Nurse Culture Assessment

Running head: CULTURAL ASSESSMENT Cultural Assessment June 14, 2008 Abstract In order to deliver nursing care to different cultures, nurses are expected to understand and provide culturally competent health care to diverse individuals. Culturally competent care is tailored to the specific needs of each client, while incorporating the individual’s beliefs and values (Stanhope & Lancaster, 2006, p. 90). By being culturally competent, nurses are able to help improve health outcomes by using cultural knowledge and specific skills in selecting interventions that are specific to each client (Stanhope & Lancaster).
Therefore, nurses “should perform a cultural assessment on every client with whom they interact with” (Stanhope & Lancaster, 2006, p. 90) to help understand client’s perspectives of health and illness and discuss culturally appropriate interventions. In this paper, the author will demonstrate how nurses can utilize a cultural heritage assessment tool to help develop a cultural competent nursing care plan, which can be referred to in Appendix A and B.
By culturally assessing client, nurses will be able to identify the needs of culturally diverse individuals and find out if what’s important to the culture is really important to the person in terms of specific health needs. Introduction In order to deliver nursing care to different cultures, nurses are expected to understand and provide culturally competent health care to diverse individuals. Nurses must find out about people’s traditions, ways of life, and beliefs about health care so that the appropriate interventions can be planned and implemented to produce culturally positive health outcomes (Stanhope & Lancaster, 2006).

By being aware of the client’s cultural beliefs and knowing about other cultures, “nurses may be less judgmental, more accepting of cultural differences, and less likely to engage in the behaviors that inhibit cultural competence” (Stanhope & Lancaster, 2006, p. 84). Most importantly, nurses must listen to the client’s perceptions of problems and work together to develop suggestions and recommendations for managing those problems.
Therefore, cultural assessments tools have been developed and are available to help assist nurses integrate “professional knowledge with the client’s knowledge and practices to negotiate and promote culturally relevant care for a specific client” (Stanhope & Lancaster, 2006, p. 82). Part I: Cultural Assessment of Client A cultural nursing assessment is recognized as a “systematic way to identify the beliefs, values, meanings, and behaviors of people while considering health history, life experiences, and the social and physical environments in which people live” (Stanhope & Lancaster, 2006, p. 5). For this reason, cultural assessments are an essential component in providing quality care to diverse individuals of different cultures. For this reason, the author used the cultural heritage assessment tool to help assess the ethnic culture of Mrs. P. Referring to Appendix A, the outline shows the interview questions and answers collected by the author per Mrs. P. Reassuring the confidentiality of the client’s interview, utilization of the cultural heritage assessment tool enabled the author to gather, classify, and analyze the culture of an American Hindu Indian.
Brief History of Ethnic and/or Racial Origins The client evaluated by the author was a 35 year old female named Mrs. P who lives in Poway, California. The immediate family composition consists of a wife and a husband who just recently got married. In regards to the client’s cultural background, the ethnic culture that Mrs. P identified with was an American Hindu Indian. Born and raised in Poway, California, Mrs. P’s father and the grandparents from the father and mother’s side were born in Punjab, India, while the mother was born in Utter Pradesh, India.
Coming from India, the client’s parents has lived in the United States for 14 years. Living in Poway since then, Mrs. P grew up in a rural setting and lived with the parents and younger brother until recently moving out when the client got married. With Hindi as the client’s native language, Mrs. P and the brother can only speak Hindi, compared to the mother and father who can both read and speak the native language. Socioeconomic Considerations With occupation and education, the client’s dad has a master’s in business and works for Gateway computers.
The client’s mom has a degree in psychology and is a housewife, and the younger brother has degree from UCSD for management science and economics and works at Boeing. As for Mrs. P, the client works as a teacher, having earned a bachelor’s degree in business administration from the University of California, Riverside, and Mr. P works as a neuro-surgeon, with a bachelor’s degree in cellular and molecular biology and in computer engineering, and masters in computer engineering.
Receiving no financial assistance, the client seemed satisfied in the current socioeconomic class of upper middle class because there are no plans of changing job. Currently owning a home with 4 bedrooms, 3 bathrooms, a living room, dining room, loft, and patio, the living arrangements for Mrs. P appear sufficient for a future family to live in. Value Orientation According to Mrs. P, respect for elders, a good education, good family background and connections, religion, and good ethics for society, are values that are held highly within the family’s culture.
Education and a highly held position in a career are very important because these values determine an individual’s status in society. Examples include doctors and engineers. Obviously, success is pertinent within the Indian culture. Indians are known for their hard work, vitality and dynamism. However, although looked as highly important, the family’s overall impression of these values do not define who a person is; these values are appreciated. Growing up, Mrs. P learned that every action requires thinking because any decision might have a negative effect on the family, and how society will react.
Family reputation is very important and in the Indian culture, individuals must be careful not to do anything to put down the family name. The Indian culture is very family-oriented, which is why family comes first. In health and in sickness, the family takes care of each other. Cultural Sanctions and Restrictions According to the client, there are no cultural sanction and restrictions that the client is aware of. For the most part, Mrs. P believes that since the parents were open-minded to the fact of living in the United States, a strict Indian culture was not experienced during childhood.
The parents understood what kind of environment the children were in and did not expect Mrs. P and the brother to be restricted to an Indian lifestyle. Communication As far as communication is concerned, Mrs. P informed the author that communication involves all members of the family, friends, and community. However, the Indian culture affects the way individuals communicate with family and friend by restricting certain topics when inappropriate. For example, foul language or sexual topics may be considered unacceptable to discuss in front of parents.
For the most part, Mrs. P’s family does get along well, which is evident by the client’s close relationship with immediate and extended family members. With such open communication to some extent and having great family relationships, Mrs. P maintains contact with all members of the family and takes the time to visit family every few weeks. Health-related Beliefs & Practices & Nutrition Health-related beliefs and practices generally emphasize taking care of the health of all members in the family. According to Mrs.
P, health-related beliefs and practices are related to nutrition. The only information that the client provided to the author was that Hindus perceive some foods as “hot” and some are “cold”, and therefore, should only be eaten during certain seasons and not in combination. There are different perceptions of “hot” and “cold” foods depending on the region of where individuals are from. From these perceptions, foods are thought to affect body functions. In the client’s case, Hindus love to cook and eat traditional dishes that are perceived as healthy.
From raima, cholay, and saag, these Indian dishes are usually made by the client’s mother because Mrs. P does not usually make the traditional cultural dishes. As far as any specific dietary restrictions, eating meat is not considered good, but some individuals within the culture still eat meat. With Mrs. P, the client strives on well-balanced meals and does not follow the ideas of hot and cold foods. The only cultural diet that is followed is not eating meat. Cultural Aspects of Disease Incidence In regards to aspects of disease, the client’s culture customs and eliefs often contribute to the decision for medical care and choice of healthcare services. Supernatural forces and excess in human needs are recognized to contribute to illness and disease, regardless of station in life. For example, the client gives that example of eating too many sweets will cause round worms and that too much sexual activity can be associated with tuberculosis. Even more so, if a disease is sexually related, the occurrence of such diseases is looked upon as disrespectful if unmarried. In addition, diarrhea can be caused by a variety of improper eating habits.
As a result, cultural treatments that may be used include homeopathic medicine, herbal remedies, mixing religion and medicine, and observing the individual within a natural environment. In the client’s case, a health problem that is currently affecting the family is high blood pressure. Religious Affiliation According to Mrs. P, the client’s religious preference is Hinduism, which is the same religion for Mr. P and all members of the immediate family. Religious beliefs and practices include believing in reincarnation and in many gods, and occasionally attending a temple.
However, the client does not belong to a religious institution nor is an active member of any religious or ethnic organization. Yet, the client does practice the Hinduism when with the family. In the author’s opinion, the client expressed ideas for becoming more involved with participating in religious or spiritual activities. As for the neighborhood, there are diverse backgrounds of different ethnic cultures and religions within the community. Developmental Considerations The only achievements and tasks fulfilled by the client’s family include having both children graduate from college and finding successful careers.
With having such high values in education and career, the author is not surprised that the parents consider graduation and a new job as very important achievements that a family member can accomplish. Even more, in the client’s sake, getting married, starting a new job, and moving into a new home were life changing fulfillments that the client has longed to achieve. As far as failures and achievements, being Indian has affected the fulfillment of achievements and perspectives of failures by placing the pressure to always be “on top of [the] game. Competition is what brings out the best in people and achieves the best results. Growing up, the client was always encouraged to excel. The expectations of families towards children were very high. With Mrs. P, the client strived to be the best because expectations were high and from the author’s point of view, the client has done very well to be at the point where the client is. Since the client’s family first start, the only health and health-related events and experiences that Mrs. P has gone through is dealing with the removal of cataracts in client’s father’s eyes.
Fortunately for Mrs. P, there have been no immediate deaths or births have taken place since the client has been born. Since the client’s the new marriage life, no health related events has occurred. Part II: Self Assessment Health-related Attitudes regarding this Cultural Group From the author’s self assessment about health-related attitudes regarding Indians, the author presumed that the most Indians are prone to respiratory infections such as tuberculosis and pneumonia, hypertension, nutritional deficits, and high risk behavior such as alcoholism and cigarette smoking.
To be perfectly honest, the main assumption that the author had in regards to this cultural groups is that individuals of the Indian culture prone to strive dietary restrictions, which lead to a number of health problems. In addition, having had an Indian roommate, the author believed that individuals of this culture hold strong cultural beliefs and values because of the parents. Parents have a strong hold in the way Indian children think and behave. From family, friends, school, and community relationships to sexual activities, education, and work, Indians are expected to be smart, careful, and successful in all aspects of life.
In the author’s opinion, such values and beliefs definitely influence and contribute to the health-related attitudes held by author because American Indians’ physical, psychological, social, and spiritual dimensions of life can eventually affect the health of these individuals. Evaluation of Author’s Values, Beliefs, & Practices In regards to the author’s values, beliefs, and practices, much of what has been embedded into the value and belief system of the author, including lifestyle practices, has been due to family, friends, and personal experience.
From respect, obedience, and honesty, to work, education, religion, rationality and practicality, and the quality of life and health, the author strives to maintain a positive outlook in life, believes that hard work and determination will lead to a successful career, marriage, and family upbringing, and appreciates life and all the fortunate blessings that are often taken for granted like ambulation, breathing, and a healthy, loving family. Family, school, health, and religion are the most important values that the author holds.
As a Catholic, the author believes that God has a plan for everything and whether life experiences are good or bad, God has a reason. Although the author does not religiously attend Church, prayer is often performed at home and at school. With school, education is an important aspect to a successful career. In the author’s opinion, knowledge is pertinent to success. Even more so, being aware of beneficial and risky lifestyle practices are necessary to maintain a healthy life. Such practices include exercise, a well-balanced diet, no smoking or drugs, and safe sexual practices.
Obviously, values, beliefs, and practices may affect the physical, psychological, social, and spiritual dimensions in life. However, being only 25 years old, the author is aware that there is still so much more to learn about life. Therefore, the author remains open to new ideas and opportunities so that additional knowledge, mistakes, achievements, and failures will continue to add to the author’s life experiences. How might Author’s values, beliefs, & practices affect Delivery of Nursing Care to this Culture Group?
The author’s values, beliefs, and practices may affect the delivery of nursing care to this culture group with the inability to empathize and understand complaints and concerns about health which leads to inaccurate assumptions about patient needs and creates assumptions that may impose ideas and interventions that may be unacceptable to the plan of care. Being unable to step outside the author’s box of values, beliefs, and practices may prevent the author from learning about another culture.
As a result, the overall affect of delivering nursing care for this culture group is making incorrect assumptions about the needs of the clients and developing a care plan that may serve no benefit in improving the quality of life. Part III- Developing a Plan of Care After culturally assessing Mrs. P, the author identified the client’s readiness for enhanced religiosity. With a new marriage, a new house, and a new job, the client expresses concern that being away from the parents may lead to decreasing active lifestyle of practicing the beliefs and practices of the Indian culture.
Even more so, the client acknowledges and expresses a desire to maintain the beliefs, values, practices that the parents have taught. Being married to a husband who does not actively practice the Indian culture, along with dealing with the expected stressors of being a new wife, taking care of a new house, and starting a new job, Mrs. P. strongly believes that maintain the values and practices of the Indian culture may be an effective coping strategy that Mrs. P is willing and ready to do. Obviously, Mrs. P. recognizes the importance of the Indian culture and is ready to enhance what had been taught to cope with the new life changes.
Referring to Appendix B, the author’s goal for the client includes verbalizing the willingness to seek help to regain desired religious beliefs and practices and acknowledging the need to strengthen religious affiliations and become involved in spiritually based programs. These two goals seem appropriate for the client because if Mrs. P is willing to seek help with maintain the Indian culture and acknowledges the need for additional resources to participate in religious activities; the client can enhance religiosity within the newly accepted life transitions.
Therefore, the interventions that the author has planned include determining the spiritual state/motivation for growth by ascertaining religious beliefs of family of origin and climate in which client grew up, discussing client’s spiritual commitment, beliefs and values, assisting the client to integrate values and beliefs to achieve a sense of wholeness and optimum balance in daily living by exploring connection of desire to strengthen belief patterns and customs of daily life, and encouraging participation in religious activities, worship/religious services, reading religious materials, etc and provide referral to community sources.
In the author’s opinion, the overall plan of care has been adapted to the specific ethnic or cultural beliefs of Mrs. P because the plan addresses the cultural needs of the client. The interventions are client-centered and do not force any assumptions or beliefs of the author or of any other culture. The client has control of the care given. Even more so, communication, education, and religion being incorporated into the plan of care which were what the client expressed as the values and beliefs that are recognized as important. Hence, keeping what is important to the client.
Conclusion To review, nurses must be able to provide culturally competent care to diverse individuals of different cultures. Culturally competent care can be accomplished by utilizing cultural assessment tools to better understand clients and other cultures in the community. Assessing the culture of an individual is an essential component in providing quality nursing care. In order to provide culturally diverse care, nurses need to take the time to learn about each client: who the client is, what the client feels and, most importantly, what the client needs.
By doing so, nurses will be able to tailor a plan of care that implements interventions that are best appropriate to a client’s specific need, delivering quality nursing care, especially when of a different culture. References Doenges, M. , Moorhouse, M. , & Murr, A. (2006). Nurse’s pocket guide: Diagnoses, prioritized interventions, and rationales (10th ed. ). Philadelphia, PA: F. A. Davis. Stanhope, M. & Lancaster, J. (2006). Foundations of nursing in the community (2nd ed). St Louis, MO: Mosby, Inc. Appendices Appendix A Cultural Assessment of Client I.
Brief History of Ethnic and/or racial origins of the cultural group with which the client identifies Q1. What ethnic culture do you identify with? A1. American Indian. Q2. Can you describe a brief history of your ethnic culture? A2. Okay. Q3. Where were your parents born? Where did they grow up? A3. India – Punjab (dad) mom – U. P (Utter Pradesh) Q4. Where were your grandparents born? A4. India Q5. Mother’s parents? A5. Punjab – India Q6. Father’s parents? A6. Punjab – India Q7. How many siblings do you have? A7. 1 younger brother. He is 28 years old.
I am 35 years old. Q8. What setting did you grow up in? urban or rural? A8. I’ve lived in Poway, California, all my life. I love it here. My area looks more rural than urban. There is a lot of open land and green grass. We’re near the mountains so we are pretty far from the city life. Q9. What is your native language? A9. Hindi Q10. Do you speak this language? A10. Yes, everyone in my family can. Q11. Do you read your native language? A11. No, just my parents. Q12. Was your original family name changed? A12. No. Well, I just recently got married, so I carry my husband’s name now.
Q13. How old were you when you came to the US? (if applicable? ) A13. I was born in U. S. A. My parents, on the other hand, came about 14 years ago. Q14. Who lived with you growing up? A14. Parents and brother II. Values Orientation Q1. What does your culture value? A1. Respect for elders, good education, good family background and connections, and good ethics for the society. Religion is also important. Our culture strives on hard work, vitality, and dynamism. Q2. Compared to western culture, how do you value achievement, materialism, ducation, work, equality, understanding of the environment, rationality and practicality, orderliness, and the quality of life and health? (in terms from your culture, if different? ) A2. I value all these things, especially education and high status in career is important. The type of careers you do are also very important and sets your status in society (doctors and engineers looked upon highly). Growing up, I learned the reputation was highly looked upon so whatever I did, I had to think before I act. Q3. How does your family value these things? A3.
My family believes these are also all important, but they do not see these things as items that define a person, but they do appreciate these things. For the most part, upholding the family name and image in society is an important aspect in our culture because family comes first. My family is very family-oriented and respect is expected within our immediate and extended relationships. III. Cultural Sanctions and Restrictions Q1. Any cultural sanctions and restrictions? A1. None that I am aware of. If there were, I certainly was not informed. I guess because my parents do not carry the Indian culture as strict as other families.
They try to be very open-minded to living in the United States and understanding the kind of environment that me and my brother live in. IV. Communication Q1. How does your family communicate with each other? A1. We talk to everyone, openly and respectfully. We talk to family, friends, and the people of the community. Q2. How does culture affect the way you communicate to family and with friends? A2. Certain things might not be accepted to be talked about in front of parents such as foul language or sexual topics. Q3. Does your family get along? A3. Definitely!
Family is very important, unless something is inappropriate or unacceptable, then that causes problems. But for the most part, being close to family is an essential aspect of our culture. Q4. Have you or do you maintain contact with: Q4a. Aunts, uncles, cousins? Brothers and sisters? Parents? A4a. Yes, especially since I moved out of the house. I try to remain in close contact with everyone. Q5. Did most of your aunts, uncles and cousins live near your home? A5. Yes Q6. How often did you visit family members who lived outside of your home? A6. Every few weeks V. Health-related beliefs and practices
Q1. Does your culture believe in traditional health beliefs or practices? A1. Much of what we believe in is related to nutrition. What we eat affects the way we function. For example, some foods are “hot” and some are “cold”, and therefore, should only be eaten during certain seasons and not in combination. Depending on what region individuals are from, different families have a different perspective of “hot” and “cold” foods. Hindus love to cook and everyone has their own perception of healthy foods, so individuals usually cook dishes that they believe are nutritional to how one may function.
Q2. Do you follow any traditional health beliefs or practices? A2. No, not really. I eat whatever my mom used to cook for me. But now that I moved out, I cook whatever I have in the fridge. I don’t really believe in the hot and cold stuff. Q3. Do you do anything to keep healthy or prevent illness? A3. Just eat right and workout. I try to eat well-balanced meals and exercise. VI. Nutrition Q1. Do you prepare foods special to your ethnic background? If yes, describe. A1. I don’t make them since I don’t know how, but my mom makes many different dishes and I enjoy eating them. rajma, cholay, saag) Q2. Are there specific dietary restrictions in your culture? A2. Eating meat is not considered good in our culture, but people still eat it. I, on the other hand, have kept that dietary restriction so I don’t eat meat. VII. Socioeconomic considerations Q1. What is your family’s occupation and education? A1. Well, my dad has masters in business and he works with Gateway computers. Mom is a housewife; brother works at Boeing and got a degree from UCSD for management science and economics. Q2. Do you receive financial assistance? A2. No Q3.
Are there any plans of changing jobs to earn a little more income? A3. Well, I just recently got hired as a teacher and I have no plans for changing my career any time soon. Honestly, my husband makes money that is definitely sufficient for our income, and I am very fortunate to find a successful man. Q4. Do you own or rent a house? A4. Eventually, we plan to own the new house we just moved into. Q5. How are living arrangements? A5. We currently own a home with 4 bedrooms, 3 bathrooms, a living room, dining room, loft, and patio. I love it here. We’re the only ones living in the house right since we just moved in.
So there is a lot of privacy and a lot of space. We are ready to start a family. XIII. Organizations providing cultural support Q1. Are there any organizations that provide cultural support for you or your family? A1. No, but I’m very interested in finding out every since I got married. XIV. Educational background Q1. Describe your educational background? And your husband? A1. I have a BS in Business Administration and my husband has a bachelor’s degree in cellular and molecular biology and in computer engineering, and masters in computer engineering. Q2.
Describe your parent’s educational background? A2. Dad – masters in business, mom has degree in psychology XV. Religious affiliation Q1. What is your religious preference? A1. Hinduism Q2. Describe your religious background, beliefs, and practices. Does your family attend Church? A2. Believe in reincarnation and many gods, occasionally attend a temple. For the most part, since I’ve moved out and my husband is not that religious, I tend to practice Hinduism at home and when I’m with my family. My parents strive on religion and since I’ve moved out, I feel like I am not as active as I used to be.
Q3. Is your boyfriend/girlfriend the same religion as you, if any? A3. Yes, husband is same religion, but he doesn’t really practice any religious or spiritual activities. Q4. Is your girlfriend/boyfriend the same ethnic background as you? A4. Yes, he is also an American Indian Q5. Do you live in a neighborhood where the neighbors are the same religion and ethnic background as yourself? A5. No, diverse backgrounds in our apartment complex Q6. Do you belong to a religious institution? A6. No, but I think it would be great if I was. Q7. Would you describe yourself as an active member?
A7. No. But again, I think being newly married; I think that being religious and spiritual may be a good thing. It’s hard to find the time to participate in religious or spiritual activities, but being a new wife with a new home and job, I think it would be good for me. Q8. How often do you attend your religious institution? A8. Very rarely anymore. I used to with my parents. Q9. Do you practice your religion in your home? A9. Yes Q10. Are your friends from the same religious background as you? A10. No Q11. Are your friends from the same ethnic background as you?
A11. No XVI. Cultural aspects of disease incidence Q1. What does your culture believe in when it comes to aspects of disease? A1. Disease and illness is often thought be caused by our culture’s customs and beliefs. From supernatural forces to having excess human needs, individuals can be affected regardless of education and status in life. Some examples I can give you is eating too many candies can lead to ringworm, excessive sexual activity can cause tuberculosis, and diarrhea can be caused by not eating a well-balanced diet. Q2. Any cultural treatments? A2.
Some like homeopathic medicines, herbal remedies, others like to mix religion with medicine and observe the patient with the natural environment. Q3. How does your culture view the occurrence of diseases? A3. If it’s a sexual disease it can be looked upon as disrespectful if you are unmarried. Q4. Are there any health problems that could affect your family now? A4. High blood pressure XVII. Biocultural variations Q1. Are you any other culture besides Indian? A1. No. Full American Indian. XVIII. Developmental considerations Q1. Describe family achievements and tasks fulfillment since your family’s start? A1.
My parents’ best achievement, as they always tell me, was having me and my brother. Other than that, my family has not had significant achievements. With a stable career and a good neighborhood, my parents have had a good life without changing their line of profession or participating in life-changing events. However, me and my brother graduated from college and have found successful careers. Even more so, I just recently got married and my parents are very proud of me to have found such a good man at the right time. Q2. How has your culture or ethnic identify affected fulfillment of achievements or failures?
A2. Growing up, my parents always encouraged me to excel. The expectations of each member were high. From work to school to even household chores, my parents expected the best out of me. In our culture it is expected to always be at the top of your game. This makes you want to always strive for the best and reach for the stars. Q4. From your family’s first start, what health and health-related events and experiences have happened? A4. Well, since I got married, there haven’t been any significant health-related experiences to note. Yet, during my family’ first start, my dad recently had his cataracts taken out.
Other than that, I have been blessed with a healthy family for the most part. Appendix B Plan of Care |Interventions |Rationales | |A. Nurse will determine spiritual state/motivation for growth by |A. Early religious training deeply affects children and is carried on | |ascertaining religious beliefs of family of origin and climate in which|into adulthood. Any conflict may family’s beliefs and client’s current | |client grew up. |learning may need to be addressed. | | | |B. Discuss client’s spiritual commitment, beliefs and values. |B. Enables examination of these issues and helps client learn more about| | |self and what he or she desires. | | | | |C. Nurse will assist client to integrate values and beliefs to achieve |C.
Becoming aware of how these issues affect the individual’s daily life| |a sense of wholeness and optimum balance in daily living by exploring |can enhance ability to incorporate them into everything he or she does. | |connection of desire to strengthen belief patterns and customs of daily| | |life. | | | | | |D.
Nurse will enhance optimum wellness by encouraging participating in |D. Encouragement allows individual to pursue what he or she wants and | |religious activities, worship/religious services, reading religious |referrals allow clients to become aware of what options are available. | |materials, etc and provide referral to community sources. | | ———————– Nursing Diagnosis:
Readiness of Enhanced Religiosity related to life changes secondary to getting married, a new house, and a new job AEB by client’s desire to strengthen religious belief patterns and customs that had provided comfort in the past, request for assistance to increase participation in religious beliefs through prayer, and requests for referrals to religious affiliation. Goal 2: Patient will acknowledge need to strengthen religious affiliations and become involved in spiritually based programs of own choice Goal 1: Patient will verbalize willingness to seek help to regain desired religious beliefs and practices Interventions

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