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REHABILITATION IN PRACTICE
Rehabilitation service utilization and determinants among peoplewith an intellectual disability: Preliminary findings in Taiwan
JIN-DING LIN1, CHIA-FENGYEN2, CHING-HUI LOH3, CHI-WEI LI1 & JIA-LING WU2
1School of Public Health, National Defense Medical Center, National Defense University, Taipei, 2Research Center for
Intellectual Disabilities Taiwan, Chung-Hua Foundation for Persons with Intellectual Disabilities, Taipei, and 3Department
of Family and Community Medicine, Tri-Service General Hospital, Taipei, Taiwan, Republic of China
Accepted February 2006
AbstractImproving rehabilitation services for people with intellectual disabilities (ID) remains an ongoing challenge in the publichealth system. The purpose of this article was to investigate the types of rehabilitation services used by people with ID anddetermine what factors predict resource utilization in Taiwan. Samples of 957 people with ID were recruited from theTaiwan National Disability Register in a cross-sectional study in 2001. The findings indicated that 24.5% of individuals withID had received rehabilitation services in the past 7 months. The main types of services used were speech andcommunication therapy (50%), psychotherapy (32.1%), occupational therapy (30.3%) and physiotherapy (25.2%). Stepwiselogistic regression was carried out for the utilization of rehabilitation services (yes/no). The model revealed that the followingfactors: (i) Major Illness Card holder, (ii) time spent in medical care, (iii) having a family physician, (iv) having illnesses,(v) age of ID individual, and (vi) gender of the main carer, were all significantly associated with the utilization ofrehabilitation services. We should reorient the healthcare system to respond adequately to the health needs of rehabilitationservice users and its determinants, and further research should focus on the effectiveness and efficiency of rehabilitation forpeople with ID in Taiwan.
Keywords: Rehabilitation, healthcare utilization, intellectual disability, Taiwan
Introduction
People with intellectual disabilities (ID) encompass a
wide range of limitations in areas such as recogni-
tion, ability and social adaptation skills, they are
more prone than the rest of population to chronic,
life-long physical, mental and social conditions that
require specific forms of health and social services
[1 – 7]. Individuals with ID often have difficulty
receiving necessary health services in the community
and tend to be overlooked by health professionals
and public health strategies in national initiatives
[5,8 – 10]. The Rehabilitation Act of 1973 in the
United States mandated prioritization of rehabilita-
tion services to people with severe disabilities [11].
The major goals of rehabilitation are: (i) to prevent
further impairment and disability, (ii) to support
adaptation to or recovery from illness or disability,
(iii) to maximize functional independence, and (iv)
to improve or maintain their biopsychosocial status
for community-based living and adaptation [12 – 13].
Rehabilitation programs generally include various
self-diagnostic tests, checks and inventories, as well
as instruments that have been developed primarily to
measure the benefits clients realize from receiving
rehabilitation services [14].
There are three models of rehabilitation. The legal/
industrial model assumes that rehabilitation programs
frequently run workshops that simulate industrial or
clerical settings whose goals are to improve voca-
tional aptitude and skills. In the educational model,
rehabilitation can be defined as the process of teach-
ing an individual the skills or competencies required
to maximize their satisfaction with minimum effort
within the community [15]. The medical model
defines rehabilitation as ‘‘the ultimate restoration of
Correspondence: Dr Jin-Ding Lin, School of Public Health, National Defense Medical Center, National Defense University, No. 161, Min-Chun E. Rd.,
Section 6, Nei-Hu, Taipei, Taiwan 114, Republic of China. Tel: 886 2 8792 3100. Fax: 886 2 8792 3147. E-mail: [email protected]
Disability and Rehabilitation, December 2006; 28(23): 1499 – 1506
ISSN 0963-8288 print/ISSN 1464-5165 online ª 2006 Informa UK Ltd.
DOI: 10.1080/09638280600648181
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a disabled person to his maximum capacity – physical,
emotional, and vocational’’ [16]. This medical
rehabilitation deals mainly with the loss and restora-
tion of physical or mental function. It utilizes medical
professionals who administer to the patients and
restore them to the healthiest condition possible [15].
In the early development of rehabilitation for people
with ID, the application of rehabilitation therapy for
clients with limited intelligence and/or limited verbal
ability, particularly those who are labeled mentally
retarded or severely psychotic, have been questioned
due to these clients lacking sufficient self-concept
ability [17]. However, health is a human right that
needs to be protected and people with ID also have a
right to be as healthy as anyone else [10]. To improve
the health of people with ID, the Constitution of the
Republic of China (Taiwan) (1947) [18] stipulates that
the government is obliged to provide all people with
basic healthcare and services. All governments should
organize their rehabilitation resources to help people
with disabilities to be included in community living
and adaptation. Recent research also highlights that
there is a growing demand for interdisciplinary reha-
bilitation for people with developmental disabilities.
However, information is lacking on the rehabilitation
service utilization patterns of this vulnerable group of
people [19]. A good rehabilitation database would
serve to help promote program accountability and
integrity, and help to identify facilitators, as well as
barriers, to successful rehabilitation of persons with
disabilities [11]. The purposes of this paper are to
outline the profile of rehabilitation utilization for
people with ID in Taiwan and to examine the factors
that affect their utilization.
Methods
Samples
This sample group is part of a retrospective, cross-
sectional study that examines the health care utiliza-
tion and policy development for people with ID in
Taiwan [20]. Subjects were recruited from the
Taiwan National Disability Registration System.
There were 71,012 individuals registered with ID
at the end of the year 2000. Subjects were stratified
by their administrative area (county or city), selected
systematically according to the proportion of ID
population in each area for the study. We anticipated
the low response rate of disability study in Taiwan, so
we over sampled by a factor of five in order to obtain
meaningful statistical data. A sample of 5040 indi-
viduals with ID was selected for the study.
Data were collected by a mail-structured ques-
tionnaire that was completed for each individual by
their main carer. To improve validity and reliability,
a pilot questionnaire was administered to the main
carers of a small number of individuals prior to the
present study. The questionnaire finally used was
developed and reviewed by 5 experts in the field of
disability, public health, and medicine. In terms of
reliability analysis, as the questionnaires were re-
turned, we tested the Cronbach a value for the
reliability and found it to be 0.91 in this study. A
total of 1071 questionnaires were returned giving a
response rate of 21.3%. Within the respondents,
there were 957 individuals with ID who supplied
complete rehabilitation utilization data for the prior 7
months (1 January 2001 to 31 July 2001) and these
were included in the analysis for the present article.
In the study, a person with ID was operationally
defined based on ‘The Protection Law for Persons
with Disabilities’ (1997) [21] in Taiwan, Republic of
China. People with ID were characterized by the
presence of significant intellectual limitation or in-
complete mental development and often had related
limitations in areas such as recognition, ability and
social adaptation skills. The administrative procedure
followed ensured that each ID case identified was
defined and classified by health authorities and then
registered with social welfare authorities.
Statistical analysis
Data was analysed using the Statistical Package for
Social Science (SPSS; version 10.0) for Windows
computer software. Descriptive statistics were used
to characterize demographic data, health and reha-
bilitation service utilization. We used the chi-square
method to test the association between rehabilitation
utilization (yes/no) and its determinants. Stepwise
logistic regression was carried out for rehabilitation
utilization with its determinants to create the model
to predict such utilization.
Results
Sample characteristics
A total of 957 people with ID were recruited to this
study. Their mean age was 25.5+ 13.6 years old. In
our sample, most of the people with ID had a mild to
moderate level of disability (36.0% and 25.8%), with
severe and profound disability accounting for 25.7%
and 12.4%, respectively. Multiple disabilities were
very common among this vulnerable group, with
nearly two-thirds of subjects further challenged by
other disabilities affecting their daily living. ‘Diffi-
culty in speaking and communication’ affected
one-third of the ID population examined, followed
by epilepsy (13.7%), psychiatric disorders (12.1%),
autism (11.9%), vision impairment (11.3%), mobi-
lity (10.1%), Cerebral palsy (7.0%) and hearing
problems (6.6%). Gender and level of disability were
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significant difference in the age group of people with
ID in the present study (Table I).
In terms of the self-reported health for people with
ID, most main carers characterized the overall health
status of their charges as being good-excellent (36.5%),
or fair (46.7%); however, 16.8% were reported to be
in poor or bad health over the 7 months prior to the
survey. Although most main carers reported the indi-
viduals with ID were in good-excellent or fair health,
the prevalence of reported illnesses among people with
ID was 47.7%, and 34% needed to take medicine
regularly in the 7 months prior to the survey.
Rehabilitation services utilization
The respondents were surveyed as to the utilization
and type of rehabilitation services that people with
ID received in the 7 months prior. The rehabilitation
services included physiotherapy (PT) for strengthen-
ing and ambulation programs; occupational therapy
(OT) to increase functional capacities, especially in
regard to self-care; speech or communication therapy
(SP) to improve language skills [22] and psychother-
apy (Psycho) for the treatment of emotional or beha-
vioral problems [23]. These services for disability
rehabilitation in the present study were supported by
the healthcare system in Taiwan. The results found
that there were 24.5% individuals with ID who had
received rehabilitation services during this time
frame (Figure 1). The main types of services used
were SP (50%), Psycho (32.1%), OT (30.3%), PT
(25.2%) and other (10.3%) (Figure 2).
Factors influencing rehabilitation utilization
The study employed the Behavioral Model of
Families’ Use of Health Services [24 – 26]. Such an
approach divides medical care utilization effect
factors into three categories: Predisposing, enabling
and need characteristics. In the present study, we
examined the effects of different factors on rehabi-
litation utilization via three categories: Demographic,
enabling and need characteristics. With regard to
demographic factors, Table II shows that the charac-
teristics of gender and age of ID individual and
marital status of the main carer affected rehabi-
litation utilization by people with ID (p5 0.05).
Table III shows that male ID individuals and those of
younger age were more inclined to use rehabilitation
services (p5 0.005).
Table I. Demographic characteristics of individuals with ID.
Age (years old)
Variable
under 12
No. (%)
12 – 17
No. (%)
18 – 44
No. (%)
45 – 64
No. (%)
Over 65
No. (%) w2 p value
Gender (n¼ 923)
Male 92
(16.8)
98
(17.9)
318
(58.0)
37
(6.8)
3
(0.6)
12.05 0.017
Female 46
(13.1)
63
(16.8)
211
(56.3)
47
(12.5)
5
(1.3)
Level of disability (n¼896)
Mild 54
(22.8)
50
(21.1)
119
(50.2)
13
(5.5)
1
(0.4)
46.57 �0.001
Moderate 54
(16.4)
62
(18.8)
191
(57.9)
20
(6.1)
3
(0.9)
Severe 20
(9.2)
31
(14.3)
131
(60.4)
31
(14.3)
4
(1.8)
Profound 9
(8.0)
16
(14.3)
70
(62.5)
17
(15.2)
0
(0.0)
Figure 1. Utilization of rehabilitation among people with ID (n¼ 957).
Rehabilitation service utilization among people with ID in Taiwan 1501
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The enabling factors in Table IV examined how
factors such as ‘family physician system’ and ‘long
waiting time in medical care’ affected the utilization of
rehabilitation services by people with ID (p50.05).
The remaining factors, household economic status,
medical accessibility, medical cost affordability and
Figure 2. Type of rehabilitation service (n¼234).
Table II. Utilization of rehabilitation services and demographic characteristics of main carers.
Rehabilitation
Variable
No
Number (%)
Yes
Number (%) w2 p value
Main carer (n¼930)
Female 374 (80.1) 93 (19.9) 9.37 0.03
Male 331 (71.5) 132 (18.5)
Age of main carer (n¼ 878)
11 – 20 30 (73.2) 11 (26.8) 23.00 0.01
21 – 30 90 (84.9) 16 (15.1)
31 – 40 138 (67.3) 67 (32.7)
41 – 50 211 (73.3) 77 (26.7)
51 – 60 105 (86.1) 17 (13.9)
61 – 70 47 (77.0) 14 (23.0)
Over 71 46 (83.6) 9 (16.4)
Education level of main carer (n¼931)
Primary school and less 215 (81.7) 48 (18.3) 11.77 0.067
Junior high school 162 (72.6) 61 (27.4)
Senior high school 209 (73.9) 74 (26.1)
College 77 (74.8) 26 (25.2)
University 36 (78.3) 10 (21.7)
Master and doctoral 7 (53.8) 6 (46.2)
Marital status of main carer (n¼ 937)
Unmarried 138 (81.7) 31 (18.3) 13.38 0.037
Married 473 (73.2) 173 (26.8)
Others 51 (70.8) 21 (29.2)
Religion of main carer (n¼ 926)
Buddhist 316 (75.8) 101 (24.2) 7.44 0.19
Daoism 202 (78.3) 56 (21.7)
Christian 25 (61.0) 16 (39.0)
Catholic 6 (66.7) 3 (33.3)
Non-specific religion 139 (75.1) 46 (24.9)
Other 14 (87.5) 2 (12.5)
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subsidy from National Health Insurance Scheme,
were not statistically significant.
Statistically significant differences were recorded
in relation to need factors in rehabilitation utiliza-
tion. Those who held a Major Illness Card, issued to
beneficiaries who have been positively diagnosed with
conditions officially designated as major illnesses or
injuries, were more likely to utilize rehabilitation
services than those without the card (p5 0.005). In
addition, individuals with ID accompanied by multi-
ple disabilities (p5 0.001) and having an illness
(p5 0.05), were more inclined to utilize rehabilita-
tion services (Table V). No significant association
between self-reported health status and rehabilitation
utilization was identified.
Stepwise logistic regression was carried out to
examine the utilization of rehabilitation services (yes/
no), with the statistically significant factors listed
in Tables I – IV identified as independent variables.
The model revealed that the factors of ‘Major Illness
Card holder’, ‘time spent in medical care’, ‘having a
family physician’, ‘having an illnesses’, ‘the age of ID
individual’, and ‘gender of the main carer’ were all
significantly associated with utilization of rehabilita-
tion services (Table VI).
Major Illness Card holders were more inclined to
use rehabilitation care than individuals without the
card, with the odds ratio (OR) 1.880 and 95%
confidence interval (CI) 1.088 – 3.249. The model
indicated that those respondents felt ‘very much’ or
‘a little’ time spent in medical care were 2.088 (95%
CI¼ 1.032 – 4.227) and 2.511 (95% CI¼ 1.369 –
4.604) times respectively more likely to require reha-
bilitation care than those respondents thought medi-
cal care to be ‘not at all’ time consuming. People
with ID who reported to have a family physician
were less likely to seek rehabilitation services than
those not having a family physician, OR¼ 0.583
(95% CI¼ 0.371 – 0.916). People with ID with an
accompanying illness were also predicted to seek
Table III. Utilization of rehabilitation services and demographic
characteristics of ID individuals.
Rehabilitation
Variable
No
Number (%)
Yes
Number (%) w2 p value
Gender (n¼ 954)
Male 408 (72.2) 157 (27.8) 9.06 0.003
Female 314 (80.7) 75 (19.3)
Age (years old) (n¼ 925)
Under 10 45 (38.1) 73 (61.9) 121.68 50.000
11 – 20 219 (73.7) 78 (26.3)
21 – 30 200 (83.0) 41 (17.0)
31 – 40 117 (89.3) 14 (10.7)
41 – 50 80 (87.9) 11 (12.1)
51 – 60 29 (87.9) 4 (12.1)
Over 61 11 (78.6) 3 (21.4)
Level of disability (n¼927)
Mild 177 (73.1) 65 (26.9) 7.50 0.057
Moderate 246 (72.6) 93 (27.4)
Severe 179 (78.2) 50 (21.8)
Profound 98 (83.8) 19 (16.2)
Table IV. Utilization of rehabilitation services, and enabling
factors.
Rehabilitation
Variable
No
Number (%)
Yes
Number (%) w2 p value
Household economic status (monthly) (n¼ 912)
Balance 306 (77.3) 90 (22.7) 2.24 0.33
Surplus 57 (69.5) 25 (30.5)
Deficit 330 (76.0) 104 (24.0)
Medical care accessibility (n¼ 762)
No difficulty 381 (74.3) 132 (25.7) 0.06 0.86
Difficulty 187 (75.1) 62 (24.9)
Having a family physician (Visiting the same physician) (n¼772)
No 353 (73.2) 129 (26.8) 5.00 0.03
Yes 233 (80.3) 57 (19.7)
Medical cost affordability (n¼ 767)
No 310 (75.2) 102 (23.8) 0.10 0.93
Yes 266 (74.9) 89 (25.1)
Time spent in medical care (n¼ 928)
Not al all 189 (83.6) 37 (16.4) 14.09 0.003
Neutral 243 (75.9) 77 (24.1)
A little 155 (69.5) 68 (30.5)
Very much 113 (71.1) 46 (28.9)
Subsidy from National Health Insurance scheme (n¼ 850)
No 345 (75.0) 115 (25.0) 0.006 1.00
Yes 293 (75.1) 97 (24.9)
Table V. Utilization of and reasons for rehabilitation services.
Rehabilitation
Variable
No
Number (%)
Yes
Number (%) w2 p value
Major Illness Card holder (n¼930)
No 612 (77.3) 180 (22.7) 12.75 0.001
Yes 87 (63.0) 51 (37.0)
Multiple disabilities (n¼ 927)
No 268 (86.7) 41 (13.3) 33.10 50.000
Yes 429 (69.4) 189 (30.6)
Having illnesses (n¼915)
No 385 (78.9) 103 (21.1) 6.84 0.011
Yes 305 (71.4) 122 (28.6)
Self-reported health status (n¼ 954)
Excellent 79 (76.0) 25 (24.0) 5.02 0.29
Good 184 (71.3) 74 (28.7)
Neutral 339 (78.3) 94 (21.7)
Poor 94 (73.4) 34 (26.6)
Bad 25 (80.6) 6 (19.4)
Rehabilitation service utilization among people with ID in Taiwan 1503
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rehabilitation services, with their OR being 2.932
(95% CI¼ 1.800 – 4.777) compared to those indivi-
duals without an illness. With respect to the factor of
‘age’ of people with ID, within the stepwise logistic
regression model, the OR was 0.933 (95% CI¼0.915 – 0.953). This means that the younger the
individual with ID, the more likely the rehabilitation
utilization. Female main carers were more likely than
male carers to report that their children with ID
had utilized rehabilitation services (OR¼ 1.564, 95%
CI¼ 1.034 – 2.365).
Discussion
There is general agreement that people with ID
are prone to life-long health or disability problems
and require rehabilitation at a significance rate. The
rehabilitation service focuses primarily on the achi-
evement of behavioral or life outcomes, i.e., successful
employment, independent living, and community
participation are the ultimate goals of the rehabilitation
service program [14]. Rehabilitation counseling at-
tempts to facilitate human change and development
through the use of an extensive set of interlocking
skills based upon specialized knowledge, and guided
by philosophical orientation and ethical guidelines
[27]. However, the effectiveness and efficiency of
rehabilitation services for people with disabilities are
not being fully investigated and scrutinized in modern
healthcare systems.
Relatively few studies examining rehabilitation
service utilization by people with ID appear in the
published literature. Modern health service systems
must recognize this group of people often ‘fall
through the cracks’, and that there is a lack of inter-
disciplinary rehabilitation services to meet their
unique, yet persistent, needs [19]. Our study in
Taiwan indicates that one quarter of people with ID
utilized rehabilitation services in the seven months
prior to the study survey. Speech and communication
therapy were the most used rehabilitation services
noted in the present study. Most people with ID
experience communication problems, and as such,
they communicate their symptoms less ably than
other people [27]. Their poor health can be partially
attributed to difficulties encountered by people with
ID to communicate problems to health professionals
in consultation settings [28]. This limits expression
of their concerns regarding their own health and
their capacity to make choices about their health and
their lifestyle.
Psychotherapy and OT were also extensively used
by people with ID in the present study. Individuals
with ID are more vulnerable to mental health
problems than the general population, and for this
reason considerable research attention has been
directed toward understanding the diagnosis and
intervention efficacy in people with ID [7,29 – 30].
Gray and Mohr stated that the main treatment of
mental health problems in this population continue
to be via medication. However, they suggested the
healthcare system should encourage seeing examina-
tion of the roles of family and environmental factors
being considered in the formulation of intervention
Table VI. Factors related to the utilization of rehabilitation services according to a stepwise logistic regression model (n¼ 597).
Variable b SE p-value OR 95% CI for OR
Constant 70.987 0.365 0.007 0.373
Major Illness Card holder
No 1
Yes 0.631 0.279 0.024 1.880 1.088 – 3.249
Time spent in medical care
Not at all 1
Very much 0.736 0.360 0.041 2.088 1.032 – 4.227
A little 0.921 0.309 0.003 2.511 1.369 – 4.604
Neutral 0.408 0.288 0.157 1.503 0.855 – 2.643
Having a family physician
No 1
Yes 70.540 0.230 0.019 0.583 0.371 – 0.916
Having illnesses
No 1
Yes 1.076 0.249 0.000 2.932 1.800 – 4.777
Age of ID individual (years) 70.069 0.010 0.000 0.933 0.915 – 0.953
Gender of main carer
Male 1
Female 0.447 0.211 0.034 1.564 1.034 – 2.365
This table only shows statistically significant factors. The variables in Tables I – IV that were statistically significant in single variable tests
were put through the stepwise logistic regression model.
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programs [29]. The role of OT is to assist those with
disabilities to improve their functional capacities,
especially in regard to self-care or retaining employ-
ment. Despite the value of the OT program, many
people with disabilities experience difficulties in obtai-
ning jobs even after the provision of such rehabilitation
services [31]. Even so, OT for people with ID is still
very much at a preliminary stage in rehabilitation
service provision in Taiwan. The findings presented
here demonstrate the high usage rate of OT among
people with ID, and highlight that the healthcare and
welfare systems should create a coordinated system to
improve the efficacy of OT rehabilitation services
among people with ID in Taiwan.
Despite the value of the rehabilitation programs,
many people with disabilities experience difficulties
in obtaining appropriate therapies and continued
assistance. There were many factors identified in the
present study that affected the utilization of rehabi-
litation services. These factors included demographic
considerations (such as, age of person with ID and
the gender of their main carer), enabling factors (such
as, the time spent in medical care and the presence of
a family physician), and need factors (such as whether
a Major Illness Card holder, and accompanying
illnesses). ID individuals in the young age group
require more rehabilitation services than adults. Long
waiting times and lack of resources may limit access
to comprehensive rehabilitation services [19]. In
addition, perceived cultural value which stigmatizes
individuals with ID is one of the strongest influences
for Asian people when seeking rehabilitation services,
and family dynamics and relationships are also known
to play an important role in the rehabilitation process
in people with disabilities [31]. It was surprising to
note, in the present study, that individuals having a
family physician used rehabilitation services less than
those who did not have a family physician. People
with ID often rely heavily upon family physicians who
are the first-line of their healthcare and referrals to
specialists are highly dependent upon the family
physicians’ awareness, empathy and knowledge of
people with ID [32]. To ensure appropriate utiliza-
tion of rehabilitation services for people with ID, it
appears necessary to examine the role and perception
of family physicians toward rehabilitation for people
with ID in Taiwan. With regard to need factors, ill-
health (Major Illness Card holder, and having a
disease) was a good indicator to predicting rehabilita-
tion utilization. This means that individuals with ID
have multiple healthcare needs compared to the
general population, and that health care policy should
reorient the healthcare system to respond appropri-
ately to their specific needs.
There are a number of limitations to this study that
should be considered. Data was collected by postal
survey and responded to by the main carers of people
with ID. As such, recall biases probably occurred.
Second, we cannot determine with certainty the
reasons behind a lack of use of rehabilitation services,
as this survey was not designed to address this issue.
However, the implications of the present study
highlight the need for the healthcare system to
address factors that affect adequate rehabilitation
utilization. Further research must focus on the effec-
tiveness and efficiency of specific rehabilitation
service types provided to people with ID in Taiwan.
Acknowledgements
This study was supported by funding from the
Department of Health, Taiwan, Republic of China
(grant no. DOH-90-TD-1153). The authors grate-
fully acknowledge the Ministry of the Interior for
providing the data from the Taiwan Disability
Registration System.
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