Preventing Child Marriage through Adolescent Reproductive Health Education
Bondowoso District Health Office

A. Problem Analysis

 1. What was the problem before the implementation of the initiative?
Gender inequality has long been a major barrier for human development in Indonesia. Based on a survey by UNDP in 2012, the gender inequality index of the country ranked 102 of 148 countries. Of particular note was that only 36.2 percent of Indonesian women completed their secondary education, and that maternal mortality and adolescent pregnancy were much more common in Indonesia than in other East Asian and Pacific nations. This high number of adolescent pregnancies contributes to the increasing risk of maternal mortality. The WHO recorded a maternal mortality rate of 8 percent for Indonesia in 2013, while neighbouring Malaysia recorded just 2 percent and Singapore 0.5 percent. Meanwhile 42.3 out of every 1000 births in Indonesia were to adolescent girls. Both maternal mortality and adolescent pregnancy have been receiving increased attention from the government of Indonesia. In 2014, the Health Ministry launched a national action plan to accelerate maternal mortality reduction; the plan includes improving access to health services for pregnant women, including teenagers. However, the adolescent pregnancy rate remains high due to child marriage still being practiced in some parts of Indonesia, especially in rural areas. According to SMERU’s “Prevalence of Child Marriage and Its Determinant Factors among Young Women in Indonesia” (2013), economic factors are the primary driver for child marriage, followed by social and cultural factors. Bondowoso, a rural district in Eastern Java, is one such place where child marriage is common. In fact, the percentage of women getting married as children in Bondowoso is the highest of all 38 districts in the province. In 2011, 50.9 percent of female teenagers got married before reaching 18 years of age. This practice is common among poor families because it is seen as the most practical way to reduce the families’ burden with, as it were, one less mouth to feed. Child marriage is also strongly supported by traditional cultural values. In the rural Madurese and Javanese cultures, parents worry that if their daughters are not married before the age of 15, the family will be humiliated because their daughters are seen as unmarriageable. Like the rest of Indonesia, most of Bondowoso’s residents are Muslim, and conservative Islamic teachings are strongly upheld there. As pre-marital sex is considered a sin in Islam, child marriage is seen as a way of avoiding pre-marital sex. This belief is reflected in the poor levels of sexual and reproductive health information provided to teenagers in the district. Child marriage in Bondowoso has caused a vicious cycle of poverty given that the vast majority of girls of school age who marry drop out of school, which later reduces the opportunities for these women to find decent jobs. In the longer term, child marriage also contributes to low rates of human development, as reflected in Bondowoso’s low human development index – the second-lowest of all 38 districts in East Java.

B. Strategic Approach

 2. What was the solution?
The Bondowoso government has been actively seeking to reduce child marriage in the district. The target audience has been students, their parents, and the wider community. The objectives are primarily to raise awareness of the importance of adolescent reproductive health (ARH) education, to prevent child marriage, and to reduce maternal and infant mortality. In 2012, the government cooperated with PKBI (Perkumpulan Keluarga Berencana Indonesia, Indonesian Family Planning Association) to conduct a baseline study to assess Bondowoso’s high maternal and infant mortality. Following the survey findings, a community group formed (known as the MSF or Multi-Stakeholder Forum) who advocated for increased attention on adolescent reproductive health. As a result, the district head included ARH into a new regulation on safe childbirth and immediate and exclusive breastfeeding. The district head also issued a formal decision letter identifying respected male and female community figures, including his wife, to act as duta kespro (reproductive health ambassadors). The district head’s wife, due to her high social status, was chosen as the role model for the program and given the title Bunda Kespro (Mother of Reproductive Health). She has been very active in promoting ARH education, and has played a significant role in building the community’s understanding of ARH and the risks of child marriage. Male and female religious leaders became a key ally in the fight to end child marriage in Bondowoso. Residents there strongly respect their religious leaders and often look to them for information. Recognizing this, the health agency began working with religious figures by training them in maternal and child health issues, ensuring their knowledge was accurate and reliable. The religious figures then were able to provide vital information on the physical and mental risks of child marriage for teenage girls and became strong advocates against this practice. The Bondowoso administration worked with Yayasan Kesehatan Perempuan (YKP), a national NGO, to introduce reproductive health awareness-raising and training in schools. Several ARH community groups formed. One group, Persatuan Guru Peduli Kespro (Teachers’ Community for Reproductive Health) was established by teachers concerned about the high number of female students dropping out of school after getting married and/or pregnant. The teachers began incorporating ARH information into orientation packages for new high school students, as well as including ARH in biology lessons. ARH education is now provided in all secondary schools in the district. The teachers also worked with community leaders and women from PKK (Pemberdayaan Kesejahteraan Keluarga, Family Welfare Body) to share their reproductive health knowledge and to encourage them to promote later marriage in their communities. On the teenagers’ side, a group of young peer educators formed Komunitas Langit Biru (Blue Sky Community) and worked with youth NGO Kampung Halaman to promote ARH. The teenagers were strongly supported by the district health agency, which recognized that teenagers were more likely to listen to their peers – this was the first time teenagers had been purposely involved in a government program in Bondowoso. The group conducts outreach activities and holds biweekly meetings. After piloting the peer-educator program in four sub-districts, it now runs in 25 areas, and the number of peer educators has risen from 24 to 279. These activities all formed part of the multi-stakeholder approach in Bondowoso district to improve ARH knowledge with the intention of reducing and eventually eliminating child marriage in the district. The number of child marriages in Bondowoso district has since declined significantly. In 2011, child marriages accounted for 50.92% of the total number of marriages. In 2012 this figure had declined to 50.53%, and by the end of 2013, child marriages made up 43.46% of marriages in the district.

 3. How did the initiative solve the problem and improve people’s lives?
The ARH program in Bondowoso is creative and innovative because it involves all sections of the community and can be said to be genuinely community-based. The program was the government’s response to the needs of the community, and pays close attention to local norms and cultures, and incorporates these elements into its activities. In Bondowoso, the community has worked alongside the health agency to campaign to end child marriage and early pregnancy and have provided accurate, appropriate and useful information on sexual and reproductive health to local teenagers, both male and female. Both genders are actively involved in the program. The involvement of male religious figures is particularly exceptional as, unfortunately, Islamic figures throughout Indonesia frequently provide incomplete reproductive health information. The district head’s wife and women’s groups have been excellent role models in promoting ARH and the risks of child marriage to local residents, especially women and girls in marginalized communities. Most importantly, teenagers themselves have been involved in the program with a leading role as educators and role models for their peers through art and the media, as well as through the election of duta kespro – a highly-coveted position. Local teens are encouraged to speak publicly about ARH.

C. Execution and Implementation

 4. In which ways is the initiative creative and innovative?
1) The initial impetus was the continued practice of child marriage, and the fact that child marriages accounted for 50.92% of total marriages in Bondowoso. Research conducted by PKBI also revealed that only 52% of mothers with children under the age of two had completed elementary school. 2) Following the survey, the district head issued Bondowoso District Head Regulation 41/2012 on Safe Delivery and Immediate and Exclusive Breastfeeding; the regulation aims to make childbirth safer for all women, and included adolescent reproductive health services. District decrees 188.45/450.A/430.6.2/2012 and No.188.45/1698/430.6.2/2013 were also issued, creating the position of Bunda Kespro and appointing the wives of village, sub-district, and district chiefs in Bondowoso as promoters of ARH. 3) It was determined, however, that government officials alone would not be sufficient to promote the program. Religious leaders, teachers, health staff, NGOs, women’s groups and young people themselves were enlisted as the primary agents for implementing the ARH program, as they interacted daily and directly with their local communities. 4) Training on ARH was provided by the government and NGO partners to students, the teachers, health workers, and religious leaders. Training was based on interactive activities relevant to each role. For example, a seven-minute sermon competition with the topic of reproductive health, was attended by 50 religious leaders. The leaders then delivered the sermons in their local communities. Teachers were taught how to incorporate ARH information into the school curriculum and lesson plans. 5) A major and unique element of the program was the inclusion of ARH education in the school orientation program for new students in junior and senior high schools. The Bondowoso Education Agency also collaborated with local NGO Edelweiss to conduct ad-hoc outreach activities, while the teachers’ group visited each sub-district to promote ARH issues among local officials and parents. 6) An ARH festival was held, at which the message of delayed marriage was disseminated. Organized under the theme "My health, my future – We embody a healthy, qualified and dignified generation", the festival was held at the offices of the district head and drew around 400 participants, including students from junior and senior high schools in Bondowoso, community leaders, women’s groups, village chiefs, and the media. 7) For teenagers, training events and competitions involving writing articles, making short videos and creating posters related to reproductive health were held. The response was very positive. For each training session, only 50 seats were available, yet more than 300 students signed up. Teenagers were trained on video making and article writing. The videos they produced conveyed the message that it is preferable for teenage girls to stay at school rather than to marry early. They included interviews with women who married early, including one at the age of 12, who encouraged young girls not to follow their examples but to stay in school and continue their education. 8) Duta kespro were appointed among teens and senior local figures to promote ARH among their peer groups. As well as their roles as peer educators, the duta kespro formed unofficial monitoring and evaluation groups with the express purpose of learning about local families who might be intending to marry off adolescent daughters, with a view to persuading the families to delay the marriage and keep the girl at school. 9) Local radio in Bondowoso routinely provided airtime for the topic of reproductive health and the prevention of child marriage during the hours teens usually listened to the radio, particularly on Saturdays. Large numbers of teens tuned in and asked questions on ARH problems faced by teenagers.

 5. Who implemented the initiative and what is the size of the population affected by this initiative?
The initiative for this program came from the district head following intense advocacy from the community. The district head gave the mandate to his wife, dubbed Bunda Kespro, to act as the “umbrella” for the program, in conjunction with the local administration and a number of NGOs and community forums, to promote ARH issues with a view to reducing child marriage. Since child marriage was so deeply embedded in the culture of the local people, particularly in rural areas, a substantial number of stakeholders needed to be involved to ensure the program’s success. They included local and national government and non-governmental agencies, including the district’s health, education, and family planning agencies; the newly-formed Multi-Stakeholder Forum (MSF); PKBI; the National Ministry for Women’s Empowerment; Edelweiss; YKP (Yayasan Kesehatan Perempuan, Women’s Health Foundation); Kampung Halaman, a youth-focused NGO; PKK, which represents female public officials and the wives of officials; women’s community groups; local male community leaders; teachers, both in their official teaching role and also as promoters of ARH issues in teachers’ associations; religious figures including male Islamic leaders and teachers, as well as female religious groups; local teenagers and students, particularly through involvement in Komunitas Langit Biru and as duta kespro; and local media and citizen journalists. The movement was further supported by an international organization USAID-KINERJA, who provided funding for the NGOs to better support the Bondowoso administration in its ARH program.
 6. How was the strategy implemented and what resources were mobilized?
The implementation of the reproductive-health activities specifically targeted at teens was supported by various components. The funds disbursed from the local administration’s budget amounted to: 2011 - Rp 249,030,500 [US$ 20,366], comprising Rp 246,818,000 from the district family planning agency, and Rp 2,212,500 from the health agency. 2012 - Rp 253,421,012 [US$ 20,725], comprising Rp 244,619,000 from the district family planning agency, Rp 3,800,000 from the health agency and Rp 5,000,000 from the education agency. 2013 - Rp 158,275,000 [US$12,944], comprising Rp 152,775,000 from the district family planning agency and Rp 5,500,000 from the health agency. 2014 - Rp 197,907,500 [US$ 16,149], comprising Rp 171,050,000 from the district family planning agency and Rp 26,857,500 from the health agency. USAID-KINERJA supported Yayasan Kesehatan Perempuan (YKP) to work with the local administration to implement the ARH program, and was funded to the amount of Rp 553,271,000 [US$ 45,615] by an international aid program. YKP also contributed Rp 23,050,000 [US$ 2,000] of their own funds to the program. In addition to this funding, two media outlets provided assistance: local radio station Radio Pasopati aired one-hour ARH talk-shows on six occasions worth Rp 2,100,000 [US$ 172], and Radar Jember, a local newspaper, published a half page of ARH coverage worth Rp 15,600,000 [US$1,274]. The value of human-resource activity by teachers, activists, religious and community leaders, KK members, Komunitas Langit Biru etc. was substantial. However, as it was largely provided voluntarily, a specific monetary value cannot be placed on it.

 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
The following outputs were achieved over the course of the ARH program in Bondowoso: a. The inclusion of adolescent health into the new Bondowoso district head regulation on safe delivery and immediate and exclusive breastfeeding was a highly successful output of the program. District decree 188.45/450.A/430.6.2/2012 followed, which appointed the district head’s wife as Bunda Kespro to coordinate the implementation of ARH promotion in schools and local communities throughout the district. This was followed by the issuance of district decree No.188.45/1698/430.6.2/2013, which saw the wives of village, sub-district, and district chiefs in Bondowoso take up roles as promoters of ARH and in the campaign to reduce child marriages. There are currently 219 district chiefs’ wives and 23 village chiefs’ wives involved in the program. b. The creation of a peer-to-peer ARH education program is a significant output. Training and awareness-raising on ARH issues is crucial to reduce and eventually eliminate child marriages in the district. The peer-to-peer activities involve all age groups, not only among teens and students but also among their parents, teachers and community leaders. c. As mentioned above, for the first time teens have been actively included in the programs to improve ARH education and the need to reduce child marriages. The initiative has led to the creation of duta kespro, a position of some status among teens and students. These ambassadors are able to address issues and concerns relevant to reproductive and sexual health issues and act along with other stakeholders as informal monitors of the child marriage situation in the district. d. ARH education is now an integral part of the student initiation program for all new junior and senior high school students throughout the district and is also being incorporated into the wider school curriculum. e. Concerned teachers have created their own teachers’ association dedicated to reducing child marriages among their students. The association has taken numerous initiatives to get the message out to sub-districts and villages, including by means of a roadshow. A similar association, Komunitas Langit Biru, has been set up by teens to promote the same ARH message. They have used social and mainstream media to promote the ARH campaign, creating innovative videos, posters and taking part in on-air discussions on local radio.

 8. What were the most successful outputs and why was the initiative effective?
The primary method of monitoring and evaluation in Bondowoso was to examine the statistics on marriages in the district throughout the period of the initiative to ascertain whether the number of child marriages in the district had declined. The Bondowoso Health Agency conducts an annual evaluation of the success of the ARH program – the Agency collects yearly data, and compares this data to the baseline data prepared by PKBI in 2011. The health agency is consequently able to examine whether there is a declining trend in child marriages. The agency then incorporates this information into their planning and budgeting. The results of this evaluation are conclusive and show that the percentage of child marriages in the district has dropped by around 14% (or 7 percentage points) in the district in the two years since the program began. With regard to monitoring the activities undertaken by specific stakeholders, the monitoring and evaluation was conducted by the institutions themselves, whether they were government agencies or NGOs. For example, health data relating to pregnancy rates and maternal and infant morbidity is collected from community health centers and passed to the health agency, and school drop-out rates are collected by schools and provided to the education agency. The overall findings are then jointly evaluated when multi-sectoral, multi-agency coordination meetings are held. ARH monitoring activities are also carried out by informal community groups comprising of teens, teachers, religious figures, and community leaders. Given the informal nature of much of this community-based activity, it can be difficult to establish specific, identifiable targets by which its success or otherwise can be measured. However, it is clear from the significant reduction in child marriages in Bondowoso in the two years since the program began, that the communities have contributed greatly to making child marriage unacceptable. In what is a uniquely innovative approach, community groups monitor local news and gossip to discover if a family is planning to marry off a teenage daughter. They will then inform the wives of local chiefs to act in their role as duta kespro. Using their influence as public figures, the duta kespro will approach the parents and urge them to delay the marriage and allow the girl to remain at school to complete her education.

 9. What were the main obstacles encountered and how were they overcome?
This program worked to change the communities of Bondowoso’s perceptions of child marriage and ARH. The biggest challenge was the local culture, particularly with regard to the stigma attached to having an unmarried daughter older than 15. The community considered child marriage to be the safest way to prevent pre-marital sex. Since talking about sexuality was taboo, parents rarely equipped their children with sufficient knowledge about reproductive health. Instead, parents preferred to simply have their daughters married off at an early age. Child marriage was also perceived as a way out of poverty; marrying off daughters at a young age meant reducing the number of family members to feed. Changing cultural values always requires long-term effort by all parties to change the community’s deeply ingrained mindset. This was especially true in Bondowoso, given the low average level of educational attainment (average time spent at school: 5.94 years) and the relatively low level of economic development. The challenge was met by the active participation of all sectors of the community working in conjunction with local and national government bodies and NGOs to promote ARH issues with the intention of reducing and eventually eliminating child marriage. This was done by means of educational and promotional activities aimed at teens, their parents and the wider community. Religious and community leaders, including the district head’s wife and the wives of district, sub-district and village chiefs, worked alongside teachers and health workers to promote ARH education at school, through orientation sessions for new students and in the wider curriculum, and in the community at large by means of roadshows, training of trainers, sermons and awareness-raising for parents. Most importantly, young people promoted ARH education as peer-to-peer educators and through their innovative use of social media, radio talkshows, and YouTube videos aimed at young people.

D. Impact and Sustainability

 10. What were the key benefits resulting from this initiative?
Positive impacts of this program on women in Bondowoso: - The number of child marriages in Bondowoso district has declined significantly. In 2011, child marriages accounted for 50.92% of the total number of marriages; in 2012, this figure had declined slightly to 50.53% of total marriages. By 2013, it had dropped significantly to 43.46% of the total marriages in the district. Therefore, in only two years, the number of child marriages has already decreased by 14.65% as a proportion of total marriages. - Although unfortunately girls – and boys – continue to leave school for economic reasons, many adolescent girls in Bondowoso who would have dropped out of school to marry have now had the opportunity to continue their studies to higher levels of education. With this extra education, these girls can better achieve their fullest potential and gain more rewarding employment. Girls are now encouraged by multiple elements of the community to delay marriage until they have completed their education and are in a position to determine whether they wish to stay at home or work. - With the increased knowledge and awareness of reproductive health issues, and the ability to properly manage them, the status of women within the family has been raised. As a result of the program, teenage girls are provided with the education about reproductive issues needed to make better informed life choices. This means that increasingly-mature wives have a greater ability to make educated decisions and can play a bigger role in building their family and shaping its destiny. - The risk of neonatal and maternal mortality has been reduced as girls are being persuaded to delay marriage and childbirth until they are physically and psychologically developed. This message has also impacted older women, as they now think more carefully about pregnancies and childbirth than before. Impact on the local administration: - The local administration’s capacity to implement ARH programs has been improved through the practical experience they gained through this initiative. It is hoped they will use their new skills and knowledge to continue to promote the prevention of child marriage with the assistance of NGOs and the community. - Better understanding of reproductive health will reduce the burden of sexual and reproductive health problems on the health agency budget. - The local government has become much more responsive to local needs as a result of the program. They are also more aware of the different health needs of different communities, genders, and age groups than previously. - Public trust in government bodies has increased, as the community can see the impact of their ARH program on the ground. The community can also see how the government responds to their needs and their advocacy. Impact on local communities: - The level of social welfare and human development index (HDI) has risen along with the higher participation in education. Maternal and infant mortality rates have dropped as a result of improving economic conditions and new families being created at an optimal age for the mothers. The HDI in Bondowoso rose from 63.81 in 2011 to 64.98 in 2012, and then again to 65.42 in 2013. - Adolescents who have a clear understanding of reproductive health will be better equipped to avoid the adverse health and moral results of poor decision-making in relation to sexual and reproductive issues. - Traditional taboos surrounding sexual and reproductive health are being broken down, and the stigma surrounding unmarried daughters over the age of 15 or 16 is being dispelled. This has been most remarkable in the extent to which male Islamic teachers and community leaders have taken an active role in promoting ARH issues and dissuading child marriage.

 11. Did the initiative improve integrity and/or accountability in public service? (If applicable)
- The initiative is made sustainable through the enactment of district-level regulations and decrees. Bondowoso District Head Regulation 41/2012 on Safe Delivery and Immediate and Exclusive Breastfeeding, which aims to make childbirth safer, including for adolescents, and district decrees 188.45/450.A/430.6.2/2012 and No.188.45/1698/430.6.2/2013, on Bunda Kespro, are now in place to act as a comprehensive legal framework for the eradication of child marriage and the general promotion of ARH issues in Bondowoso. - The district head’s wife as Bunda Kespro will continue her activities, promoting ARH issues and reducing child marriage. The roles of the teenage duta kespro and the voluntary contributions of teachers associations, women’s groups, religious leaders and other stakeholders will also continue. - Training-of-trainers programs put in place have enabled ever-larger numbers of teachers and health workers to promote delayed marriage and better awareness of reproductive health education among students, their parents and the community. This will allow the initiative to self-spread in the coming years. - ARH education has been firmly incorporated in the student orientation programs for new students in all junior and senior high schools in the district. This will continue, as will the inclusion of ARH education in school subjects. - Awareness-raising among local youth through peer-to-peer education will continue and will feature successful students who have postponed marriage until a mature age, as well as spreading the word about the negative impacts of child marriage, such as higher rates of maternal and infant mortality. - Local media and citizen journalists are using their new knowledge to cover issues relating to child marriage and ARH. The resulting media items will ensure media coverage continues to put pressure on the government to end child marriage. Awareness-raising of ARH through art and social media is also ongoing. - From a cultural point of view, the taboos surrounding sexual and reproductive health in traditionally conservative local communities have to a large extent been broken. Islamic figures in the district now take an active part in promoting and discussing ARH issues in their teaching and sermons. - This initiative can be replicated throughout Indonesia, provided that there is commitment and leadership from the regional heads, local administrations and community leaders. The Bondowoso administration is very proud of their program, and the district head has spoken about it at numerous events. Other districts, such as Sambas in West Kalimantan and Bulukumba in South Sulawesi, have indicated their interest in replicating the program. - It is important to note that the program, whilst a response by the local administration to community needs, is not a top-down series of regulations but rather a grass-roots based initiative involving all sections of the community – government officials, NGOs, volunteers, teachers, health workers, religious figures, women, and young people themselves. Having a personal stake in the success of the campaign means it is more sustainable than a campaign handed down from above.

 12. Were special measures put in place to ensure that the initiative benefits women and girls and improves the situation of the poorest and most vulnerable? (If applicable)
Lessons learned: - The success of this program does not belong to any one government agency, department or institution, but is rather thanks to a joint effort by the Bondowoso district government, the district head, NGOs, health workers, teachers, the media, and the local communities. A key lesson was that although the initial steps may be harder than if working with only one partner, the long-term benefits of multi-stakeholder programs are substantial and sustainable. - Cooperation with religious figures, community leaders and the media is required to raise awareness of ARH issues and child marriage, and to provide forums for young people to communicate and express ideas of common concern to further promote ARH. - The most important aspect of implementing changes in attitudes to ARH and reducing child marriage, however, is that of young people themselves. Young people must be actively included in programs, such as being given training, support and encouragement to take a leading role in peer-to-peer education. Other ways the Bondowoso government and its NGO partners involved teenagers included establishing the roles of ARH ambassadors, and encouraging adolescents to speak out on child marriage and reproductive health through generationally-relevant forms of art and media such as videography. - From this initiative, it can be seen that cultural norms can be changed – even when those norms are deeply-ingrained and are centred on sensitive issues such as the sexual and reproductive health of adolescents. Nonetheless, behavioural change requires time and commitment, and cannot simply be imposed by governments on local communities. It must involve the genuine support of the community, as seen in Bondowoso. Recommendations: - Child marriage also occurs among students who go to privately-run Islamic boarding schools in Bondowoso. Some form of program or MoU between the government and the schools to ensure that their students are provided with adequate and appropriate reproductive health information, and that teachers encourage students to delay marriage until after school. - It is necessary to cooperate with the Ministry of Religious Affairs so that local offices can provide appropriate reproductive health education for young couples who are planning to marry. Pre-marital counseling is already mandatory, but does not include reproductive health information. Young couples should be encouraged to delay marriage, or at very least to delay pregnancy until both husband and wife are physically and psychologically ready to have children. - We recommend that Bondowoso’s initiative to reduce child marriage be replicated throughout Indonesia. Child marriage remains common throughout the country, and is a particular issue in poorly-developed rural areas where education and health facilities are lacking. The implementation of initiative such as Bondowoso’s in more Indonesian districts would go a long way in reducing and ultimately eradicating child marriage.

Contact Information

Institution Name:   Bondowoso District Health Office
Institution Type:   Government Agency  
Contact Person:   Mohammad Imron
Title:   Mr  
Telephone/ Fax:   0332 421341
Institution's / Project's Website:  
E-mail:   titikernaerawati@yahoo.com  
Address:   Jl. Imam Bonjol 13, Bondowoso
Postal Code:   68217
City:   Bondowoso
State/Province:   East Java
Country:  

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