Factors associated with the use of mosquito bed nets: results from two cross-sectional household surveys in Zambézia Province, Mozambique
Moon et al. Malar J
Factors associated with the use of mosquito bed nets: results from two cross-sectional household surveys in Zambézia Province, Mozambique
Troy D. Moon 0 2 3
Caleb B. Hayes 0
Meridith Blevins 0 1 2
Melanie L. Lopez 5
Ann F. Green 0 2
Lazaro González‑Calvo 0 2
Omo Olupona 4
The Ogumaniha‑ SCIP Zambézia Consortium
0 Vanderbilt Institute for Global Health , 2525 West End Avenue, Suite 750, Nashville, TN 37203 , USA
1 Department of Biostatistics, Vanderbilt University , Nashville, TN , USA
2 Friends in Global Health , Maputo , Mozambique
3 Department of Pediatrics, Division of Infectious Diseases, Vanderbilt University , Nashville, TN , USA
4 World Vision International , Maputo, Mozam‐ bique
5 World Vision US , Federal Way, WA , USA
Background: Malaria remains a major threat to some 3.2 billion persons globally. Malaria contributes heavily to the overall disease burden in Mozambique and is considered endemic. A cornerstone of Mozambique's vector control strategy has been to strive for universal coverage of insecticide‑ treated nets (ITN). Methods: The study is a population‑ based cross‑ sectional survey of female heads‑ of‑ household in Zambézia Province, Mozambique conducted during August-September, 2010 and April-May, 2014. Analyses accounted for a stratified two‑ stage cluster sample design. Outcomes of interest included sleeping under a mosquito net during the previous night. Descriptive statistics were calculated for three oversampled districts and for the entire province. Multivariable logistic regression analysis was used to estimate factors associated with both changes over time and increased mosquito bed net usage. Results: Of the 3916 households interviewed in 2010 and 3906 households in 2014, 64.3 % were in possession of at least one mosquito bed net. A higher proportion of households in Namacurra (90 %) reported possession of a mosquito net, compared to Alto Molócuè (77 %) and Morrumbala (34 %), respectively in 2014. Of pregnant respondents, 58.6 % reported sleeping under a mosquito net the previous night in 2010 compared to 68.4 % in 2014. Fifty percent of children 0-59 months slept under a mosquito net the previous night in 2010 compared to 60 % in 2014. Factors associated with use of a mosquito net for female head‑ of‑ household respondents were higher education, understanding Portuguese, larger household size, having electricity in the household, and larger household monthly income. As travel time to a health facility increased (per 1 h), respondents had 13 % lower odds of sleeping under a mosquito net (OR 0.87; 95 % CI 0.74-1.01, p = 0.07). Pregnant women in 2014 had a 2.4 times higher odds of sleeping under a bed net if they lived in Namacurra compared to Alto Molócuè (95 % CI 0.91-6.32, p = 0.002 for district). Higher maternal education, living in Namacurra, and acquisition of mosquito bed nets were associated with a child 0-59 months reporting sleeping under the net in the previous night in 2014. Conclusions: Intensified focus on the poorest, least educated, and most distant from health services is needed to improve equity of ITN availability and usage. Additionally, while some districts have already surpassed goals in terms of coverage and utilization of ITN, renewed emphasis should be placed on bringing all geographic regions of the province closer to meeting these targets.
Malaria; Prevention; Long‑ lasting insecticide treated bed nets; Mozambique
Malaria remains a major threat to some 3.2 billion
persons globally. According to the World Health
Organization (WHO), 214 million cases of malaria occurred in
2015, leading to 438,000 deaths. Eighty-eight percent of
these deaths occurred in the Africa region [
]. Malaria is
one of the two leading causes of death in Mozambique,
accounting for 29 % of all deaths in 2008 [
]. In 2011,
malaria was reported as the leading cause of death in
children under 5 years [
]. Contributing heavily to the
overall disease burden in Mozambique, malaria is
considered endemic throughout the country . Transmission
occurs year round but with seasonal peaks during and
directly after the rainy season, typically from December
to April [
]. While Mozambique´s entire population of 26
million is considered at risk for malaria, regional
prevalence can be quite different across the country, ranging
from 1.5 % in Maputo in the south to 54.8 % in Zambézia
Province in the north in 2011. Additionally, a threefold
higher prevalence has been reported in rural areas
compared to urban [
Mozambique´s National Malaria Control Programme
is responsible for developing policy, planning, and
coordinating all malaria control activities within the
country. In recent years, major investments have been made
through programmes such as the United States
President’s Malaria Initiative (PMI) and the Global Fund to
Fight AIDS, Tuberculosis, and Malaria (Global Fund).
Mozambique´s National Malaria Prevention and
Control Strategic Plan: 2012–2016 continues to focus
heavily on four proven and highly effective prevention and
treatment strategies: insecticide-treated mosquito nets
(ITNs), indoor residual spraying (IRS), diagnosis and
treatment with artemisinin-based combination therapy
(ACT), and intermittent preventive treatment of
pregnant women (IPTp) [
For several years, a cornerstone of Mozambique’s
vector control strategy has been to strive for universal
coverage of ITNs [
]. Coverage and mosquito net usage
have been slowly increasing amongst key target groups.
For example, nationwide from 2007 to 2015 the
proportion of children under 5 years of age using an ITN in the
previous night increased from 7 to 36 % [
surveys conducted as part of the Malaria Decision
Support System Project in Zambézia Province, a high malaria
prevalence region, reported an increase of ITN usage in
children under 5 years from 29.8 % in 2006 to 34.3 % in
]. Despite these reported increases, the country
has not yet been able to report a consistent and sustained
decline in malaria incidence [
Current ITN distribution strategies prioritize extremely
vulnerable populations and strive for 80 % coverage of
young children and pregnant women [
shows that further protective effects can be gained when
sufficient portions of all individuals at risk consistently
utilize mosquito nets. As such, coverage of entire
populations will be required to achieve large reductions in
malaria burden in endemic countries such as
Mozambique . However, ownership of nets does not always
translate to proper utilization [
]. In 2009,
Mozambique officially adopted a policy of universal coverage,
defined as one ITN for every two persons [
Determining the best strategies for attaining and maintaining this
universal coverage remains uncertain [
include the need for establishing appropriate algorithms
for determining the number of mosquito nets needed for
]; promoting proper use and replacement
of old and torn nets [
]; as well as understanding the
local social norms and other determinants that
contribute to increased uptake and utilization [
Set against this backdrop, the Ogumaniha project
began implementation in Zambézia Province,
Mozambique in late 2009. The project is funded by the US
Government under the United States Agency for
International Development (USAID) Strengthening
Communities through Integrated Programming (SCIP) award and
implemented by a consortium of partners led by World
Vision. In the local Echuabo language, Ogumaniha means
“united/integrated for a common purpose”. The
overarching goal of this 5-year project (currently extended into
a 6th year) is to improve the health and livelihoods of
women, children and families in Zambézia Province by
pursuing an integrated, innovative, and sustainable
community-based programme supporting cross-sector
integration of USAID’s development actions in the province.
In order to achieve the above objectives, the
Ogumaniha consortium structured its interventions through
a mixture of training and capacity building of local
community volunteer groups called community health
committee’s (CHC), as well as direct implementation of
activities by consortium partners. CHC’s are networks
of volunteers within a community usually consisting of
20–30 volunteers. These volunteers are then divided into
thematic areas of community support such as nutrition;
maternal health/family planning/reproductive health;
home based care; water and sanitation; home visits and
active case finding for persons living with HIV; child
health; local economic development; and malaria
education and prevention. Ogumaniha’s malaria related
activities primarily focused on community-based education
messages and behaviour change communications
promoting improved health-seeking behaviour, as well as
the active identification and referral of suspected malaria
cases in the community to a health facility for testing
and treatment. In addition, the Ogumaniha consortium
assisted provincial supply chain systems for the monthly
transport of ITN´s to the province’s 200+ health
facilities in order to stock programmes supporting universal
distribution within antenatal care clinics and for children
under 5 years of age seen at the health facility.
The implementation of mass ITN campaigns for
universal coverage began a slow roll-out across the country
in 2010. In 2012, with support from the Global Fund and
World Bank, 11 of 17 districts in Zambézia Province
benefitted from mass distribution. In line with the goals of
the National Malaria Control Strategic Plan 2012–2016,
plans were established for a coordinated increase in
universal ITN distribution with Global Fund, World Bank
and PMI support targeting 90 % of districts nationwide
by the end of calendar year 2014 [
]. The Ogumaniha
consortium was not directly involved in universal mass
ITN campaigns, though World Vision, the consortiums
principle partner, began supporting mass ITN campaigns
in Zambézia Province with Global Fund support in 2015.
Integral to Ogumaniha’s design is a strong
monitoring system and project evaluation based on performance
indicators agreed upon with USAID and the provincial
government. To estimate changes over time,
populationbased household surveys were conducted at the project´s
beginning and end [
]. This report is a review of malaria
specific cross-sectional survey data collected at baseline
(August and September 2010) and endline (April and
May 2014), in order to assess mosquito bed net
possession and factors associated with their use.
Sample design and data collection
The design and implementation of this study are detailed
]. Briefly, survey teams completed
interviews in 262 enumeration areas (EA) across Zambézia
Province. A large representative sample (201 EA) was
obtained from three diverse districts (Alto Molócuè,
Namacurra, and Morrumbala) in order to increase the
precision of survey results while minimizing costs. To
further maintain a degree of generalizability across the
province, a sample of households were selected for
interview throughout the remaining 14 districts (Fig. 1).
At both baseline and endline the same questionnaire
was utilized. While survey responses were not collected
from the same households in both surveys, the same
sampling methodology was utilized with
interviewers returning to the same EAs as in baseline. The
Ogumaniha survey tool collects information on over 500
variables in eight dimensions and was developed by a
multi-disciplinary team of researchers from
Vanderbilt University and the University Eduardo Mondlane in
Maputo. The survey designers borrowed many questions
and scales deemed appropriate from previous national
surveys in Mozambique and other international
surveys such as the Demographic Health Survey (DHS) and
Multiple Indicator Cluster Survey (MICS). Survey
questions covered household demographics; economic
status; health knowledge, attitudes and practices; access to
health and malaria-related services and products; access
to improved water and sanitation; nutritional intake; and
In both surveys, fourteen mobile teams consisting of a
team leader and four interviewers administered the
survey face-to-face using mobile phones with an electronic
questionnaire installed for data collection. Local
authorities were notified prior to the arrival of the survey team.
From topographic maps, the survey teams divided the
EAs into four quadrants. Starting in the center of the
assigned quadrant, interviewers selected a direction,
then chose the first household in that direction (i.e.
starting point), and approached the nearest four households
for interview. Female interviewers conducted the survey
with female heads-of-household, defined as the only or
principal wife of the immediate family of the household.
The female head-of-household was chosen as it was felt
she was the most likely person to be familiar with the
health and care taking of the entire family. In polygamous
families, the eldest wife was selected. Interviewers were
trained to conduct interviews in Portuguese or in one of
the five predominant local languages. Household surveys
were conducted at the end of rainy season, representing
the peak malaria transmission period for that year.
All analyses accounted for a stratified two-stage
cluster sample design. The three outcomes of interest
included whether the female heads-of-household,
pregnant female heads-of-household, or children aged
0–59 months slept under a mosquito bed net during the
previous night. Descriptive statistics were calculated for
three oversampled districts and for the entire province.
Continuous variables were reported as weighted
estimates of median (interquartile range [IQR]) and
categorical variables were reported as weighted percentages,
with each observation being weighted by the inverse of
the household or child sampling probability.
Multivariable logistic regression analysis with robust covariance
estimation to account for clustering was used to
estimate factors associated with bed net usage for the three
groups of interest. Only households from the
oversampled districts were included in the regressions.
Covariates were identified a priori and they included: age,
education, Portuguese understanding, household size,
district, whether all bed nets were donations, whether all
bed nets were purchased, monthly income, travel time
to health facility, household electricity, bed net
distribution at current pregnancy (pregnant group only), and
recent fever in child (child group only). Family income
was reported in meticais (MZN) (1USD ≈ 36MZN in
August 2010 and 1USD ≈ 31MZN in April 2014). If
there was evidence of non-linearity (Wald test p < 0.10),
continuous variables were modeled using restricted
cubic splines [
]. Missing values of covariates were
accounted for using multiple imputation techniques.
R-software 3.2.2 was used for analyses.
Participation in the household surveys was completely
voluntary, no incentive was provided for participation.
At enrollment written informed consent was obtained.
Approvals for study implementation were obtained at
the national level from the National Directorate for
Public Health of the Ministry of Health (Direcção Nacional
de Saúde Publica) and at the Provincial level from the
Provincial Health Directorate of Zambézia Province
(Direcção Provincial de Saúde-Zambézia). Survey
protocol, questionnaires, and informed consent documents
were approved by both the Inter-institutional Committee
for Bioethics in Health-Zambézia (Comité
Inter-institucional de Bioética em Saude-Zambézia) and the
Vanderbilt University Institutional Review Board (IRB).
A total of 3916 surveys at baseline (2010) and 3906
surveys at endline (2014) were completed in 262 EAs across
14 districts in Zambézia Province. Of these, 7628 (97.5 %)
surveys had sufficient data completed to be databased
for analysis (Table 1). Table 2 summarizes demographic
information for the female head-of-household
respondents. The median age was 29 (IQR 23–37) in 2010 and
27 years (IQR 22–34) in 2014. Across both surveys, most
women (>67 %) reported being married or in a
commonlaw relationship. Province-wide, median years of formal
education in 2010 was 2 years (IQR 0–4) compared to 3
years (IQR 0–5) in 2014. While very few women at
endline (3.3 %) had a reported education beyond secondary
school (10th grade), 25.4 % of women in Alto Molócuè
and 14.8 % of women in Namacurra reported
completing between 6 and 10 years of education, compared to
Morrumbala, in which only 5 % of women reported
completing more than 2 years of formal education. Median
household size was five persons, with >75 % of
households having a least one child under the age of 5 years.
In both surveys, roughly 84 % of households interviewed
reported a monthly household income of less than 1000
MZN per month (< $1 USD per day). Portuguese
language understanding was limited with only 39 %
reporting understanding at baseline and 43.1 % at endline. Most
households (roughly 80 %) were located in rural areas,
with only between 5 and 10 % of respondents reporting
access to electricity in the home.
Of households interviewed at baseline and endline,
roughly 64 % were in possession of at least one mosquito
bed net (Table 3). When analysed by the three oversampled
districts, a much higher proportion of households in
Namacurra (90 %) reported possessing a mosquito net, compared
to Alto Molócuè (77 %) and Namacurra (34 %), respectively
in 2014. When asked to respond to “who normally sleeps
under the mosquito net?” roughly 50 % of respondents in
both surveys reported “everyone”, however district specific
differences existed. At endline, Alto Molócuè and
Namacurra reported “everyone” in 63.8 and 79.3 % of
respondents respectively, compared to just 22.7 % in Morrumbala.
Province-wide, between 2010 and 2014, the proportion
of respondents who reported sleeping under a mosquito
net in the night prior to survey implementation increased
across all populations groups surveyed, with the largest
proportional increase seen for the female head-of-household
(46.9–83.8 %) and children 0–12 months (48.3–71.2 %).
In analysis of just the three oversampled districts,
multivariable logistic regression was used to assess changes
over time in mosquito net utilization, as well as factors at
endline associated with use of a mosquito net in the night
prior to survey administration. In comparison to
baseline, female heads-of household (OR 7.67, 95 % CI 6.43,
9.16), women pregnant at the time of survey
administration (OR 2.17, 95 % CI 1.78, 2.64), and children
0–59 months (OR 3.48, 95 % CI 2.80, 4.33) all had a two
to eightfold higher odds of sleeping under a mosquito net
the previous night in 2014 (Table 4).
For female head-of-household respondents, the
characteristics at endline associated with mosquito net
utilization in the previous night were higher education,
understanding Portuguese, larger household size,
having electricity in the household, and larger household
monthly income (Table 5). Mode of acquisition for
mosquito nets, whether all donated or all purchased, was
significantly associated with mosquito net utilization.
Compared to Alto Molócuè, respondents from
Namacurra were more likely (OR 4.51, 95 % CI 3.06–6.65) to
report sleeping under a mosquito net the previous night;
while respondents from Morrumbala had a 25 % lower
odds (OR 0.75; 95 % CI 0.52–1.80, p < 0.001 for district).
As travel time to a health facility increased (per 1 h),
respondents had 13 % lower odds of sleeping under a
mosquito net (OR 0.87; 95 % CI 0.74, 1.01, p = 0.07).
After adjusting for demographic variables, pregnant
women had 27 times higher odds of sleeping under
a mosquito net if all bed nets were purchased (95 %
CI 12.79, 58.04, p < 0.001) and 13 times higher odds if
all bed nets were received as a donation (95 % CI 7.84,
22.76, p < 0.001). Additionally, pregnant women had 2.4
times higher odds of sleeping under a bed net if they
lived in Namacurra (95 % CI 0.91, 6.32, p = 0.002 for
Similar trends were seen when questioned about
mosquito net utilization in children 0–59 months
living in the household. Higher maternal education (OR
1.50; 95 % CI 1.09, 2.07, p < 0.001), living in Namacurra
(OR 4.18; 95 % CI 2.73, 6.40, p < 0.001), and access to
mosquito bed nets were most associated with the child
being reported as sleeping under a mosquito net in
the previous night (Table 6). Slightly more than half of
children 0–59 months slept under a mosquito net in
the previous night. When analysed by age, the odds of
sleeping under a mosquito net was greatest for newborn
children and decreased until about 20 months, such that
children aged 24–59 months had similar bed net use
Mozambique´s national vector control strategy includes
achieving universal access to at least one of the
following interventions: (1) living in a household sprayed with
insecticide or (2) having access to ITNs [
]. As a public
health intervention, ITNs have been shown to have both
direct and indirect effects on the dynamics of malaria
transmission in a community. When used by high-risk
populations such as children under 5 years old and
pregnant women, ITNs are known to decrease both overall
malaria mortality and all-cause child mortality [
Additionally, modelling has shown that when a critical
mass of at-risk persons are consistently using ITNs, the
indirect protective effect at a community level can be
greater than the direct effect of individual use .
The study examined changes since baseline in ITN use
and the factors associated with use of ITNs in
Zambézia Province, Mozambique at endline. No survey
questions were asked related to indoor residual spraying. The
baseline survey was conducted at the end of dry season
in August–September and the endline survey was
conducted in April–May, directly after the end of rainy
season (December 2013–April 2014). The overall household
possession (64.3 %) of a least one mosquito net among
the study population is consistent with ITN coverage
reported in neighboring Tete Province (62.5 %)
during a similar household survey conducted at the
beginning of rainy season, December 2013 [
it is compatible with achieved results reported in prior
national surveys and reflects a continuation of the steady
rise in Mozambican household ITN coverage over time
3, 5, 31
]. Nevertheless, it is still far less than the
universal (100 %) coverage recommended by the WHO [
Intense efforts are underway to further expand ITN
distribution across the country, but it remains unclear as to
how to achieve “universal coverage” and how to measure
its success or not. Definitions of universal coverage have
ranged from distribution of a fixed number of bed nets
per household regardless of size, to distribution of one
net per every two persons in the household, or finally to
having one net per household sleeping space [
Mozambican national policy as of 2009, each household
should have at least one mosquito net for every two
persons living there . While these surveys did not directly
address the one net per two person policy, results showed
that for priority target populations (children <5 years old
and pregnant women), the proportion reporting
sleeping under a mosquito net in the night prior to survey
implementation increased in 2014 as compared to 2010
Socio-economic factors including higher education,
understanding Portuguese, having a higher household
Missing values of predictors were accounted for using multiple imputation
a There are 2906 respondents included in this multivariable logistic regression model
b There are 790 respondents included in this multivariable logistic regression model
income, and living in a house with electricity were
positively associated with the female head-of-household
sleeping under a mosquito net on the night prior to being
interviewed. These findings are consistent with studies in
which women and children from households with higher
income, positively benefited from both the
accessibility and affordability of preventive and curative measures
for malaria [
]. Despite this, free distribution of bed
nets has been shown to contribute to increased coverage
and equity in their use. When commercial sectors are the
only option for bed net availability, ownership is limited to
the richest families . Distance to a health facility was
inversely related with odds of sleeping under a mosquito
net in the previous night. Proximity to health facilities,
markets, and town centers have been linked in other
studies to increased ITN utilization, likely due to improved
transportation accessibility and access to mosquito net
distribution points [
]. Other studies in
Mozambique have found that poorer households were no less
likely to own a bed net, just less likely to “buy” a bed net
. With this in mind, generalized accessibility through
a variety of alternatives becomes an important factor. For
There are 2936 children included in this multivariable logistic regression model
Missing values of predictors were accounted for using multiple imputation
rural Zambézia Province, in which 58.2 % of its population
is considered multi-dimensionally poor [
], the finding
that more bed nets were purchased than received through
donations, highlights that current Mozambican strategies
to achieve universal ITN coverage through mass
donation strategies have not yet reached saturation. In order
to maximize household mosquito bed net ownership and
use, a combination of both free distribution strategies as
well as commercial options will likely be needed.
Current strategies for ITN use in Mozambique call for
80 % coverage in high-risk populations such as children
under 5 years old and pregnant women [
(59.9 and 68.4 % coverage, respectively) still fall
considerably short of that target. Like female heads-of-household
in general, socio-economic factors were most
associated with a pregnant woman sleeping under a bed net,
though these trends did not quite reach the same
statistical significance (Table 5). The association between higher
maternal education and ITN use by children under five
years old (OR 1.50, p < 0.001; Table 6) has been noted by
other studies. Educated parents are both more likely to
come into contact with malaria prevention educational
materials and more likely to encourage children to sleep
under a net [
7, 37, 38
Reported findings show continued progress in
Zambézia Province in terms of household ITN coverage and
the proportion of high-risk populations utilizing a bed
net in the prior night. However these province-wide
estimates obscure variations of progress among and within
districts and geographic regions. When looking at only
three oversampled districts, Morrumbala performs
considerably less in terms of ITN coverage (34 %) and
utilization uptake compared to Alto Molócuè and Namacurra.
Namacurra outpaced national goals with 89.6 % of
households reporting at least one ITN and with 87.6 % of
pregnant women and 88.9 % of children under five years old
reporting sleeping under a mosquito bed net in the prior
evening. Alto Molócuè, has not achieved national targets,
yet appears to be following more closely to national trends
and on pace for meeting national targets in the near term.
It is important to note that at the time of endline survey
implementation, Morrumbala was a district that had not
yet benefited from strategies for universal bed net
distribution through the Ministry of Health, PMI, or the
current Global Fund malaria programme, though it has been
covered by indoor residual spraying (IRS) since 2007.
In comparison, Alto Molócuè began receiving universal
mass ITN campaigns in 2012, and Namacurra in 2013. As
of 2014, the only ITNs that were distributed in
Morrumbala were done so at antenatal care clinics as part of
programmes funded through PMI. All the same, only 24.5 %
of pregnant women in Morrumbala reported receiving a
mosquito bed net during their last pregnancy, compared
to 64 and 74.2 % reported for Alto Molócuè and
Namacurra, respectively. Provincial health supply chain
systems for commodity distribution are the same whether
the commodity is intended for health facility
interventions or community related health campaigns. The fact
that other districts are currently prioritized ahead of
Morrumbala to receive ITN under the universal coverage
strategies, likely has resulted in an overall decreased
number of free mosquito bed nets available in
Morrumbala, including ITNs intended for distribution within
antenatal care clinics. Universal distribution of free ITNs
is currently planned to begin taking place in Morrumbala
in 2017 with Global Fund support.
Large-scale investments are currently underway to
expand both prevention and treatment strategies to
combat malaria in Mozambique. Zambézia Province, one
of the four identified high malaria prevalence and high
population-dense provinces, will continue to be a focus
for interventions from programmes such as PMI and the
Global Fund. Strategies aimed at maximizing the impact
of ITN include “universal” ITN distribution defined as
one ITN per every two persons and distribution of ITN
to pregnant women at antenatal care clinics. Described
here are the province wide disparities in work done to
date. Of particular concern is that interventions seem to
favor those households of higher socioeconomic status.
Intensified efforts and focused attention on the poorest,
least educated, and most distant from health services is
needed to improve equity of ITN availability and usage.
Additionally, while some districts have already
surpassed goals in terms of coverage and utilization of ITN,
renewed emphasis should be placed on bringing all
geographic regions of the province closer to meeting these
TM, MB, AG, LG, and ML were involved in design of the study. TM, CH, and
MB were involved in statistical analysis. TM, CH, MB, AG, and ML participated
in drafting and revising the manuscript and interpretation of findings. LG,
TM, AG, OO and MB participated in data acquisition. All authors read and
approved the final manuscript.
The authors declare that they have no competing interests.
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