent t-test, b= chi square test, c=likelihood ratio,M= Mean, SD=Standard Deviation Table 2. The Level of Exercise Behavior Change of Participants in The Experimental and Control Group Pre- Intervention (N = 61) Group Experimental Control
Contemplation n (%) 9 (29.0) 11 (36.7)
Preparation n (%) 13 (41.9) 12 (40.0)
Action n (%) 6 (19.4) 5 (16.7)
Maintenance n (%) 3 (9.7) 2 (6.7)
P-value 0.915
Table 3. The Level of BMI and Blood Glucose of Participants in The Experimental and Control Group Pre- Intervention (N = 61) Experimental group Control group (n = 31) (n = 30) BMI (kg / m2 ) M,(SD) 26.60 (1.021) 26.83 (0.973) Blood Glucose M,(SD) 225.25 (20.099) 229.16 (20.067) a = independent t-test, M = Mean, SD = Standard Deviation
P-value 0.372a 0.450a
Table 4. Occurrences of Exercise Behavioral Change of Participants in The Experimental Pre and Post-Intervention Program (N = 61) Contemplation n (%) Before 9 (29.0) After 1 (3.2) d = McNemar test
Preparation n(%) 13 (41.9) 5 (16.1)
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Action n(%) 6 (19.6) 17 (54.8)
Maintenance n(%) 3 (9.7) 8 (25.8)
P-value 0.000d
Jurnal INJEC Vol. 1 No. 1 Juni 2016: 24–33 Table 5. Occurrences of Exercise Behavioral Change of Participants in The Control Group Pre and Post-Intervention Program (N = 61) Contemplation n (%) Before 11 (36.7) After 8 (26.7) d = McNemar test
Preparation n (%) 12 (40.0) 13 (43.3)
Action n (%) 5 (16.7) 8 (26.7)
Maintenance n (%) 2 (6.7) 1 (3.3)
P-value 0.370d
Table 6. Comparison of Mean Scores of BMI and Blood Glucose Level of Participants in The Experimental Group Pre-Intervention and Post-Intervention Using Dependent T-Test (N = 31)
BMI (Kg/m2) Blood Glucose SD = Standar Deviation
Experimental Group Pre Intervention Post Intervention Mean SD Mean SD 26.6 1.02 26.22 1.01 225.25 20.09 195.00 7.33
t
p-value
7.133 7.980
.000 .000
Table 7. Comparison of Mean Scores of BMI and Blood Glucose Level of Participants in The Control Group Pre and Post-Intervention Using Dependent T-Test (N = 30) Control Group Pre Intervention Post Intervention Mean SD Mean SD 26.83 0.97 26.66 1.00 229.16 20.06 218.86 25.92
BMI (Kg/m2) Blood Glucose
t
p-value
1.753 1.887
.090 .069
SD = Standard Deviation
Table 8. Comparison of The Level of Exercise Behavioral Changes in Participants Between The Two Groups Post-Intervention By Exercise Consultation Program (N = 61) Group Experimental Control
Contemplation n (%) 1 (3.2) 8 (26.7)
Preparation n (%) 5 (16.8) 13 (26.7)
Action n (%) 17 (54.8) 8 (26.7)
Maintenance n (%) 8 (25.8) 1 (3.3)
P-value .000
Table 9. Comparison of Mean Scores of BMI and Blood Glucose Levels in Participants Between The Two Groups Using Independent T-Test (N = 61) Experimental Group (n = 31) M (SD) BMI Pre-intervention Post-intervention Blood Glucose Pre-intervention Post-intervention
Control group (n = 30) M (SD)
t
p-value
26.60 (1.02) 26.22 (1.01)
26.83 (0.97) 26.66 (1.00)
-.901 .153
.879 .658
225.25 (20.09) 195.00 (7.33)
229.16 (20.06) 218.86 (25.92)
-.760 -4.926
.450 .000
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Exercise Consultation Program on Exercise Behavioral Changes (Rinco Siregar, dkk.) and 26.22 (SD = 1.014) respectively, these results of dependent t-test shows that the BMI of participants after participating in the exercise consultation program has significantly declined (t = 7.133, p < .05) (Table 6). However, the BMI of participants in the control group shows no significant change (t = 1.753, p > 0.05). Moreover, Table 6 and 7 highlighted the followings: blood glucose levels of participants in the experimental group, pre-intervention and post- intervention program are 225.25 (20.09) and 195.00 (7.33) respectively, these results of dependent t-test shows that blood glucose levels of participant has declined significantly after participating in the exercise consultation program (t = 7.80, p < .05) (Table 6). But no significant change amongst participants in the control group (t = 1.887, p > 0.5) (Table 7). The result of this study has demonstrated signif icant differences in behavioral changes in exercise outlook as evidenced by substantially declining blood glucose levels among participants in the experimental group after attending the exercise consultation program, whereas findings with participants in the control group have shown no significant changes. Table 8 shows that the majority of participant in the experimental group has progressed to the action stage (54.8%) after attending the exercise consultation program. Where as participants in the control group were stays in their stage (no change). Further analysis using Chi-square test revealed a significant difference of success rate of behavioral change between the experimental and control groups (Chi-square test = .000, p < .05). Table 9 has also highlighted: no significant difference of mean scores of BMI of participants between the experimental group and the control group post-intervention of exercise consultation program, whereby mean scores of BMI of the experimental group and the control group were 26.22 (SD = 1.01) and 26.18 (SD = 1.15), respectively. Further analysis using independent t-test has revealed no significant difference in BMI between participants in the experimental group and
Table 1 shows that the mean age of the participants were 63.12 years (SD = 3.61) for the experimental group and 45.2 years (SD = 3.91) for the control groups. Majority of the participants in both groups are of female gender, and the majority are classified as married. Majority are Muslim (with 63.30% of the control group. And of participants of the control group are junior high schools graduates (46.70), the experimental group are 38.70%. Before intervention, in table 2 shows that pre- intervention, the majority of the participants in the experimental and control group are in the preparation stage of exercise behavior change of TTM (41.9% and 40.0%), respectively. And these results of chi-square test shows no significant different exercise behavioral change in the experimental and control group before intervention (p = 0.915, p > .05). The average BMI are 26.60 (1.02) kg/m2 and 26.83 (0.973) kg/m2 for the experimental group and the control group respectively. In addition, mean scores of blood glucose are 225.25 (20.099) mg/dl and 229.16 (20.067) mg/ dl, for the experimental group and the control group respectively, these results of independent t-test shows that no significant different in the mean scores of BMI (p = 0.372, p > .05) (Table 3) and blood glucose (p = 450, p > .05). Table 4 shows that post- intervention, the majority of the participants in the experimental group had progressed to the action stage of change of TTM (stage 4) (54.8%). There is a significant different exercise behavioral change before and after given an intervention (p = .000, p < 0.05). The majority of the participants in the control group (43.3%) remained in the same stages of TTM (stage 3), and only 3.3% of the participants had progressed to the maintenance stage (stage 4). Further statistical test using McNemar test found that there is no signifficant different exercise behavioral change in the control group (p = 0.370, p > 0.370). In table 6 and 7 highlighted the followings: mean scores of BMI of participants in the experimental group, pre-intervention and post-intervention, were 26.6 (SD = 1.021) 29
Jurnal INJEC Vol. 1 No. 1 Juni 2016: 24–33 increase self-efficacy and awareness of the benefits of physical exercise, thereby lowering mental barriers to exercise. Limited motivation and exercise knowledge could be barriers to taking up regular exercise among adults of T2DM with overweight. Therefore, the exercise consultation should aim to support and motivate patients taking up exercise, as well as helping patients to recognize their unhealthy behaviors. Enhancing patient’s motivation and educating patients about the benefit of exercise are the most successful strategies of engaging patients to attain increased level of exercise. High levels of physical exercise have correlation with patients progressing their stage of change (Kirk et al., 2010), and it would be good if they could maintain their exercise behavior changes (Kirk et al. 2003; Jeackson et al. 2007; Hasler et al., 2000). Appropriate interventions at the patient’s different stages of change, together with adequate support like frequent contact to monitor and motivate behavioral changes in patients of T2DM are keys to success of changing their exercise behaviors. In this study, changes in exercise behaviors progressing from preparation stage to action stage amongst subjects were greater in numbers than changes from the contemplation stage. The interventions strategy should be designed specifically for different stages of behavioral change (Marcus et al., 1992; Prochaska et al., 2008; Kirk et al., 2007) this is a very important factor, as for example, par ticipants in the contemplation or preparation stage needs to be aware of safety aspect, frequency and intensity of exercise required to gain health benefits. Researchers had raised the participants’ understanding of the importance of exercise to control their blood glucose level. Researchers had also introduced and provided exercise information to the participants to make them comfortable. Barriers of individual should be identified and solve to help motivate participants to be active physical exercise behavior. Discussion of personal obstacles to exercise and hence, the strategies to overcome their personal barriers, as well as setting exercise goal and relapse prevention are also important issues.
those in the control group (t = .153, p > .05). Again table 9 has highlighted the followings: mean scores of blood glucose levels, postintervention of exercise consultation were 195.00 (SD = 7.33) and 218.86 (25.92) for the experimental and the control group respectively. This result shows that blood glucose levels of participants participated in an exercise consultation program is lower than those who do not. The result of independent t-test obtained has also confirmed the significant differences of blood glucose levels between participants in the experimental group and those in the control group (t = - 4.369, p < .05). DISCUSSION As for the control group, the findings showed no significant changes in exercise behavior between data recorded at baseline and throughout the 12 weeks of follow-up. While subjects in the experimental group had significantly changed their exercise behaviors by progressing from the contemplation or preparation to the action stage which was the ultimate goal leading to the benefits of lowered blood glucose level, whereby the patients’ exercise behaviors might have been influenced by the exercise consultation program to progress to the next stage, which was considered a significant change. The finding of this study is consistent with findings of previous studies (Plotnikoff et al., 2011; Kirk et al., 2003) which had also found that subjects exhibited significant progress in their exercise behavioral changes over a 6 month exercise consultation program, much more so than those who were not involved in the program. Moreover, the findings of this study have added to the previous study’s belief that patients of T2DM could be motivated to improve their exercise behavior over a relatively shorter period than one though it would take (Jackson et al., 2007). However, this study has also limited its scope of further explanation regarding the maintenance stages of exercise behaviors. The exercise consultation might motivate subjects to become more physically active and 30
Exercise Consultation Program on Exercise Behavioral Changes (Rinco Siregar, dkk.) continued to receive routine care including advice on diet, but not evaluated.
The exercise consultation enhancing patient’s and motivated patients to attain physical exercise. Controlling blood glucose level might be improved by doing exercise for at least 30 minutes each session 3 times a week. The findings in this study had shown that blood glucose levels became lowered amongst participants participated in regular exercise. These findings were consistent with several previous studies which highlighted that a 4–6 week of performing diabetes exercise for 30 minutes each session 3 times a week had significantly reduced blood glucose levels (Indryani et al., 2007; Unirawati and Soetjiatie, 2011; Mawarti and Sriwahyuni, 2012; Utomo et al., 2012). Physical exercise undertaken by patients of T2DM can lead to increased glucose utilization because of active muscles movement and lowered blood glucose levels (Colberg et al., 2010). Through exercise consultation program conducted with patients of T2DM can achieve blood glucose control, and regular physical exercise would significantly improve glycemic control (Colberg et al., 2010; Sigal et al., 2007), increases muscular strength (Toledo et al., 2007), improves insulin sensitivity (Toledo et al., 2007), reduces body weight/decrease in BMI (Colberg et al., 2010; Sluijs et al., 2005; Marcus et al., 2008; Allen et al., 2008), thereby improving physical fitness, and reducing depression (Shin et al., 2009) and achieving lowered blood pressure (Colberg et al., 2010). Moderate physical exercise activity, like exercise of diabetes (Santoso, 2010), brisk walking are known to be a part of diabetes management as well as preventing complication in diabetes. This study revealed that no significant change in BMI or body weight both of participant in the experimental group and control group. This study finding was consist with another study using personal counseling to induce behavioral change towards increased physical activity in people of T2DM (Kirk et al., 2003). The effect on BMI might be attributed to several factors, the difference in physical activity interventions in this study and the other study could have influenced changes in BMI. In addition, in this study both groups
CONCLUSION Exercise consultation program is a simple approach providing counseling specifically to the patient’s current attitude, confidence, and motivation in order to promote increased physical exercise activity. Consultation and supervision of gymnastic diabetes may improve exercise activity resulting in lowered blood glucose levels and BMI. This program is feasible to encourage people with T2DM to take up physical exercise at community health center. This intervention could be delivered by any member of the diabetes care team at community health center with minimal training in the delivery cognitive behavioral interventions and physical activity knowledge related to diabetes. RECOMMENDATION Exercise consultation based on TTM is useful intervention for promoting exercise behavioral change in patients of T2DM. The results of exercise consultation program should be studied with a longer follow up period to evaluate the maintenance of physical exercise behavioral change with a much larger sample size of patients of T2DM under different setting in community area. REFERENCES Allen, N.A. et al. 2008. Continuous glucose monitoring counseling improves physical activity behaviors of individuals with type 2 diabetes: A randomized clinical trial. Diabetes Research and Clinical Practice, 80(3), pp. 371–379. American Diabetes Association. 2004. Physical Activity/Exercise and Diabetes. Diabetes Care 27(1), pp. 58–62. American Diabetes Association. 2011. Standards of Medical Care in Diabetes. Diabetes Care, 34(1), pp. 11–61. Basic Health Research (BHR)/Riset Kesehatan Dasar (RIKESDAS). 2013. Laporan Nasional 2007: Badan Penelitian dan 31
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