The triple burden malnutrition is presently persistent in developing countries and accelerated by poor quality of diets which children are fed (UNICEF, 2019) with under-nutrition being the major problem with 820 million people undernourished (FAO, 2019 and WFP, 2012). It confers negative consequences on individuals and Populations since it causes increased health costs, reduced productivity, lagged economic development and continuous cycle of ill-health and poverty (WHO, 2018). Under-nutrition contributes to almost half (45%) of all the <5 deaths today (WHO, 2018; UNICEF, 2018). Though the numbers of undernourished people have fallen from 815 million to 777 million people, still this is unacceptable since still around 52 million children < 5 years are affected by wasting (FAO, 2017). Appropriate nutrition is vital for desired growth, and development in children (Bhutta et al., 2013). Insufficient amounts and eminence of complementary foods coupled with inappropriate feeding practices increase the rate of infection thus making children who haven’t attained 2 years of age much susceptible to stunting (White et al., 2017). There exists inadequate knowledge, inappropriate feeding practices, food insecurity and less attention to children <5 years due to inadequate advocacy and campaigns (KNBS & ICF macro, 2015)
Global under-nutrition 820 people are under-nourished with over 22% children < 5 years still stunted and over 50 million wasted (FAO, 2019). Child undernutrition has been prevalent in countries with low and middle-incomes thus remaining pervasive and consequently damaging conditions (Black et al., 2017). Around 2 billion children suffer from micronutrient deficiencies due to inadequate diet affecting their growth and brain development, school performance later in life (UNICEF, 2019). Wasting is still a challenge in the world today whereby 7.3% of children are wasted with 2.4% severely wasted (UNICEF/WHO/World Bank, 2019). The initial 1000 days of life of children prove to be a precarious moment for optimal child growth, and development (WHO, 2018). Optimal feeding of infants depends on what the progenies are fed, how they are fed, when, where, and who feeds them (UNICEF, 2019). This has not been achieved because there is a need for more communication platforms which could be used to capacity built the caregivers and mothers (Obare et al., 2012)
In Africa, particularly in the sub-Saharan region, child under-nutrition remains high with a drastic decline in nutrition status during the period of complementary feeding (Black et al., 2013). These rates have brought about increased disease burden hence high mortality levels (Danaei et al., 2016). The lack of adequate knowledge thus inappropriate infant feeding practices prove to be major contributor to increased morbidity and mortality among infants which have also led to increased rates of stunting (White et al., 2017). The interventions should focus at the period of window of opportunity so as to prevent morbidity and mortality rates thus avert any long-term harm which may befall infants and young children (Fabrizio et al., 2014)
In Kenya stunting is at 26% with a proportion of 8% of severe stunting for children aged 18-23 months with Nairobi city county rating at 18% (KNBS & ICF macro, 2015). Wasting is at 7% for children 6-11 months old in age and underweight at 11% (KNBS & ICF macro, 2015). Infant mortality is 39% and under-nutrition is 13.67% (KNBS & ICF macro, 2015). Studies from the informal settlement areas of Nairobi show that for children under five, 46% are stunted, 11% underweight and 2.5% wasted (Kimani-Murage et al., 2015). Inadequate knowledge and practice on appropriate breastfeeding plus poor complementary feeding prove to be the foremost causes of under-nutrition in children (Olatona et al., 2017). Therefore, there is need for more interventions to enhance knowledge gain on proper complementary feeding practices which involves; timely initiation of weaning foods at the age of six months alongside breastfeeding till the age of 2 years, right feeding frequency within a particular age and consuming diverse foods (Manikam et al., 2017).
To attain optimal complementary feeding, there is a need of establishing education system to focus on mothers (Ledoux et al., 2016) to change their knowledge, attitudes, and practices. The existing interventions to address KAP of mothers who have children below 2 years include; face to face nutrition counseling, use of printed posters that are put on the wall for the mothers to read, use of mother and child clinic booklet and health talks as the mothers sit awaiting to be served at the maternal and child health clinics. Despite the interventions, the stunting rates are still high and more interventions are needed to support the existing ones (Kimani-Murage et al., 2015).
Video learning enhances mastery skills and recall/remembrance which improves an individual’s knowledge (Ledoux et al., 2016). The use of nutrition education videos in locally understood language on complementary feeding is likely to be an appropriate educational tool for the illiterate mothers attending clinics in these health facilities. They will serve as a channel of communication which will increase the frequency of contact with information while increasing memory as more senses (audio-visual) are put in play. These videos can also be watched elsewhere if they are transferred to a portable device.
Factors associated with complementary feeding
Demographic Characteristics and Complementary Feeding
Complementary feeding is influenced by; – the mothers’ education level especially the ones with little education are more likely to introduce complementary foods too early (Wijndaele et al.,2009). High literacy among mothers is directly proportional to timely initiation of complementary foods for nurslings, and young children (Rao, 2011). Gebru (2007) established that the employed mommies are more likely to start complementary foods prior to 6 months unlike the unemployed ones. The inappropriate practice of complementary feeding among this population is due to inadequate information which is mostly brought by inadequate method of communication (Mucheru et al., 2016). Studies have shown that behavior change communication targeting especially young, single and illiterate mothers or caregivers in the developing countries will reduce morbidity and mortality rates in a great way (Olatona et al., 2017).
Most mothers in households which have poor feeding practices tend to be associated with large family size (Jansen et al., 2015) which is mostly attributed to inadequate knowledge on child spacing in developing countries (Fabrizio et al., 2014). Married mothers tend to have positive attitudes consequently practice on complementary feeding compared to their counterparts because of the support they get from their partners (Kimani-Murage et al., 2011). The informal settlements have a majority of young mothers who are inexperienced in child feeding due to inadequate information and poor attitude which results to improper practice of Infant and Young child feeding practices (Bahl et al., 2009). Therefore, there is a need of establishing another method of communicating messages on Infant and Young Child Feeding to these mothers as Haider et al. (2010) shows that it can improve the knowledge and practice which is also an indication of an improved attitude.
In Kenya, according to Kimani-Murage et al. (2011) who did a research in Nairobi informal settlements to establish the determinants of child feeding practices found that unmarried women practiced too early initiation of complementary foods than their married counterparts. According to Roy (2009), urban slum children below 6 months were initiated to complementary foods owing to apparently insufficient breast milk by their mothers. This concurred with the study which was done in Kibera slums in Nairobi, Kenya.
Socio-Economic Characteristics and Complementary feeding
According to Mucheru et al. (2016), maternal education, employment/unemployment and occupation directly relate to complementary feeding. This concurred with the studies which were done nationally in Kenya that showed that educated mothers had better child feeding practices compared to the illiterate (KNBS & ICF macro, 2015). There is low or high adherence to good feeding practices of Infant and Young children among mothers depending on the occupation of the household head, the mother and how the family income is handled in matters of good in a household (Engebretsen et al., 2007).
Many households in the informal settlements do not allocated income for food due to inadequate knowledge, unemployment among the majority and large families (Mututho, 2012; Korir, 2013; Kimani-murage 2015 and Black et al., 2013). Therefore, to improve the complementary feeding practices, there is a need of coming up with an educational intervention (Bhandari et al., 2004) to supplement the existing methods geared towards improving the maternal knowledge and attitudes for better practices.
Water, Sanitation and Hygiene and Complementary Feeding
Water is an important element in the body of children (UNICEF, 2019) since they are mostly prone to childhood infections which manifest high fevers leading to dehydration (WHO, 2019). Mothers who continue breastfeeding after 6 months, their children had far much better weight for height standard deviation than their counterpart (Srivastava, 2006; Magarey et al., 2015). Cultural practices have been a great hindrance to proper water, sanitation and hygiene practices and this can be made better through proper communication with an aim of improving the maternal knowledge and probably practice on complementary feeding (Fabrizio et al., 2014).
In the informal settlements, studies show that there is a need of additional methods which can be used in complementary feeding messaging to improve the knowledge of mothers and other members of the community in a simplest manner they can understand (Abuya et al., 2012). Inadequate observation of hygiene and sanitation in the introduction of complementary feeding due to inadequate knowledge has led to increased undernutrition especially stunting in the developing countries (Danaei et al., 2016). Therefore, well packaged messages on water, sanitation and hygiene should be put in place for a successful complementary feeding since according to Magarey et al. (2015), the mode of handling the Infant and Young Children will be greatly influenced by the knowledge borne by the mothers or the caregivers.
Substantial evidence have shown that behavior change can be achieved to better up water, sanitation, and hygiene practices in various households through using a good channel of passing information (Fabrizio et al., 2014). An intervention using video education to promote appropriate feeding practices by Bhandari, (2004) showed an improvement in physical growth of infants. Similar studies done by Madise (1991) in Botswana found that children initiated to complementary feeding at the age of 4 months or younger experienced more than 11 episodes of diarrhea compared to those exclusively breastfed for 6 months before introduction of complementary foods.
Maternal Knowledge and Complementary Feeding
Understanding the Role of Appropriate Infant Feeding for their Growth
The most desirable global goal is to reduce infant and young child malnutrition through appropriate infant feeding (Olatona et al., 2017). Estimates show that the worldwide load of malnutrition for the under-fives is 149 million children being stunted, 146 million underweight and 49 million children wasted (WHO, 2018; Mukuria et al., 2016). Linear growth for all healthful children in the world since birth till 5 years have similar features worldwide (Aguayo, 2017).
According to the causal matrix of under-nutrition (UNICEF, 2014) the major underlying factor of malnutrition is the care given to infants and young children. Childhood nutrition deficiencies in the early age of children leading to impaired growth is not only detrimental in academic abilities of children but also diminished capacity of earning in future (Fabrizio et al., 2014). One of the key care practices that has a significant consequence in a child’s growth, and development is complementary feeding (Aguayo, 2017). There should be sustained breastfeeding alongside complementary feeding up to 2 years for children since it is very important for their growth and development (Olatona et al., 2017).
Appropriate practice of complementary feeding could avert up to 6% of child’s mortality per year (White et al., 2017). Mothers and care givers from poor resource settings have been noted to have inappropriate infant feeding practices (Dewey, 2016) due to inadequate knowledge which has affected the growth, and development of infant, and young children who come from those areas. Thus, there is much need of improving maternal knowledge on the complementary feeding in order to realize good health and nutrition outcomes among infant and young children (Yohannes et al., 2018). Additional methods and approaches can be used to relay information thus equip the mothers and caregivers with adequate knowledge on complementary feeding.
Initiation of Complementary Feeding
Globally, infant, and young child feeding guidelines commend that there be timely initiation of diverse complementary foods to bridge the nutrient gap that is created as a child grows (WHO, 2018). Timely initiation of complementary foods is vital for better growth, and development in infants (Manikam et al., 2017). Introduction of complementary foods before the required time is hazardous to children and can make them very much susceptible to diseases (White et al., 2017). Unfortunately, most mothers introduce complementary foods early compared to those who introduce late due to inadequate knowledge (Yohannes et al., 2018).
Improved complementary feeding habits forecast better rectilinear growth results for children especially before attaining the age of 2 years (Aguayo, 2017). This should begin at 6 months of infants and go alongside with breastfeeding (Williams et al., 2016). Most studies done in different African countries such as in Uganda (Engebretsen et al., 2007), Ethiopia (Agedew & Demissie, 2014), South Africa (Mamabolo et al., 2004) and Kenya (KNBS & ICF macro, 2009) report that majority of the children are initiated into complementary feeding before attaining the age of 6 months. Gebru (2007) indicated that children are given complementary foods at 4 months old since most mothers and caregivers lack adequate knowledge.
Poor transition from exclusive breastfeeding to complementary feeding has been associated with high risk of children not realizing their full potentiality in future life due to high mortality rates (Manikam et al., 2017). Globally, only 64.5% of infants who are aged 6-8 months are fed with solid, soft, and semisolid foods according to WHO recommendations (White et al., 2017) which also indicate little consumption of a balanced diet since children from most households’ are fed on the staple foods.
In informal settlements like in Nairobi, 63.1% of infants are fed on complementary foods earlier before attaining the age of 6 months because of inadequate knowledge and low education levels among the mothers or caregivers (Muchina, 2010). This implies that infants are exposed to gastrointestinal complications in tender age leading to diarrhea, impaired nutrition status and increased morbidity and mortality rates (KDHS, 2014). There have been many interventions to improve complementary feeding among infants and young children but nothing much has changed (Aguayo, 2017); still there exist gaps on knowledge thus influencing practice negatively.
Complementary Foods and Dietary Diversity
There should be diversification of complementary foods (Williams et al., 2016) when feeding infants and young children. This maintains micro-nutrient and macronutrient adequacy within the frame of complementary foods (Nankumbi et al., 2012). Keen observation of dietary diversity leads to reduced risks of underweight, stunting, and wasting among children (Bhutta et al., 2013).
It has been found that the level of maternal education has a great influence on complementary feeding practices (Manikam et al., 2017). The period between birth to age 2 years is marked with much nutrient deficiencies which interferes with the child’s optimal growth and development (KDHS, 2014). Between the age of 6-9 months rarely do infants meet minimum dietary diversity but between 9 to 23 months they perform above average (Olatona et al., 2017). Therefore, it’s important for the mothers and caregivers to utilize postnatal care to gain appropriate knowledge which can lead to improved complementary feeding practices (Yohannes et al., 2018).
Children 6-23 months should feed from 4 food groups minimally out of the 7 commended foods (WHO, 2018) for proper growth and development. These food groups entail the following: Grains, roots and tubers, legumes and nuts, dairy products, flesh foods, eggs, Vitamin A-rich fruits and vegetables and other fruits and vegetables. A study done in Mongolio found that most children consumed < 2 food groups (Lander et al., 2005). In some areas like Mwingi district, Eastern Kenya, about 60% of children consumed starchy staples and oils (Macharia et al., 2010) both of which are associated with mothers and care givers having inadequate knowledge on child feeding.
Therefore, there is a need for additional awareness creation methods for instance the use of audio-visual methods, Information Education and Communication materials or any other method which is targeting behavior change for betterment of dietary diversity during complementary feeding among mothers and caregivers.
Complementary Feeding and Meal frequency
Lowest possible meal frequency is the fraction of progenies aged 6 to 23 months old who take soft, semisolid, and solid foods (but comprising milk foods/products also for nonbreastfed children) in the minimum number of times recommended by WHO (WHO, 2008). This is clearly shown that the number of times an infant, and young child is to be fed depends on the age of the child: 2 times for the age of 6-8 months for the breastfed infants, 3 times for 9-23 months for the breastfed children and 4 times for those children who are between 6 to 23 months old (WHO, 2008). These meals comprise of main foods given to children and also the snacks (other than frivolous amounts).
Studies done in Brazil, Romulus-Nieuwelink et al. (2011), among breastfed infants aged 8 months showed that children were fed well and met the recommended lowest possible meal frequency of 3 times each day. This study was also in agreement with the other one which was done in Burkina Faso, Sawadogo et al. (2011) which focused on examining the time of initiation of complementary food, and the dietary diversity which found out that infants received 2 meals each day at 9 months and 3 meals each day for those who were 12 months old of age.
In Kenya, children are not fully fed in the needed number of times more especially in the poor resource setting areas (KDHS, 2014). It was clearly found that children from mothers who had no education had greater chances of wasting, precisely 10%, than those whose mothers had received some education (KDHS, 2014). Equipping mothers and caregivers with specific information and messages like meal frequency requirements for the infants and young children may improve complementary feeding practices (Yohannes et al., 2018). Therefore, from the findings discussed above, this calls for raising awareness to mothers and caregivers to improve their maternal knowledge and practice on meal frequencies which are appropriate for the infants and young children so as to curb the rising rates of malnutrition among infants and young children (Manikam et al., 2017)
Complementary Feeding and Minimum Acceptable Diet
There exists a positive relationship between complementary feeding and the nutrition wellbeing of children (Kimwele, 2014). Unattained lowest possible acceptable diet is a predictor of wasting for children aged 6 to 23 months of age (Korir, 2013). Studies show that the shift of food consumption by humans from traditional foods to fast foods like soft drinks, and cookies has also made the feeding practices for children to change (Caetano et al., 2010).
There might be consumption and meeting of minimum acceptable diet but on the other hand consuming less healthy foods in large amounts (Korir, 2013). There is poor consumption of minimally acceptable diet especially in the low-income earners like in the slum areas because of low purchasing power by its residents (White et al., 2017).
In Kenya, only 2 in ten children (21%) aged 6 to 23 months are fed correctly and meets the lowest possible acceptable diet (KNBS & ICF macro, 2015). There is better meeting of the minimum required diet between the ages 12 to 17 months, 24%, and worst is between 6-8 months which indicate 17% of children who are fed with minimum acceptable diet (KNBS & ICF macro, 2015). These findings agree with the study which was done in Indonesia by Ahmad et al. (2018) which also found out that minimum acceptable diet was below average, 40% among the mothers with children aged 6 to 23 months.
Therefore, to curb the suboptimal complementary feeding which consequently affect the minimum acceptable diet among children aged 6-23 months, there is great need of equipping and enlightening child bearing mothers with appropriate messages on how to feed children so as to heighten infant and young child feeding practices and meet minimum acceptable diet (Ahmad et al., 2018; Yohannes et al., 2018)
Complementary feeding frequency with continued breastfeeding
There should be promotion and support of foods for age-appropriate so as to make the practice of complementary feeding successful (Aguayo, 2017). The way children are transited to complementary foods and the feeding experience they encounter isn’t only crucial for their immediate survival, growth, and development but also for their potentiality in future life (White et al., 2017). Most mothers and caregivers have inadequate knowledge thus low knowledge on carrying out the transition process to complementary feeding and that is why there is still high rates of malnutrition among children who are Under Five years (Bhutta et al., 2013).
Complementary foods should be given in various frequencies depending on the age of children: 2 times for those children who are breastfed and aged 6-8 months, 3 times for breastfed children with ages 9-23 months and for the children aged 9-23 months and are not breastfed, should be fed at least 4 times (WHO, 2010). Though meeting the nutritional needs through appropriate complementary feeding in a poor resource setting is a challenge, due to knowledge inadequacies which in turn impact negatively on practice, leading to high malnutrition rates and hindrance to proper development in early childhood (Dewey, 2016), much advocacy can be done to boost the mothers’ and caregivers’ knowledge hence influencing their practice (Aguayo, 2017). This could lead to behavior change and reduced child morbidity and mortality rates.
In Kenya, the national data shows that the percentages; 72.5%, 65.0%, 60.7% and 57.7% of children are fed the lowest possible recommended times or more for 6-8, 9-11, 12-17 and 18-23 ages respectively (KNBS & ICF macro, 2010). The period between birth and 2 years is marked with much nutrient deficiencies which interferes with the child’s optimal growth and development (Fabrizio et al., 2014). This occurs as a result of poor practices on complementary feeding among the caregivers and mothers because of inadequate knowledge on complementary feeding. Along the complementary foods, infants, and young children are to be breastfed till the age of at least 2 years (Ricci & Caffarelli, 2016). The need for more advocacies among mothers to elevate their knowledge is needed which will in turn enable them feed their infants and young children as expected to attain better growth and development (Aguayo, 2017).
If good methods are used to campaign against malnutrition, there will be a great change in people’s way of life leading to better nutrition among children (Fabrizio et al., 2014). Insufficient amounts coupled with poor quality of complementary foods and inappropriate feeding practices threatens children’s health, and nutrition (Bhutta et al., 2013). As a child grows, there is an increased need of nutrients by the body for full growth and development (Sayed & Schönfeldt, 2018). This knowledge needs to be shared with the mothers and caregivers so as to enable them practice appropriate infant and young child feeding practices.
Maternal Practice and Complementary Feeding
Even though there have been much efforts to promote good practices on complementary feeding, there has been low uptake (Mutiso et al., 2018). It is a common practice for early introduction of complementary foods among the infants (Sayed & Schönfeldt, 2018). In Kenya, the percentage of children breastfeeding up to 20 to 23 months old is 51%. It is further shown that 21% of progenies of age 6 to 23 months old consume appropriate diet (KNBS & ICF macro, 2015).
Therefore, there is need for increasing awareness on continuous breastfeeding with appropriate complementary feeding to enhance the nutrition status of children. Studies illustrate that improved infant, and child care activities are likely to reduce deaths of underfives by 19 % in those countries which have high mortality rates (Agedew & Demissie 2014).
Handling, Preparation and storage of complementary foods
Globally, the objective of preventing and controlling diseases also targets on improving how food is prepared and stored more especially for the infants and young children (Quick et al., 2015). Inadequate knowledge and poor attitude coupled with cultural practices have contributed to great hindrance to complementary feeding in some communities especially in developing countries more especially on food preparation and storage (Fabrizio et al., 2014). To alleviate such challenges, there is a need of nutrition education so as to provide relevant knowledge that can empower mothers and caregivers to enhance behavior change (White et al., 2017). Safe preparation, storage, and serving of complementary food for the infants, and young children is as important as the food itself (Manikam et al., 2017).
The caregiver should wash her or his hands before preparing food and feeding the infants and young children. Food should be stored under good hygienic conditions and served immediately after preparation (WHO, 2012). Mostly, complementary foods at the initiation point to the infants are of low energy, and micronutrients, unhygienic prepared, and stored leading to exposure of children to infections that lead to diarrhea, thus resulting to growth faltering. Educating mothers and caregivers on appropriate preparation and storage of complementary foods should be major areas to train and educate mothers (Savalia et al., 2013) so as to achieve the required behavior change.
Feeding during and after illness
Children should continue breastfeeding more and be fed during illness and giving them extra food after the illness (UNICEF, 2014). The infant should be well fed with fluids at this period because of exposure to much dehydration due to increased fever. In these fluids, water should take a large portion since it is neutral (Gessese et al., 2014) and can efficiently restore the lost water that might have been experienced. Most mothers and caregivers in the informal settlements do not feed their children adequately during illness due to inadequate knowledge on feeding the under 5 years’ children during illness (White et al., 2017)
The amounts of foods per meal, the age, texture and frequency can be summarized as in the table below:
Different amounts of food, frequencies and texture at different ages of children.
|Age||Texture||Frequency||Amounts of food per meal|
|6 Months||Infant to be started with small amounts and consistencies and increase as the child grows older||Should be fed 2 times a day with frequent breast milk||Should be given 2 tablespoon and increase as the child grows|
|7-8 months||The infant should be started with thick porridge & well mashed family foods.||Should be fed 3 times a day with a snack and frequent breast milk depending on his or her appetite.||Snacks can be given too (1-2) Should be given 2-3 spoonful per feed with gradual increment to half 250ml cup|
|9-11 months||Should be given finely chopped foods that the baby can pick||This should be 3 meals on top of the breast milk dependent of the appetite of the baby 1 snacks can be given||Give ¾ cup of food per meal of family food|
|12-23 months||The child should be given the family food and if need be, it can be chopped or mashed.||3 meals should be given on top of breastfeeding depending on the appetite of the child.||2 snacks can be given 1 cup (250ml) cup should be given.|
Adopted from WHO (2008), Infant and Young Child Feeding Counseling Guide
Effect of nutrition education video lessons on knowledge, attitude and practices of mothers on complementary feeding
The strongest determinants of good child nutrition are education and nutritional knowledge (Abuya et al., 2012). Caregivers lack up-to-date knowledge on optimal feeding especially infant and young children during complementary period (Mukuria et al., 2016). According to Kumar et al. (2006), Inadequate knowledge on the appropriate complementary feeding is an important risk aspect for stunting, wasting and underweight. When mothers and caregivers keenly observe dietary timely initiation, dietary diversity, good meal regularity and lowest possible acceptable diet, there will be decreased risks of underweight, stunting, and wasting (White et al., 2017).
Therefore, there is a need of more nutrition education approaches to enhance behavior change (White et al., 2017). Behavior change interventions have been used largely and noted to have a vital role in improving complementary feeding practices thus leading to improved children’s growth and development (Fabrizio et al., 2014). The target of nutrition education is to change the behavior and perceptions (Welch & Sheridan, 2000).
Social cognitive theory is very much useful in this aspect since it depicts a person’s self-efficacy and the expected outcome (Bandura, 2004). The use of video education to modify health behaviors is the best than many other education forms (Tuong et al., 2014). It has also been noted that the use of videos as a method of education serves as cost-effective where people can just observe what other people have acted (Sirota & Hamez, 2013). To a great extent, educational videos have been found to be the most effective tool in changing maternal knowledge and practices on complementary feeding (Scheimann et al., 2010).
Appropriate complementary feeding practices can bring a great change by impacting positively on maternal and caregiver’s attitude and practices on complementary feeding for the children under 5 years. Mothers need to learn, understand and prevent the problem of nutritional inadequacy of complementary foods quality-wise and quantity-wise which is the major crisis in the developing countries today. Even though there are a number of strategies put in place to improve complementary feeding in Kenya, complementary feeding practice is still very poor with many children receiving complementary foods very early below the recommended, 6 months, by WHO.
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