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Laura Bennett and Judith Dyson review the literature to find out
how this issue has become such a problem among inmates and
why policies to reduce it are not being implemented successfully
Laura Bennett was an MSc
student at the time of writing.
She is now a support time and
recovery worker for the Evolve
Hull Eating Disorder Service
Judith Dyson is a lecturer in
mental health at the University
of Hull
Date of submission
September 15 2013
Date of acceptance
December 4 2013
Peer review
This article has been subject to
double-blind review and has been
checked using antiplagiarism
Author guidelines

This article explores barriers that prevent or interfere
with the implementation of policies for reducing
deliberate self-harm in adults in prisons and the levers
that aid implementation. An integrative literature
review was conducted of 12 studies of deliberate
self-harm in the prison service between 2000 and
2012. Data were analysed thematically. Six themes
were identified: knowledge; attitudes; emotion; staff
skills; environment; and resisting treatment. The
authors argue that having identified barriers and
levers, the next stage is to address them so that the
high levels of self-harm in prison can be reduced.
Attitudes, depression, emotion, injury, inmates,
mental health, prison, self-harm, suicide
SELF-HARM AND suicide have become increasing
public concerns in recent years, but an
aspect that is less frequently reported is the
number of incidents that occur within Her
Majestys Prison Service. There are numerous policy
documents identifying this problem and suggesting
measures to address it (Home Office 1984, 1986,
Scottish Home and Health Department 1985,
Phillips 1986, Backett 1987), but these have not been
implemented (Her Majestys Inspectorate of Prisons
(HMIP) 1996, 1997, 1999, 2000, Health Advisory
Committee for the Prison Service 1997, Prison Service
and NHS Executive Working Group 1999a, 1999b).
This article reviews the literature on self-harm
and suicide in prisons, as well as barriers to

14 September 2014 | Volume 18 | Number 1

implementing strategies, and levers that could

help address them.
Self-harm is: Self-poisoning or injury, irrespective
of the apparent purpose of the act (National
Institute for Health and Care Excellence (NICE)
2004); and suicide is: Death caused by self-directed
injurious behaviour with any intent to die as a result
of the behaviour (Wenzel et al 2009).
There are many reasons why incidents of self-harm
occur in prisons. For example, inmates diagnosed
with depression (Klonsky and Muehlenkamp 2007)
and mental health issues (Hawton et al 2001) are
more likely to self-harm. A history of drug misuse
(Beasley 2000, Cuellar and Curry 2007) and the
presence of certain feelings such as cynicism,
resentment, hopelessness, self-doubt, guilt and
self-criticism are reported by inmates to precipitate
incidents of self-harm (Herpertz et al 1997). This is
also true of those who have suffered abuse as a child
or who have been in an abusive relationship as an
adult (Kenning et al 2010), and of inmates who suffer
a bereavement or who have children removed during
their prison stay (Kenning et al 2010). The stress of
prison may also influence the likelihood of self-harm:
inmates report that being placed in isolation may
precipitate such behaviour (Edwards 2000), as can
boredom (Borrill et al 2005).
The number of individuals reported to have
self-harmed in 2010 was 6,639 in England and Wales
(Ministry of Justice 2012). Reasons cited for the high
number of prison episodes of self-harm include
ineffective procedures to reduce incidents (Rickford
2003, Shaw et al 2003). Historically, investigations
into prison suicides are rare. However, in 1982 the

Rex Features

Art & science | offender health

death of an 18-year-old prisoner following an
episode of self-harm resulted in a verdict of lack of
care on the part of the prison (Smith 1984).
A wave of political, media and public concern,
and a spate of prisoner deaths, caused the Home
Office to instigate an official inquiry into the practices
of suicide prevention in prisons (HMIP 1990, Tumim
1990). Year after year, recommendations have
been made to prevent self-harm but have not been
implemented (HMIP 1996, 1997, 1999, 2000, Health
Advisory Committee for the Prison Service 1997,
Prison Service and NHS Executive Working Group
1999a, 1999b). A literature review was therefore
conducted to identify barriers to and levers for
implementing suicide and self-harm prevention
policies in the prison service for adult inmates.

Search strategy
The databases searched included CINAHL,
Medline, and PsycINFO. Key author searches were
conducted and reports from the Ministry of Justice
and the Department of Health were examined.
Search terms were adult, deliberate self-harm,
depression, incarcerat*, mental health, offend*,
prison, inmate, psychiatr* and suicid* in
various combinations.
Due to the lack of literature on this subject, search
inclusion criteria were broad. Papers were taken
from peer-reviewed journals and although quality
levels varied, they were appraised with quality at the
forefront of the criteria. They were all considered
to be at a more-than-satisfactory level of quality.
Peer-reviewed papers had to report, investigate
or contain information related to the barriers
and levers to implementing self-harm and suicide
prevention policies in prisons. They also had to
include participants aged 18 years and over who were
considered to be adult offenders. Figure 1 identifies
the numbers of papers found and discarded at each
stage of the review. Because of varied methodologies
in the literature that was included, a thematic
analysis was used following the six-step framework
identified by Braun and Clarke (2006).

Thematic analysis of the papers revealed 23 codes;
these were amalgamated into six themes and
16 sub-themes that were relevant to the research
question (Figure 2). Details of included papers are
summarised in Table 1 (page 18).

The themes identified were:
16 September 2014 | Volume 18 | Number 1

Figure 1

Systematic search methods and results

Papers identified using search criteria


After title review to remove duplicates


After abstract review to remove irrelevant papers


After full paper review to remove irrelevant papers


Resisting treatment.
Knowledge Lack of knowledge about the issue
of self-harm and lack of training in how to deal
with such incidents were barriers to implementing
prevention strategies (Maden et al 2000, Borrill et al
2003, Pannell et al 2003, Ireland and Quinn 2007,
Kenning et al 2010). Kenning et al (2010) also
found that lack of motivation was often associated
with lack of training and knowledge of self-harm
in prisons, which meant prison staff were less
willing to want to help. Nurses working in prisons
identified a lack of support in dealing with
self-harm, and staff believed their lack of
knowledge was linked with poor confidence when
dealing with prisoners who self-harm (Ireland and
Quinn 2007, Kenning et al 2010).
Recommendations to improve the implementation
of self-harm prevention policies included more
training for all staff members who deal with
self-harming inmates (Pannell et al 2003).
Attitudes Attitude was identified as something that
could either enhance or prevent the implementation
of suicide and self-harm prevention procedures.
Some officers believed self-harming behaviour was
used to manipulate the staff and/or rules so that
the inmate could get what they want or require,
rather than something that required care (Ireland
and Quinn 2007). Ireland and Quinn (2007) found

that although attitudes towards the general prisoner

population were generally positive, attitudes
towards self-harming inmates were not. Officers
often refused to refer inmates for treatment and did
not keep episodes of harm confidential, frequently
sharing information with other inmates.
Although it was acknowledged that positive
attitudes could be helpful in supporting the
implementation of recommended care, the literature
suggests positive attitudes are rare (Borrill et al
2005, Ireland and Quinn 2007, Kenning et al 2010,
Marzano et al 2012). A clear link was found between
a lack of training and negative attitudes towards
inmates who self-harm (Borrill et al 2005, Ireland
and Quinn 2007, Kenning et al 2010). Training
was identified in some prisons, but the focus of
such training tended to be more on filling in forms
than treating inmates (Pannell et al 2003). When
training did include reasons why prisoners engage
in self-harming behaviour, it influenced attitudes
positively (Pannell et al 2003). Kenning et al (2010)
investigated the opinions of prison officers and
healthcare staff, and whether their attitudes and
opinions could affect service delivery. Officers
believed self-harming behaviour was used to
manipulate officers and rules for the inmates own
benefit, whereas healthcare staff believed it to be
Officers believed that many inmates with
mental illnesses were beyond help; an opinion
not shared by the nurses who were surveyed.
Officers considered that this difference in attitudes
might be due to being desensitised to self-harm

because it happens so frequently. Borrill et al (2005)

reported the experiences of survivors of severe selfharm incidents. Many inmates thought they had
received positive reactions from healthcare staff,
who listened and offered support. However, the time
that healthcare staff spent with inmates was brief.
Emotions The emotions of staff can influence the
implementation of policy towards the care and
treatment that inmates who self-harm should
receive. Marzano et al (2012) questioned inmates
about staff responses. Inmates reported that officers
did not care about or understand their behaviour.
Officers were seen to be unsympathetic and did not
take inmates actions seriously. Inmates accused
healthcare staff of being rude, judgemental and
patronising, reporting that they accused them of
being attention-seekers and time-wasters. Nurses
were said to demonstrate anger and annoyance.
Borrill et al (2005) identified that, from an
inmates point of view, tension that derives from
relationships with prison officers can affect
the implementation of policies. The emotion
demonstrated by staff, combined with the negative
attitudes reported, may go some way to explain the
limitations on therapeutic relationships. Examples
of such limitations are lack of trust, which could
lead officers to think inmates are being ignorant
or ungrateful and therefore cancelling treatments
or activities, or inmates feeling unable to talk
to officers because previously when they had
spoken with them confidentially, the information
had been shared with other officers and inmates.

Figure 2 Barriers and levers to self-harm and suicide prevention policies

Barriers and















Staffing levels

Lack of trust




Identifying risk




September 2014 | Volume 18 | Number 1 17

Art & science | offender health

Table 1

Papers included

Author, date
and country

Type of study



Main findings

Maden et al


Risk factors for deliberate

self-harm in prison

n=1,741 male

White prisoners are more likely to self-harm than

other ethnicities. Lack of training means deliberate
self-harm is not always identified.
More communication is needed.

Dear et al 2001,


Differences between
prisoners who have and
have not self-harmed.

n=71 male inmates

Staff need to develop more effective methods for

identifying distress.

Borrill et al 2003,


Patterns of self-harm and

attempted suicide among
white and black/mixed race
female prisoners.

n=301 female

More methods of individual and group

communication needed for inmates, staff
and outside services.

Pannell et al
2003, Australia

and interviews

Prison officers beliefs

regarding prisoners who

n=76 male inmates

and male/female

Training is needed for all staff. Current training

is too focused on form-filling and not enough on
the care and treatment of inmates.

Roth and Presse

2003, Canada

Case report

Nursing interventions for


Female inmates

Care for prisoners who self-harm is demanding.

Prisoners often resist care and treatment.

Borrill et al 2005,


Learning from near

misses. Women who
survived an incident of
severe self-harm in prison.

n=15 female inmates

Improvements to the general prison regime needed,

including training and support for staff.

Palmer and
Connelly 2005,

controlled trial

Depression, hopelessness
and suicide ideation among

n=24 males inmates

Patients resist treatment due to fear that care will

be withdrawn. Treatment by counselling, medical
intervention and occupational activities is the
most successful.

Young et al 2006,


Risk of harm: inmates who

harm in prison psychiatric

n=242 males

Patients resist treatment when forced to take part

in something they were coerced into doing, rather
than accessing treatment by choice.

Ireland and Quinn

2007, UK

Case control

Officers attitudes toward

prisoners who self-harm.

n=162 male (100)

and female (62)

Women more likely than men to report positive

attitudes towards prisoners who self-harm.
Attitudes more negative than towards other

Kenning et al
2010, UK

controlled trial
and interviewing

Prison staff and female

prisoners views on

n=30 male (6)/

female (24) inmates,
governors, healthcare
staff and officers

Officers attribute harm motives as manipulation

and attention-seeking. Differences between staff
understanding of self-harm may lie in training.

Suto and Arnaut

2010, US


Suicide in prison:
a qualitative study.

n=24 male inmates;

mean age=31.83

Causes include depressive thoughts, feelings

of hopelessness, loneliness, guilt and/or shame
related to crime, anxiety, paranoid ideation,
impulsivity, relationship issues with family,
inmates or staff.

Marzano et al
2012, UK


n=20 male inmates;

Prisoners perspectives:
ethnicity=18 white,
impact of staff responses
on self-harming behaviours. 2 other

18 September 2014 | Volume 18 | Number 1

Prison officers, nurses, and doctors said to be

ill-prepared to deal with deliberate self-harm and
often display hostile attitudes and behaviours.


Limitations on the implementation of psychological

interventions are, for instance, a lack of trust or not
having someone to communicate, which can leave
an inmate feeling vulnerable, leaving them open to
being bullied and therefore increasing the risk of
self-harm (Borrill et al 2005).
Emotional tension between staff and inmates
can make implementation of self-harm prevention
policies difficult (Borrill et al 2005). Tension can
lead to resentment and reluctance among prison
officers to implement guidelines that essentially
demonstrate caring (Borrill et al 2005, Marzano et al
2012). At the same time, inmates do not want to
receive treatment because of their anger towards
officers at the poor way they consider they are
treated (Borrill et al 2005, Kenning et al 2010, Suto
and Arnaut 2010, Marzano et al 2012). All papers
cited here rely on prisoners perspectives; no paper
was found that considered emotional barriers to
the implementation of self-harm policy from the
perspective of staff.
Skills Ireland and Quinn (2007) and Kenning et al
(2010) identify an absence of the skills necessary
to implement self-harm policies. To follow such
guidelines staff need to be skilled in communication,
in particular in active listening. Only one quarter of
participants in the study by Ireland and Quinn (2007)
recall being given training related to self-harm.
In prisons that offered more extensive self-harm
training, staff demonstrated greater awareness
and skills (Dear et al 2001, Kenning et al 2010).
Pannell et al (2003) found that where training was
offered it was focused on attempted suicide after
the act, rather than prevention, and was centred on
form-filling rather than people.
Despite acknowledging that training would
improve skills in terms of recognising changes in
inmates behaviour, such as distress, anger and
stress, such training was still rare (Dear et al 2001,
Ireland and Quinn 2007).
Environment Environmental factors can be
considered a barrier or lever when implementing
policies. Inmates report that staffing levels are
low and staff time is not always used effectively
(Dear et al 2001, Borrill et al 2005, Suto and Arnaut
2010). In a study where inmates who survived
incidents of severe self-harm were interviewed,
one of the measures identified to be useful was
occupational activity to reduce anxiety and distract
from intrusive thoughts. There are, however, few
out-of-cell activities (Borrill et al 2005).
Co-operation with other services is important
when maintaining care for inmates who self-harm

(Marzano et al 2012) yet services do not always work

in a multidisciplinary manner (Kenning et al 2010).
There is disagreement about whether healthcare staff
or officers should take responsibility for inmates who
self-harm (Liebling 1994, Borrill et al 2005).
Resisting treatment Inmates resistance to treatment
is another barrier to implementing policies in prison
(Roth and Presse 2003, Palmer and Connelly 2005,
Young et al 2006, Kenning et al 2010). Patients refuse
treatments for a number of reasons. Roth and Presse
(2003) found that inmates in a vulnerable state resist
treatment because of a lack of trust. Counselling is
the treatment most resisted. Inmates reported that
it is easier to reject help than to trust prison and/
or medical staff, depending on previous experiences
(Kenning et al 2010).
One reason for this is that inmates are wary that
treatment could be withdrawn; it is not uncommon
for people who should be receiving treatment for
drug and mental health issues to refuse help because
they do not want to have treatment withdrawn if
they harm themselves or have a break in their care
due to relocation within the prison (Palmer and
Connelly 2005, Kenning et al 2010). Treatment is also
resisted when inmates are forced to take part in it,
rather than accessing treatment by choice. In these
instances, inmates fail to comply to protest against
a lack of autonomy and choice (Palmer and Connelly
2005, Young et al 2006).

The aim of this study was to identify what helps
and what hinders the implementation of policies for
reducing self-harm among adults in prisons. The
barriers and levers identified include knowledge,
attitudes, emotion, skills, environmental factors and
inmates resisting treatment.
Despite a dearth of literature on this subject,
there is consistency in the research about what can
be seen as a barrier or lever to implementation of
appropriate policies, even if this is not the specific
hypothesis of the literature. Cooper (1998) and
Pope et al (2007) believe that having literature with
diverse methodology could affect the quality of the
overall study, whereas Dixon-Woods et al (2004)
consider a mix of literature types to be a positive
reaction within a study because of the triangulation
and the ability to cross-examine ideas to find the
most relevant recommendations.
Another limitation was the age of the studies
used. Although it can be seen that self-harm
reduction policies had not been implemented at the
time of the study, prison service policies are being
updated constantly and it is possible that previous
September 2014 | Volume 18 | Number 1 19

Art & science | offender health

recommendations may have been implemented since
the publication of the included studies.
There is a great deal of evidence for the failure
of prisons to implement self-harm prevention
policy (HMIP 1990, 1996, 1997, 1999, 2000, Health
Advisory Committee for the Prison Service 1997,
Prison Service and NHS Executive Working Group
1999a, 1999b). Biannual and annual prison reports
(HMIP 1990, 1996, 1997, 1999, 2000, Health
Advisory Committee for the Prison Service 1997,
Prison Service and NHS Executive Working Group
1999a, 1999b) offer recommendations, stress the
importance of change to reduce self-harm and
identify that previous recommendations have not
been implemented. Some of the literature cited
in this review identifies the barriers and levers
to implementation. The next step is to consider

strategies to minimise these barriers and

increase the uptake of these important self-harm
prevention procedures.

Implications for practice

There is a need for training to:
Enhance understanding of self-harm.
Positively influence attitudes (Pannell et al 2003).
Improve self-harm prevention skills (Ireland and
Quinn 2007).
Address emotional coping skills.
Improve staff coping (Marzano et al 2012).
Address environmental factors, such as staffing
levels, occupational activity (Borrill et al 2005)
and interdisciplinary working.

Online archive
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using the keywords
Conflict of interest
None declared

Backett S (1987) Suicide in Scottish prisons.
British Journal of Psychiatry. 151, 218-221.
Beasley S (2000) Deliberate self-harm in
medium security. Nursing Management.
6, 8, 29-33.
Borrill J, Burnett R, Atkins R et al (2003)
Patterns of self-harm and attempted suicide
among white and black/mixed race female
prisoners. Criminal Behaviour and Mental
Health. 13, 4, 229-240.
Borrill J, Snow L, Medlicott D et al (2005)
Learning from near misses: interviews with
women who survived an incident of severe
self-harm in prison. The Howard Journal of
Criminal Justice. 44, 1, 57-69.

Health Advisory Committee for the Prison

Service (1997) The Provision of Mental Health
Care in Prisons. Prison Service, London.

Klonsky D, Muehlenkamp J (2007) Self-injury:

a research review for the practitioner. Journal
of Clinical Psychology. 63, 11, 1045-1056.

Her Majestys Inspectorate of Prisons

(1990) Suicide and Self-harm in Prison Service
Establishments in England and Wales.
Home Office, London.

Liebling A (1994) Suicide amongst women

prisoners. The Howard Journal. 22, 1, 1-9

Her Majestys Inspectorate of Prisons (1996)

Patient or Prisoner? A New Strategy for Health
Care in Prisons. Home Office, London.
Her Majestys Inspectorate of Prisons (1997)
Women in Prison: A Thematic Review by
HM Chief Inspector of Prisons. Home Office,

Braun V, Clarke V (2006) Using thematic

analysis in psychology. Qualitative Research
in Psychology. 3, 2, 77-101.

Her Majestys Inspectorate of Prisons (1999)

Suicide is Everyones Concern: A Thematic
Review by HM Chief Inspector of Prisons for
England and Wales. Home Office, London.

Cooper H (1998) Synthesizing Research: A

Guide for Literature Reviews. Third edition.
Sage Publications, Thousand Oaks,
California CA.

Her Majestys Inspectorate of Prisons (2000)

Annual Report of HM Chief Inspector of Prisons
for England and Wales 1998-1999. Home Office,

Cuellar J Curry T (2007) The prevalence and

comorbidity between delinquency, drug abuse,
suicide attempts, physical and sexual abuse,
and self-mutilation among delinquent Hispanic
females. Hispanic Journal of Behavioral
Sciences. 29, 1, 68-82.

Herpertz S, Sass H Favazza A (1997)

Impulsivity in self-mutilative behavior:
psychometric and biological findings. Journal
of Psychiatric Research. 31, 4, 451-465.

Dear G, Thomson D, Howells K et al (2001)

Self-harm in Western Australian prisons:
differences between prisoners who have
self-harmed and those who have not.
Australian and New Zealand Journal of
Criminology. 34, 3, 277-292.
Dixon-Woods M, Shaw R, Agarwal S et al
(2004) The problem of appraising qualitative
research. Quality and Safety in Health Care.
13, 3, 223-225.
Edwards K (2000) Stigmatizing the stigmatized:
a note on the mentally ill prison inmate.
International Journal of Offender Therapy
and Comparative Criminology. 44, 4, 480-489.

Home Office (1984) Suicide in Prison: A Report

by HM Chief Inspector of Prisons. Her Majestys
Stationery Office, London.
Home Office (1986) Report of the Working
Group on Suicide Prevention. Her Majestys
Stationery Office, London.
Ireland J, Quinn K (2007) Officer attitudes
towards adult male prisoners who self-harm:
development of an attitudinal measure and
investigation of sex differences. Aggressive
Behavior. 33, 1, 63-72.
Kenning C, Cooper J, Short V et al (2010)
Prison staff and women prisoners views on
self-harm: their implications for service delivery
and development: a qualitative study. Criminal
Behaviour and Mental Health. 20, 4, 274-284.

Hawton K, Houston K Townsend E (2001)

Psychiatric and personality disorders in
deliberate self-harm patients. British Journal of
Psychiatry. 178, 1, 48-54.

20 September 2014 | Volume 18 | Number 1

Maden A, Chamberlain S, Gunn J (2000)

Deliberate self-harm in sentenced male
prisoners in England and Wales: some ethnic
factors. Criminal Behaviour and Mental Health.
10, 3, 199-204.
Marzano L, Ciclitira K, Adler J (2012) The
impact of prison staff responses on
self-harming behaviours: prisoners
perspectives. British Journal of Clinical
Psychology. 51, 1, 4-18.
Ministry of Justice (2012) Safety in Custody
Statistics: Quarterly Update to 31 December
2012. (Last accessed:
May 28 2014.)
National Institute for Health and Care
Excellence (2004) The Short-term Physical
and Psychological Management and Secondary
Prevention of Self-harm in Primary and
Secondary Care National Clinical Practice
Guideline 16. British Psychological Society
and RCPsych, London.
Palmer E, Connelly R (2005) Depression,
hopelessness and suicide ideation among
vulnerable prisoners. Criminal Behaviour
and Mental Health. 15, 3, 164-170.
Pannell J, Howells K, Day A (2003) Prison
officers beliefs regarding self-harm in
prisoners; an empirical investigation.
International Journal of Forensic Psychology.
1, 1, 103-110.
Phillips M (1986) A Study of Suicide and
Attempted Suicides at HMP Brixton, 1973-1983.
Directorate of Psychological Services, Home
Office, London.
Pope C, Mays N, Popay J (2007) Synthesizing
Qualitative and Quantitative Health Research:
A Guide to Methods. Open University Press,

Prison Service and NHS Executive Working

Group (1999a) Suicide in Prisons: Research,
Policy and Practice. Pavilion Publishing,
Prison Service and NHS Executive Working
Group (1999b) The Future Organisation of
Prison Health Care. Department of Health,
Rickford D (2003) Troubled Inside: Responding
to the Mental Health Needs of Women in Prison.
Prison Reform Trust, London.
Roth B, Presse L (2003) Nursing interventions
for parasuicidal behaviours in female offenders.
Journal of Psychosocial Nursing. 41, 9, 21-29.
Scottish Home and Health Department (1985)
Report of the Review of Suicide Precautions at
HM Detention Centre and HM Young Offenders
Institution. Her Majestys Stationery Office,
Shaw J, Appleby L, Baker D (2003)
Safer Prisons: A National Study of Prison
Suicides 1999-2000 by the National Confidential
Inquiry into Suicides and Homicides by People
with Mental Illness. Department of Health,
Smith R (1984) The state of the prisons. Deaths
in prison. British Medical Journal (Clinical
Research Edition). 288, 6412, 208-212.
Suto I, Arnaut G (2010) Suicide in prison:
a qualitative study. The Prison Journal.
20, 3, 288-312.
Tumim S (1990) Report of a Review by Her
Majestys Chief Inspector of Prisons in England
and Wales of Suicide and Self-Harm in Prison
Establishments in England and Wales.
Her Majestys Stationery Office, London.
Wenzel A, Brown G, Beck A (2009) Cognitive
Therapy for Suicidal Patients: Scientific and
Clinical Applications. American Psychological
Association, Washington DC.
Young M, Justice J, Erdberg P (2006) Risk of
harm: inmates who harm themselves while
in prison psychiatric treatment. Journal of
Forensic Science. 51, 1, 156-162.


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