Health equity refers to the study of differences in the quality of health across different populations. Health equity is different from equality, as it refers only to the absence of disparities in controllable aspects of health; it is not possible to work towards complete equality in health, as there are some factors of health that cannot be controlled. Equity implies some kind of social injustice. Thus if one population dies younger than another because of genetic differences, we tend to say that there is a health inequality, but if they die younger due to lack of access to medicines, we might say that there is a health inequity. These inequities may include differences in the "presence of disease, health outcomes, or access to health care" across racial, ethnic, sexual orientation and socioeconomic groups, among others.
Health equity falls into two major categories: horizontal equity, the equal treatment of individuals or groups in the same circumstances; and vertical equity, the principle that individuals who are unequal should be treated differently according to their level of need.
Disparities in the quality of health across populations are well-documented globally. Particularly, a lack of health equity is evident in both developed and developing nations. The importance of equitable access to healthcare has been cited as crucial to achieving many of the Millennium Development Goals. According to Thomas LaVeist, Director of the Hopkins Center for Health Disparities Solutions, there are six key factors that contribute to health disparities: socioeconomic conditions, social and physical environments, access to quality care, cultural competency, health literacy, and empowered healthcare consumers.
- 1 Socioeconomic Status
- 2 Ethnic and racial disparities
- 3 LGBT minority group health disparities
- 4 Healthcare equity and sex
- 5 Health Inequality and Environmental Influence
- 6 Disparities in access to health care
- 7 Disparities in quality of health care
- 8 Plans for achieving health equity
- 9 Health inequalities
- 10 Poor Health and Economic Inequality
- 11 See also
- 12 References
- 13 Further Notes
- 14 External links
Socioeconomic status is both a strong predictor of health, as well as a key factor underlying health inequities across populations. Socioeconomic status has the capacity to profoundly limit the capabilities of an individual or population, manifesting itself through deficiencies in both financial and social capital. It is clear how a lack of financial capital can compromise the capacity to maintain good health. In the UK, prior to institution of the NHS reforms in the early 2000s, it was shown that income was an important determinant of healthcare resources. Maintenance of good health, through the utilization of proper healthcare resources, can be quite costly and therefore unaffordable to certain populations. In China, for instance, the collapse of the Cooperative Medical System left many of the rural poor uninsured and unable to access the resources necessary to maintain good health. Increases in the cost of medical treatment made healthcare increasingly unaffordable for these populations. This issue is further perpetuated by the rising income inequality in the Chinese population. Poor Chinese were often unable to undergo necessary hospitalization and failed to complete treatment regimens, resulting in poorer health outcomes. Similarly, in Tanzania, it was demonstrated that wealthier families were far more likely to bring their children to a healthcare provider; a significant step towards stronger healthcare. Some scholars have noted that unequal income distribution itself, can be a cause of poorer health for a society as a result of "underinvestment in social goods, such as public education and health care; disruption of social cohesion and the erosion of social capital."
The role of socioeconomic status in health equity extends beyond simple monetary restrictions on an individual's purchasing power. In fact, social capital plays a significant role in the health of an individual and their community. It has been shown that those who are better connected to the resources provided by the individuals and communities around them (those with more social capital) live longer lives. In fact, the segregation of communities on the basis of income occurs in nations across the globe and has a significant impact on quality of health as a result of a decrease in social capital for those trapped in poor neighborhoods. Social interventions, which seek to improve healthcare by enhancing the social resources of a community, are therefore an effective component of campaigns to improve a community's health. It has been shown that community healthcare approaches fared far better than individual approaches in the prevention of heart disease mortality in one study.
Education is an important factor in healthcare utilization. An individual may not go to a medical professional or seek care, if they don’t know the ills of their failure to do so, and the value of proper treatment. Over time, the likelihood of giving birth at home has increased rapidly among women with lower educational status in Tajikistan, however education still has a significant impact on the quality of prenatal and maternal healthcare. Those with primary educations consulted a doctor during pregnancy at significantly lower rates (72%) when compared to those with a secondary education (77%), technical training (88%) or a higher education (100%). There is also evidence for a correlation between socioeconomic status and health literacy, as wealthier families were more likely to recognize disease in their children than those that were poorer in a study of Tanzanian families.
Ethnic and racial disparities
||The examples and perspective in this section deal primarily with the United States and do not represent a worldwide view of the subject. (March 2012)|
The United States historically had large disparities in health and access to adequate healthcare between races, and current evidence supports the notion that these racially-centered disparities continue to exist and are a significant social health issue. The disparities in access to adequate healthcare include differences in the quality of care based on race and overall insurance coverage based on race. The Journal of the American Medical Association identifies race as a significant determinant in the level of quality of care, with ethnic minority groups receiving less intensive and lower quality care. Ethnic minorities receive less preventative care, are seen less by specialists, and have fewer expensive and technical procedures than non-ethnic minorities.
There are also considerable racial disparities in access to insurance coverage, with ethnic minorities generally having less insurance coverage than non-ethnic minorities. For example, Hispanic Americans tend to have less insurance coverage than white Americans and receive less regular medical care. The level of insurance coverage is directly correlated with the level of access to healthcare including preventative and ambulatory care.
A 2010 study on racial and ethnic disparities in health done by the Institute of Medicine showed that these differences cannot be accounted for in terms of certain demographic characteristic like insurance status, household income, education, age, geographic location and severity of conditions is comparable. Even when the researchers corrected for these factors, the disparities persist.
It is pretty widely recognized that minority groups generally have higher death rates from cancer, heart disease and diabetes than whites. Gerard Boe’s article cites studies that show major disparities in health care as it relates to specific diseases:
- Heart Disease: African Americans are 13% less likely to be recommended for and undergo coronary angioplasty and 1/3 less likely to undergo bypass surgery than whites. Death rates from heart attack and stroke are 29% and 40% higher, respectively, among African Americans than whites
- Asthma: Of preschool aged children who were hospitalized for Asthma related conditions, only 7% of African American children, 2% of Hispanic children compared to over 20% of White children are prescribed medications to prevent future Asthma related hospitalizations.
- Breast Cancer: Studies have found that the length of time between and abnormal mammogram and further diagnostic testing to determine if a patient has cancer is more than twice as long in Asian-American, African American and Hispanic women than it is in White women. African American women are more than twice as likely as white women to die of cervical cancer and have the highest rate of breast cancer death of any racial or ethnic group
- Compared with rates in whites, the rates of diabetes are 1.9 times higher among Hispanics, two times higher among African Americans, and 2.6 times higher among Native Americans
- Some of these disparities are actually worsening. For example, the African American–to-white ratio of infant mortality has steadily increased during the past 2 decades and now is at 2.5:1
His article also discusses the increased incidence of receiving little or no routine and usual care and therefore, reduced chance of receiving preventative care and other health services.
- Hispanic children are almost three times as likely to receive no routine and usual source of health care as White children.
- Only 16% of White patients have a lack of routine and usual sources of health care compared to about 20% of African Americans and 30% of Hispanic patients.
Racial and Ethnic disparities in children: 31.4 million Children in the United States are of non-white race or ethnicity (March 2010), this compromises 43% of American children and shows an increase over 11% since 2000. Mortality rates are substantially higher in minority children for all-cause mortality. Overall mortality rates are consistently found to be significantly higher in African American and other minority children. Specifically, disparities are found in specific mortality rates for certain diseases, acute-lymphoblastic leukemia and congenital heart defect among others. Asthma has also been a topic of many studies.
Race is considered to be more strongly associated with higher rates of African American children with unmet health care needs and lower access to primary health care providers than income is.
One of the most important ways to help reduce health disparities is to work to reduce language barriers between patients and physicians. Language barriers are a major problem because of five main difficulties:
- First, arriving at an accurate diagnosis is difficult, because an adequate history cannot be obtained.
- Second, treatment options cannot be adequately explained and discussed.
- Third, it is impossible to obtain truly informed consent for diagnostic and therapeutic procedures.
- Fourth, any attempts to provide health education are severely compromised.
- Finally, it is very difficult for physicians to act as effective advocates for patients we do not really know.
If physicians and other clinicians are able to reduce language barriers the resulting improved communication can improve compliance, reduce the number of emergency room visits, and enhance patient understanding. Gunderman suggests that there are a few ways for physicians and the health care system in general to reduce language barriers like using nonverbal communication through gestures, the use of visual aids, and printed materials and videos in patients' native languages. They can also improve their fluency in the non-English equivalents of basic medical terms. The use of trained interpreters can also prove extremely valuable.
There is debate about what causes health disparities between ethnic and racial groups. However, it is generally accepted that disparities can result from three main areas:
The Institute of Medicine report, Race, Ethnicity, and Language Data identifies current models for collecting and coding race, ethnicity, and language data; ascertains the challenges involved in obtaining these data in health care settings; and makes recommendations for improvement.
A study of 20,000 cancer patients in the United States found that African Americans are less likely than European Americans to survive breast cancer, prostate cancer, and ovarian cancer even when given equal care, but that other forms of cancer had equal survival chances, which suggests that biological factors may be at work.
The National Partnership for Action to End Health Disparities (NPA) was established to mobilize a nationwide, comprehensive, community-driven, and sustained approach to combating health disparities and to move the nation toward achieving health equity. The mission of the NPA is to increase the effectiveness of programs that target the elimination of health disparities through the coordination of partners, leaders, and stakeholders committed to action. http://minorityhealth.hhs.gov/npa/
The National Stakeholder Strategy (NSS) for Achieving Health Equity is a product of the NPA. This document provides a common set of goals and objectives for public and private sector initiatives and partnerships to help racial and ethnic minorities—and other underserved groups—reach their full health potential. The strategy incorporates ideas, suggestions and comments from thousands of individuals and organizations across the country. Local groups can use the National Stakeholder Strategy to identify which goals are most important for their communities and adopt the most effective strategies and action steps to help reach them. http://minorityhealth.hhs.gov/npa/templates/content.aspx?lvl=1&lvlid=33&ID=286
LGBT minority group health disparities
See also LGBT issues in medicine.
Sexuality has become a major source of discrimination and inequity in health. Homosexual, bisexual, and transgender populations experience a wide range of health problems related to their sexuality and gender identity. One of the egregious inequities that face LGBT individuals is discrimination from healthcare workers or institutions. In a study of the quality of healthcare for South African MSM, a cohort of individuals were interviewed about their health experiences. The researchers found that homosexually identified MSM felt that their access to healthcare was limited by their inability to find clinics who employed healthcare workers who did not discriminate based upon their sexuality. They often faced "homophobic verbal harassment from healthcare workers when presenting for STI treatment." Further, those MSM who did not identify as homosexuals did not feel comfortable discussing - and did not disclose - their sexual activity with healthcare workers, limiting the quality of their sexual healthcare. Similarly, a survey of the United States revealed that transgender individuals faced a significant level of discrimination with 19% of individuals having experienced a healthcare worker refuse care because of their gender 28% having faced harrassment from their healthcare worker, 2% having faced violence, and 50% having a doctor who was not qualified for to provide transgender care.
Furthermore, healthcare for LGBT populations is hindered by a lack of medical research on such groups. Without the appropriate studies, it is difficult to assess what the proper strategies are for treatment of these groups. For instance, a review of medical literature regarding LGBT patients revealed that there is a significant gap in our understanding of breast cancer, which is more prevalent among lesbian and bisexual women, as it is unclear whether this is a result of probability or another cause. Similarly, the review notes that it is generally assumed that these groups of women have a lower incidence of cervical cancer than their heterosexual counterparts, and as a result they have a low rate of screening, despite the fact that it is unclear whether they are actually at a decreased risk for the disease. In addition, it is difficult to conduct retrospective studies on LGBT populations as a result of a failure to note sexual orientation on death certificates.
Healthcare equity and sex
The results in comparing inequities in access to adequate healthcare and gender show that women in the United States generally have higher levels of access to care. These disparities can be explained in part by looking at rates of overall insurance coverage (privatized and publicly assisted) between men and women, the effects of certain socioeconomic factors on levels of coverage between men and women, and overall gender-based differences in perceptions of health and health care.
In the United States, women have better access to healthcare, in part, because they have higher rates of health insurance. In one study of a population group in Harlem, 86% of women reported having health insurance (privatized or publicly assisted), while only 74% of men reported having any health insurance. This trend in women reporting higher rates of insurance coverage is not unique to this population and is representative of the general population of the US.
Gender-based perceptions of health and healthcare may help explain some of the lag of men behind women in levels of insurance coverage. Women report higher rates of illness than men, which barring the idea that women are sicker than men, indicates women are more likely to seek medical care out and are therefore more likely to possess medical insurance.
Gender-related disparities in access to healthcare are also related to socioeconomic factors including geographic job-market differences and differing levels of government assistance available to men and women. There are fewer job opportunities with insurance coverage available to men and women living in poorer communities, and of these opportunities, women tend to occupy more of the jobs with these benefits. Government assistance available to these individuals without job-related coverage varies between men and women, with women, especially women with children, receiving a higher percentage of available public assistance than men. Ultimately, for both men and women discrepancies in access to adequate healthcare is largely based on socioeconomic issues including income and full-time work status, with both groups of men and women with higher levels of income and full-time work receiving greater access to adequate healthcare.
Health Inequality and Environmental Influence
Minority populations have increase exposure to environmental hazards that include lack of neighborhood resources, structural and community factors as well as residential segregation that result in a cycle of disease and stress. The environment that surrounds us can influence individual behaviors and lead to poor health choices and therefore outcomes. Minority neighborhoods have been continuously noted to have more fast food chains and fewer grocery stores than predominantly white neighborhoods. These food deserts affect a family’s ability to have easy access to nutritious food for their children. This lack of nutritious food extends beyond the household into the schools that have a variety of vending machines and deliver over processed foods. These environmental condition have social ramifications and in the first time in US history is it projected that the current generation will live shorter lives than their predecessors will.
In addition, minority neighborhoods have various health hazards that result from living close to highways and toxic waste factories or general dilapidated structures and streets. These environmental conditions create varying degrees of health risk from noise pollution, to carcinogenic toxic exposures from asbestos and radon that result in increase chronic disease, morbidity, and mortality. The quality of residential environment such as damaged housing has been shown to increase the risk of adverse birth outcomes, which is reflective of a communities health. Housing conditions can create varying degrees of health risk that lead to complications of birth and long-term consequences in the aging population. In addition, occupational hazards can add to the detrimental effects of poor housing conditions. It has been reported that a greater number of minorities work in jobs that have higher rates of exposure to toxic chemical, dust and fumes.
Racial segregation is another environmental factor that occurs through the discriminatory action of those organizations and working individuals within the real estate industry, whether in the housing markets or rentals. Even though residential segregation is noted in all minority groups, blacks tend to be segregated regardless of income level when compared to Latinos and Asians. Thus, segregation results in minorities clustering in poor neighborhoods that have limited employment, medical care, and educational resources, which is associated with high rates of criminal behavior. In addition, segregation affects the health of individual residents because the environment is not conducive to physical exercise due to unsafe neighborhoods that lack recreational facilities and have nonexistent park space. Racial and ethnic discrimination adds an additional element to the environment that individuals have to interact with daily. Individuals that reported discrimination have been shown to have an increase risk of hypertension in addition to other physiological stress related affects. The high magnitude of environmental, structural, socioeconomic stressors leads to further compromise on the psychological and physical being, which leads to poor health and disease.
Individuals living in rural areas, especially poor rural areas, have access to fewer health care resources. Although 20 percent of the U.S. population lives in rural areas, only 9 percent of physicians practice in rural settings. Individuals in rural areas typically must travel longer distances for care, experience long waiting times at clinics, or are unable to obtain the necessary health care they need in a timely manner. Rural areas characterized by a largely Hispanic population average 5.3 physicians per 10,000 residents compared with 8.7 physicians per 10,000 residents in nonrural areas. Financial barriers to access, including lack of health insurance, are also common among the urban poor.
Disparities in access to health care
Reasons for disparities in access to health care are many, but can include the following:
- Lack of insurance coverage. Without health insurance, patients are more likely to postpone medical care, more likely to go without needed medical care, and more likely to go without prescription medicines. Minority groups in the United States lack insurance coverage at higher rates than whites.
- Lack of a regular source of care. Without access to a regular source of care, patients have greater difficulty obtaining care, fewer doctor visits, and more difficulty obtaining prescription drugs. Compared to whites, minority groups in the United States are less likely to have a doctor they go to on a regular basis and are more likely to use emergency rooms and clinics as their regular source of care.
- Lack of financial resources. Although the lack of financial resources is a barrier to health care access for many Americans, the impact on access appears to be greater for minority populations.
- Legal barriers. Access to medical care by low-income immigrant minorities can be hindered by legal barriers to public insurance programs. For example, in the United States federal law bars states from providing Medicaid coverage to immigrants who have been in the country fewer than five years.
- Structural barriers. These barriers include poor transportation, an inability to schedule appointments quickly or during convenient hours, and excessive time spent in the waiting room, all of which affect a person's ability and willingness to obtain needed care.
- The health care financing system. The Institute of Medicine in the United States says fragmentation of the U.S. health care delivery and financing system is a barrier to accessing care. Racial and ethnic minorities are more likely to be enrolled in health insurance plans which place limits on covered services and offer a limited number of health care providers.
- Scarcity of providers. In inner cities, rural areas, and communities with high concentrations of minority populations, access to medical care can be limited due to the scarcity of primary care practitioners, specialists, and diagnostic facilities.
- Linguistic barriers. Language differences restrict access to medical care for minorities in the United States who are not English-proficient.
- Health literacy. This is where patients have problems obtaining, processing, and understanding basic health information. For example, patients with a poor understanding of good health may not know when it is necessary to seek care for certain symptoms. While problems with health literacy are not limited to minority groups, the problem can be more pronounced in these groups than in whites due to socioeconomic and educational factors.
- Lack of diversity in the health care workforce. A major reason for disparities in access to care are the cultural differences between predominantly white health care providers and minority patients. Only 4% of physicians in the United States are African American, and Hispanics represent just 5%, even though these percentages are much less than their groups' proportion of the United States population.
- Age. Age can also be a factor in health disparities for a number of reasons. As many older Americans exist on fixed incomes which may make paying for health care expenses difficult. Additionally, they may face other barriers such as impaired mobility or lack of transportation which make accessing health care services challenging for them physically. Also, they may not have the opportunity to access health information via the internet as less than 15% of Americans over the age of 65 have access to the internet. This could put older individuals at a disadvantage in terms of accessing valuable information about their health and how to protect it. On the other hand, older individuals in the US (65 or above) are provided with medical care via Medicare.
Disparities in quality of health care
Health disparities in the quality of care exist and are based on language and ethnicity/race which includes:
- Problems with patient-provider communication. Communication is critical for the delivery of appropriate and effective treatment and care, regardless of a patient’s race, and miscommunication can lead to incorrect diagnosis, improper use of medications, and failure to receive follow-up care. The patient provider relationship is dependent on the ability of both individuals to effectively communicate. Language and culture both play a significant role in communication during a medical visit. Among the patient population, minorities face greater difficulty in communicating with their physicians. Patients when surveyed responded that 19% of the time they have problems communicating with their providers which included understanding doctor, feeling doctor listened, and had questions but did not ask. In contrast, the Hispanic population had the largest problem communicating with their provider, 33% of the time. Communication has been linked to health outcomes, as communication improves so does patient satisfaction which leads to improved compliance and then to improved health outcomes. Quality of care is impacted as a result of an inability to communicate with health care providers. Language plays a pivotal role in communication and efforts need to be taken to ensure excellent communication between patient and provider. Among limited-English proficient patients in the United States, the linguistic barrier is even greater. Less than half of non-English speakers who say they need an interpreter during clinical visits report having one. The absence of interpreters during a clinical visit adds to the communication barrier. Furthermore, inability of providers to communicate with limited English proficient patients leads to more diagnostic procedures, more invasive procedures, and over prescribing of medications. Poor communication contributes to poor medical compliance and health outcomes. Many health-related settings provide interpreter services for their limited English proficient patients. This has been helpful when providers do not speak the same language as the patient. However, there is mounting evidence that patients need to communicate with a language concordant physician (not simply an interpreter) to receive the best medical care, bond with the physician, and be satisfied with the care experience. Having patient-physician language discordant pairs (i.e. Spanish-speaking patient with an English-speaking physician) may also lead to greater medical expenditures and thus higher costs to the organization. Additional communication problems result from a decrease or lack of cultural competence by providers. It is important for providers to be cognizant of patients’ health beliefs and practices without being judgmental or reacting. Understanding a patients’ view of health and disease is important for diagnosis and treatment. So providers need to assess patients’ health beliefs and practices to improve quality of care. Patient health decisions can be influenced by religious beliefs, mistrust of Western medicine, and familial and hierarchical roles, all of which a white provider may not be familiar with. Other type of communication problems are seen in LGBT health care with the spoken heterosexist (conscious or unconscious) attitude on LGBT patients, lack of understanding on issues like having no sex with men (lesbians, gynecologic examinations) and other issues.
- Provider discrimination. This is where health care providers either unconsciously or consciously treat certain racial and ethnic patients differently from other patients. This may be due to stereotypes that providers may have towards ethnic/racial groups. Doctors are more likely to ascribe negative racial stereotypes to their minority patients. This may occur regardless of consideration for education, income, and personality characteristics. Two types of stereotypes may be involved, automatic stereotypes or goal modified stereotypes. Automated stereotyping is when stereotypes are automatically activated and influence judgments/behaviors outside of consciousness. Goal modified stereotype is a more conscious process, done when specific needs of clinician arise (time constraints, filling in gaps in information needed) to make a complex decisions. Physicians are unaware of their implicit biases. Some research suggests that ethnic minorities are less likely than whites to receive a kidney transplant once on dialysis or to receive pain medication for bone fractures. Critics question this research and say further studies are needed to determine how doctors and patients make their treatment decisions. Others argue that certain diseases cluster by ethnicity and that clinical decision making does not always reflect these differences.
- Lack of preventive care. According to the 2009 National Healthcare Disparities Report, uninsured Americans are less likely to receive preventive services in health care. For example, minorities are not regularly screened for colon cancer and the death rate for colon cancer has increased among African Americans and Hispanic populations. Furthermore, limited English proficient patients are also less likely to receive preventive health services such as mammograms. Studies have shown that use of professional interpreters have significantly reduced disparities in the rates of fecal occult testing, flu immunizations and pap smears.
Plans for achieving health equity
Health inequality is the term used in a number of countries to refer to those instances whereby the health of two demographic groups (not necessarily ethnic or racial groups) differs despite comparative access to health care services. Such examples include higher rates of morbidity and mortality for those in lower occupational classes than those in higher occupational classes, and the increased likelihood of those from ethnic minorities being diagnosed with a mental health disorder. In Canada, the issue was brought to public attention by the LaLonde report.
In UK, the Black Report report was produced in 1980 to highlight inequalities. On 11 February 2010, Sir Michael Marmot, an epidemiologist at University College London, published the Fair Society, Healthy Lives report on the relationship between health and poverty. Marmot described his findings as illustrating a "social gradient in health": the life expectancy for the poorest is seven years shorter than for the most wealthy, and the poor are more likely to have a disability. In its report on this study, The Economist argued that the material causes of this contextual health inequality include unhealthful lifestyles - smoking remains more common, and obesity is increasing fastest, amongst the poor in Britain.
Poor Health and Economic Inequality
Poor health outcomes appear to be an effect of economic inequality across a population. Nations and regions with greater economic inequality show poorer outcomes in life expectancy, mental health, drug abuse, obesity, educational performance, teenage birthrates, and ill health due to violence. On an international level, there is a positive correlation between developed countries with high economic equality and longevity. This is unrelated to average income per capita in wealthy nations. Economic gain only impacts life expectancy to a great degree in countries in which the mean per capita annual income is less than approximately $25,000. The United States shows exceptionally low health outcomes for a developed country, despite having the highest national healthcare expenditure in the world. The US ranks 31st in life expectancy. Americans have a lower life expectancy than their European counterparts, even when factors such as race, income, diet, smoking, and education are controlled for.
Relative inequality negatively affects health on an international, national, and institutional levels. The patterns seen internationally hold true between more and less economically equal states in the United States.The patterns seen internationally hold true between more and less economically equal states in the United States, that is, more equal states show more desirable health outcomes. Importantly, inequality can have a negative health impact on members of lower echelons of institutions. The Whitehall I and II studies looked at the rates of cardiovascular disease and other health risks in British civil servants and found that, even when lifestyle factors were controlled for, members of lower status in the institution showed increased mortality and morbidity on a sliding downward scale from their higher status counterparts. The negative aspects of inequality are spread across the population. For example, when comparing the United States (a more unequal nation) to England (a less unequal nation), the US shows higher rates of diabetes, hypertension, cancer, lung disease, and heart disease across all income levels. This is also true of the difference between mortality across all occupational classes in highly equal Sweden as compared to less-equal England 
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