Statement of the Problem
Background and Significance of Study
Summary
Hypothesis
Operational Definitions
Methodology
General Design and Procedures
Sample
Instrument
Procedures for Data Collection
Procedures for Data Analysis
Limitations
Review of the Literature
Theoretical Framework and Rationale
Summary
Study and Analysis of Data
Results
Conclusions
References
Appendix
List of Illustrations
Illustrations
Style Manual
Statement of Problem
Purpose
The purpose of this study was to determine the type of social and
physical environment that residents in a custodial, retirement or
extended care facility prefer. A self-administered questionnaire was
used to obtain these data. Demographic and age information of the
participants was obtained at the time of the survey and was included in
the results.
Background and Significance of Study
As the population ages, the need for appropriately planned
facilities will increase greatly. If these facilities are planned with
the marketing concept in mind, i.e. ( customer driven ), then they
will provide the optimum satisfaction to the clients and the maximum
efficiency to the providers. Rodgers (1985), in The IBM Way states
that IBM has only three major operating principles. They are as
follows:
1. The individual must be respected.
2. The best service possible will be provided.
3. All tasks will be performed with the idea that they can be performed in
a superior fashion with zero defects.
We apply these principles to the construction and planning of the
custodial facilities by asking the potential consumers what they prefer
and then integrate this information into a compilation of theory and design.
Summary
While the aforementioned practices may seem time consuming and
impractical in our modern society, only when this type of effort is
expended can the consumer truly be served. The purpose of this study
is to compile information so that administrators can manage effectively
and planners and architects will be able to build or convert existing
facilities to meet the needs and desires of the frail and the elderly.
Hypothesis
The following hypotheses were examined to determine which type of
social and physical design would be the most desirable and advantageous
for the elderly and frail.
1) Every effort would be made to make the environment similar to
the ideal setting before retirement, i.e., maximum amount of
personal freedom with the minimum amount of personal energy
expenditure.
2) Every opportunity will be taken to encourage autonomy in all
aspects of day to day living, with an emphasis on self
management.
3) Every effort would be made to make to establish guidelines for
the social as well as the physical aspects of the facility,
i.e., How many rooms?, What type of building security?, What
types of recreational activities?, Should pets be allowed?,
etc. Definitions
The following operational definitions describe terms used in
this study:
1) Elderly - Those persons over the age of 65 or persons who
would be likely candidates for living in a custodial setting.
2) Frail - Those persons that cannot for reasons of ill health
or chronic illness, manage day to day activities without the
assistance of others.
3) Customer Driven - When the wants and desires of the customer
determine the characteristics of the product delivered to
them.
4) Lifecare - This is a general term that is used to define
residential facilities that emphasize minimal to full care to
the individual(s) during sickness and health. These services
can range from monthly on-site blood pressure clinics to full
service nursing home care.
5) Board and Care - This is a residential care facility generally
consisting of less than twenty five units. The level of care
is generally less than a skilled nursing facility, but more
than senior citizen apartment complexes.
Methodology
General Design and Procedures
The general design of this research project was an experimental,
self-administered, questionnaire. The survey consisted of five (5)
pages of questions that recorded the social and physical accommodation
preferences of the respondents. Attached to the questionnaire were
food coupons worth $1.00 to the participants.
The questions were arranged in ascending order according to
Maslow's " Hierarchy of Needs ", beginning with the physiological needs
and ending with the self-esteem needs.
Kagan (1968) stated that man is an organism that will strive
for higher goals or achievements only after the lower goals are
fulfilled. To elaborate:
1. " All humans are wanting beings. " What they want depends
on what they have already.
2. " A satisfied need is not a motivater of behavior, only
unsatisfied needs motivate behavior. " An organism that
requires air for its continued existence will only be
cognizant when it is deprived of it.
3. " Human needs are arranged in a series of levels, a
hierarchy of importance. "
MASLOW'S HIERARCHY OF NEEDS
SELF-ACTUALIZATION
ESTEEM
( INCLUDING SELF RESPECT AND FEELINGS OF SUCCESS )
BELONGINGNESS AND LOVE
SAFETY ( SECURITY, ORDER AND STABILITY )
PHYSIOLOGICAL ( SATISFACTION OF HUNGER, THIRST AND SEX )
At the lowest level of needs are the physiological needs. These
are the needs that must be satisfied to maintain life. The next level
consists of the safety needs. These are basically protection from
physical harm.
If physiological needs are relatively satisfied, the social needs
begin to motivate behavior. Examples of social needs are wanting to
belong to a larger group or individual, to associate, to gain
acceptance from their peers, and to give and receive friendship and
affection.
Esteem or egotistical needs are addressed at the next level of
hierarchy. The need for self-esteem, self-respect and independence is
developed at this level.
At the apex of the need hierarchy pyramid is the need for self-
realization or self-actualization. It is, in the broadest sense, a
creativeness in realizing one's fullest potentials, whatever they may
be.
The survey was designed to address these needs by beginning with
the safety needs and going towards self-actualization.
The questions relating to types of security required relate to the
safety needs, just as the questions relating to volunteer work relate
to self-actualization; to the "giving of one's self freely without
concern for physical or monetary reward."
Respondents indicated either Yes, No or Don't Know or chose a
response from the choices offered according to their preference in each
category. This study was experimental in nature because it asks
participants to study the questions and make a judgement based on their
own experiences.
Sample
The sample was sent to fifty (50) respondents whose ages varied
from thirty (30) to ninety (90) years of age. Their current residence
type varied from renting, to owning their own homes. Notice was given
to the participants that all data were confidential and would be used
only for the purposes of this study. ( See Appendix A for survey )
To be included within the studied group, the individuals must have:
1) Been able to read and write in English.
2) Been willing to participate in the study.
Test Instrument
The Needs Assessment Questionnaire was designed for this study by
the author of this proposal. The survey was of the self-administered,
experimental nature. Contained within this questionnaire was a general
background information survey.
Procedures for Data Collection
Questionnaires were hand delivered to two independent sites in
Ohio and Michigan. The respondents answered the questions and returned
them to the proper questionnaire facilitator. The facilitator then
insured that they were returned to the author either by mail or in
person.
Returned questionnaires were logged and filed until all of them
were returned or until the allocated time period was over. Finally,
all data were summarily analyzed.
Procedures for Data Analysis
Upon receipt of completed surveys, file numbers were be recorded
and logged. Data from surveys were analyzed as follows:
1) The mean, mode and median ages of the respondents were
calculated.
2) The total of the responses was compared to the individual
choices for each question and the results were displayed in
a histogram fashion or pie chart fashion. ( See Study and
Analysis of Results.)
Limitations
Since this was a self-designed instrument, no claims are made
for its reliability or validity. If the questions were answered
truthfully it addressed the underlying question of the study, namely,
what are the preferences in a varied population for the social and
physical characteristics of group housing?
As the sample size increases, the sampling distribution of the
mean can be approximated by the " normal or bell-shaped distribution ".
This is true regardless of the distribution of the individual values in
the population. Statisticians have found that regardless of how
nonnormal the population distribution is, once the sample size is at
least 30, the distribution of the mean will be approximately normal.
General assumptions can then be made about the sample relative to the
overall population.
Theoretical Framework and Rationale
Goldberg (1986) says that during the next 35 years, industrial
nations like the USA can anticipate unprecedented growth in the elderly
population ( 65 years of age or older ). At the beginning of this
century less than 5% of the population were elderly. This proportion
has more than doubled since then and is expected to rise to as much as
14.6% by the year 2020.
Gurland et al (1981) stated that the primary reasons for this
increase were the control of neonatal and post partum death rates,
along with the a reduction in the birth rate.
In the state of Michigan, the effects of the burgeoning elderly
population are beginning to show. Twenty per cent of the state's 440
nursing homes were fined by the Department of Public Health from 1982
to 1985. Goldberg (1986) reports further that thousands of Michigan
residents are living in nursing homes that have been fined for violating
their patients' rights, abusing patients, and in some cases,
providing such poor care that they died.
The incidents range from the first fine brought by the State against
the Ambassador Nursing Home in 1982 for bathing a patient in
scalding water which eventually resulted in his death, to a fine in
1986 for serving melon with rind instead of fruit cups, as was originally
planned on the menu.
V. Katherine Gray et al (1985) describes a St. Paul Minnesota
study that examined why people moved into nursing or retirement homes.
There were two types of reasons; push and pull. Push factors were the
negative reasons that influenced their decisions like deteriorating
neighborhoods, crime, poor transportation and the cost of living. Pull
factors were the positive reasons for leaving like heated garages, snow
removal, improved proximity to mass transportation and health care.
She also wrote that 85 percent said that they would consider retirement
housing. Only 15 percent said that they would never consider it.
Parmiter (1984) describes the location characteristics of the
elderly population. 5 percent of the population are institutionalized,
7 to 8 percent are in an age segregated facility and 70 percent are
home owners. In addition, 60 to 80 percent of the homeowners own their
homes free and clear. Seiler (1986) indicates in his analysis of the population that
the elderly can be divided in three segments: the " go go " segment
(typically, ages 65 - 74 ), which is completely independent and
requires little in the way of specialized real estate or services;
the " slow go " segment (ages 75 - 84), which require some degree
of assistance and modified real estate services as well as specific
personal services and the " no go " segment (85 and Over), which is
highly dependent and requires specialized services and facilities.
Housing for the " go go " market is essentially the same as it is
for the slightly younger group of " empty nesters " whose children have
left home. This type of unit is similar to the condominium / town
house or recreational models and requires few special considerations.
Retirement communities aimed at this " slow go " and the " no go "
markets are not only physical structures; they deliver a wide variety
of services. Almost all of these communities provide independent
living units with a package of service amenities that includes: meal
service; transportation programs; planned social, cultural and
recreational activities; maid and or laundry service; twenty four hour
emergency call systems, security programs and a limited access to
nursing staff.
Retirement communities that offer access to nursing care are
normally financed differently. Non care providers normally
are set up on a " rental only " basis and enter into leasing agreements
that vary from monthly to annually. The primary advantage of this type
of a program is that there is no need for a large capital outlay. The
disadvantage is that the residents are more subject to arbitrary
increases in the fees due to inflation or other variances.
The care providing community normally operates with an endowment
agreement when the resident begins occupancy. This is a large fee that
is generally not refunded to the residents if they die or leave the
community. The resident may receive a partial refund that declines
with the number of years of residence for a period of five to eight
years. In most cases, the residents also pay a continuing monthly fee.
In return for the endowment, the care providing community assumes
certain responsibilities relative to the residents for their
lifetime, including the responsibility for skilled nursing care. In
many early communities, the residents were guaranteed unlimited
skilled nursing care with no increase in the monthly fees. Lifecare
centers began to proliferate during the middle of the 1980's.
These centers are designed for elderly people who don't want
to have to worry about home maintenance and upkeep, who don't want to
worry about cooking their own meals and who don't want to worry about
continued health care costs in an emergency.
Linnon (1986) describes one of these facilities. A retired couple
can pay an up-front security deposit of between $ 8,000.00 and
$ 15,000.00 that is fully refundable, along with a monthly fee of
about $ 1500.00. This entitles them to two meals a day in a hotel
style dining room, transportation to local activities, access to a
library and cocktail lounge and housekeeping service once a week.
Health services are available at this facility, but these fees are
separate from the organization fees. In 1989, The Marriott Corporation
will complete one of the first for-profit Lifecare Centers at Canyon
Lakes in San Ramon, California. The entrance fee or endowment is
$ 125,000.00, of which 90% is refundable. The fee guarantees all of
the social amenities plus health care for the rest of the resident's
life.
Penn (1987) states that the average retiree today is much
different than ten years ago. If you are a typical retiree today, you
are in your mid to late 50's, socially and physically active. This
group is looking for an outlet for their social, financial and physical
needs.
All of these communities are not successful, as Paulson (1987)
points out. The facility called the " Cloisters " which advertised
"Life Care ... Assured " , is in receivership with $ 14,000,000.00 in
outstanding debts.
The 81 residents that paid an entrance fee of between $ 50,000 to
$ 100,000 each to be admitted, have a roof over their heads, but no
daily meal services, no medical services and none of the other
amenities that were promised to them.
A three year wait to be admitted to one of the better Lifecare
centers is not uncommon. Applicants are expected to be in reasonably
good health and able to live unassisted.
Langdon (1988) discusses the high cost at one of the Lifecare
centers named Duncaster. He states that moving into this complex is
like buying a very expensive insurance policy. A person moving into
Duncaster would pay a minimum of $ 77,935.00 up front and $ 1699.00 per
month. A resident that stays no longer than three months can receive a
refund of all of their initial payment. After three months a prorated
amount will be returned up to forty months; after which no refund is
available. Duncaster's grounds are lavish, including seventy two acres
of woodlands and grassy knolls. Also included in this retirement oasis
are a greenhouse, library, woodworking shop, and an auditorium.
Less affluent facilities also exist. A company called Cardinal
Properties of Columbus, Ohio is building congregate care facilities.
These facilities do not have the expensive " endowment " fee, or the
greenhouse, but it does have a community dining area, beauty shop,
transportation to local areas, and a monthly rental fee of only
$ 799.00 per month.
There is also a movement towards " mainstreaming " the elderly
back into the center of the community by renovating existing structures
and converting them into Lifecare centers. This keeps the elderly in
circulation by locating them in the center of a small downtown area in
an old hotel and renovating it to suit their needs.
Astrachan ( 1986 ) reports that not everyone in a continuing care
community is there to relax. Dr. James A. Hagans moved to Covenant
Village with his parents to facilitate their care. Hagans, 58, cares
for his parents, aged 92 and 93, who are not invalids but require
assistance in their daily activities. He purchased two of the units
adjacent to each other and had a door cut between them.
He chose Covenant Village because, " As your needs increase, the
support is already here and readily available." 50% of the initial
investment of the approximately $40,000.00 is set aside to defray the
costs of skilled nursing care. Should the tenant utilize more that the
original amount, they are required to pay for the additional services.
In 1986 there were 600 Lifecare communities in the United States.
The number is estimated to increase to 1500 by the year 2000, according
to the accounting firm of Laventhol and Horwath in Philadelphia. Most
of these will be run by real estate developers or by church affiliated
and other nonprofit organizations. Dwight (1985) states that people
considering retirement communities consider the availability and the
quality of healthcare services as major criteria to guide their decisions.
Dwight performed a study involving more than 7000 respondents
across the country. Many aspects of the sociophysical environment
were examined. Physical assessment, preventive healthcare, mental
assessment and the care for the terminally ill was examined in the
broad area of healthcare.
Barber shops, Beauty shops, Physical fitness rooms and jacuzzis
were assessed in the are a of social, recreational, and cultural
amenities. Homemaker, laundry service and maid service were the areas
of general service that were considered.
Based on the questions relating to maid service, jacuzzis, etc.,
this was a survey of the relatively affluent individuals whose annual
income was found to be greater than $ 20,000.00 per year.
The results of the survey indicated that approximately 50% of the
population surveyed felt that nursing home services must be accessible
to them. 19% would not want a nursing home on-site, and 25% would not
want not want it off-site.
Respondents showed a strong desire for related health services
to be available. These alternative services consisted of in-home
assistance by registered nurse or having a registered nurse on-call
24 hours a day. 66% stated that indicated that they preferred the
full time access to a nurse.
Physical assessments were found to be more important to the
residents of the Eastern part of the country rather than the Western.
Overall 61% said that some type of routine physical exam was necessary.
Dwight also found that the availability of recreational, social
and cultural amenities were important to the decision of where to
relocate. Barber shops and Beauty shops were considered a "must have" in
14%, 22%, and 33% of the population in the Eastern, Southwest and the
West respectively.
Stark differences were found with respect to physical fitness
rooms and jacuzzis. Only 10%, 18% and 45% of the respondents in the
Eastern, Southwestern and West felt that these were necessary.
Little difference was found relative to the availability of
convenience stores or snack bars across the country with only an
average of 20% favoring this option.
The concept of safety and security was also examined. Emergency
call systems were felt to be a requirement by an average of 33% of all
of the respondents while over 35% of the population felt that there
must be a uniformed security guard present at all times.
General services such as access to public transportation, private
limousine service, cleaning and laundry service showed a mixed results
with variances attributed to the preretirement utilization of these
services.
The rapid inflation of the late 1970's brought many of these
early communities to the brink of financial collapse because the costs
for the unlimited nursing care increased far greater than their
capacity to pay. Modern care providing communities are now limiting
the amount of skilled nursing care that they provide to some fixed
dollar amount.
Wright (1987) reports on a relatively recent phenomenon called
the Board and Care. This particular project was built in a former
convent and financed with a $250,000 dollar federal grant. Kate
Sloan, a housing specialist for the American Association of Retired
Persons, calls this project marvelous because it offers a kind of care
that is not widely available elsewhere. Mary's House offers room and
board but no health care to its residents, who pay less than half of
the national rate for nursing home care. For $1200.00 dollars per
month, residents get three home cooked meals a day, 24 - hour
supervision, and personalized rooms similar to those in college
dormitories.
Charles Gilchrest, former Montgomery county executive, states
that this board and care is a perfect example of the housing that we
can develop as an alternative to prevent the premature or needless
institutionalization of our frail senior citizens.
Other experts see a key role played by nonprofit board and care
units in meeting the needs of the middle class elderly who can neither
afford costly alternatives nor live safely on their own.
" The big word today is deinstitutionalization," says Ms. Brady,
founder of Mary's House. " That's what this is. When you take people
out of a nursing home facility and into a homelike setting like this,
it's the accomplishment of a goal unto itself. "
Ms. Brady says that the disappointing search for adequate housing
for her mother led her to become an activist in the field. Ms. Brady
was able to convince the Archdiocese of Washington D.C. to lease it to
the low income housing group that she heads. She then obtained a
federal grant for building renovations, with additional funding
generated by local fund raising activities and contributions. Much of
the food comes through free state programs and nearly all of its
furniture was donated by local churches.
The home's 15 vacancies were filled as soon as they were available
and a sizeable waiting list has been developed.
Summary
The population of America is aging. This will bring new
opportunities to the housing and community development industries.
These markets are very capital and management intensive, and are not
merely a matter of diversification of ordinary home building
techniques. They require complex planning and dedicated concern for
the aging and their special requirements.
Study and Analysis of Data
Results
Of the 50 surveys distributed, 33 were returned. This is a return
rate of 66%. With n = 33, the mean age was 71 with a standard
deviation of 17. The median age was 74 and the mode was 80. In terms
of background information, 61% owned a car, 52% owned their homes and
19% rented their homes. 88% enjoyed the changing of the seasons and
16% were employed.
The relatively high return rate was due to two factors. The
instrument and the facilitators. The instrument included food coupons
worth $ 1.00 dollar at a local McDonald's restaurant. The facilitators
at each site personally saw to the completion and the return of the
surveys to the author. 91% of the respondents favored a single story
dwelling, 3% two stories, and 6% greater than two. 48% favored a
bedroom / kitchen while 33% favored a bedroom only. 97% required a
private bathroom and 82% said that they would not like to share their
room with any other people.
These data support the same conclusions reported in the
Dwight (1985) study and the journal information on utilization. That
is, the respondents preferred an apartment where they could prepare
meals for themselves, indicating the necessity of kitchen facilities.
They also requested that a common kitchen or cafeteria type restaurant
be available for the majority of their dining requirements.
This is also reflected in the occupancy rates, i.e., those units
with the integral kitchen facilities are the most often rented, while
those that do not are not as popular.
Relative to nearby services, the responses were as follows; 14.2%
requested medical care, 13.7% said drug store, 13.2% said bank. 11.7%
wanted a Church, 11.2% wanted a food store and 7.6% wanted a library.
7.1% said bus stop, 6.6% Mcdonald's, 5.6% said public park, 5.1% said
laundry, and 4.1% said Wendy's.
This information is in concert with what Dwight says about medical
care. 14.2% of the population stated that they preferred medical care
to be located within a three block radius of the facility. This
instrument did not examine the type of medical care, i.e., long term,
physical assessment, etc., but judging from the age of the majority of
the recipients, this author believes that they meant medical care
that would normally be delivered by a General Practitioner in the
office setting as opposed to a long term care facility.
72% favored three meals a day, 25% favored two. Cafeteria style
was the preferred serving style with 49% family style was 43% and
restaurant style was 6%. Preferred Beverages were milk 33%, coffee
32%, and tea 19%.
Special diets that were rated were low cholesterol 30% low sodium
25%, low fat 23%, and weight watcher 19%. Of specific ethnic foods
tested, Polish was 18%, German, Hungarian, Irish, Kosher, and Oriental
were 15%, with Arabic, American, and Italian at 7%. 48% thought the
cost of the meals should be included in the rental fees, 33% said cash,
12% said voucher or meal ticket and 7% said credit cards should be
considered.
Meal preferences relative to frequency and type were what the
author expected for this population. This population consisted mostly
of first generation Americans with strong ethnic and religious
backgrounds.
In terms of security and safety, 37% favored a security guard, 27%
said name tags, and 18% said ID badges. Unlimited visitation by family
and friends was greater than 29%, while visitation by clergy was
described as 25%.
Dwight's survey also indicated a strong desire for safety and
security. She states that 35% of her respondents felt that it was
necessary to have a uniformed security guard on the premises, compared
to 37% of this author's respondents. This may be in part due to the
fact that primary material possessions, i.e., photographs, furniture,
etc., acquire an elevated sense of importance or a " This is
all I have left " scenario. Therefore, if the elderly have made the
transition from their own homes, they want to be certain that their
remaining valuables will be well protected.
Should married couples share the same room?, 100% said yes; Should
unmarried couples?; 55% said no, 18% said they didn't know, 27% said
yes. Overnight visiting was favored by 64%, 12% said no and 24% said
they didn't know or that it depended on the situation and the
facilities available.
55% of the respondents said that unmarried couples should not be
allowed to stay in the same room. This is due, I believe, to the
prevailing age of the respondents, with its mean being 71 years and
57.7% of the respondents being 67 years of age or older.
25% said that pets should not be allowed. 19% said that birds
were acceptable, 17% said dogs, 24% fish, 14% turtles and 10% said
cats.
These data imply that 75% of the respondents were not opposed to
pets at the facility. However, the majority of them, 35%, stated that
they preferred " low maintenance ", pets. These were pets that
required little or no outdoor exercise.
The important aspect here is not so much owning a pet, but access to
the pet function which is the source of comfort and unconditional
acceptance that a pet can confer on its owner.
Less that 36% said that they would be interested in working at
either volunteer or part time work. This is due their relative incomes
and lifestyles during their years in the workplace. Volunteering is
out of place in their normal social and age group.
Extracurricular activities were rated as follows: Bus tours were
#1 at 13%, cards was #2. Gardening and live performers were tied for
#3 with 9.4%. Crafts and live theater were #4 at 8.7%, bingo was #5 at
8.1%, books were #6 at 6%, bowling and fishing were tied for #7. Golf,
quilting, and sewing were #8 at 3.4%, estate planning was #9 at 2.7%,
while boating was #10 at 2%.
The selection of these activities is typical for upper lower and
lower middle to upper middle income respondents with an estimated
annual income of less than $ 20,000.00.
Golfing, boating and estate planning were notably low on the preference
scale, while bus tours and card playing were the highest.
Overall, these results were representative of a group of people
who were more interested in their own safety and security than self-
actualized activities as volunteering. I believe that this is due to
their strong work ethics and ethnic backgrounds. Nothing was ever
handed to them. They had to work hard for everything that they had,
and therefore did not readily advocate the " giving " of anything to
others that did not earn it directly.
Conclusions
Based on the available data, the ideal facility would be
designed in the following manner.
It would consist of a single story dwelling with each unit having
a private bath and bedroom and rudimentary kitchen facilities. Primary
services located within a three block area would be General
Practitioner delivered medical care, a drug store, bank and library.
Security would be provided by a uniformed security guard and all of the
residents would have either name tags or pins. Family friends, and
clergy would have unlimited visiting privileges and special overnight
accommodations would be made available for family emergencies. Meals
would be provided three times per day and included in the rental cost
if desired. If not, a cash system or meal ticket program could be
arranged. Coffee, Tea, and Milk would be provided with meals with
alcoholic beverages available on special occasions for an additional
cost. Special diets would be made available if recommended by a family
physician. Various types of ethnic food would be available on an
intermittent basis. Pets would only be allowed in segregated areas of
the facility. Part time and volunteer work would be made available to
those residents who desired and were able to perform it.
The data that were generated by these surveys surprised me. I
did not expect the "elderly" to have the same types of preferences that
"normal" people have. I have also shown that if you wish to design a
facility for the individuals that we consider to be the "elderly", we
must consider a wide range of variables including the physical, social
and financial characteristics of the target population and not just
age.
Special Thanks
Special thanks to Mrs. Julia Horvat and Mrs. Leona Kirk, who were,
respectively, the Ohio and Michigan survey facilitators whose
assistance made this project possible.
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