TABLE 11-1Community Assessment using the Community-as Partne

TABLE 11-1
Community Assessment using the Community-as Partner Model
OBSERVATIONS
DATA
I. Community Core- The people who reside in a geopolitical
community or the population of a community. Criteria to
evaluate when assessing the core include the community’s
history, current demographics, and the values and beliefs of
community residents.
II: Interrelated subsystems:
1. Physical Environment- Observations of the climate, terrain,
natural boundaries, commercial systems, neighborhoods,
religious symbols, planning studies, and so on.
2. Health and social services- Hospitals & clinics, home health
care, extended care facilities, public health services, counseling
& support services, clothing, food, shelter, and special needs
services.
3. Economics- Household median income, percentage of persons
living in poverty, employment status, occupational categories,
and union activity.

4. Safety & transportation- Information about protection
services (fire, police, water treatment, solid waste) and ai r
quality. Information on public transportation.
TABLE 11-1 (continued)
5. Politics and government- Type of city government, political
action groups, & political party affiliation.
6. Communication- Formal communication sources (e.g.,
newspapers) & informal communication sources (bulletin
boards, posters)
7. Education- Educational status of community members &
educational sources.
8. Recreation- Recreational facilities.
Stressors- Tension-producing situations within the community,
such as increase in substance abuse among teens within the
community.
Normal level of defense- Health statistics for the community
(e.g., mortality & morbidity)
Flexible line of defense- Community responses to current
stressors.

Lines of resistance- Established strengths within the community
(e.g., shelters, food banks).
After analyzing the data write a community diagnosis. Please
refer to your readings on how to write a community diagnosis.
1
Running Head: COMMUNITY ASSESSMENT
Community Assessment: Westerly
Jane Smith
New England Institute of Technology

2
COMMUNITY ASSESSMENT
Introduction
I conducted my community assessment in the town of Westerly,
Rhode Island
using the community-as partner model, which is based off
Neuman’s systems theory. The
model was beneficial tool when collecting data, analyzing that
data, and making
conclusion about the data, as it relates to health problems in the
community of Westerly.
The latter in conjunction with my overall impression of the
Westerly community
contributed to the creation of a community nursing diagnosis,
which lead to the planning,
implementation and evaluation of health problems and needs
within the community.
Community Core

In my quest to acquire knowledge about the people who reside
in the geopolitical
community of Westerly, I needed to first examine the
community’s history. According to
the State of Rhode Island Historical Preservation & Heritage
Commission (n.d.),
Westerly is a part of Washington County, is approximately
thirty-three square miles
toward the corner of southwestern Rhode Island and is roughly
42 miles southwest from
Providence. Westerly was once occupied by Indians thousands
of years ago. Although the
exact dates are undetermined since Indian sites have not yet
been dated, it is known that
when the Europeans arrived in American, The Narragansett
Indian tribe had already been
well established. The Narragansett Indians occupied the area up
until about 1632. Today,
those Indians who resided in Westerly for centuries are only
remembered through liberal
sprinklings of place name throughout the land and through
artifacts that can be found at

3
various archeological sites. (State of Rhode Island Histor ical
Preservation & Heritage
Commission, n.d.).
The town of Westerly has a total of 16 villages (i.e. Avondale,
Bradford, Dunn’s
Corners, Havershame, Misquamicut, Napatree Point, Pleasant
Hill, Pleasant View, Potter
Hill, Sandy Point, Shelter Harbor, Stillmanville, Watch Hill,
White Rock and Wi)
(RI.gov, 2016). The demography of the community core helped
me gather information
regarding the population of people who reside in Westerly. The
tables below are a
breakdown of the demographic profile of the town, population
race, ethnicity, education,
age and income according to the State of Rhode Island Division
of Planning Department
of Administration (n.d.):
Table 1-1
Race Population % of Population
White 21,360 94.0%

Black / African American 285 1.3%
American Indian &
Alaskan Native
110 0.5%
Asian 424 1.9%
Native Hawaiian & other
Pacific Islander
0 0.0%
Other 138 0.6%
Two or more races 403 1.8%
Total 22,720
4
Table 1-2
Ethnicity Population % Of Population
Hispanic or Latino (any

race)
388 1.7%
Not Hispanic or Latino 22,332 98.3%
Total 22,720
Table 1-3
Educational Attainment Population 25 – Years &
Older
% Of Population 25 –
Years & Older
Less than 9th grade 549 3.4%
9 th – 12 th grade, no diploma 1,505 9.2%
High school diploma or
GED
4,577 27.9%
Completed some college 2,888 17.6%
Associate degree 1,890 11.5%
Bachelor’s degree 3,209 19.6%

Master’s degree 1,460 8.9%
Professional degree 216 1.3%
5
Doctorate degree 85 0.5%
Total 16, 379
Table 1-4
Household Income Households % Of Occupied
Households
Less than $10,000 362 3.8%
$10,000 - $14,999 393 4.1%
$15,000 - $24,999 965 10.1%
$25,000 - $34,999 848 8.8%
$35,000 - $49,999 1,429 14.9%
$50,000 - $74,999 1,770 18.5%
$75,000 - $99,999 1,191 12.4%
$100,000 - $149,999 1,523 15.9%

$150,000 - $199,999 663 6.9%
$200,000 or more 438 4.6%
Total 9,582
Median household income: $60,532
Interrelated Subsystems
Physical Environment
6
The State of Rhode Island Historical Preservation and Heritage
Commission (n.d.)
noted that most of the boundaries in Westerly are natural. The
Pawcatuck River separates
Westerly from the towns of Hopkinton, Rhode Island, both
Stonington and North
Stonington, Connecticut. The town also has several physical
zones that are very distinct,
all of which were shaped by a continental glacier. A very sharp
topographic boundary
follows Route 1A and is roughly one mile wide. The boundary
is sometimes referenced

as terminal moraine because of its very irregular landscape that
has many depressions and
hills; some of which are water-filled. The Coastal plain is south
of Route 1A. It was
formed by the sand and gravel that washed out of terminal
moraine. (State of Rhode
Island Historical Preservation & Heritage Commission, n.d.). In
addition to Rhode
Island’s natural board being surrounded by the Atlantic Ocean,
which is the back yard to
some residents that live on the coastline of Westerly, there are
many ponds that are
scattered throughout the town.
Built environments, such as housing and neighborhoods, are
potential health
indicators. The United States Census Bureau (2000) revealed
that 5,994 residents are
owners of housing units and 3,408 residents are renters of
housing units. According to
Area Vibes (n.d.a), the median cost to purchase a home is
$278,100. The median rent
asked is $1,081. The median home cost in Westerly is about
58% more than the estimated

national average. The median rent price is about 18% more than
the estimated national
average. The number of renters who occupy households is
roughly 11% higher than the
estimated national average, whereas the number of homeowners
in Westerly is about 6%
lower than the estimated national average. (Area Vibes, n.d.a).
7
Health and Social Services
Westerly has one hospital that is voluntary non-profit according
to City-Data
(2017). There are four nursing homes, two of which have built
in rehabilitation centers in
them, a health center and a dialysis center (City-Data, 2017).
The following table is of
percentage rates of the health and nutrition of Westerly-ians
according to City-Data
(2017):
Table 2-1
Healthy diet rate Westerly: 50.6% Rhode Island: 48.8%

Average health of
teeth/gums
Westerly: 47.3% Rhode Island: 45.7%
Average BMI Westerly: 28.7 Rhode Island: 28.6
Mental health issues Westerly: 22.2% Rhode Island: 21.9%
People who do not drink
alcohol
Westerly: 11.2% Rhode Island: 10.7%
Average hours of sleep Westerly: 6.9 Rhode Island:6.8
Overweight people Westerly: 35.0% Rhode Island: 33.7%
General health condition Westerly: 56.2% Rhode Island: 55.2%
Average hearing condition Westerly: 77.4% Rhode Island:
78.2%
Westerly was listed number two on the top 101 cities who had
the highest percentage of
residents who visited a dentist in the past year (City-Data,
2017). Lastly, there are a total
8

of 58 group practices in Westerly with a wide array of services
to meet the needs of the
residing population (Health Grades, 2017).
City-Data (2017) also disclosed past health violations and
monitoring violations
that occurred in Westerly. They only cited health violation was
in May 2012 regarding
water contamination with coliform. Compliance was achieved in
July 2012. As for
monitoring violations, there were three occurrences in 2006 and
in 2012, all of which
compliance was achieved within a two month time frame. As for
air quality, the air
quality index (AQI) level in Westerly was 98.9 in 2013, which
was worse than the
average. (City-Data, 2017).
Economics
The State of Rhode Island Historical Preservation & Heritage
Commission (n.d.),
noted that until around the 1800, agricultural interest were very
important as the widely
spread population steadily grew. Commercial and manufacturing
companies were very

small-scale, local enterprises. Shortly after 1800, a decline in
the population occurred, but
the population remained constant until the surge of industrial
development occurred
1840, which triggered the large increase within the population.
In that year, the
population was 1,912; by 1875 the population number almost
tripled reaching 5,408.
(State of Rhode Island Historical Preservation & Heritage
Commission, n.d.).
Currently, the job market has drastically improved since 1874
and thus the
economic conditions have improved. The average income,
according the State of Rhode
Island Division of Planning Department of Administration
(n.d.), is $60,532. That median
household income number is 10% higher compared to the
national average (Area Vibes,
9
n.d.b) Neighborhood Scout (2016) noted that the most prevalent
jobs for the residents of

Westerly are mixed with both white and blue-collar
occupations. In general, the town of
Westerly is made up of sales, office workers, professionals and
service providers. There
are an exceptional amount of people who work in either office
and administrative support
positions (13.91%), management occupations (10.40%) and
sales (10.18%). Westerly
also has more residents who work with computers or math than
95% of other places in
the U.S. (Neighborhood Scout, 2016).
Transportation and Safety
The State of Rhode Island Historical Preservation & Heritage
Commission (n.d.),
noted that Westerly only has three major highways (i.e. U.S. 1,
Historic Post Road, and
State Highway 3, Nooseneck Hill Road), that help funnel traffic
both to and from the
Westerly Village and nearby Connecticut. Penn Central Railroad
also goes back and forth
through Westerly Village, providing passenger service. Passing
the northern end of town
is Interstate 95, which offers both a direct and high-speed

connection. In 1978 a modern
highway called Route 78, also known as the Westerly By-Pass,
was created and skirts the
town. It serves to help speed travelers both to and from the
shore areas in the town.
Toward the end of Route 78 and Post Road is Westerly State
Airport, one of the major
links between the mainland and Block Island. (State of Rhode
Island Historical
Preservation & Heritage Commission, n.d.).
Area Vibes (2015) noted that the crime rate in Westerly is
roughly 34% under the
national average. For every 100,000 residents, there are 5.19
crimes that occur daily.
10
There is a 1 in 53 probability of being a victim to any crime.
The total number of year to
year crimes has decreased by 30%. Westerly is considered safer
than 69% of cities
within the U.S. (Area Vibes, 2015). It appears that the local law
enforcement, Westerly

Police Department, does a good job maintaining citizen safety.
An observation I made was that law enforcement is strict on
impaired driving. In
Westerly, there are sometimes traffic safety marketing using
road side monitors that
display the phrase ‘Drive Sober or Get Pulled Over’ or ‘Drive
Now. Text Later’,
Occupant protection is enforced through enforcement of the
click it or ticket law.
According to the Rhode Island Department of Transportation
(2014), the percentage of
seat belt use in Washington County (i.e. Westerly) was 86.8%
for drivers and 88.0% for
passengers.
Politics and Government
There are more Democratic political party members in Westerly
than there are
Republican political party members (City-Data, 2017).
According to Westerly Rhode
Island (2016), in both the Town Council and School Committee ,
there are three
Democrats, two Republican and two Independent party council
members. The Senator of

the General Assembly is a republican, but the Representative in
the General Assembly,
Congressional Delegation US Senator in Congress and the US
Representative in
Congress are Democrats. Every term, except for the School
Committee and the
Congressional Delegation US Senator in Congress, are two-year
terms. The School
Committee is a four-year term and the Congressional Delegation
US Senator in Congress
is a six-year term. (Westerly Rhode Island, 2016).
11
Communication / Recreation
Churches were and still are a way for the resident of Westerly
to gather, worship
and converse with one another. According to the State of Rhode
Island Historical
Preservation & Heritage Commission (n.d.), churches were
organized at an early century
in Westerly. During that time, the Westerly area was primarily
Baptists and

Sabbatarian’s. In the mid-nineteenth century Episcopalian,
Catholic, Congregations and
Methodist churches were organized. (State of Rhode Island
Historical Preservation &
Heritage Commission, n.d.). In my observation of churches in
Westerly, the majority are
that of the Catholic faith. However, City-Data (2015) estimated
that 53.5% of the
Westerly population either does not have a specific religion or
simply do not attend
church.
Communication also takes place in many forms of recreation.
For example, in my
observations over the past half-decade of living in Westerly, I
have observed individuals
going to Wilcox Park to walk. There are also many festivals that
take place in the park
throughout the year as well. In addition, there are several other
community parks and
fields for children, families and friends to play. Gyms and the
YMCA have also been
places where all age group go to socialize and workout. In both
the Spring and Summer
time, many people will paddle board in ponds or go to the beach

to relax or surf. There
are outdoor volleyball and tennis courts. In the winter there is
an outdoor ice skating
rank. Cell phone and internet based social media communication
/ coverage is abundant
in the community. Local bakeries and coffee shops sometimes
offer free Wi-Fi.
Education
12
School enrollment refers to when students attend school, private
or public
(Moving Ideas, 2017). According to the State of Rhode Island
Historical Preservation &
Heritage Commission (n.d.), the first school, which is no longer
standing, was built in
1792 and was used to orchestrate town meetings, devotional
purposes, and education. In
1832, eight private and eleven public schools were created as
education became universal
(State of Rhode Island historical Preservation & Heritage
Commission, n.d.). Currently,

Westerly has three elementary schools, one private and one
public middle school, and
one high school (City-Data, 2017). Additionally, Neighborhood
Scout (2016) noted that
the education level for residents of Westerly is substantially
higher compared to typical
US communities. However, the test scores for Dunn’s Corners
School (grades KG – 04),
State Street School (grades KG – 04), Spring brook Elementary
School (grades KG – 04),
Westerly Middle School (grades 05 – 08) and Westerly High
School (grade 09 – 12)
range between 63 and 82; with the average test score being 74%
(Area Vibes, n.d.c). All
the schools, with the exception of Westerly High School, has a
play ground for children
to play. Westerly High School has a football, baseball, soccer
and lacrosse fields; a track
and an indoor basketball court.
Community Diagnosis
Based on all the data collected on the community of Westerly, I
was able to
identify a few barriers that the community is faced with, as it
relates to the normal level

of defense, it was hard for me to find data and or statistics on
the mortality/morbidity rate
within the Westerly community. However, the level of overall
health that the community
has reached overtime, according to City-Data (2017), is 56.2%;
which is higher than the
13
overall percentage for the state of Rhode Island. Although the
percentages for mental
health issues and obesity were not too high, obesity being the
higher of the two, they
were still higher than the overall percentage for the entire state
which poses health
problems.
As previously mentioned, obesity is a health stressor that is
noted in the
community and is detrimental to the health of residents. Arikan
et al. (2014), noted that
the prevalence of obesity has an increasingly unhealthy problem
because of changes in
one’s diet and lifestyle. It places individuals at a higher risk to

develop cardiovascular
diseases by causing other health related problems such as
atherosclerosis, diabetes,
hypertension, etc. There are many fast food restaurants in the
community of Westerly.
There are 17 pizza restaurants alone.
Problem-solving capabilities and or patterns of coping seem to
have improved the
overall health rate in westerly by reducing automotive fatalities.
For example, there has
been a decrease in automotive fatalities because of cracking
down on drunk driving and
texting while driving. However, drug overdoses appear to be a
big stressor for the
community of Westerly as well as for the rest of the state of
Rhode Island.
According to Trust for America’s Health (2013), statistics
indicate that Rhode
Island is ranked 13th for the highest mortality rate of drug
overdose in the United States.
The latter is a stressor for the community of Westerly.
According to a report
Prescriptions Drug Abuse: Strategies to Stop the Epidemic, 15.5
per 100,000 individuals

suffer from overdose fatalities (Trust for America’s Health,
2013). The deaths extend
across all age groups, classes, ethnicities and gender lines (The
Westerly Sun, 2014). I
14
was unable to attain the actual number of drug overdoses that
occurred in Westerly from
the Westerly Police Department without submitting a request
that would have taken four
weeks to process, but there have been many arrests in
connection with drug paraphernalia
possession, intent to sell, and risk of injury to a minor amongst
other things (12 WPRI
Eyewitness News, 2014; The Westerly Sun, 2014a ; The
Westerly Sun, 2015). Rhode
Island received an eight out of 10 for possible indicators of
favorable strategies that can
help curb drug abuse (Trust for America’s Health, 2013).
The flexible line of defense is weakened because of the drug
overdoses, which
cause social and health stressors. Lines of resistance were

strengthened when the
Department of Behavioral, Developmental Disabilities and
Hospitals issued a response to
what was termed as “a recent increase in narcotic overdose”
deaths within the state, was
prompted action of emergency regulations (The Westerly Sun,
2014). The new
regulations require behavioral healthcare providers to authorize
the drug Naloxone to be
given to patients who they know or who may be opioid-
dependent. Rules also mandate
the medication be offered to people in residential areas and in
preparation for discharge
from detoxification settings. Emergency regulations require
overdose treatment trainings,
including the administration of Naloxone, and overdose
prevention to all staff personnel
in behavioral healthcare organizations. (The Westerly Sun,
2014).
Community Nursing Diagnosis
There were many stressors that were found in the Westerly
community as it
relates to health. Education in relation to the stressors can help
residents improve their

health and life expectancy so that they can continue to
contribute to the community. The
15
following is my prioritized nursing diagnosis (Omaha System,
2016; Omaha System,
2016a; & Omaha System, 2016b).
1. DOMAIN: HEALTH-RELATED BEHAVIORS
i. Problem: Nutrition
ii. Problem Classification Scheme
a) Modifiers: Individual and Potential
b) RISK FACTORS
● Many fast food restaurants
● Change in diet (i.e. increase in caloric intake and or portion
size)
● Change in lifestyle (i.e. physical inactivity)
● Poverty
iii. Intervention Scheme

a) Category: Teaching, Guidance, and Counseling
b) TARGETS AND CLIENT-SPECIFIC INFORMATION
● Education
● Dietary management (i.e. limit sugar intake and decrease
portion size).
● Encourage change and responsibility (i.e. assess readiness)
c) Category: Treatments and Procedures
d) TARGETS AND CLIENT-SPECIFIC INFORMATION
16
● Behavior modification
● Exercises
● Stress management
● Support group
e) Category: Case Management
f) TARGETS AND CLIENT-SPECIFIC INFORMATION
● Dietary management

● Nutritionist care
iv. Projected Evaluation
a) Knowledge
● 4 – adequate knowledge
b) Behavior
● 4 – Usually appropriate behavior
c) Status
● 4 – minimal signs/symptoms
2. DOMAIN: HEALTH-RELATED BEHAVIORS
i. Problem: Substance Use
ii. Problem Classification Scheme
a) Modifiers: Individual and Potential
b) RISK FACTORS (Mayo Clinic, 2017)
● Family history (i.e. addiction)
● Being male
17
● Having another type of mental health disorder

● Peer pressure
● Poor family involvement
● Anxiety, depression and loneliness
● Taking highly addictive drugs
iii. Intervention Scheme
a) Category: Teaching, Guidance, and Counseling
b) TARGETS AND CLIENT-SPECIFIC INFORMATION
● Coping skills
● Education
c) Category: Treatments and Procedures
d) TARGETS AND CLIENT-SPECIFIC INFORMATION
● Behavior modification
● Discipline
● Stress management
● Support group
e) Category: Case Management
f) TARGETS AND CLIENT-SPECIFIC INFORMATION
● Community outreach worker services

● Continuity of care
● Change in environment
● Finances
18
● Social work/counseling
● Transportation
iv. Projected Evaluation
a) Knowledge
● 4 – adequate knowledge
b) Behavior
● 4 – Usually appropriate behavior
c) Status
● 4 – minimal signs/symptoms
Due to the complexity of obesity etiology, I have limited my
diagnosis of obesity in
Westerly as being related to poor nutrition and or the intake of
more food than is required

for one’s metabolic needs, as evidenced by their being many
fast food restaurants and
physical inactivity.
19
References
12 WPRI Eyewitness News. (2014). Five arrested after month-
long drug sting. Retrieved
January 29, 2017 from
http://wpri.com/2014/02/28/five-arrested-after-month-long-
drug-sting/
Area Vibes. (2015). Westerly, ri crime. Retrieved January 19,
2017 from
http://www.areavibes.com/westerly-ri/crime/
Area Vibes. (n.d.a). Westerly, ri housing. Retrieved January 28,
2017 from
http://www.areavibes.com/westerly-ri/housing/
Area Vibes. (n.d.b). Westerly, ri employment. Retrieved

http://www.areavibes.com/westerly-ri/employment/
Area Vibes. (n.d.c). Westerly, school information. Retrieved
http://www.areavibes.com/westerly-ri/education/
Arikan, I., Karakaya, K., Erata, M., Tüzün, H., Baran, E.,
Levent, G., & Yeşil, H. K.
(2014). Fighting obesity campaign in turkey: Evaluation of
media campaign
efficacy. Central European Journal of Public Health, 22(3), 170-
174.
City-Data. (2017). Westerly rhode island. Retrieved January 21,
2017 from
http://www.city-data.com/city/Westerly-Rhode-Island.html
Health Grades (2017). Group practices directory, rhode island,
westerly. Retrieved from
https://www.healthgrades.com/group-directory/ri-rhode-
island/westerly
Mayo Clinic. (2017). Drug addition – risk factors. Retrieved
February 4, 2017 from
http://www.mayoclinic.org/diseases-conditions/drug-
addiction/basics/risk-factors/
CON-20020970

20
Moving Ideas. (2017). Westerly, ri city data – population,
homes, statistics. Retrieved
January 19, 2017 from http://www.movingideas.org/westerly-ri/
Neighborhood Scout. (2016). Westerly, ri real estate and
demographic information.
Retrieved January 19, 2017 from
https://www.neighborhoodscout.com/ri/westerly/
Omaha System. (2016). Problem classification scheme.
Retrieved February 4, 2017 from
http://www.omahasystem.org/problemclassificationscheme.html
Omaha System. (2016a). Intervention scheme. Retrieved
February 4, 2017 from
http://www.omahasystem.org/interventionscheme.html
Omaha System. (2016b). Problem rating scale for outcomes.
Retrieved February 4, from
http://www.omahasystem.org/problemratingscaleforoutcomes.ht
ml
Rhode Island Department of Transportation. (2014). 2014 seat
belt use in rhode island.

http://dot.ri.gov/documents/community/safety/2014_Seat_Belt_
Usage.pdf
RI.gov. (2016). Town of westerly. Retrieved January 19, 2017
from
https://www.ri.gov/towns/view/westerly/
State of Rhode Island Division of Planning Department of
Administration. (2015).
Westerly 2015 data points for comprehensive planning.
Retrieved January 19,
2017 from
http://www.planning.ri.gov/documents/comp/comp16/2015West
erly.pdf.
21
State of Rhode Island Division of Planning Department of
Administration. (2015a).
Planning for recreation. Retrieved January 26, 2017 from
http://www.planning.ri.gov/documents/comp_handbook/3_Recre
ation.pdf
State of Rhode Island Historical Preservation & Heritage
Commission. (n.d.). Historic

and architectural resources of westerly, rhode island: A
preliminary report.
http://www.preservation.ri.gov/pdfs_zips_downloads/survey_pd
fs/westerly.pdf
The Westerly Sun. (2014). Statewide drug overdoses prompt
action. Retrieved January
29, 2017 from
http://www.thewesterlysun.com/news/state/3592600-
129/statewide-drug-overdose
s-prompt-action.html
The Westerly Sun (2014a). Westerly man held on heroin
charges. Retrieved January 29,
2017 from
http://www.thewesterlysun.com/news/policecourts/3612695-
129/westerly-man-he
ld-on-heroin-charges.html
The Westerly Sun (2015). Local police detectives make 7 heroin
arrests in pawcatuck.
http://www.thewesterlysun.com/news/policecourts/7357251-
129/police-arrest-7-i

n-stonington-heroin-bust.html
United States Census Bureau. (2000). Profile of general
demographic characteristics:
2000. Geographic area: Westerly town, washington county,
rhode island.
22
https://censtats.census.gov/data/RI/0604400977000.pdf
Westerly Rhode Island. (2016). Elected officials as of the
november 8, 2016 general
election. Retrieved January 28, 2017 from
http://westerlyri.gov/DocumentCenter/View/294

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