Minority blood donations have historically been low in the United States (Yazer et al., 2017). Increasing the proportion of minority blood donations is essential to reducing blood transfusion complications, particularly in individuals with sickle cell disease (SCD) and thalassemia, for several reasons (Yazer et al., 2017). First, SCD and thalassemia disproportionately affect minority racial and ethnic populations in the United States. For example, SCD occurs in about 1 in every 500 African American (AA) births, 1 in every 36,000 Hispanic-American births, and 1 in every 100,000 Caucasian births (Hassell, 2010). Thalassemia is prevalent in populations with roots in the Mediterranean, Middle East, Indian subcontinent, Southeast Asia, and China (Li, 2017). Second, blood from donors—with similar backgrounds as the recipients—is more likely to be a close match (Frye et al., 2014). Unmatched blood can cause potentially severe transfusion complications. Therefore, there is a critical need for blood donations from minorities to improve transfusion outcomes in minority populations.
Individuals with hemoglobin disorders often need transfusions—sometimes chronically and sometimes intermittently. If exposed to unmatched donor blood, the risk is alloimmunization: the development of antibodies to the foreign red blood cell antigens (Charbonneau & Daigneault, 2016). Increasing blood donations among minorities can ensure better access to minor antigen-matched units; however, strategies for promoting donation in these populations require awareness of the unique characteristics of minority groups and blood donation, as well as programs that address facilitators and barriers to minority blood donation (Charbonneau & Daigneault, 2016; Frye et al., 2014). The goals of this systematic review are to expand the knowledge of facilitators and barriers to minority blood donation and to recommend strategies that will increase blood donations within minority communities.
Blood transfusions increase hemoglobin levels, increase blood flow, improve oxygen delivery to the tissues, and dilute the abnormal red blood cells containing sickled hemoglobin, thus increasing the number of circulating normal red blood cells (Estcourt, Fortin, Hopewell, Trivella, & Wang, 2017). Phenotypic incompatibility in blood transfusions results in the development of antibodies over time that attack red blood cells, making subsequent transfusions less effective and increasing the risk of transfusion complications (Charbonneau & Daigneault, 2016). These antibodies to antigens, if present in subsequently transfused blood, will trigger a dangerous hemolytic transfusion reaction when transfused red blood cells are destroyed by the immune system (Estcourt et al., 2017).
Minority blood donors are essential for a diverse supply of blood because they provide greater access to corresponding phenotypes, often rare ones, required for individuals with diseases such as SCD and thalassemia. However, minorities are historically underrepresented among blood donors. In the United States, an estimated 11% to 21% of blood donations are from minority populations based on the National Blood Collection & Utilization Survey 2011 (U.S. Department of Health and Human Services, 2011). More recent surveys from eight blood centers in 17 states noted decreasing blood donations overall and a continued underrepresentation of minority donors. For example, Black or AA donors constituted approximately 5% of all donors from 2006 to 2015 (Yazer et al., 2017). A decreased proportion of minority blood donors has also been reported in Canada (Charbonneau & Daigneault, 2016) and France (Grassineau et al., 2007).
Increasing minority blood donations is a complex public health issue with several barriers to minority blood donations. Minorities have reported higher deferral rates and lack of awareness about the process of blood donation (Frye et al., 2014). Less than 1% of all donors experience events such as fainting and fatigue (U.S. Department of Health and Human Services, 2011); however, despite a relatively low occurrence of adverse events, fear of these events is a commonly reported barrier to blood donation among minority populations (Shaz, Demmons, Hillyer, Jones, & Hillyer, 2009). Barriers to blood donation also include deferment due to low hemoglobin, consisting of almost half (48%) of all deferrals from all potential donors in the United States (U.S. Department of Health and Human Services, 2011). Mobile blood drives remain the major source (66%) of blood collections in the United States (U.S. Department of Health and Human Services, 2011). These blood drives often recruit minority populations in the community, at local churches, and other gatherings, yet a substantial or sustainable increase in donations from these blood drives has not been found (Yazer et al., 2017).
The current knowledge on facilitators and barriers to minority blood donations is limited. Systematic reviews on blood donations and blood donors exist, although none address blood donation issues specific to minorities and none review the race/ethnicity of study samples (Bagot, Murray, & Masser, 2016; Bednall, Bove, Cheetham, & Murray, 2013; Godin, Vézina-Im, Bélanger-Gravel, & Amireault, 2012). In addition, Bednall et al. (2013) reviewed blood donation behavior and intentions and cited the need for research with minorities as they often report additional barriers to blood donation. The purposes of this systematic review are to examine the facilitators and barriers to minority blood donations and recommend strategies to increase donations in the community. Therefore, the following research question was asked: What are the facilitators and barriers to blood donation in minority populations?
Prior to beginning the systematic review, the principal investigator (PI) conducted a preliminary search to ensure the absence of similar reviews and gain understanding of existing literature on minority blood donations. We consulted experts on systematic review and meta-analyses: a librarian with expertise in nursing and health literature and experts on minority blood donation and blood transfusion complications associated with the hemoglobinopathies of SCD and thalassemia, on search approach and terminology and goals of the review. The systematic review proceeded using Preferred Reporting Items for Systematic Reviews and Meta-Analyses, and the research question served as basis for identification, selection, and appraisal of studies and collection and analysis of data from reviewed studies (Moher, Liberati, Tetzlaff, & Altman, 2009).
The literature search began in August 2017 using the electronic databases CINAHL Plus With Full Text, Academic Search Complete, MEDLINE, PsycINFO, Sociological Collection, Cochrane Library, ProQuest Dissertation and Theses, and PubMed. Search alerts were also initiated for databases that continued the search through December 2017. There were no restrictions on publication year, publication type, or article type. The keywords used in the search included combinations of the following words: blood donation, blood donor, minority, AA, Black, race and ethnicity, and Hispanic or Latino. The search databases and search combinations are presented in Table 1.
Inclusion and Exclusion Criteria
Inclusion criteria were (a) data-based studies that sampled minority blood donors and minority blood donations or included minorities in description of blood donor samples; (b) data from minority participants on process of blood donation; and (c) English language. Exclusion criteria were (a) data-based studies on blood donation using blood center or national survey data and (b) methodological and theoretical studies. In addition, in multiple data-based reports of a single study sample, only one sample was reported with data from each study analyzed.
The title and abstract of each article in the search pool (n = 1,352) were carefully reviewed by the PI. Initial review focused on removal of duplicate articles and exclusion of articles obviously not relevant to search terms (e.g., animal studies, etc.). The resulting pool (n = 545) was further refined by excluding articles that focused on viral and bacterial infections, genetic components of bloods, and risk for alloimmunization. Articles originating from countries outside of the United States were retained as long as the abstracts were in English. Detailed review of abstracts excluded summary reports, historical reviews, literature reviews, editorials, periodicals, or news briefs and articles that were not data based.
The remaining 42 full-text articles were reviewed in their entirety. Of the articles reviewed, 18 articles contained demographic data from blood centers or “blood banks” and national surveys. Some articles reported data from blood centers regarding the effectiveness of an intervention or program; however, the data were not linked to participants (e.g., an increase in blood donations in a blood center was attributed to a program without data to indicate that donors were engaged or participated in program). We excluded articles that focused on blood centers without data from minority blood donors on donations.
Of the 24 remaining articles, 5 were qualitative studies, 2 were mixed methods, and 17 were quantitative descriptive. Eight of the quantitative descriptive articles included qualitative data and descriptions from participants, while 9 contained quantitative data only. Statistical methods are relevant to a meta-analysis to integrate the results of studies—particularly intervention studies (Moher et al., 2009). Based on the primarily descriptive data from the articles and the lack of intervention studies, the systematic review proceeded as a descriptive meta-synthesis (Finfgeld, 2003), focusing on the facilitators and barriers to blood donation in minority populations with 15 articles.
Meta-synthesis is the qualitative aggregation and interpretation of descriptive findings that have been abstracted from study findings (Finfgeld-Connett, 2010). Similar to a meta-analysis, a meta-synthesis includes a purpose, research question, inclusion criteria, study and sample characteristics, and qualitative data collection and data analysis techniques (Sherwood, 1999). A meta-synthesis examines a broad phenomenon (Finfgeld, 2003), such as facilitators and barriers to blood donations in minority populations.
Data were abstracted from 15 articles in the following categories: study design and data analysis methods, sample size, participant race/ethnicity and gender, donor type (nondonor or experienced donor), geographic location (United States or other country), and community location (e.g., community, church, college, etc.). Narratives from participants, themes, and strategies presented were abstracted from the findings, discussions, and conclusions.
An inductive approach was used to analyze commonalities, differences, patterns, and themes in study findings; interpret the findings; and synthesize the findings to generate new knowledge about the phenomena of study (Finfgeld, 2003; Paterson, 2001). The findings were categorized and later collapsed into themes (Finfgeld-Connett, 2010). The steps of the thematic analysis included (a) translating the findings of each study into themes, (b) comparing and contrasting the themes by identifying similarities and differences among themes, and (c) determining the key themes and hypothesizing how themes relate to each other (Paterson, 2001).
In the analysis, each study was reviewed by the PI, and themes were validated by the PI and the research team with a total of three members (Paterson, 2001). The research team had expertise with minority blood donations, minority populations with SCD and thalassemia, research with minorities, and qualitative methods. Sampling and data analysis decisions were recorded in field notes and an audit trail, and consensus on decisions was achieved among the research team (Finfgeld-Connett, 2010; Paterson, 2001).
The initial search yielded 1,352 articles. After eliminating duplicates and nonrelevant articles (n = 807), excluding articles by abstract (n = 503), and excluding articles by full text (n = 26), 15 articles were included in this systematic review (See Figure 1).
Evaluation of Article Pool
The final review article pool included 15 articles. Of note, seven articles (47%) were published in the journal Transfusion, a publication dedicated to blood banking and transfusion medicine topics. Other articles were published in transfusion medicine, hematology, and laboratory/pathology journals (n = 5; 33%). Few articles were published in general medical and health-related journals (n = 3; 20%). All articles were published in peer-reviewed journals.
Study and Sample Characteristics
The study sample included 3,698 participants. Participants' race/ethnicity and gender were not described in all studies. Of the participants described, participants were Black or AA (n = 2,125), White or Caucasian (n = 874), or other/not defined (n = 699). Hispanic (n = 32) or Non-Hispanic (n = 134) participants were also represented.
When reported, there were more male (n = 1,665) than female (n = 1,353) participants. There was variation in how studies presented donor data (e.g., never, first-time, repeat, routine, “multi-gallon”); thus, participants were grouped as experienced donors (n = 1,634) with a history of blood donation or nonexperienced donors (n = 799) with no history of blood donation. Studies recruited from the community (n = 11 studies), blood centers (n = 3), and colleges (n = 1) in the United States (n = 7), Australia (n = 4), Canada (n = 2), and regions of Africa (n = 2).
The themes that were identified from the data provided insights into the experiences of minorities with blood donation. Common themes emerged from the analysis of the descriptions and narratives. Shared themes included (a) knowing a blood recipient; (b) identifying with culture, race/ethnicity, and religious affiliation; and (c) medical mistrust and misunderstanding. These themes are described below, and data are presented to support the themes.
Knowing a Blood Recipient
The theme of knowing a blood recipient reflected connection to family and friends in need of blood transfusions (Amoyal et al., 2013; Asenso-Mensah, Achina, Appiah, Owusu-Ofori, &Allain, 2014; Charbonneau & Tran, 2013; Royse & Doochin, 1995; Tran, Charbonneau, Valderrama-Benitez, 2013). Donors were characterized as direct family (parents, siblings, or children), indirect family (grandparents, uncle or aunt, or spouse), and not family (friend, church member, school, or work mate) in a study of donors' potentially becoming repeat donors in sub-Saharan Africa (Asenso-Mensah et al., 2014). The participants donated blood “because they were asked” and because “the patient needed blood” (Asenso-Mensah et al., 2014, p. 800). In a study of processes of change to increase blood donation for AA in the United States, responses were “hearing people's personal stories is inspiring” and “something happens to someone in my family,” when asked about emotions associated with donating blood (Amoyal et al., 2013, p. 1283).
Donating blood to someone that they know was commonly described by minority participants. Both multigallon donors and periodic donors reported having someone in their families who had received blood as a reason to donate in a study of differences among donor groups (Royse & Doochin, 1995). A request from friends or family was also a common reason to donate blood in a study of AA church members in Atlanta (Shaz et al., 2009). Participants described needing transfusions themselves or knowing people who needed blood transfusions, stating that they gave “for their children” or “for their family and neighbors” (Charbonneau & Tran, 2013, p. 177). One participant stated, “…it's very well looked upon to give our blood to family…but giving to a stranger, I think that's a little more limited,” suggesting that donating to family was preferred over donation to an unknown recipient (Charbonneau & Tran, 2013, p. 177). Participants revealed that they were more inclined to donate to a member of their family or community, stating, “…if you know the person and the person is sick…help with some blood…” and “Giving to a member of the family or wife, say she is having a baby and she is hemorrhaging, I'm sure most fathers would say, ‘hey, give some blood because it's his wife and his kid…’” (Tran et al., 2013, p. 519). Knowing a blood recipient made a donor or potential donor more likely to donate blood.
Identifying With Culture, Race/Ethnicity, and Religious Affiliation
The theme of identifying with culture, race/ethnicity, and religious affiliation is an extended commitment beyond family and friends to a larger community of culture, race/ethnicity, and/or religion. Participants identified cultural and ethnic similarities and differences and religious beliefs that affected blood donations (Charbonneau & Tran, 2013; Mathew et al., 2007; Polonsky, Brijnath, & Renzaho, 2011; Renzaho & Polonsky, 2013; Robbins et al., 2015; Tran et al., 2013).
Culture was the focus of studies of migrant minorities. In a study of sub-Saharan AA migrants in Australia, the role of home country culture included the need for approval from family as part of their culture; however, participants acknowledged they would disregard culture and family approval if those that they knew needed blood (Polonsky, Brijnath, et al., 2011). In later studies, the authors found that acculturation was not associated with blood donation for African migrants in Australia and that their home culture beliefs were still prevalent (McQuilten, Polonsky, & Renzaho, 2015; Renzaho & Polonsky, 2013). Culture is a consideration in whether or not an individual chooses to donate blood.
Participants expressed openness to messages promoting blood donations in communities to specific races. For blood center employees, community leaders, and donors in Canada, Black participants felt more comfortable donating to someone in the community and suggested the promotion of blood donation using strategies that focused on the community (Tran et al., 2013). In a study of donors and nondonors by Mathew et al. (2007, p. 733), Black participants described community as “the AA community” and felt that donating to benefit their own community, such as blood drives for SCD or victims of violence, was a motivator to donate blood. In a culturally tailored intervention study to promote minority blood donations, participants described “feeling guilty for not donating” after completing the intervention (Robbins et al., 2015, p. 232). Identifying with culture and race/ethnicity may increase the likelihood of donating blood by minorities.
Ethnicity and religion are described as a unique part of minority blood donations. Participants from ethnic minorities perceived the uniqueness of their blood and described, “…doing something good for society,” with giving blood being “a combination between a generous act and an obligation, for you and the community…,” in a study of the symbolism of blood donation in Canada (Charbonneau & Tran, 2013, pp. 175–176). Religious values were associated with blood donation, with participants noting, “…blood is a symbol of sacrifice, of life…” and “…you are giving life when you are giving blood…” (Charbonneau & Tran, 2013, p. 177). Identifying with ethnicity and religion provided a reason to donate blood for some minorities.
Medical Mistrust and Misunderstanding
The theme of medical mistrust and misunderstanding, including not understanding the medical reasons for deferral, was described by participants as barriers to minority blood donation (Boulware et al., 2002; Grossman, Watkins, Fleming & Debaun, 2005; Mathew et al., 2007; McQuilten et al., 2015; Oswalt & Gordon, 1993; Polonsky, Brijnath, et al., 2011; Polonsky, Renzaho, & Brijnath, 2011; Renzaho & Polonsky, 2013; Tran et al., 2013). Participants reported the lingering effects of the Tuskegee Syphilis Study and other medical experiments that exploited minorities, as well as exclusion from donating during the 1980s during the human immunodeficiency virus (HIV) epidemic, as barriers to donating (Polonsky, Brijnath, et al., 2011; Polonsky, Renzaho, et al., 2011; Tran et al., 2013). In a focus group study of donors and nondonors, participants mentioned a news story about the waste of donated blood in the aftermath of the September 11 in the United States as another reason to not donate (Mathew et al., 2007).
A commonly held idea among Black participants was that blood donation was somewhat suspicious, their blood was unwanted, and their blood should preferably not be given (Tran et al., 2013). Black leaders from Caribbean and African origins believed that they could not give blood, or that if their blood donation was accepted, the blood would later be discarded (Tran et al., 2013). Participants in Australia who were migrants from sub-Saharan Africa also questioned whether their blood was wanted and used (Polonsky, Brijnath, et al., 2011). Participants felt that their blood would be excluded based on their race and the perception that they have a disease, stating, “You can give blood…but you're African, you can't, because the people are afraid of you. You might have AIDS…” and “They think you are HIV-positive so, as a result, you are rejected outright. Even if you volunteer to go, they wouldn't take you, they wouldn't accept it…” (Polonsky, Brijnath, et al., 2011, p. 340; Polonsky, Renzaho et al., 2011, p. 1815). In later studies, medical mistrust was negatively associated with knowledge about blood donation (McQuilten et al., 2015; Renzaho & Polonsky, 2013). Thus, medical mistrust is an important barrier to minority blood donation.
Medical misunderstanding, including unclear explanations to donors of medical reasons for deferrals given by healthcare providers, were cited as barriers to minority blood donations. Lapsed donors incorrectly viewed themselves as permanently deferred for temporary deferrals such as low hemoglobin (Mathew et al., 2007). A participant in a study of minorities in Canada described, “As a young adult, [she was] refused without further explanations…was once more rejected…the nurse took some time to explain her exclusion…the nurse reminded [her] not to take this rejection personally, even pleading with her to attempt to donate at a later date…” (Tran et al., 2013, p. 519). Participants reported being deferred for reasons that were not made clear to them: “They are supposed to spell out the characteristics of people that can give blood, otherwise I will just go and tell everyone, ‘You can't donate blood’…” which may result in misinformation in the community (Polonsky, Brijnath, et al., 2011, p. 339). The existing medical mistrust, combined with misunderstanding by potential blood donors, reduces the likelihood of minority blood donations.
The reviewed studies demonstrate that facilitators and barriers to minority blood donations are complex and exist concurrently. Facilitators include knowing a blood recipient and identifying with culture, race/ethnicity, and religious affiliation. Barriers include medical mistrust and misunderstanding. Strategies can be developed from knowledge of these facilitators and barriers to guide future research, education, and policy on minority blood donations.
Knowing a blood recipient—most often family and friends—was often the reason for minority donors to give blood. Donor perspectives of knowing a recipient have been studied in living kidney donors (Agerskov, Ludvigsen, Bistrup, & Pedersen, 2016). Kidney donations were primarily for family members. Donors were very attentive to the needs of the recipients—not just their own care after the procedure. Ultimately, the donation led to a greater connection and perception of closeness between donor and recipient (Agerskov et al., 2016). A strengthened relationship between donors and recipients may extend to minority blood donors and recipients.
The theme of knowing a blood recipient offers strategies to facilitate minority blood donation through engagement of family and friends. Minority blood donors verbalized that they were more likely to donate blood to someone they know who needed a blood transfusion. Thus, blood recipients may be key to accessing and engaging potential donors. Existing educational materials used for donors can be given to recipients to distribute to family and friends who may be potential donors. Strategies that recruit recipients, and subsequently educate and empower them to engage minority donors, can facilitate minority blood donations.
Experiences of identifying with culture, race/ethnicity, and religious affiliation enhanced donation among donors desiring to benefit the community and donors with similar experiences and beliefs. In a review, culture and religion influenced whether ethnic minority women participated in cervical cancer screening (Chan & So, 2017). Ethnicity and religion were successfully incorporated into health promotion interventions for ethnic minority groups in a study of health researchers and promoters (Liu et al., 2016). Identifying with culture, race/ethnicity, and religious affiliation can influence health behaviors and can promote minority blood donors to benefit the health of others.
As a theme, identifying with culture, race/ethnicity, and religious affiliation provides insights for strategies that may enhance donation. Strategies that engage members of the community as champions or recruiters can be used to facilitate potential minority donors in the community. These champions can be present at community events (e.g., health fairs, blood drives, and festivals) and community centers (e.g., churches, schools, and senior centers). In addition, similar to engaging blood recipients to recruit family and friends, community champions can distribute educational materials to other potential minority blood donors.
Medical mistrust and misunderstanding deterred minorities from donating blood. A systematic review of qualitative studies highlighted fear of experimentation and intrusiveness of screening methods as unique among AA men with colorectal screening (Adams, Richmond, Corbie-Smith, & Powell, 2017). Mistrust at the provider and organizational level decreased participation in screenings (Adams et al., 2017). Participants were unsure of their decisions, needed guidance and support from healthcare providers, and expressed feelings of misunderstanding, judgment, and medical abandonment in a systematic review of qualitative studies on patient and caregiver perspectives on end-of-life care in chronic kidney disease (Tong et al., 2014). Knowledge and guidance from trusted providers are necessary to encourage blood donations and enhance donor experiences for the future.
The theme of medical mistrust and misunderstanding presents a significant, longstanding barrier for minority blood donations; however, strategies that reduce this barrier and increase trust and knowledge can increase donations. The direct engagement of the community using educational materials, community educators, and addressing any lingering issues with trust and previous experiences should be a routine strategy. Participants described consistent issues and historical events. These topics must be the focus of conversations with potential donors. Blood recipients and champions in communities can also increase trust and knowledge.
Recommendations for Research, Practice, Policy, and Education
This study confirms the need for community education and communication about blood donation and its positive effect on fellow community members, including friends and family, in racial and ethnic minorities that are underrepresented among blood donors. It further suggests the need to rebuild trust among minority communities.
Future research should include theory-based, quantitative, and intervention studies in minority populations. The emerging use of theoretical frameworks shows promise in study development and provides a basis for future studies for minority blood donations. The Transtheoretical Model (Prochaska & DiClemente, 1983) and Theory of Planned Behavior (Ajzen, 1991) are well-established theories that have been used in public health and other disciplines to describe an individual's behavior. Both are suitable to study the behaviors of blood donors, including minorities. Assimilation Theory (Gordon, 1964) and Culture Fusion Theory (Kramer, 2000) focus on culture and are well-suited for studies with underrepresented minority blood donors. In addition, studies on blood donors and blood donations should include minority participants—whether the study itself is focused on minorities—and data should be presented to reflect any differences in minority perceptions and outcomes. A single web-based intervention study found in the review was conducted in the United States (Robbins et al., 2015). There is a need for well-developed intervention studies that focus on minority populations.
Blood donations are a specialized area of clinical practice with specific approaches to donors and donation protocols. Healthcare providers who do not practice in this area may have limited knowledge of blood donation protocols and may be further limited with no personal experience as a donor, therefore limiting the ability to engage donors and promote donations in minority populations. Meta-synthesis findings can lead to the development of clinical protocols (Finfgeld-Connett, 2010), and findings from this review emphasize the need for tailored approaches and protocols for minority blood donors.
The findings from meta-synthesis studies can also facilitate development of healthcare policy (Finfgeld-Connett, 2010). Policy on U.S. blood donations should focus on national efforts to engage minority blood donors and use advocates and stakeholders in the community to enhance grassroots efforts (Singleton & Spratling, 2018). Studies conducted outside of the United States primarily focused on blood donations among migrant minorities, racial and ethnic disparities, and barriers to blood donations imposed on migrants. This illustrates the need to address policies that affect the ability to donate blood by minorities.
Of note, this review found frequent recurrence of specific authors and research teams, indicating that few researchers are focusing on this much-needed area of research. In addition, the majority of articles were published in journals focused on transfusions and blood disorders, leaving a knowledge gap in nursing, medical, public health, and other general health literature. Dissemination of knowledge on minority blood donors and blood donations is needed in a variety of journals targeting many disciplines and healthcare providers. Lay information should also be developed for and dispersed to potential donors and minority communities.
This systematic review was limited by varied data and methods across studies. The authors adhered to rigorous data abstraction and analysis, but the variation in studies may have limited the review. The focus of the review was studies on minority blood donations; however, there were studies that included both minority and nonminority populations. The data presented from these studies may not have exclusively presented or separated minority participant data.
This systematic review adds to the growing body of literature on minority blood donations, expanding knowledge of facilitators and barriers and recommending strategies to increase minority blood donations in the community. Previous studies, including systematic reviews, have presented isolated findings on minority blood donations. This systematic review and meta-synthesis analyzed and summarized the findings from a sample of descriptive studies to present overarching themes from the studies and subsequently present strategies to facilitate and decrease barriers to minority blood donations.
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