Research Center REACH

A deskilling and challenging journey: the lived experience of Indonesian nurse returnees

Kurniati, A., Chen, C. M., Efendi, F., & Ogawa, R. (2017). A deskilling and challenging journey: the lived experience of Indonesian nurse returnees. International Nursing Review, n/a-n/a. https://doi.org/10.1111/inr.12352

Aim: To illuminate the lived experiences of Indonesian nurses who previously worked as caregivers in Japanese residential care facilities, by exploring the journey of becoming returnees.
Background: The creation of bilateral agreements between Indonesia and Japan has facilitated the
movement of Indonesian nurses to work as caregivers in Japan since 2008. While this decision raised concerns with regard to the degradation of nursing skills, little is known about this issue from the perspective of nurse returnees and how the experience affects their life.
Method: A hermeneutic phenomenological method was employed for this study. A purposive sample of 15 Indonesian nurse returnees participated in this study. Semi-structured interviews were conducted in four of Indonesia’s provinces between August and October 2015. Data were analyzed thematically, supported by QSR NVIVO 10 software.
Findings: Four key themes emerged from the data analysis: (i) returning home; (ii) going back to zero; (iii) walking through a difficult journey; (iv) overcoming barriers. These findings described the lived experiences of nurse returnees when they got back to the country of origin.
Conclusion: Indonesian nurse returnees experienced deskilling and struggled to re-enter the nursing profession or to find other non-nursing jobs. The significant impact of this migration on individual nurses with regard to maximizing the benefits of return migration deserves further investigation. Implication for nursing and health policy: The Indonesian government, jointly with other stakeholders, should develop a brain gain strategy to align returnees’ expertise with the needs of the national labor market. The public-private partnership should be strengthened to utilize returnees in healthcare services

Discussion:

For returnees in this study, their homecoming was driven by contract termination as a result of failing the examination, family consideration and the feeling of being under pressure in Japan. This ?nding is in line with other return migration studies. Expired contracts have been among reasons compelling the return of Filipino nurses to their home country (Lorenzo et al. 2007). Cassarino (2008) reported that 12.6% of North African migrants were forced to return home due to losing their job. Family was among the strong motives for returning home considered by Ghanaian health professionals (Adzei & Sakyi 2014) and Indonesian nurses (Hirano et al. 2012). In our study, returnees who were both certi?ed and  non-certi?ed caregivers claimed their stressful work experience in Japan contributed to their decision to return. Feeling distressed has also been reported by internationally educated nurses working in Iceland (Magnusdottir 2005) and the USA (Jose 2011). Language and communication barriers, discrimination and different working environment are among common stressors experienced by foreign educated nurses (Moyce et al. 2015). Brain waste occurs when overseas educated health professionals are unable to apply their professional skills in the destination countries (Alam et al. 2015), and this is referred to by Kingma (2006) as a gradual deskilling process. Deskilling has been experienced by migrant nurses who worked as professional nurses (Alexis & Shillingford 2015; Pung & Goh 2016) or as lower-skilled health workers (Salami et al. 2014). For the returnees examined in this study, inability to perform nursing interventions had decreased their skills. Deskilling was unforeseen, because Indonesian nurses were unfamiliar with the caregiver job description (Nugraha & Hirano 2016) and they expected to improve their nursing career and learn advanced technology in Japan (Hirano et al. 2012). The migration policy of Indonesian nurses emphasizes on the expansion of work opportunities and acquisition of new knowledge, skills and work experience (MoH 2012). The dispatch of Indonesian nurses to Japan as caregivers, therefore, is mainly a way to overcome the saturated domestic labour market, but has not yet fully addressed the issue of deskilling and reintegration of returned professionals. Retaining nurses within the nursing profession has remained a global concern in maintaining a robust health system (International Council of Nurses 2013). The dif?culties faced by returnees are particularly related to their return to nursing or their career path. In this study, only three of the 15 returnees (20%) were employed in nursing areas, which is in contrast to a previous study on the return migration of Jamaican nurses by Brown (1996), which found that 76% of these returned to nursing practice. Sadly, Efendi et al. (2013) also found that Indonesian returnees who previously worked as nurses in Japan under the EPA also had a problem in ?nding jobs. Although there are no clear data on nursing unemployment, Indonesia’s labour market is reported to have low capacity to absorb new nursing graduates (Suwandono et al. 2005). The overall unemployment rate in Indonesia is quite high, at 6.18% in 2015, or approximately 7.56 million people of productive age unemployed (BPS 2015). As noted by the returnees in this study, supports from the Indonesian government and the Indonesian National Nursing Association are strongly required in facilitating their return. Having refresher training is crucial to enable them to go back
to the nursing profession. Constructing a returnees’ database and the placement in public hospitals in underserved areas would be a signi?cant contribution in strengthening the health workforce. Haour-Knipe & Davies (2008) emphasized the important role of government in developing such a mechanism. In general, returned Indonesian migrants lack support and urge the government to intervene (International Labour Organization 2015). Both the Japanese and Indonesian governments regularly run job fairs once a year to link between prospective employers and returnees (Efendi et al. 2013). This collaborative effort should be strengthened further by aligning returnees’ competency into the national ageing policy. The caregiving background of nurse returnees would be bene?cial for leveraging the quality of care in the elderly long-term care industry in Indonesia. Returnees who were unable or unwilling to join the nursing workforce utilized the ?nancial and human capital gained in Japan to support their living in their home country. This is parallel with the global pattern of nurse migration in which returnees bring back ?nancial, human and social capitals (Haour-Knipe & Davies 2008). This ?nancial capital is often used to improve the economic status of the family or to start businesses. A migration study of doctors and nurses carried out by Brown & Connel (2004) found that returnees chose self-employment or establishing their own businesses using capital collected from savings and remittances which might compensate their skill drain. The human capital, as expressed by the study participants, is manifested in the acquisition of Japanese language pro?ciency and positive work attitude. Pro?ciency in the Japanese language helped some of the participants to be employed at Japanese companies or health facilities. Returnees’ positive in?uences from their work experience were also con?rmed in a previous study by Efendi et al. (2016), which found that Indonesian migrant nurses in Japan adopted discipline as a work ethic and way of life.
Limitations This study is not without limitations. First, although coming from the same cultural background, the interviewers were not known by most returnees. The participants might be cautious or hesitant about speaking more openly. Second, only participants from Java Island were recruited, thus ignoring disparities among regions in Indonesia.

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Determinants of utilization of antenatal care services among adolescent girls and young women in Indonesia

F. Efendi, C. M. Chen, A. Kurniati, and S. M. Berliana, “Determinants of utilization of antenatal care services among adolescent girls and young women in Indonesia,” Women Heal., vol. 57, no. 5, pp. 614–629, 2017.

ABSTRACT
Due to the high number of maternal deaths, provision of antenatal care services (ANC) in Indonesia is one of the key
aims of the post-Millennium Development Goals agenda. This study aimed to assess the key factors determining use of ANC
by adolescent girls and young women in Indonesia. Data from the Indonesia Demographic and Health Survey 2012 were used, with a focus on married adolescent girls (aged 15–19 years, n = 543) and young women (20–24 years,n = 2,916) who were mothers. Bivariate and multiple logistic regression analyses were performed to determine the factors associated with ANC use. The findings indicated that adolescents were less likely to make ANC visits than young women. Richer women were more likely to make four ANC visits in both groups compared to the poorer women. Living in urban areas, higher educational attainment, and lower birth order were also all associated with higher levels of receiving ANC among young women. The results showed that socio-economic factors
were related to the use of ANC among adolescent girls and young women. Ongoing health-care interventions should thus put a priority on adolescent mothers coming from poor socioeconomic backgrounds.

Discussion:

A number of efforts have been made by the Indonesian government to improve the use of ANC in recent years, including the Universal Healthcare Delivery system, Integrated Health Posts in each village, and the Expanding Maternal and Neonatal Survival program (MoH 2014). However, as reported in the Indonesia Health Profile in 2012, the country still needs to increase its efforts to achieve the national and MDGs targets (MoH 2013). Mounting evidence from developed and developing countries shows that adolescent mothers are at high risk of suffering adverse health outcomes for both their babies and themselves (Fatusi and Hindin 2010; Gortzak-Uzan et al. 2001; Malamitsi-Puchner and Boutsikou 2006; UNICEF 2005). Among both age groups examined in the current study, ANC use was lower than the recommended national standards. Approximately 70% and 80% of the adolescent and young women mothers in this survey received at least four ANC visits, respectively. Our analysis found a number of factors that had a significant relation to the use of ANC for the different age groups. For adolescent girls, only socio-economic status had a positive association with four ANC visits. For the young women living in an urban area, mothers who had a higher level of educational attainment, higher income status, and greater mass media exposure were more likely to have adequate ANC use, while higher parity of young women was negatively associated with the use of four ANC visits. Adolescent girls with middle-income status were two times as likely to have the recommended number of ANC visits than those with low-income status. Meanwhile, young women in the high-income group were three times as likely to have four ANC visits compared to those in the low-income group. Similarly, Singh et al. (2012) found that women in rural India aged 15–19 years old with higher socio-economic status were more likely to use full ANC services than those in the poorest category. The government of Indonesia is now seriously addressing the issue of health inequality between provinces. The results of the current study clearly illustrate the importance of geographical factors in determining adequate use of ANC, with women in urban areas much more likely to achieve this than those in rural areas. This may be linked with the accessibility of ANC services in different areas, with women in urban areas finding these easier to access than those in rural areas. For example, data from the Ministry of Villages, Disadvantaged Regions and Transmigration noted that the average distance to a midwife practice within rural areas was 34 km, while nationally it was only 16 km (Kemendesa-PDT 2015). Moreover, Indonesia has about 74,405 rural villages with 52.97% categorized as underdeveloped and the majority located in the eastern part of Indonesia (Kemendesa-PDT 2015). In 1989, the Indonesian government launched a village-based midwife program in response to high mother and infant death rates. Within 7 years every village in Indonesia thus had a skilled birth attendant or midwife (MoH 2013). In addition, community initiatives undertaken with the establishment of Integrated Health Post (Posyandu) program further enhanced accessibility to such care (MoH 2013). However, despite these efforts inequalities between various regions still remain, and thus policy makers should focus on developing innovative or non-standard approaches to address this issue, based on the actual situations in various areas, with the current study providing findings to inform these approaches. The findings of this study indicated a significant association between maternal education and adequate use of ANC, which is supported by previous research (Ciceklioglu, Soyer, and Öcek 2005; Navaneetham and Dharmalingam 2002; Titaley, Dibley, and Roberts 2010). This may be because women who have higher educational attainment may have acquired more knowledge about maternal and child health and the potential benefits of ANC, thus resulting in a higher level of ANC use (Titaley, Dibley, and Roberts 2010). In this context it should be noted that Indonesia is on track to increase access to education among women across the nation. As reported in a recent study, the school participation rate increased from 55% in 2009 to 61% in 2012 among girls aged 16–18 (Badan Pusat Statistik 2014). However, even though Indonesia has a 9-year compulsory education system, 2.6% and 2.7% of adolescent girls and young women in this study, respectively, remained uneducated. It is thus suggested that by further working to improve the education level of its citizens, and meeting the specific needs of target populations, the government can get closer to achieving its goals with regard to reducing adolescent pregnancy, as well as maternal and infant death rates. Mass media exposure was found to be significantly associated with the use of ANC among young women, consistent with previous studies (Navaneetham and Dharmalingam 2002; Pallikadavath, Foss, and Stones 2004), as the communication channel used to convey health-related messages plays an important role in the decision to use health-care services (Grilli et al. 2000). Television is an especially good medium, because it persuades the audience in a visual and auditory manner and is likely to influence significantly more people than other forms of media. Moreover, health messages need to be tailored to the target populations, particularly when these are illiterate women in Indonesia. The current study found that young women who had their first birth between ages 20–24 years were more likely to have four ANC visits than women who had more births by this age. Earlier research showed that women were significantly more likely to use antenatal health-care services for their first deliveries (Chakraborty et al. 2003; Rai, Singh, and Singh 2012), as these are seen by the mothers as riskier than subsequent deliveries. The time and resource constraints faced by women with higher parity have also been reported to have an association with the low use of ANC in larger families (Elo 1992; Wong et al. 1987), and thus messages about the importance of ANC during pregnancy should be targeted at this group. The results of the present study showed that the income status of mothers was significantly associated with the use of ANC for both age groups. Similarly, other studies have found that high-income status is positively related to greater use of maternal health-care services (Målqvist et al. 2013; Matijasevich et al. 2010). Low economic status is generally a barrier to accessing health-care services (Celik and Hotchkiss 2000; Overbosch et al. 2004). This issue is especially important in Indonesia, which has around 28 million people living in poverty, or 11.47% of the total population (BPS 2013). To address this issue, the government launched a Universal Delivery Care (Jampersal) plan, which allows pregnant women to deliver their children in a health-care facility for free (MoH 2013). This plan also covers ANC services for up to four visits, with more visits available to those women who have complications during pregnancy. However, as noted in an earlier study, not all women who are able to use this plan, due to the mother’s preferences, additional costs that can be incurred during labor, distance to the health facility, and administrative problems (Trisnantoro 2011). One of the solutions that has been suggested to address this issue is to rely on the initiative of the local communities. One of the unique aspects of Indonesia’s health system is the concept of community empowerment (MoH 2009), and the main goal of health development is independence. To achieve this, however, each community needs sufficient knowledge, and the health workers who are on the frontline of such efforts, for instance, nurses, midwives, and other health workers, need to be empowered to convey health messages to the community. The results of this study call for a deeper debate on early marriage and pregnancy, and the negative outcomes of these life events on every level of the community. In Indonesia, the minimum age of marriage for girls is 16 years, and for boys it is 19 years (Government of Indonesia 1974). This study showed that the mean age at marriage was 15.9 years for the adolescent girls, and this young age is an issue that requires special attention from a reproductive health perspective. In addition, some studies showed that early
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sexual activity and childbearing can harm the health of both the mother and infant, and this should be highlighted in the related educational efforts (Hampton 2010; Raj et al. 2010). The Indonesian government has claimed that, with the current population make-up, the nation is expected to have a demographic dividend in the near future (Kemenkokesra 2012). As stated by Tirtosudarmo (2013), “A demographic dividend is when the proportion of people in the productive age group (15–64 years) reaches a maximum, and the dependency ratio is at its lowest level.” Preparation for this golden period should thus be made in advance. In thisregard,itistimetoinvestinyoungwomen’shealth,particularlyadolescents and young mothers, who play a great role in determining the well-being of the next generation. Taking into account the results of this study, future policies andprogramsmustaddressadolescents andyoungmothersto meettheirneeds better for accessible, reliable, and affordable ANC. The present study, makes several noteworthy contributions to the issue of ANC use among adolescent girls and young women in Indonesia. The ANC use rates for both age groups were found to be below the national standard, and this issue needs to be urgently addressed. Current government policies and programs should thus target low-income households, with an emphasis on the sexual and reproductive rights of adolescent girls. Limitations The Indonesia Demographic Health Survey (IDHS) provided limited information on certain topics, and this restricted available detailed data and may have resulted in certain uncontrolled factors confounding the results. Moreover, the data were all self-reported, which might have resulted in recall and/or social acceptability bias. In addition, all variables were assumed to be fixed over a period of 5 years prior to the survey (ceteris paribus). A further limitation was that the use of secondary data may have resulted in misclassification of information and/or a lack of comparability with regard to the results from earlier works that used standard instruments. In addition, this study used a cross-sectional design, which prohibited the assessment of the temporal and thus potentially cauasal relations among the variables.

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Lived experience of Indonesian nurses in Japan: A phenomenological study

F. Efendi, C. M. Chen, N. Nursalam, R. Indarwati, and E. Ulfiana, “Lived experience of Indonesian nurses in Japan: A phenomenological study,” Japan J. Nurs. Sci., vol. 13, no. 2, pp. 284–293, 2016.

Abstract
Aim: The movement of Indonesian nurses via a bilateral agreement with Japan has led to a substantial number of migrants to work as nurses in that nation’s healthcare system. The purpose of this research was to develop a deeper understanding of the meaningful experiences of Indonesian nurses while working in Japanese hospitals.
Methods: In this phenomenological study, sampling was purposive and was based on information shared by ?ve Indonesian nurses. The data were collected in interviews; the analysis was thematic.
Results: Six key themes were identi?ed: (i) seeking better than before; (ii) communication
challenges; (iii) the nursing examination as a culmination; (iv) differences in nursing practice;
(v) cultural differences; and (vi) the bene?ts of living in the developed country. Among these challenges, communication as the basis of shared meaning and understanding was viewed as a complex issue, by both patients and coworkers.
Conclusion: The results of this study call for further intervention in supporting Indonesian nurses living in Japan in their struggle with the issue of communication. The emphasis on language acquisition for personal and professional objectives, and the bridging of cultural differences as well, should be considered in an international context.

Discussion:

This study yielded six themes that captured Indonesian nurse migrants’ successful experiences while working in Japan. The ?rst theme was communication. Indonesian nurses were better prepared for facing communication encounters in daily living or in their personal lives. In fact, they were required to work with patients around the clock to gather patient information and ascertain their needs, develop a plan of care, implement the chosen care plan, and evaluate the effects of this implementation. Those activities require an advanced level of communication skills. Communication is a critical point in nursing care. According to Thorsteinsson (2002), communication is more than transmitting the information from nurse to patients, it also involves feeling, trust, and empathy. All of the respondents perceived communication as a complex process between the sender and receiver. Even if they are well prepared, somehow nursing communication requires skill, technique, and processes that are familiar. They must have not only haveabilitiesrelatedtospeaking,reading,andwritingin kanji (Chinese characters used in Japanese writing), but they also need a thorough understanding of these processes. The success rate on the Japanese national examination was only 9.6% of the total number of foreign nurses who applied in 2013 (Kobayashi, 2013). In line with other research, the communication barrier is somewhat of a problem for migrant nurses when talking to both patients and peers (Alexis & Vydelingum, 2004, 2005). Dif?culties also arose from differences between what they had learned formally and what was required in daily nursing care. For example, their coworkers talk or write in speci?c terminology that they may not have heard before. The communication dif?culties were also a result of unfamiliar dialects, and problems related to talking with the elderly and reading and writing in kanji were also reportedinanotherstudy(Alam&Wulansari, 2010). The second theme was cultural differences. Japanese people are well known as being disciplined and punctual. Because of this, Indonesian nurses were challenged to understand the host culture and adjust to a new environment. For Indonesians, showing up late by 1 or 2minuteswouldbeconsideredunremarkable.However, the Japanese are particularly punctual, and they may be irritatedwithnurseswhoshowuplatetowork(Condon & Masumoto, 2011). Another issue related to cultural differences was family bedside attendance. In Indonesia, it is assumed that the family members will have a great deal of involvement in facilitating a secure and safe environment. Throughout the period of hospitalization, at least one relative will stay by the patient’s side and help provide basic personal care and mental support around the clock. The third theme was seeking a better life than before. The reasons behind migration were complex. It was not only for career and economic reasons, as reported by other researchers (Dywili, Bonner, & O’Brien, 2013; Kingma, 2008), but also because of their interest in living in Japan. It is a very interesting phenomenon because Japan is famous for its high technology and for being a strong economic power. Numerous Japanese products ?ood the Indonesian market, and also there is history between Japan and Indonesia that occurred during the colonization era. This image and bonding has attracted a great deal of curiosity among Indonesians that has led them to enter the Japanese labor market. The fourth theme was differences in nursing practice. Amongthedifferencesdiscoveredwasthatnursingpractice was accorded major regulatory protection. Under the Japanese law, Japanese nurses are much more independent and accorded more protection. Article 5 of the Act on Public Health Nurses, Midwives, and Nurses de?nes a nurse as a person under licensure from the Minister of Health, Labor, and Welfare to provide medical treatment or assist in medical care for injured and ill persons or puerperal women, as a profession (MHLW, 1984). Unlike the situation in Indonesia, the nursing profession is on the way forward to being recognized as a professional profession from what once wasviewedasaso-calleddoctor’s“servant”(Nursalam, Efendi,Dang,&Arief,2009).Atthetimeofwritingthis article, a draft Nursing Act has been approved by the
F. Efendi et al. Japan Journal of Nursing Science (2016)
6 © 2016 Japan Academy of Nursing Science © 2016 Japan Academy of Nursing Science 289
Japan Journal of Nursing Science (2016) 13, 284–293 Indonesian nurses in Japan
House of Representatives on 25 September 2014, after 10 years undergoing tough scrutiny (DPRRI, 2014). In addition, many Indonesian nurses are not well informed of the role of the family in caring for the sick in Japanese society. It was surprising for them that family members did not assist with ADL at all. In Indonesia, the patients’ families help them with ADL. Indonesian family members provide intimate care for those whom they love and view it as a privilege. The ?fth theme was the nursing examination as a culmination. The hardest part of the process for foreigners to get a nursing license in Japan is the national examination. Despite extra help from the Japanese government, time extensions, and translation of kanji into hiragana (phonetic characters which are easier to read), the passing rate has been stuck around 9.6% (Japantimes, 2013). Apart from the language barrier, other issues related to the content and questions on the national examination may need further study. The role of Japanese institutions in facilitating their learning, either in the Japanese language or nursing knowledge should be encouraged as an added value of this program. While the participants are proud of who they are and of being a nurse and working in Japan, their wish is that they can support their family and their nation as a whole. The last theme was the positive impact of migration on the nurses’ lives. Indonesian nurses found value and satisfaction in their working experience in the Japanese health system. They perceive enjoyment from living in an advanced country. While working in Indonesia, nurses’ salaries are categorized at a low level in hospitals, particularly in the case of those not accorded civil servant status. Their earnings range $US 150–300/ month, depending on the location and ?nancial capacity of the hospital; some recent news has even reported that nurses’ salaries are below $US 150/month (Berita Jatim, 2013; Gajimu, 2012). This situation may drive nurses out of the country when they ?nd that the same work they are doing in Indonesia is rewarded abroad at a higher salary. The economic bene?ts can become the driving factor that attracts them to work in Japan. Substandard nurse salaries all over Indonesia has become a serious issue that has led to higher levels of migration. Living in Japan would be a dream for some Indonesians, and an initial study conducted by Hirano and Wulansari (2009) showed that Indonesian applicants have high expectations related to living and working in Japan. Indonesians with a limited knowledge of Japanese culture may think that working in Japan is prestigious. The living costs and taxes are
high, but Japanese hospitals will pay nurses as assistant nurses in the range of $US 1100–1800/month, a number that may allow some nurses who are living in a big city the ability to save on expenses. It was normal for them to think about the ?nancial bene?ts since they may be able to send money back home while contributing to Japan’s health system. The aspect of communication and different nursing practices should not be interpreted as a universal problem faced by Indonesian nurses in every receiving country. Hence, it must be viewed as a need for good preparation related to training and education, either in the sending or the receiving country, in order to create a goldstandard.Thespiritofinternationalizationwhichis re?ected in the curriculum by several nursing education institutions in Indonesia may be adjusted to the need of each receiving country. The ?ndings of the current study are consistent with those of Alexis and Shillingford (2014) as well as those found by Jose (2011), who described role restrictions, a dif?cult journey, and cultural shock experienced by international nurses in the UK and the USA. Language barriers, communication, and different work cultures have been reported by other studies as challenges faced by foreign nurses (Brunero, Smith, & Bates, 2008; Higginbottom, 2011; Sochan & Singh, 2007; Xu, 2007; Xu,Gutierrez,&Kim,2008).Otherthannegativeexperiences, this study corroborates the ideas of Liou and Cheng (2011), who noted some bene?ts of working in developed countries. In addition, the present authors’ ?ndings imply that relevant stakeholders should provide privileges or speci?c interventions for nursing candidates who are transitioning or facing the Japanese nursing examination. This study may help decisionmakers who are involved in government-to-government migration policies to develop support for international migrants, speci?cally nurses. The above discussions of Indonesian nurse immigrants to Japan reveals the connectedness and dependency that occurs between Japan and Indonesia. The degree of connection and dependency varies; therefore, the impact may also vary for both countries. International nurse recruitment is a quick ?x to meet the need of a country that is suffering from shortages (Aluttis, Bishaw, & Frank, 2014). However, it may create complex situations and dilemmas in the sending country (Efendi, Mackey, Huang, & Chen, 2015). Indonesia, as a developing country that is suffering a health worker crisis, and as such could negotiate with the Japanese authorities to take into account the needs of Indonesia. Examples of needed strategies for Indonesian nurses are support for domestic health personnel retention, technology and skill transfers, facilitating return migration, and even ?nancial support.

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