Cardiovascular disease (CVD) is the leading cause of death in the United States and African Americans (AA) have a disproportionately greater burden of CVD as compared to Whites. The American Heart Association (AHA) Life’s Simple 7 (LS7) framework outlines goals for attaining ideal cardiovascular health. Yet, there is a lack of evidence summarizing best practices to maximize LS7 attainment. The objective of the present study was to systematically review the extant peer-reviewed literature on community-engaged and community-based participatory research (CBPR) aimed at improving one or more LS7 metrics among AA.
PubMed, CINAHL, and Embase databases were searched. We included articles that reported quantitative results for one or more of the following LS7 metrics: physical activity, diet, cholesterol, blood pressure, body mass index, smoking, and glycemia. We included analyses with a greater than 50% AA study population focused on adults (≥18 years of age).
Of the 1008 unique studies identified, 54 met inclusion criteria; 27 of which were randomized controlled trials. 50% of studies assessed more than one LS7 metric but only two studies evaluated all seven of the LS7 metrics. No studies had a high proportion of AA males. 40 studies improved at least one LS7 metric at the study end-point. Formative research was used in many studies to guide intervention design. Studies were of varying quality, but overall rated “fair” using a modified approach to the National Institute of Health quality assessment tool.
There is insufficient data to recommend a specific community-engaged or CBPR intervention to improve attainment of LS7 metrics among AA. Future studies using rigorous methodology with increased gender diversity and utilizing the AHA LS7 framework are required to establish a validated program to improve LS7 in AAs.
Citation: Elgazzar R, Nolan TS, Joseph JJ, Aboagye-Mensah EB, Azap RA, Gray DM II (2020) Community-engaged and community-based participatory research to promote American Heart Association Life’s Simple 7 among African American adults: A systematic review. PLoS ONE 15(9): e0238374. https://doi.org/10.1371/journal.pone.0238374
Editor: Eyal Oren, San Diego State University, UNITED STATES
Received: January 20, 2020; Accepted: August 14, 2020; Published: September 1, 2020
Copyright: © 2020 Elgazzar et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the manuscript and its Supporting Information files.
Funding: The authors received no specific funding for this work.
Competing interests: The authors have declared no competing interests exist.
Abbreviations: AA, African American; CVD, Cardiovascular Disease; AHA, American Heart Association; LS7, Life’s Simple 7; CBPR, Community-Based Participatory Research
Cardiovascular disease (CVD) is the leading cause of death in the United States . CVD incidence and mortality is highest among racial and ethnic minorities . This is of critical importance as the percentage of ethnic minorities are projected to vastly increase in the United States. Estimates show that African Americans (AA) will see a 42% population increase between 2014 and 2060 . AA, in particular, have a disproportionately greater burden of CVD and lower life expectancy, as compared to Whites [1, 4, 5]. CVD disparities among AA are facilitated by a high prevalence of a multitude of risk factors, such as obesity, hypertension, and diabetes mellitus , in addition to the interaction of social and behavioral health factors . Furthermore, there are striking gender differences which interface racial health disparities. The burden of chronic disease is substantially higher in AA males, who have the highest age-adjusted all-cause mortality of any race-gender group in the U.S . In 2015, the life expectancy of non-Hispanic Black males was 71.8 years compared to 78.1 for Black females and 78.7 for Whites of both sexes . In addition to the higher rates of CVD, Black men are also twice as likely to die from CVD than White men .
Given that behavioral and biological factors contribute to a large percentage of health, the American Heart Association (AHA) in 2010 outlined goals for reaching ideal cardiovascular health through the Life’s Simple 7 (LS7) framework . The framework consists of modifiable lifestyle behaviors and biometric factors, including smoking status, body mass index (BMI), physical activity, diet, total cholesterol, blood pressure, and blood glucose. There have been numerous studies showing associations of higher attainment of LS7 with lower risk of CVD, diabetes, and cancer. Additionally, interventions addressing multiple risk factors are more likely to reduce rates of fatal CVD when compared to single risk factor interventions . However, little evidence exists reviewing best practices to maximize LS7 attainment in communities and populations that have high prevalence of CVD along with various chronic diseases and all-cause mortality.
Multi-ethnic cohorts including AA [12–14] and studies focused specifically on AAs  showed that higher attainment of ideal cardiovascular health as defined by the seven factors (i.e., smoking abstinence or cessation, BMI <25 kg/m2, adequate levels of physical activity, healthy diet, total cholesterol <200 mg/dL, blood pressure <120/80 mmHg, and fasting glucose <100 mg/dL in the absence of diabetes mellitus) is associated with significantly lower risk of CVD . Moreover, ideal cardiovascular health is associated with lower risk of incident cancer and type 2 diabetes [15, 16]. Compared to Whites, Chinese Americans and Hispanic Americans, AAs have lower attainment of ideal LS7 metrics . In addition to individual lifestyle and behavior factors, there are environmental and psychosocial factors that are framed within the social determinants of health (SDOH) that impact the disproportionate burden of chronic disease in AAs. The SDOH are “the conditions in which people are born, grow, live, work and age,” which include domains such as economic stability, education, and built environment . In general, AAs are disproportionately burdened by poor status of SDOH . These upstream factors play a key role in the development of CVD risk factors . Racism is an additional burden on AAs that may impact the individual (individual racism) and underlies inequities in the social determinants of health across AA communities through structural racism, such as lower educational levels, higher poverty, higher violence, and exposure to environmental toxins [21, 22]. On the individual level, there is evidence that racism contributes directly to the higher incidence of HTN in AA  and interpersonal racism is associated with increased long-term stress levels . This is further magnified by the social and environmental barriers that stem from institutional racism, such as its negative effect on socioeconomic status and healthcare access, highlighted by the impact of redlining [25, 26].
Successful efforts to activate and engage large numbers of AAs to attain ideal cardiovascular health with the goal of reducing disparities in CVD, diabetes, and cancer are vastly needed. However, successfully implementing such interventions can be challenging. Community-engaged research can aid in mitigating this challenge. It overcomes some limitations of the traditional medical model by integrating the cultural, social, and environmental contexts that underlie clinical and public health initiatives . Guided by the social ecological model, community-engaged research is broadly characterized as the process of multidisciplinary collaborative work among community groups sharing special interests to address problems and customize solutions specific to that community . Community-based participatory research (CBPR) is one type of community-engaged research.
CBPR is a highly involved cooperative approach which mobilizes and empowers communities through research partnerships to develop, implement, test, and sustain effective interventions targeted toward a population’s unique goals and challenges . While community-engaged research gives communities shared ownership over the products of research, CBPR goes a step further by necessitating that community stakeholders participate in all stages of research . Through the shared exchange of expertise, CBPR focuses on improving health by involving community members, public leaders, civic organizations, and academic institutions at all levels of research development and translation. CBPR, as well as community engaged research overall, has demonstrated favorable intervention acceptability . Furthermore, utilization of such strategies may be critical to engaging and reducing disparities in attainment of ideal LS7 metrics among AAs.
Within the community-engaged and CBPR frameworks, formative research is often utilized in order to culturally tailor interventions to the population of interest, especially when targeting lifestyle changes . Rather than testing a specific hypothesis, formative research uses qualitative and/or quantitative methods such as interviews, focus groups, direct observation, and surveys, to inform the design and implementation of interventions which take into account community attitudes, needs, and barriers .
With AAs attaining fewer ideal components of the LS7 framework, improved knowledge of effective disease prevention strategies aiming to mitigate the disproportionate rates of premature morbidity and mortality among AA due to CVD, diabetes, and cancer are necessary. LS7 interventions developed using CBPR and community-engaged research principles may have significant impact at the individual and population levels. However, best practices to conduct such work have yet to be established. This systematic review aims to examine the current literature on interventions targeting LS7 improvement in AAs. Specifically, this review will focus on CBPR and community-engaged research used to evaluate efficacy and effectiveness of interventions using one or more LS7 metrics in AAs.
We conducted a systematic review of English-language literature to identify and synthesize extant literature on the assessment of one or more LS7 metrics within CBPR and community-engaged interventions for AAs. We searched MESH/Headings and keywords for terms associated with African American, black, community-based participatory research, community engagement, cardiovascular health, cardiovascular disease, physical activity, exercise, healthy diet, nutrition, smoking, smoking cessation, body weight, BMI, blood pressure, hypertension, blood sugar, diabetes, glycemic control, cholesterol, and cholesterol VLDL. In June 2018, we queried PubMed, Embase, and CINAHL databases for relevant articles without time constraints. The search was repeated in December 2019 to include new articles published up to December 16th, 2019. Search strategies are presented in the S1 Appendix. All articles were imported into Covidence Software for reference management . There is not a registered protocol associated with this systematic review.
Articles were screened and reviewed based on selection criteria. Inclusion criteria were applied to meet the study purpose. We included articles that reported quantitative results for the outcomes of interest relating to one or more of the following LS7 health components: physical activity, diet (such as fruit and vegetable consumption), cholesterol, blood pressure, body mass index, smoking, and glycemia (glucose or hemoglobin A1c). Interventional study designs were eligible for inclusion. These included both experimental designs such as randomized controlled trials and cluster randomized trials, as well as quasi-experimental designs such as variations of pre-post tests with or without a comparison group. We included analyses with a greater than 50% AA study population focused on adults (≥18 years of age). Interventions included in the review employed principles of community-engaged research (at a minimum) or community-based participatory research. For example, interventions involving recruited participants from the target population, carried out in community settings such as churches, schools, and businesses, as well as those involving community coalitions in the planning, conduct, and/or analysis of the research study were included. Articles were excluded if they did not meet inclusion criteria. Specifically, studies were excluded if they did not involve ≥ 50% AA adults, present quantitative results for the outcomes of interest, or use community-engaged or CBPR methods.
The following describes the iterative process of review. Citations were gathered through the literature search. There were 124 duplicates which were subsequently removed. Four reviewers (RE, TSN, JJJ, and DGII) reviewed 1008 titles and abstracts for inclusion and exclusion. Disagreements were resolved through review and consensus by all four reviewers. Full text review of 226 articles was conducted in the same manner based on inclusion and exclusion criteria. During full text review, we used ascendency and descendancy to identify relevant articles for inclusion. After full text review, two reviewers (RE, TSN, JJJ, and DGII) performed the critical appraisal (quality assessment) of each of the 54 remaining articles using the National Heart, Lung, and Blood Institute Study Quality Assessment Tools from the National Institute of Health (NIH) with a modified approach . This NIH tool evaluates internal and external validity, in addition to sources of bias, confounding, and other potential flaws specific to each study design. For example, criteria being assessed for controlled studies included methods of randomization, blinding, and sample size. By affirming or negating each query in the tool, studies can be assessed for an overall quality rating of “good”, “fair”, or “poor.” Our team determined “good” studies to be those affirming at least 70% of the items in the assessment tool. “Fair” studies affirmed 50%-69% and “poor” studies affirmed less than 50% of the items in the tool. No studies were excluded based on the quality rating. Questions comprising the quality assessment tool for each study design are included in the S1 Appendix. Finally, data was extracted from selected articles and collated into matrices for content analysis. Data points include author, study design, description of sample, mean age of participants, LS7 metric(s) assessed, description of intervention, and results.
A total of 966 citations were gathered through the initial literature search in Pubmed, CINAHL, and Embase. An additional 12 studies were gathered through other sources (reference searches). Using the same search strategies, 154 citations were added in December 2019. In total, 1008 studies remained after 124 duplicate articles were removed. We excluded 782 citations which were irrelevant based on review of titles and abstracts. We collected full text articles for the remaining 226 studies which were reviewed based on inclusion and exclusion criteria. Through the full text analysis, 172 additional studies were rejected. Our systematic review thus identified 54 unique studies meeting inclusion criteria and further assessed for data extraction. Complete results of the search and review process are detailed in the PRISMA flow diagram (Fig 1).
General study characteristics
Of the 54 included studies in our review, twenty-seven (50%) were randomized trials (Table 1). The remaining twenty-seven studies (50%) were quasi-experimental studies which used some variation of pre-post test design to analyze data at baseline and post-intervention (Table 2). Studies varied widely. The interventions ranged from 5 weeks to 5 years in duration. Sample sizes ranged from 23 to >10,000 study participants. Forty of the 54 studies (74%) demonstrated statistically significant improvements in one or more LS7 metrics at the final endpoint of the study.
Formative research was employed in 36 studies (67%) to guide intervention development and implementation. The majority of these (72%) achieved statistically significant outcomes in the intended LS7 target(s). Information on community needs, perceptions, and values were primarily gathered during planning phases before an intervention began, often with input from community-partners or stakeholders. Some studies also incorporated formative assessments during or after the intervention in order to evaluate program appropriateness and participant satisfaction. Various methods were identified: interviews were used in 8 studies, focus groups were used in 16 studies, and qualitative or quantitative surveys were used in 14 studies. Less commonly, other formative research approaches such as direct observation were also used [37–40].
With regards to the quality assessment, 11 studies (20%) were rated as good; 35 studies (65%) were rated as fair; and 8 studies (15%) were rated as poor. Among controlled studies (i.e. randomized trials), the most common limitations to quality were lack of double blinding as well as drop-out rates > 20% at the study end-point. In many studies, authors also failed to report that the sample size was adequately large to detect outcome differences with sufficient power. Among pre-post test studies, many lacked the following features: enrollment of all eligible participants who met inclusion criteria, a sufficiently large sample size to provide confidence, blinding of study evaluators to the participants’ intervention exposures, and use of interrupted time-series design. Notably, compared to pre-post test and other study designs, randomized trials were more likely to have an overall quality rating of good to fair.
No studies were specifically designed for African American men. Seven studies specifically targeted African American women [41–47]. Of the remaining 47 studies aimed at both African American men and women, 32 studies had females accounting for more than 70% of participants.
All studies were conducted in the community setting. Specifically, 22 (41%) of the selected studies described faith-based programs. Two studies included schools [48, 49] and 3 took place in public housing developments [44, 50, 51].
The intervention outcomes of 27 studies included physical activity; 21 included blood pressure; 23 included weight or BMI; 7 included smoking status; 9 included blood glucose; 6 included cholesterol; and 23 included change in diet.
Only two studies evaluated changes in all LS7 components [52, 53]. These interventions were related to the faith-based nutrition and exercise program conducted in AA churches in Minnesota: “Fostering African-American Improvement in Total Health [FAITH!].” [52, 53] Overall, twenty-seven (50%) studies targeted more than one LS7 metric. Such interventions, with > 1 LS7 metric, were more likely than not (70%) to have statistically significant improvements in outcome measures. For studies with ≥3 LS7 metrics, the most commonly combined targets were blood pressure, physical activity, and BMI/weight. Diet interventions were most likely to be paired with physical activity. Interventions targeting blood glucose most often incorporated blood pressure and/or BMI/weight components.
Sixteen out of 27 studies measuring physical activity achieved statistically significant increases in levels of physical activity post-intervention. Data primarily consisted of participants’ self-reported behaviors gathered through surveys and activity ranking scales which varied widely between studies. Other measures included number of steps per day and weekly time expenditures engaging in recreational or moderate to vigorous physical activity. Among effective interventions, almost all delivered educational materials focused on promoting greater at-home activity levels and developing weekly routines to meet fitness goals. Of the effective interventions, a majority created fitness goals and other physical activity plans with groups facilitated by coaches or leaders recruited from the community to better represent and serve said population [54–59]. Other studies allowed participants to establish individualized goals and activity plans [60, 61]. In addition, studies also incorporated supervised exercise ranging from 10 to 90 minutes per week during group sessions. Such activities included walking, stretching, aerobics, strength training, and dancing [35, 38, 39, 61–63]. Few interventions targeted local environments through community and policy changes to encourage neighborhood walking/jogging as well as recreational physical activity by increasing bike paths and play areas [51, 64]. Overall, studies that utilized multiple approaches to encourage activity (such as group exercise in addition to tailored curriculum or at-home activities) were more effective than those using only one form of intervention.
Only 10 out of the 21 studies which measured changes in blood pressure achieved statistically significant blood pressure reduction. Among these studies, systolic blood pressure decreased by 8.17 mmHg on average following intervention [43, 45, 53, 65–68]. Physical activity and diet change were the main approaches for attaining blood pressure control. Coach led walking groups were commonly employed methods [39, 45, 65, 66]. Nutritional components emphasized the DASH diet (Dietary Approaches to Stop Hypertension) in conjunction with the use of community gardens and assistance with healthy food shopping [43, 45, 65, 66, 69]. Interventions ranged in duration from 6 weeks to 5 years; however, longer duration did not consistently correlate with the effectiveness of the intervention. Faith based initiatives used similar intervention techniques but had a lower percentage of studies achieving statistically significant outcomes with regards to blood pressure management [43, 60, 61, 70, 71].
Thirteen of the 23 studies evaluating body weight or BMI achieved statistically significant results. Almost all studies promoted wellness plans targeting diet and physical activity to meet weight loss goals. This was done primarily in the group setting, such as group exercise sessions; however, few studies incorporated individualized meetings to discuss weight management. Three interventions used curricula which were guided by the Diabetes Prevention Program (DPP) [40, 72, 73]. Effective interventions varied in duration and ranged from 6 weeks to 5 years. Among these, many employed faith-based programs or recruited participants from church communities [39, 40, 43, 52, 60, 63, 68, 72, 74]. The average reduction in BMI was 2.03 kg/m2 [40, 43, 45, 72, 75]. Average weight loss was 4.36 pounds [40, 43, 45, 60, 63, 68, 74, 75]. Other studies reported percent of participants losing greater than 5% of baseline weight or a decrease in the prevalence of those who were overweight or obese [39, 47, 69, 73]. Interventions focused on both physical activity and diet were more likely to achieve statistically significant weight loss than those targeting diet alone.
Of the seven studies evaluating smoking cessation, four had statistically significant results. Average post-intervention self-reported quit rate was 24% [44, 76, 77]. Studies shared similar intervention methods. Control groups primarily received self-help material such as pamphlets. Mass media campaigns delivering print and electronic communication, including mediums like social media and news/radio stations, were commonly used to promote changes in smoking behavior [64, 77, 78]. In the church setting, scriptural messaging was the primary tool used to encourage smoking cessation [52, 76]. Interventions which incorporated free nicotine replacement therapy generally sustained greater rates of abstinence at long term follow-up when comparing intervention and control groups [44, 78].
Six out of the nine studies reporting results in glycemic control evaluated improvements in diabetes as a primary outcome [52, 65, 72, 79–81]. Among the 5 studies with statistically significant results, there was an average decrease in blood glucose of 6.4 mg/dL and Hemoglobin A1c level of 0.7% post-intervention [39, 65, 72, 80, 81]. Interventions commonly implemented lifestyle modifications and used trained coaches to deliver culturally-tailored curricula focused on diet, self-care, and diabetes knowledge [79–82]. Other studies implemented group physical activity and walking programs to attain improved glycemic measures [39, 65]. The intervention duration, which varied from 8 to 32 weeks, did not consistently correlate to the significance of results.
Only six studies evaluated changes in cholesterol. Three of these interventions, which achieved statistically significant results, were longer in duration (31 weeks on average). Although interventions targeted dietary changes, programs primarily focused on physical activity through walking groups as a means to improve blood lipid levels [39, 41, 65, 82]. Among these studies, HDL levels increased by an average of 5.7 mg/dL and total cholesterol was reduced by 2.2 mg/dL [39, 41, 65].
Sixteen of 23 studies reporting dietary outcomes achieved statistically significant results. Diet modifications aimed at increasing fruit and vegetable (FV) intake, whole grains, and fiber, while decreasing consumption of sugary drinks and fat. Diet education also emphasized portion control and healthy snacking habits. Some curricula adapted material from specific diets, such as the DASH diet [66, 82]. Among studies reporting change in fruit and vegetable consumption, there was an average increase in FV intake by 0.7 servings/day [48, 50, 53, 68, 83–86]. In addition to group informational sessions, effective studies also employed hands-on methods such as cooking classes, demonstrations, and taste testing to promote better nutrition [46, 68, 83, 87]. Policy and community changes such as improving access to farmer’s markets, community gardens, and healthier options at local retailers were also effective strategies [64, 88]. Few studies also directly provided participants with produce or money to purchase fresh foods [50, 82]. Intervention duration did not consistently correlate with improved outcomes.
Life’s Simple 7 (LS7) metrics—an AHA framework for ideal cardiovascular health against which reduction in risk for CVD, diabetes, and cancer can be measured—are empirically supported as a means to reduce development of disease and premature mortality. This review provides a comprehensive account of community-based participatory research and community-engaged interventions applying LS7 metrics to AA. Community-engaged interventions can provide more holistic strategies to address upstream factors such as racism and the social determinants of health underlying the mechanisms leading to racial health disparities.
Overall, we found a lack of consensus on best practices to apply and attain the metrics within interventions represented by wide variation in intervention strategies, intervention efficacy, and insufficient study quality to generalize findings. Moreover, quality did not consistently correlate to the statistical significance of study outcomes.
However, we found that implementation of the interventions shared commonalities. In this review, interventions guided by formative research data were found to increase the effectiveness of community programs. Importantly, formative research can aid researchers in both formulating and modifying interventions to be culturally relative and optimize intended effects. Furthermore, faith-based entities and community health workers are common vehicles for health promotion activities and interventions. Faith-based interventions among AAs are heralded as an approach to assist communities with building capacity with other communities [89, 90]. And although there is a need to enhance the training of and educational programs for church and health ministry leaders who deliver such interventions , faith-based organizations have a longstanding history of credible health promotion for the AA community and, as such, faith-based partnerships have been recommended as a necessary driver of national health promotion efforts [92, 93]. This is not surprising, given that evidence suggests that more AA engage with a faith-based organization and AA have the highest church attendance rates in the US as compared to other racial and ethnic groups [94–96]. Similarly, utilization of community health workers is an evidence-based approach to navigating AAs beyond barriers to adoption of healthy behaviors and practices (such as mistrust of healthcare providers in medical settings), adherence of provider recommendations, academic-community partnerships and cultivating community capacity for health promotion [97–101]. This review demonstrated statistical benefit of faith and community health worker-based interventions, but the clinical benefit is unclear and generalizability of these findings is significantly limited by the variance in study quality.
Content identified within studies included in this review ranged from one to seven LS7 metrics. The most common targets were diet, weight, and blood pressure, and less than 10% of the reviewed studies addressed smoking status. There is a dire need for comprehensive approaches targeting all seven metrics, as there is a graded relationship between the number of ideal cardiovascular health metrics attained and the risk of cardiovascular disease . This effect is even more pronounced among AA as compared to Whites . Therefore, interventions targeting more than one LS7 metric may have greater potential to substantially reduce black-white disparities in CVD. Further, a more holistic approach to health promotion as opposed to singular targets is both preferred  and feasible  within AA community. Thus, although inclusion of multiple intervention components and assessments may be difficult to analyze, researchers must become more adept in planning such studies to increase uptake and overall outcomes.
There are limitations to this review. First, this review was conducted in three databases and only included full text, peer-reviewed publications. It is possible that potentially relevant studies to this review were missed due to incomplete retrieval of the existing literature as well as variable indexing across databases. Second, there is a dearth of knowledge surrounding the application of all LS7 metrics within targeted interventions for AAs. Of those that were found with one or more LS7 metrics, most exhibited relatively fair appraisal quality. Primary concerns with quality derived from high attrition rates and lack of power to detect effects. Therefore, findings must be interpreted with caution. There were also variable intervention techniques and metrics used across studies, limiting the ability to identify best practices. More research using randomized experimental designs with sufficient sample sizes and high retention rates is needed to strengthen the literature on application of community-based and–engaged LS7 interventions, especially among AA men who were underrepresented in the current studies.
This review highlights opportunities for academic-community collaborations in addressing disparities among AAs, gaps in community-engaged and community-based participated research, and various ways to capitalize on community capacity to deliver interventions with some indication that such methods can be acceptable and promising to reduce the CVD burden. Academic institutions engaging the community and establishing shared responsibility can build infrastructure to support the development, implementation and dissemination of acceptable, evidence-based, effective and sustainable interventions for future use [103, 104]. Yet, based on the available studies, there is insufficient data to recommend a specific community-engaged or CBPR intervention to improve attainment of AHA LS7 metrics among AAs. Future studies aiming to reduce disparities in CVD and/or chronic disease such as diabetes and cancer among AAs may benefit from use of the comprehensive AHA LS7 framework, greater engagement of AA males, and be conducted with more rigorous study methodology. High-quality, generalizable studies are of vital importance in identifying strategies to achieve health equity.
S2 File. PRISMA checklist LS7 review.
We would like to thank Anna Biszaha from The Ohio State University Health Sciences Library for her expertise and assistance with the systematic review process including development of our search strategies.
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