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    • Abstract: Zdrav Vestn 2009; 78: 281–8 281Raziskovalni prispevek/Research articleSTRESS BURDEN IN WOMEN IN REPRODUCTIVE AGE IN

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Zdrav Vestn 2009; 78: 281–8 281
Raziskovalni prispevek/Research article
STRESS BURDEN IN WOMEN IN REPRODUCTIVE AGE IN
SLOVENIA – SOME CAUSES AND CONSEQUENCES
BREME STRESA PRI ŽENSKAH V RODNEM OBDOBJU V SLOVENIJI – NEKATERI
VZROKI IN POSLEDICE
Majda Pahor,1 Živa Novak-Antolič,2 Lijana Zaletel-Kragelj3, 4
University College of Health Studies, University of Ljubljana
1
2
Department of Obstetrics and Gynaecology, University Medical Centre Ljubljana
3
Chair of Public Health, Faculty of Medicine, University of Ljubljana
4
CINDI Slovenia Preventive Unit, Health Centre Ljubljana, Slovenia
Abstract
Background Stress is one of basic risk factors influencing different health states, including reproductive
health of women. The study was aimed at measuring the level of stress in different groups of
women in order to identify high-risk groups for stress and relate them to birth rate dynamics
in Slovenia.
Methods The data originate from the national health behaviour database in adults aged 25–64. Data
collected in 2001 were used. The sample size was 15,379. Among them there were 4,942
women in reproductive age (25–49 years). The response rate of the mailed questionnaire
in this group was 68 %, with 3,181 questionnaires being eligible for analysis. Binary mul-
tiple logistic regression was used to determine the impact of age, education, type of work,
marital status, self-assessed social class, and type of residence community on the prevalence
of frequent perception of stress.
Results The overall prevalence of frequent perception of stress was 29.7 %. The highest odds ratios
(OR) for stress were registered in women in age group 40–44 (OR40–44 vs 25–29 = 1.35, p = 0.048),
with the lowest (ORuncompleted primary vs primary = 1.73, p = 0.038) and the highest education levels
(ORcollege vs primary = 1.76, p = 0.008; ORuniversity vs primary = 1.80, p = 0.006), employed in industry
as heavy workers (ORheavy workers in industry vs housekeepers/students = 1.76, p = 0.010), divorced (ORdivorced
vs consensual union
= 1.72, p = 0.013), self-classified in the lowest social classes (ORlower vs upper-middle =
3.25, p < 0.001; ORlabour vs upper-middle = 1.57, p = 0.011); and residents of suburban communities
(ORsuburban vs rural = 1.27, p = 0.029).
Conclusions Public health activities to reduce stress burden among women in reproductive age in Slovenia
(e.g. changes of legislation, changes of workplace behaviour) should be focused on women
with lowest education and of lowest social class, especially working in heavy industry, and
on employed women with highest education.
Key words stress; prevalence; women; reproductive age; high risk groups
Izvleček
Izhodišča Stres je eden od najpomembnejših dejavnikov tveganja za številna zdravstvena stanja, med
katerimi so predvsem duševne motnje, vedno pogosteje pa ga povezujemo tudi z boleznimi
srca in žilja. Med drugim lahko močno vpliva tudi na rodno zdravje, kar je tudi eno od
meril, da ga uvrščamo med velike javnozdravstvene probleme. V Sloveniji je tega pojava več
med ženskami kot med moškimi. Kot kaže, so med ženskami bolj ogrožene prav ženske v
Corresponding author / Avtor za dopisovanje:
Lijana Zaletel-Kragelj, Chair of Public Health, Faculty of Medicine, University of Ljubljana, Zaloška 4, 1000 Ljubljana, Slovenia, tel.:
+386 1 543 75 40, fax: +386 1 543 75 41, E-mail: [email protected]
282 Zdrav Vestn 2009; 78
rodnem obdobju. S to študijo smo želeli oceniti raven pojava v različnih podskupinah žensk
v rodnem obdobju, prav tako pa ga postaviti tudi v odnos z rodnostno dinamiko v Sloveniji,
z namenom da bi identificirali bolj ogrožene skupine, kar bi prispevalo k učinkovitejšemu
ukrepanju na tem področju.
Metode Podatki izhajajo iz podatkovne baze o vedenjskih dejavnikih tveganja za nenalezljive
bolezni pri odrasli populaciji v starosti 25–64 let, v katero so se začeli stekati podatki v letu
2001. Uporabili smo podatke za leto 2001. V raziskavo je bilo vabljenih 15.379 odraslih
prebivalcev iz vse Slovenije. Med njimi je bilo 4.942 žensk v rodnem obdobju (v starosti
25–49 let). Stopnja odzivnosti na raziskavo je bila v tej populacijski skupini visoka in je
znašala 68 %. Za analizo je bilo glede na postavljena merila uporabnih 3.181 vprašalnikov.
V analizi smo za ocenjevanje vpliva starosti, stopnje izobrazbe, vrste dela, ki so ga opazo-
vanke opravljale, zakonskega stanu, družbenega sloja, v katerega so se opazovanke same
uvrščale, in tipa bivalne skupnosti na zaznavanje in obvladovanje stresne obremenjenosti
uporabili multivariatno metodo, natančneje binarno logistično regresijo.
Rezultati V celotni skupini opazovank je bila prevalenca pogostega zaznavanja stresa 29,7 %. Ocenje-
vanje razmerja obetov (RO) je pokazalo, da so bili najvišji obeti za prisotnost opazovanega
pojava med ženskami, starimi 40–44 let (RO40–44 let vs 25–29 let = 1,35, p = 0,048), ženskami z
najnižjo (ROnedokončana osnovna šola vs dokončana osnovna šola = 1,73, p = 0,038) in najvišjima dvema stop-
njama izobrazbe (ROvišja šola vs dokončana osnovna šola = 1,76, p = 0,008; ROvisoka izobrazba ali več vs dokončana
osnovna šola
= 1,80, p = 0,006), ženskami, zaposlenimi v industriji kot delavkami (ROtežke delavke
v industriji vs gospodinje/študentke
= 1,76, p = 0,010), ločenimi ženskami (ROločene vs živeče v izvenzakonski skupnosti
= 1,72, p = 0,013), ženskami, ki so se same uvrstile v najnižja dva družbena sloja (ROčisto
spodnji družbeni sloj vs zgornji srednji družbeni sloj
= 3,25, p < 0,001; ROdelavski družbeni sloj vs zgornji srednji družbeni sloj = 1,57,
p = 0,011); in ženskami, ki so bivale v predmestnih bivalnih skupnostih (ROprimestno okolje vs vaško
okolje
= 1,27, p = 0,029).
Zaključki Višja stresna obremenjenosti med Slovenkami v rodnem obdobju bi lahko pomembno
vplivala na rodnostno dinamiko v populaciji. Čeprav se morda na prvi pogled zdi, da je
to predvsem demografski problem, pa se moramo zavedati, da bo postal eden največjih
javnozdravstvenih problemov v bližnji prihodnosti. Ne bo zaobšel sistema zdravstvenega
varstva in bo v veliki meri vplival na strukturo in delovne naloge zdravstvenih delavcev,
še posebej zdravnikov. Današnja dejavnost zdravnikov, povezana s skrbjo za ženske v
rodnem obdobju, je usmerjena predvsem v ohranjanje in krepitev njihovega dobrega
telesnega zdravja (redni preventivni ginekološki pregledi in še posebej dobra oskrba no-
sečnic). Manj so aktivnosti usmerjene v duševno zdravje te občutljive populacijske skupine,
zelo malo pa v socialno zdravje žensk v rodnem obdobju (npr. skrb za zdravo oziroma
zdravju naklonjeno delovno in bivalno okolje). To sicer ni naloga zdravnikov specialistov s
področja ginekologije in porodništva, postati pa bi morala pomembna naloga zdravnikov
specialistov javnega zdravja in drugih strokovnjakov s tega področja. V Sloveniji danes
močno primanjkuje znanja za odločitve, temelječe na dokazih, ki lahko močno vplivajo na
zdravje ljudi. Za dobro celostno zdravje žensk v rodnem obdobju pa bi bile take odločitve
ključnega pomena.
Ključne besede stres; prevalenca; ženske; reproduktivno obdobje; visoko ogrožene skupine
Introduction
ratio being 1.35:1 (29.7 % vs. 22.0 %).5 Parallel to this
Stress, especially at the workplace, is recognized as one problem is the problem of a very low birth rate, which
of basic risk factors influencing different disorders and is one of the lowest in the European region.6 A constant
diseases. Mostly it is related to mental disorders, but decrease is being registered for decades, the most in-
lately a lot of research on the relation between stress tensive in the 20 years between 1983 and 2003 (1983:
and cardiovascular diseases was also done.1, 2 Among 13.9, 2003: 8.7 per 1,000 population).6–8 In spite of the
others fertility also could be influenced by stress.3 increase since 2003 (2004: 8.9, 2005: 9.0, 2006: 9.4, and
In Slovenia according to health behaviour survey 2001 2007: 9.8 per 1,000 population),6, 9 Slovenia experi-
in adults (age 25–64), the overall prevalence of fre- ences one of the lowest values of total fertility rate in
quent perception of stress is 24.3 %. It is significantly Europe (1991: 1.46; 1995: 1.28; 2001–2003: 1.20; 2005:
higher in women (27.0 %) than in men (21.0 %).4 Even 1.26).6, 10 There is a possibility that all these problems
more, when women in reproductive age (25–49 years) are to some extent related to each other.
were compared to the women out of this age (50–64 With this background, we have started a study focused
years), the prevalence was considerably higher, the on stress in women in reproductive age, aiming at
Pahor M, Novak-Antolič Ž, Zaletel-Kragelj L. Stress burden in women in reproductive age in Slovenia 283
working out the guidelines for diminishing its high Binary multiple logistic regression method was used to
prevalence in this population group. The main hypoth- estimate the strength of the association between stress and
eses to be addressed were that there are differences in risk factors using multivariate method.13 Dummy variables
perceiving stress with regard to age, level of education, were created for all variables considered in the model. The
employment, marital status, social class, and perma- simple method was applied with the group with the lowest
nent residence social environment. prevalence of stress as a baseline category for comparison
and then replaced with another group if necessary, ac-
cording to the multivariate analysis results.13
Participants and methods In all statistical tests p-value of 0.05 or less was considered
Data were collected in May–June 2001 in a cross-sec- significant. SPSS statistical package for Windows Version
tional survey, which is conceptually a part of a wider 15.0 (SPSS Inc., Chicago, IL, USA) was used for analysis.
international project in the frame of the Countrywide
Integrated Non-communicable Diseases Interven- Results
tion (CINDI) programme, supported by the World
Health Organization, CINDI Health Monitor (CHM).11 Out of 4,942 women in the reproductive age included
A stratified random sample was drawn from the cen- in the sample, 4,875 were possible to contact (67 were
tral population registry of Slovenia. The sampling was not included because of changing of the domicile,
performed by the Statistical Office of Slovenia (SORS). severe illness or death). The response rate was 67.7 %
A self-administered postal questionnaire was used, (3,302/4,875). The respondents did not statistically
based on the CHM Core Questionnaire.11 The response differ from non-respondents in age (p = 0.191) and
rate was increased by reminding non-respondents residence community distribution (p = 0.444). Over-
twice (the first reminder contained a new question- all representativeness of the sample was assessed as
naire form whereas the second was only a new invita- good. The questionnaires of 3,181 respondents were
tion letter) and by a lottery with prizes associated with eligible for analysis after matching the data on age with
healthy behaviour (visits to health resorts, bicycles basic sample data provided by SORS.
etc.). An extensive media campaign was also mounted The observed outcome was possible to establish in
at national and regional levels. 3,170/3,181 (99.7 %) participants. Among them, 943
The total sample size was 15,379, and the age range (29.7 %) perceived tension, stress or heavy pressure
was 25–64 years. In this initial sample 4,942 women in every day or frequently, and had at least minor dif-
reproductive age (25–49 years) were included. ficulties in coping with these feelings. Estimates of
The research protocol for the survey was approved by prevalence of stress in different population groups
the Ethical Committee of Slovenia in spring 2001. are presented in Table 1.
Stress and related feelings were assessed on the basis Univariate assessment using the chi-square test showed
of two questions: (a) »How often do you feel tense, statistically significant impact of all observed risk fac-
stressed, or under a lot of pressure?« (1 – never; 2 – ra- tors on stress with the exception of permanent resi-
rely; 3 – sometimes; 4 – frequently, 5 – every day), and dence community (Table 1).
(b) »Do you feel that you are able to cope with these All data necessary to perform the logistic regression
feelings?« (1 – I can cope with them easily; 2 – I can analysis were present in 2,813 women (88.4 %). The
cope with them with moderate effort; 3 – I can cope results of the multivariate analysis showed a statisti-
with them with major effort; 4 – I can barely cope with cally significant impact of all observed risk factors on
them, 5 – I cannot cope with them at all). The observed stress (Table 2).
outcome was defined on the basis of cross-classifica-
tion of both questions: frequent (frequently or every Discussion
day) perception of tension, stress, or heavy pressure
with at least minor difficulties in coping with these Our study has found clear connection between stress
feelings. In short we called it »stress«. reporting and age, level of education, employment,
The observed outcome was related to sex; age: 25–29, marital status, social class and social environment of
30–34, 35–39, 40–44, or 45–49 years; education level: the permanent residence in women in reproductive
uncompleted primary (less than 8 years of education), age in Slovenia. On the basis of the research methods
primary (8 years), vocational (10–11 years), secondary we used, it is difficult to find out specific lines of con-
(12 years), college (14–15 years), or university (16 years nection between reported level of stress in women
or more); type of work: heavy work in rural economy, and fertility rates. However, there are indications that
heavy work in industry, administrative/intellectual work, both phenomena are connected and we will discuss
housekeeper/student, disability pensioner, or involuntary the results in the light of the social circumstances of
unemployed (job seeker); social class (self-classification): women in Slovenia.
lower, labour, middle, upper-middle, or upper; and type of The results of our study showed that within this popula-
residence community: urban, suburban, or rural. tion group the prevalence of stress was increasing from
Estimates of the prevalence of stress were assessed for the youngest age, in which the prevalence was about the
each subgroup of women in reproductive age regarding average for total adult population (24.3 %)4 to the age
the above mentioned characteristics, whereas the strength group 40–44. Afterwards a slight decrease in the preva-
of the association between the occurrence of stress and lence of stress was registered (Table 1). These results su-
each of selected risk factors was univariately estimated pport the basic findings of the research regarding stress.4
using the chi-square test.12 This should be an alert for public health (PH) planning in
284 Zdrav Vestn 2009; 78
Table 1. Estimates of prevalence ( %) of frequent percepti- Slovenia as birth-giving is being postponed to higher age
on of tension, stress or heavy pressure with at least minor every year. In the period 1999–2007, age-specific birth
difficulties in coping with these feelings in different popu- rate per 1,000 population in age group 20–24 drastically
lation groups according to risk factors in 3,170 women decreased (1999: 60.9; 2003: 44.3; 2007: 39.2), while in
in reproductive age: CINDI Health Monitor survey Slo- age group 30–34 it drastically increased (1999: 55.3;
venia 2001. 2003: 70.7; 2007: 93.0). It increased drastically also in age
Tab. 1. Ocena prevalence (v %) pogostega zaznavanja group 35–39 (1999: 17.5; 2003: 21.8; 2007: 31.9), while in
stresa ali večjega pritiska z vsaj manjšimi težavami ob- age group 25–29 it remained almost stable (1999: 97.7;
vladovanja v različnih populacijskih skupinah glede 2003: 94.8; 2007: 102.4),7, 8 only an isolated temporary
na različne dejavnike tveganja pri 3.170 ženskah v increase was registered in the year 2000 (»millennium
rodnem obdobju. (Vir: raziskava »Dejavniki tveganja baby-boom«: 102.7).7 Another indicator showing the
za nenalezljive bolezni pri odraslih prebivalcih Slove- same trend is the average age of mothers at the delivery
nije« za leto 2001). of the first child, which is increasing (1990–1994: 24.3
years; 1995–1999: 25.6 years; 2000–2004: 27.0 years; 2004:
Estimate of
Risk Factor
prevalence ( % )
27.5 years, 2007: 28.2 years).7, 8 If this trend will continue,
Ocena
p* Slovenia will soon join the countries with the highest
Dejavnik tveganja
prevalence ( %) proportion of mothers giving birth at age 35 years or
Age (years) 25–29 24.4 0.041 older. According to European Perinatal Health Report
Starost (leta) 30–34 30.4 for 2004 among these countries are Finland, Sweden,
35–39 29.4
40–44 32.9 Ireland, Germany, Italy, and Spain.14 Most women in Slo-
45–49 30.5 venia have their first child when they are 25–29 years old.
Level of education incomplete primary
41.4
0.032 However, they decide whether to have more children or
Stopnja izobrazbe nedokončana osnovna
primary
not when they are above 30. The mean age of mothers at
29.7 birth of any child is rapidly increasing (1990–1994: 26.5
dokončana osnovna
vocational
29.1 years, 1995–1999: 27.7 years; 2000–2004: 28.8 years, 2005:
poklicna
secondary 29.4 years, 2007: 29.9 years). When taking into conside-
27.2
srednja ration the fact that the stress level increased from 24.4 %
college in the age group 25–29 to 30.4 % in the age group 30–34,
31.9
višja
university although this increase was statistically not significant,
31.9
visoka ali več we can assume that it might have an impact on their
Type of work heavy work in rural economy
32.2
0.038 decision to have one child only. Younger generations
Vrsta dela težko delo v kmetijstvu
heavy work in industry also postpone setting up own households and getting
34.6
težko delo v industriji married. This trend is also reflected in increasing mean
administrative/intellectual work
28.9 age at first marriage. For brides, for example, it increa-
administrativno/intelektualno delo
houskeeper/student sed for 2.7 years in last 15-year period (1995–1999: 25.6
22.4
gospodinja/študentka years; 2000–2004: 27.3 years; 2005 28.2 years; 2007: 28.3
disability pensioner
invalidsko upokojena
28.8 years).7, 8 The lowest prevalence of stress could be a re-
unemployed (job seeker) flection of this phenomena in the youngest age group,
32.2
nezaposlena (iskalka zaposlitve) namely postponing »adult« responsibilities, like getting
Marital status married
30.1
0.028 involved in a stable relationship or getting married, ha-
Zakonski stan poročena
consensual union ving children, establishing one’s own household etc.,
26.4
izvenzakonska skupnost to the age over 30. On the other side, cultural norms
single in Slovenia put enormous pressure on women aged
26.4
samska
divorced 30–35. On the one hand they are »obliged« to create
38.1
ločena a family, while on the other they want to consolidate
widowed
vdova
37.5 their professional career, and this pressure cannot be
Social class lower < 0.001
totally managed. Consequently the stress breaks out. In
50.0 women aged 40–44 the possible explanation is that the
(self-classification) spodnji
Družbeni sloj labour
33.4 stress is mostly related to highly stressful professions
(samoopredelitev) delavski
middle with a low job control,4 and to the changes in marital
26.3
srednji status. Both will be discussed later. The perception of
upper-middle stress in this age group could have consequences in the
28.9
zgornji srednji
upper sense of intergenerational influence – the next-genera-
36.4
zgornji tion women try to avoid negative experiences of their
Residence urban
29.9
0.298 mothers and consequently some of them do not create a
community mestna
Bivalna skupnost suburban
family of their own or they diminish the number of chil-
31.7 dren if they are faced to choose between professional
primestna
rural
28.5 career and traditional women’s role in the society.
vaška
The level of education distribution shows a marked
*: Chi-square test »U distribution«. This is in accordance with the results
*: χ2 kvadrat test
of another recent study, which showed that in Slove-
nia the lowest and the highest educated population
groups get the lowest support at their workplace,15
Pahor M, Novak-Antolič Ž, Zaletel-Kragelj L. Stress burden in women in reproductive age in Slovenia 285
Table 2. Results of logistic regression analysis of risk factors for stress in 2,813 women in reproductive age: CINDI
Health Monitor survey Slovenia 2001.
Tab. 2. Rezultati multivariatne analize dejavnikov tveganja za stress pri 2.813 ženskah v rodnem obdobju. (Vir:
raziskava »Dejavniki tveganja za nenalezljive bolezni pri odraslih prebivalcih Slovenije« za leto 2001.)
Risk Factor Observed category Reference category Odds ratio (95 % CI*) p
Dejavnik tveganja Opazovana kategorija Referenčna kategorija Razmerje obetov (95 % IZ)
Age (years) 30–34 25–29 1.17 (0.87–1.57) 0.305
Starost (leta) 35–39 25–29 1.14 (0.85–1.52) 0.394
40–44 25–29 1.35 (1.00–1.83) 0.048
45–49 25–29 1.16 (0.85–1.57) 0.347
Level of education incomplete primary primary
1.73 (1.03–2.91) 0.038
Stopnja izobrazbe nedokončana osnovna dokončana osnovna
vocational primary
1.22 (0.90–1.65) 0.202
poklicna dokončana osnovna
secondary primary
1.31 (0.93–1.85) 0.128
srednja dokončana osnovna
college primary
1.76 (1.16–2.67) 0.008
višja dokončana osnovna
university primary
1.80 (1.19–2.72) 0.006
visoka ali več dokončana osnovna
Type of work heavy work in rural economy housekeeper/student
1.49 (0.87–2.56) 0.145
Vrsta dela težko delo v kmetijstvu gospodinja/študentka
heavy work in industry housekeeper/student
1.76 (1.14–2.71) 0.010
težko delo v industriji gospodinja/študentka
administrative/intellectual work housekeeper/student
1.39 (0.92–2.09) 0.118
administrativno/intelektualno delo gospodinja/študentka
disability pensioner housekeeper/student
1.45 (0.69–3.07) 0.331
invalidsko upokojena gospodinja/študentka
unemployed (job seeker) housekeeper/student
1.45 (0.87–2.41) 0.151
nezaposlena (iskalka zaposlitve) gospodinja/študentka
Marital status married consensual union
1.14 (0.88–1.47) 0.317
Zakonski stan poročena izvenzakonska skupnost
single consensual union
1.06 (0.76–1.49) 0.715
samska izvenzakonska skupnost
divorced consensual union
1.72 (1.12–2.63) 0.013
ločena izvenzakonska skupnost
widowed consensual union
1.53 (0.77–3.03) 0.223
vdova izvenzakonska skupnost
Social Class lower upper-middle
3.25 (1.73–6.11) < 0.001
(self-classification) spodnji zgornji srednji
Družbeni sloj labour upper-middle
1.57 (1.11–2.22) 0.011
(samoopredelitev) delavski zgornji srednji
middle upper-middle
1.05 (0.79–1.39) 0.749
srednji zgornji srednji
upper upper-middle
1.19 (0.55–2.59) 0.657
zgornji zgornji srednji
Residence urban rural
1.09 (0.89–1.33) 0.399
community mestna vaška
Bivalna skupnost suburban rural
1.27 (1.02–1.57) 0.029
primestna vaška
* CI – confidence interval
* IZ – interval zaupanja
the least of it from superiors. One of the reasons for empowerment measure (GEM). This indicator which
stress is a permanent threat of loosing employment, measures women’s active participation in the public
which is extremely important in Slovenia, because sphere is for Slovenia rather low. According to the
the contribution of a woman to the family budget is United Nations Development Programme Human
substantial (in nurses for example 53 %).16 In Slovenia development report 2007/2008 the GEM value was
women are in general slightly more educated than 0.611 ranking Slovenia on the 41st place out of 93
men (1996: women 10.8, and men 10.6 years of edu- countries (the highest value was in Norway: 0.910;
cation).10 Also, their level of education is increasing the lowest value was in Yemen: 0.129).20 Differences
more rapidly than that of men.10 About 57 % of hig- between sexes in the average wage also still persist,
her education students and about 60 % of graduates despite slightly higher educational level in women.19
are women.17 Also the education of women is more All this is reflected in the connection between stress
adapted to job requirements.18 But they are concen- and social class.
trated in sectors, which require fewer skills an d are Employed women are especially vulnerable to stress. The
at much lower levels of the employment hierarchy. consequences of stress in the workplace have become
Their professional engagement is limited to specific the major research issue today and many studies have
tasks, which generally do not involve managerial posi- related adverse work conditions to a variety of health prob-
tions that are associated with higher levels on the lems,21–23 also to those related to reproduction.2, 3, 24 The
hierarchical scale and consequently to higher presti- most vulnerable group regarding the employment status
ge.10, 19 An indicator of women’s position is the gender and the nature of work in our study are women perform-
286 Zdrav Vestn 2009; 78
ing heavy work in industry, and in this group the decrease partnership are


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