Dietitians' attitudes and beliefs regarding peer education in nutrition.
Peer education (PE) is a model whereby a trained, but uncertified, peer educator (PEer) provides a service to clients/patients. Services can include health education, mentoring, social support, or counselling. PE with both adults and children has been used by health professionals, including dietitians, with positive outcomes related to improving attitudes and behaviours [1, 2] such as food intake [3-5] and disease risk factors and outcomes, e.g., weight  and glycemic control .
Traditionally PEers, also called lay or community health workers, were utilized in underserved populations in developing countries where universal health care is unavailable [8, 9]. More recently, however, PEers have been used in developed countries to reach more people, more often, and to make programs more accessible and cost effective, especially for marginalized communities with health inequities [5-7, 10-12]. Interestingly, while cost may be a rationale for the use of PE programs, cost-effectiveness studies are difficult to find . More often, it is thought that PEers from the target population have a deeper understanding of the population with respect to language, social norms, cultural values, beliefs, and behaviours and as a result may be better able to deliver and reinforce appropriate health messages [14, 15]. Turner and Shepherd  proposed that PEers who are perceived as credible are able to achieve successful program outcomes because participants can identify with the PEer and as such may be more accepting and open to receiving information from them. This is particularly useful when working with target populations that are highly influenced by peers, such as youth and cultural groups [3, 16, 17]. In addition, PE has also been used to provide opportunities for experiential learning for post-secondary students [18, 19].
Despite the positive outcomes of PE, there may be some resistance by health professionals to using PEers [8, 20, 21], which may minimize or impede the implementation of PE programs. Thus it is important for program-planning decision makers to understand the attitudes and beliefs of health professionals. The objectives of this research were to investigate dietitians' attitudes and beliefs regarding PE and to determine whether their attitudes and beliefs vary by practice area.
An online survey was developed and disseminated to assess Canadian dietitians' attitudes and beliefs about PE. The survey collected demographic information (11 questions including some related to area of practice and clientele) and respondents' attitudes and beliefs about PE (20 questions of which 14 had sub-components for a total of 98 items e.g., benefits to participants, PEers, and dietitians; effectiveness with different target populations; and barriers and limitations to using PE models). Descriptions of the survey questions are located in table footnotes. The online survey took 20-30 min to complete; however, this included a section not reported in this paper due to a small sample size (n < 50), whereby a subset of respondents reported on their experiences with specific PE programs.
The survey items were developed based on PE literature and pretested with a small sample of dietitians to determine face validity and technological ease of use. The pretest invitation was sent electronically to 16 dietitians in various areas of practice. Ten dietitians (62.5%) responded, and investigators utilized their responses to inform further refinement of the survey. Response categories were nominal or 5-point Likert-like scales (strongly agree to strongly disagree). Some questions offered small text boxes for respondents to make brief comments. As such, some quotes are used in the discussion to provide further context to the results.
The survey was emailed in June 2009 to a systematic random sample of 1198 dietitians from a total sample of 4453 members of Dietitians of Canada (DC), excluding student members and those who receive DC communications in French. A modified Dillman method of survey delivery  was used whereby the respondent sample was sent an email with a link to the survey. After the second and third weeks a reminder email was sent in an attempt to increase response rates. A final contact was made 1 week later in a last attempt to achieve a response. This study received ethical approval from the Health Sciences Research Ethics Board of Western University.
Data and statistical analyses
Dietitian's attitudes and beliefs regarding PE were measured on a 3- or 5-point Likert-like scale. Data were analyzed using SAS 9.2 (SAS Institute, 2008, Cary, NC). Demographic data were compiled using descriptive statistics. RMANOVA with Tukey's post hoc were conducted for sector, target population, health goals, strategies, benefits, and limitations by practice area (clinical, community/public health, and all others were collapsed into one category) and subject as the repeated factor, as the dietitian's attitude to one item would likely be related to their other responses in that category.
Total attitude scores (TAS) were generated from 59 items assessing beliefs about effectiveness of PE and PEers (the higher the score, the more positive the perception of PE). The TAS was calculated to assess whether dietitians have an overall positive or negative attitude regarding PE, and whether this differed by area of practice. TASs by area of practice were compared by ANOVA.
The response rates before the first, second, and third reminders were 8%, 13%, and 17%, respectively; with a final response rate of 19% (n = 229). Response rates for specific questions may be lower than 19% as respondents were able to skip questions. In addition, repeated measures analyses requires responses to all questions analyzed together or the statistics program omits respondents' data. Respondents' demographic characteristics are reported in Supplementary Table 1 (1). The national response rates are in line with the distribution of dietitians across Canada  when dietitians who receive correspondence from DC in French are excluded, as the sample did not include these individuals. The 2 most reported practice areas were clinical and community/public health practice at 39.9% and 26.1%, respectively, which is also in line with national practice-area rates . All other practice areas (private practice, foodservice, long-term care, business/industry, and education/government) accounted for the remainder (34%) with no one practice area representing more than 15% of the respondents.
Survey participants were asked to choose from a list of terms identified in the literature that best described a peer from the community who is trained by a health professional. While 31% indicated the term used should depend on the program, the next most commonly chosen term was PEer (27%). Terms chosen less often included peer leader (14%) and community health worker (9%).
Dietitians' attitudes and beliefs about PE are reported in Table 1. In brief, most dietitians (91%) agreed/strongly agreed that PE programs should be viewed as a collaborative intervention by the PEer and health professional, but fewer (78%) agreed/strongly agreed PE should only be used as an extension/complement to healthcare professionals. Most (65%) respondents agreed/strongly agreed that PEers have the potential to interact with more clients/participants than health professionals, and 69% agreed/strongly agreed that they can interact more often. Almost 80% of respondents agreed/strongly agreed that PEers can provide credible information if given sufficient training, and 75% agreed/strongly agreed that PE is a cost-effective model. Less than half of dietitians (37%) agreed/strongly agreed that PEers could achieve comparable outcomes to health professionals.
Survey participants were asked to choose "more, just as, or less" for a series of statements comparing PEers with health professionals. Most responded that PEers are just as (40%) or more (58%) approachable than health professionals and 56% and 43% believed PEers were just as or more likely, respectively, to build rapport. When asked if participants are more, just as, or less likely to obtain information from PEers, most dietitians chose more (60%) or just as likely (18%), but 22% did choose less likely. Lastly, most respondents thought that participants were more or just as likely to change attitudes and/or beliefs (81%) or to gain knowledge (75%) when advised by peers.
The mean [+ or -] SD TAS was 226 [+ or -] 26 (range 121-292; maximum 295). Community/public health dietitians had significantly higher TASs compared with clinical dietitians (234 [+ or -] 23 vs. 221 [+ or -] 27, respectively; P = 0.03), whereas the "other" group was not significantly different from either (225 [+ or -] 24). There was no significant difference in TAS for dietitians who had been previously involved in a PE program, compared with those who had not (data not shown).
Dietitian respondents believed community/public health to be a more appropriate sector for the effective delivery of PE nutrition interventions compared with clinical practice (Table 2). Participants agreed/strongly agreed that a PE model could be effective with a wide range of target populations with the highest agreement for cultural groups and the lowest for pre-adolescents. Nevertheless, dietitians were generally in agreement that all population groups listed (adolescents, post-secondary students, rural populations, new mothers, adult women, people with disabilities, older adults, pregnant women, employees, and adult men) were appropriate target populations for PE.
Respondents had significantly higher levels of agreement for the effectiveness of PE for healthy eating/lifestyle goals compared with prevention and self-management, and they disagreed that PE was effective for treatment (Table 2). Similarly, respondents had significantly higher levels of agreement for the usefulness of PE as a social support strategy compared with goal setting. It is noteworthy that all the strategies posed to respondents (social support, role modelling, skill building, information dissemination, self-monitoring, and goal setting) had mean values above 3, suggesting that there was agreement that all of these strategies would be appropriate in a PE model. Nutrition assessment and development of nutrition care plans were not posed as strategies as these were deemed to be roles of dietitians.
When asked about the benefits of PE to participants (Table 3), respondents agreed most strongly that increased social support and building community capacity were benefits for participants, whereas the lowest levels of agreement were for changes in attitudes, behaviours, and social norms. For benefits to PEers, respondents identified experience and empowerment as the most agreed upon benefits. Overall, respondents scored higher levels of agreement for the benefits to PEers than for the participants. Regarding benefits to dietitians, respondents had the highest levels of agreement that increased linkages to communities of interest, building community capacity, and extended resources were benefits; however, health benefits for the client was rated significantly lower. delivery of misinformation, challenges in supporting and mentoring PEers, and challenges with sustainability (Table 4). Barriers/limitations related to client care and client satisfaction had the lowest level of agreement, with mean values suggesting that many dietitians disagreed that these are barriers/limitations to PE.
Overall 63% of survey respondents agreed/strongly agreed that PE is an effective model for delivering nutrition education interventions and 59% of respondents agreed/strongly agreed that PE should be used more often in nutrition (Table 1). Many (60%) participants said they would be interested in learning more about the use of PE in nutrition or health-related interventions.
Studies have demonstrated positive outcomes using PE in several areas of practice [1, 6, 13, 24-26]. In the dietetics field, peer-led programs have improved participants attitudes and beliefs , knowledge and skills , and behaviours e.g., food budgeting  and fruit and vegetable intake [3, 5]. With respect to treatment, PE programs have shown success by decreasing participant weights  and improving glycemic control . It is important, therefore, to understand dietitians' attitudes and beliefs toward PE, specifically related to population groups and health goals, as well as their perception of the benefits and limitations. This study reveals that the majority of dietitians generally have a positive attitude about PE in nutrition. Most agree it is an effective model for delivering nutrition education interventions and believe it should be used more often. Recent research supports dieitians' views that PEers could be utilized more often in Canada, and that greater progress in addressing health inequities in marginalized communities could be attained with increased use of PEers and PE programs .
There is neither a single model nor a universally established term for PEers. They are often referred to as community health workers , and less often as outreach workers, patient navigators, or other more specific terms such as Community Food Advisors [3, 12]. Survey respondents were provided with definitions to avoid confusion and asked to select which term best describes a peer from the community that is trained by a health professional. The most commonly chosen response was that "the term used is dependent on the program," suggesting that dietitians understood the need to tailor the label to the program, as was done in The Healthy Kitchen--La Cocina Saludable program whereby Hispanic grandmothers or grandmother figures were chosen as PEers and called "abuelas" (grandmother) to recognize the respect and honour afforded to these community members . While every PE program must assign a name for their PEer, it is useful to utilize a general term that describes the concept. The next most commonly chosen response among the dietitian respondents was PEer; however, it is noteworthy that community health worker is a very common term in the literature , but it was chosen less often by dietitians.
Other authors have recognized that PEers, when perceived as credible, are able to influence their peers because these individuals are more accepting and open to receiving information and guidance from someone with whom they can relate [2, 13, 30]. Similarly, dietitian respondents agreed that PEers are more approachable and more likely to build rapport with their peers than health professionals. Respondents also agreed that if PEers are given sufficient training they can provide credible information. Adequate training is, however, an area of concern in PE literature as the amount of training provided to PEers varies tremendously from 1 to up to 18 training sessions, with many programs considered to have low-intensity training . Furthermore, the majority of respondents agreed that PE should only be used as an extension or complement to the work of healthcare professionals, suggesting that dietitians recognize the importance of having the appropriately trained health professional manage the PE program.
Dietitian respondents most strongly agreed that cultural groups, adolescents, and post-secondary students were target populations for which PE was likely to be effective. These results are supported by the literature on PE whereby many programs have been implemented with Hispanic/Latino and African-American cultural groups [3, 7, 24-26] and post-secondary students [10, 17-19]. Although employees and new moms were target populations for which dietitians had lower levels of agreement, research suggests PE is effective with these target groups as well [4, 5, 24], perhaps offering future opportunities for peer nutrition education programs. The lowest level of agreement for effectiveness of PE was with pre-adolescents, perhaps due to the young age of the peers; however, Stock et al.  demonstrated an improvement in healthy-living knowledge, behaviour, and attitudes in elementary school students when older students were PEers to younger students.
Dietitian respondents from this study perceived PE to be most effective for healthy eating/lifestyle goals followed by prevention and self-management goals. Dietitians generally did not agree that PE should be used for treatment of disease. This concurs with respondent attitudes that PE is more effective in the community/public health sector and with the higher TAS of community/public health versus clinical dietitians. In an open-ended survey question, 1 respondent commented that "Private practice and clinical practice require a level of skills that could not be achieved by peer education due to the complex physiological/biological nature of this work." In the literature, however, PEers have been successful in programs that include detection and treatment of obesity and chronic diseases [3, 7, 28], suggesting that dietitians could consider expanded roles and responsibilities for PEers.
Dietitians agreed there are many benefits to PE programs for the PEers themselves, with the highest levels of agreement for experience, empowerment, and skill development. To our knowledge, only 2 studies have investigated the positive effects of PE on the PEer [6,27]. Both of these studies showed positive results for PEers, with one of the studies demonstrating stronger outcomes for PEers than participants . In the current study, dietitian respondents had higher levels of agreement for benefits to PEers compared with participants, supporting the idea that the benefits for PEers are greater than for the participants. This phenomena could occur because the PEer receives more in-depth training and skill development and spends more time delivering program components compared with participants, allowing for repetition of concepts and enhanced learning outcomes .
Although PE models offer many benefits, there are also challenges and limitations . Dietitian respondents were most likely to agree that limited financial resources, as well as lack of organizational support and inadequate funding to provide compensation to PEers were barriers of implementation. Even when PEers are not paid, there are still costs associated with training and program delivery, and these do require organizational support . Other challenges identified included the support and mentoring required for PEers, the delivery of misinformation, inconsistencies with program delivery, and the challenge of sustaining the program. These are important factors to consider when planning a PE program. It is noteworthy that most dietitians disagreed that decreased quality of client care or decreased client satisfaction were barriers or limitations.
Although this study provides important information about dietitians' perceptions of PE, the study response rate was lower than anticipated despite using the Dillman method with 3 reminders . This may have been related to the administration of the survey in the early summer. Nevertheless, the sample of dietitians was representative of dietitians demographically and was large enough to obtain significant differences. As with most surveys that invite participants, there is likely a selection bias toward dietitians who are interested in PE, but there was a range of responses suggesting diversity of opinion among respondents.
RELEVANCE TO PRACTICE
Dietitians often manage peer-nutrition education programs as a way to extend their reach in educating community members about healthy eating and food literacy. This research adds to our knowledge and understanding of the benefits and barriers to utilizing PE. Overall, dietitians in Canada generally have a positive attitude towards PE. They recognize its usefulness and effectiveness in community settings and with specific populations. Dietitians, could however, be challenged to consider PE in settings and target populations not previously considered. Overall, these results will be useful to decision makers, dietitians, and other health professionals in establishing PE programs in nutrition and other disciplines because the implementation of PE programs are dependent upon buy-in from these stakeholders. More research is needed to understand best practices for PE in the dietetic profession, as dietitians, PEers, and participants are likely to obtain greater benefits with more effective use of PE models.
We offer our sincere thanks to Marlene Wyatt from DC who assisted in delivering the survey to the sample of dietitians. Thank you also to the dietitians who completed the survey. Financial support: This project was funded by an internal graduate student research grant from Brescia University College.
Conflict of interest: The authors have no conflict of interest.
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PAULA D. N. DWORATZEK, RD, PhD (a,b); JOANNE STIER, MScFN (a)
(a) Division of Food and Nutritional Sciences, Brescia University College at Western University, London, ON; (b) Schulich Interfaculty Program in Public Health, Schulich School of Medicine and Dentistry, Western University, London, ON
(1) Supplementary data are available with the article through the journal Web site at http://dcjournal.ca.www.nrcresearchpress.com/doi/suppl/10.3148/cjdpr-2016-009.
Table 1. Dietitians' attitudes and beliefs regarding peer education. % Statements regarding PE Agreement * Success of a PE program is influenced by: adequate training for PEers 99 support/mentoring for PEers 99 monitoring/evaluation of PEers 98 PEers interpersonal and social skills 99 PEers communication skills 98 PEers shared values with the target 92 population PE programs should: be collaborative interventions by PEers and 91 healthcare professionals only be an extension/complement to 78 healthcare professionals PE models are useful in: group settings 81 one-on-one peer mentoring 60 PEers can provide credible information if given 79 sufficient training PE is a cost effective model 75 Participants in PE programs are respectful of 69 PEers PEers can interact with clients more often than 69 health professionals PEers have the potential to interact with more 65 clients/participants than health professionals PE is an effective model for delivering nutrition 63 education interventions Participants think PEers are credible 61 PE should be used more often in nutrition 59 PEers can achieve comparable outcomes to 37 health professionals * Agreement was based on a 5-point Likert-like scale: 1 = strongly disagree to 5 = strongly agree; percent agreement was obtained by collapsing agree and strongly agree. PE, peer education; PEer, peer educator. Table 2. Dietitians degree of agreement with the effectiveness/ usefulness of peer education. Effectiveness/usefulness RDs' degree of agreement of peer education (mean [+ or -] SD) Effectiveness in specific sectors of dietetic practice (n = 175) * Community/public health 3.7 [+ or -] 1.0 (a) Food service 3.4 [+ or -] 1.0 (b) Long-term care 3.1 [+ or -] 1.1 (c) Business 3.0 [+ or -] 1.1 (c) Education/government 2.9 [+ or -] 1.1 (c) Private practice 2.4 [+ or -] 0.9 (d) Clinical 2.4 [+ or -] 1.1 (d) Effectiveness with specific target populations (n = 171) ([dagger]) Cultural groups 4.0 [+ or -] 0.7 (a) Adolescents 3.8 [+ or -] 0.8 (ab) Post-secondary students 3.8 [+ or -] 0.8 (bc) Rural populations 3.7 [+ or -] 0.8 (bcd) New moms 3.7 [+ or -] 0.9 (bcd) Adult women 3.6 [+ or -] 0.8 (bcd) People with disabilities 3.6 [+ or -] 0.9 (cd) Older adults 3.6 [+ or -] 0.8 (cde) Pregnant women 3.6 [+ or -] 1.0 (cde) Employees 3.6 [+ or -] 0.9 (cde) Adult men 3.5 [+ or -] 0.9 (de) Pre-adolescents 3.4 [+ or -] 1.1 (e) Effectiveness for specific health goals (n = 186)([double dagger]) Healthy eating 3.8 [+ or -] 0.9 (a) Prevention 3.4 [+ or -] 1.1 (b) Self-management 3.4 [+ or -] 1.0 (b) Treatment 2.3 [+ or -] 1.1 (c) Usefulness for specific strategies (n = 181)([section]) Social support 4.2 [+ or -] 0.7 (a) Role modelling 4.0 [+ or -] 0.8 (ab) Skill building 3.9 [+ or -] 0.8 (bc) Information dissemination 3.7 [+ or -] 0.9 (cd) Self-monitoring 3.7 [+ or -] 0.9 (d) Goal setting 3.7 [+ or -] 0.9 (d) Degree of agreement was based on a 5-point Likert-like scale: 1 = strongly disagree to 5 = strongly agree. Means with different superscript letters are significantly different. * Degree of agreement to the statement: "PE is an effective model to deliver nutrition interventions in each of the following sectors." RMANOVA for sector by practice area (community, clinical, or other) showed no main effect of practice area; however, there was a main effect of sector (P < 0.001). ([dagger]) Degree of agreement to the statement: "PE is an effective model for the following target populations." RMANOVA for target population by practice area showed a main effect of practice area (P = 0.001) with Community/PH dietitians having higher degrees of agreement (data not shown). Similarly, there was a main effect of target population, P < 0.001, but no significant interaction. ([double dagger]) Degree of agreement to the statement: "PE is an effective model for the following health goals." RMANOVA for health goals by practice area showed no main effect of practice area; however, there was a main effect for health goals (P < 0.001). ([section]) Degree of agreement to the statement: "The following strategies are useful in PE." RMAVOVA for strategies by practice area showed no main effect of practice area; however, there was a main effect for strategy (P < 0.001). RDs, Registered Dietitians; PE, peer education. Table 3. Dietitians degree of agreement with the benefits of peer education. Benefits of peer RDs' degree of agreement, education (mean [+ or -] SD) Benefits for participants (n = 159) * Increased social 4.1 [+ or -] 0.6 (a) support Building community 4.1 [+ or -] 0.6 (ab) capacity Increased awareness 4.0 [+ or -] 0.7 (bc) Empowerment 4.0 [+ or -] 0.7 (bcd) Increased self-efficacy 3.9 [+ or -] 0.6 (cde) Skill development 3.9 [+ or -] 0.6 (cde) Increased knowledge 3.8 [+ or -] 0.7 (cdef) Attitude change 3.8 [+ or -] 0.7 (def) Behavior change 3.7 [+ or -] 0.7 (ef) Changed social norms 3.7 [+ or -] 0.7 (f) Benefits for peer educators (n = 161) ([dagger]) Experience 4.3 [+ or -] 0.6 (a) Empowerment 4.3 [+ or -] 0.6 (ab) Skill development 4.2 [+ or -] 0.5 (ab) Increased knowledge 4.2 [+ or -] 0.5 (ab) Building community 4.2 [+ or -] 0.6 (ab) capacity Increased awareness 4.2 [+ or -] 0.6 (ab) Increased self-efficacy 4.2 [+ or -] 0.6 (b) Increased social 4.0 [+ or -] 0.6 (c) support Attitude change 3.9 [+ or -] 0.6 (cd) Behaviour change 3.9 [+ or -] 0.6 (cd) Changed social norms 3.8 [+ or -] 0.7 (d) Benefits for RDs (n = 165) ([double dagger]) Community linkages 3.8 [+ or -] 0.9 (a) Building community 3.4 [+ or -] 1.1 (a) capacity Extended resources 3.4 [+ or -] 1.0 (a) Health benefits for 2.3 [+ or -] 1.1 (b) client Degree of agreement was based on a 5-point Likert-like scale: 1 = strongly disagree to 5 = strongly agree. Means with different superscript letters are significantly different. * Degree of agreement to the statement: "the following are benefits of PE for participants." RMAVOVA for benefits by practice area showed no main effect of practice area; however, there was a main effect for benefits (P < 0.001). ([dagger]) Degree of agreement to the statement: "the following are benefits of PE for Peer Educators". RMAVOVA for benefits by practice area showed no main effect of practice area; however, there was a main effect for benefits (P < 0.001). ([double dagger]) Degree of agreement to the statement: "the following are benefits of PE for RDs". RMAVOVA for benefits by practice area showed a main effect of practice area (P = 0.001) with Community/PH Dietitians having a higher degree of agreement (data not shown). Similarly, there was a main effect for benefits (P < 0.001). RDs, registered dietitians; PE, peer education. Table 4. Dietitians' degree of agreement with the following barriers or limitations to peer education. RDs' degree of agreement, mean [+ or -] SD Barriers or limitations to PE (n = 152) Limited financial resources 4.1 [+ or -] 0.8 (a) Delivery of misinformation 4.0 [+ or -] 0.9 (ab) Challenges in supporting and 4.0 [+ or -] 0.8 (ab) mentoring PEers Challenges with sustainability 4.0 [+ or -] 0.8 (abc) Inconsistency in program delivery 3.9 [+ or -] 0.9 (abc) Biases of PEers 3.9 [+ or -] 0.9 (abc) Lack of organizational priority to 3.9 [+ or -] 0.8 (abc) support Inadequate funding to provide 3.8 [+ or -] 0.8 (bc) compensation for PEers Challenges with retention of PEers 3.8 [+ or -] 0.8 (bcd) Professional protectionism by RD 3.7 [+ or -] 1.1 (bcde) Difficulty recruiting PEers 3.7 [+ or -] 0.8 (cdef) Difficulty training PEers 3.6 [+ or -] 1.0 (def) Increased difficulty in justifying the 3.4 [+ or -] 1.2 (efg) need for RD services Decreased opportunity for RD to 3.4 [+ or -] 1.1 (fg) develop rapport with clients Conflict between PEer and RD 3.2 [+ or -] 0.9 (gh) Decreased quality of client care 3.0 [+ or -] 1.1 (hi) Decreased client satisfaction 2.9 [+ or -] 0.9 (I) Degree of agreement was based on a 5-point Likert-like scale: 1 = strongly disagree to 5 = strongly agree. RMAVOVA for barriers/ limitations by practice area (community/clinical/other) showed no main effect of practice area; however, there was a main effect for benefits/limitations (P < 0.001). Means with different superscript letters are significantly different. PE, peer education; RDs, registered dietitians; PEer, peer educator.
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|Author:||Dworatzek, Paula D.N.; Stier, Joanne|
|Publication:||Canadian Journal of Dietetic Practice and Research|
|Date:||Dec 1, 2016|
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