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Patien
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Pra
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8
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127
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p
u
n
itiv
e
r
esp
o
n
s
e
to
er
r
o
r
is
v
iewe
d
as
a
s
er
io
u
s
is
s
u
e
th
at
n
ee
d
s
to
b
e
ad
d
r
ess
ed
,
h
ea
lth
ca
r
e
p
r
o
f
ess
io
n
als
in
Ar
ab
co
u
n
tr
ies
co
n
tin
u
e
to
b
eliev
e
th
at
a
'
cu
ltu
r
e
o
f
b
lam
e'
ex
is
ts
th
at
p
r
ev
en
ts
th
em
f
r
o
m
r
ep
o
r
tin
g
in
cid
en
ts
[
7
]
,
[
8
]
.
C
o
n
d
u
cted
a
m
eta
-
an
aly
s
is
o
f
1
1
d
escr
ip
tiv
e
s
tu
d
ies
o
n
h
o
s
p
ital
s
taf
f
an
d
d
is
co
v
er
ed
th
at
o
n
ly
8
.
3
an
d
3
2
.
3
p
er
ce
n
t
o
f
r
esp
o
n
d
en
ts
to
t
h
e
r
ev
iewe
d
ar
ticles
r
ated
I
r
a
n
'
s
p
atien
t
s
af
ety
c
u
ltu
r
e
as
e
x
ce
l
len
t
o
r
v
er
y
g
o
o
d
,
r
esp
ec
tiv
ely
.
A
p
r
ev
io
u
s
s
tu
d
y
was
c
o
n
d
u
cted
to
i
n
v
esti
g
ate
th
e
ass
o
ciatio
n
b
etwe
en
th
e
p
er
ce
p
tio
n
s
o
f
th
e
s
af
et
y
cu
ltu
r
e
o
f
h
o
s
p
ital
em
p
lo
y
ee
s
an
d
th
e
p
e
r
f
o
r
m
an
ce
o
f
h
o
s
p
it
al
s
af
ety
;
it
f
o
u
n
d
a
s
tatis
ticall
y
p
o
s
itiv
e
r
elatio
n
o
f
at
least
o
n
e
s
af
ety
cu
ltu
r
e
co
m
p
o
s
ite/d
im
en
s
io
n
with
s
elec
ted
ad
v
e
r
s
e
e
v
en
ts
[
9
]
.
I
n
an
o
th
er
r
esear
ch
,
f
in
d
in
g
s
s
h
o
wed
th
at
a
clea
r
cu
ltu
r
e
o
f
p
atien
t
s
af
ety
is
ass
o
ciate
d
with
a
l
o
wer
r
ate
o
f
co
m
p
licatio
n
s
f
o
r
p
atien
ts
an
d
f
ewe
r
ad
v
er
s
e
e
v
en
ts
[
1
0
]
.
I
t
is
d
escr
ib
ed
a
s
a
cu
ltu
r
e
t
h
r
o
u
g
h
wh
ich
n
u
r
s
es
ar
e
awa
r
e
o
f
m
is
tak
es,
en
c
o
u
r
ag
ed
to
a
d
d
r
ess
th
em
,
an
d
im
p
r
o
v
e
th
ei
r
ca
p
ac
ity
to
lear
n
f
r
o
m
p
ast
m
is
tak
es
an
d
tak
e
co
r
r
ec
tiv
e
ac
tio
n
[
1
1
]
.
A
m
et
a
-
an
aly
s
is
,
in
clu
d
in
g
1
1
d
escr
ip
tiv
e
s
tu
d
ies
o
n
h
o
s
p
ital
s
taf
f
,
s
h
o
wed
t
h
at
o
n
ly
8
.
3
a
n
d
3
2
.
3
%
o
f
th
e
r
esp
o
n
d
e
n
ts
o
f
th
e
r
ev
iewe
d
a
r
ticles
h
a
v
e
r
ated
p
atien
t
s
af
ety
c
u
ltu
r
e
in
I
r
a
n
as
e
x
ce
llen
t
an
d
v
e
r
y
g
o
o
d
,
r
esp
ec
tiv
ely
[
8
]
.
T
h
e
im
p
o
r
tan
t
r
o
le
o
f
t
h
e
p
atien
t
s
af
ety
cu
lt
u
r
e
in
clin
ic
al
s
ettin
g
s
r
eq
u
ir
es
im
p
r
o
v
em
e
n
t [
1
2
]
,
[
1
3
]
.
So
cio
cu
ltu
r
al
n
o
r
m
s
r
elatin
g
to
m
u
ltip
le
s
o
cial
d
if
f
er
e
n
ce
s
,
s
u
ch
as
g
en
d
er
,
ca
n
in
f
lu
e
n
ce
h
ier
ar
ch
ical
r
elatio
n
s
h
ip
s
in
r
ea
l
life
[
1
4
]
.
A
p
e
r
s
o
n
'
s
g
en
d
er
h
as
m
a
n
y
f
ac
ets
an
d
ca
n
c
h
an
g
e
at
an
y
tim
e
[
1
5
]
.
W
o
m
en
,
m
e
n
,
an
d
p
eo
p
le
o
f
all
g
en
d
er
id
en
titi
es
an
d
ex
p
r
ess
io
n
s
ar
e
all
in
clu
d
ed
in
th
e
co
n
ce
p
t
o
f
g
en
d
er
,
as
ar
e
t
h
e
s
o
cially
c
o
n
s
tr
u
cted
r
o
les
an
d
e
x
p
ec
tat
io
n
s
th
at
a
r
e
im
p
o
s
ed
o
n
th
em
b
ased
o
n
th
eir
ascr
ib
ed
o
r
ac
tu
al
g
en
d
er
[
1
5
]
.
Sev
er
al
s
tu
d
ies
in
th
e
f
ield
o
f
s
u
r
g
er
y
an
d
an
esth
esia
h
av
e
h
ig
h
lig
h
ted
th
e
r
o
le
o
f
g
en
d
er
in
s
h
ap
in
g
th
e
ex
p
e
r
ien
ce
s
an
d
o
u
tco
m
es
o
f
h
ea
lt
h
ca
r
e
p
r
o
f
ess
io
n
als
[
1
6
]
,
[
1
7
]
.
T
h
e
r
o
le
o
f
g
en
d
e
r
in
th
e
in
ter
p
r
o
f
ess
io
n
al
team
is
m
o
r
e
c
o
m
p
lex
an
d
war
r
an
t
s
f
u
r
th
er
in
v
esti
g
atio
n
,
e
v
en
th
o
u
g
h
it
h
as
b
ee
n
in
cr
ea
s
in
g
ly
s
tu
d
ied
at
th
e
le
v
el
o
f
th
e
in
d
iv
id
u
al
h
ea
lth
ca
r
e
p
r
o
v
id
er
.
Fo
r
in
ter
p
r
o
f
ess
io
n
al
ed
u
ca
tio
n
an
d
tr
ain
in
g
,
th
is
co
u
ld
h
a
v
e
s
ig
n
i
f
ican
t
im
p
licatio
n
s
,
esp
ec
ially
in
lig
h
t
o
f
th
e
g
r
o
wth
an
d
in
cr
ea
s
ed
in
v
estme
n
t
in
eq
u
ity
,
d
iv
e
r
s
ity
,
an
d
in
cl
u
s
io
n
.
I
n
th
is
s
tu
d
y
,
we
e
x
a
m
in
ed
s
ex
d
if
f
er
e
n
ce
s
in
p
at
ien
t
s
af
ety
cu
ltu
r
e
p
r
ac
tices a
m
o
n
g
n
u
r
s
es in
K
ar
awa
n
g
,
I
n
d
o
n
esia.
2.
M
E
T
H
O
DS
2
.
1
.
Study
des
ig
n
T
h
is
s
tu
d
y
was
co
n
d
u
cted
u
s
in
g
a
cr
o
s
s
-
s
ec
tio
n
al
d
esig
n
at
a
g
en
e
r
al
p
u
b
lic
h
o
s
p
ital
in
Kar
awa
n
g
,
W
est
J
av
a,
I
n
d
o
n
esia.
T
h
er
e
is
o
n
ly
o
n
e
g
en
e
r
al
p
u
b
lic
h
o
s
p
ital
in
Kar
awa
n
g
.
It
h
as
b
ec
o
m
e
a
r
ef
e
r
en
c
e
h
o
s
p
i
tal
in
th
is
ar
ea
with
d
if
f
e
r
s
eth
n
icity
b
o
th
h
ea
lth
ca
r
e
p
r
o
v
id
er
s
an
d
p
atien
ts
.
2.
2
.
Sa
m
ple
T
h
e
cr
iter
ia
f
o
r
in
clu
s
io
n
we
r
e
s
en
io
r
n
u
r
s
es
wh
o
wo
r
k
in
eith
er
clin
ical
o
r
m
an
ag
e
r
ial
p
o
s
itio
n
s
(
th
is
s
u
b
s
et
[
s
en
io
r
n
u
r
s
es]
in
clu
d
es
r
o
tatin
g
s
h
if
ts
in
n
u
r
s
es,
d
ir
ec
t
war
d
/u
n
it
s
u
p
er
v
is
o
r
s
[
h
ea
d
n
u
r
s
es],
r
o
tatin
g
s
h
if
t
n
u
r
s
in
g
s
u
p
e
r
v
i
s
o
r
s
,
n
u
r
s
e
ed
u
ca
to
r
s
,
n
u
r
s
e
m
an
ag
er
s
,
an
d
n
u
r
s
e
ex
ec
u
tiv
es),
h
av
e
at
least
3
y
ea
r
s
o
f
n
u
r
s
in
g
d
ip
lo
m
a,
h
a
v
e
at
least
6
m
o
n
th
s
o
f
cu
r
r
en
t
wo
r
k
p
lace
ex
p
er
ien
ce
.
W
h
ile
th
e
ex
clu
s
io
n
cr
iter
ia
wer
e
n
u
r
s
e
w
h
o
ta
k
es
leav
e
d
u
e
to
s
ick
n
ess
o
r
m
ater
n
ity
leav
e
,
n
u
r
s
e
f
o
llo
win
g
s
p
ec
if
i
c
tr
ain
in
g
o
n
p
atien
t saf
ety
d
u
r
i
n
g
th
is
s
tu
d
y
,
an
d
u
n
willin
g
n
ess
to
p
a
r
ticip
ate.
T
h
e
s
am
p
le
s
ize
f
o
r
th
is
an
al
y
s
is
h
as
b
ee
n
d
eter
m
in
ed
ac
c
o
r
d
in
g
to
tab
les
f
r
o
m
C
o
h
en
.
I
t
h
as
b
ee
n
esti
m
ated
th
at
6
4
p
ar
ticip
an
ts
will
n
ee
d
to
h
av
e
c
o
n
f
id
e
n
ce
i
n
th
e
r
esu
lts
at
a
m
ed
iu
m
-
e
f
f
e
ct
s
ize
[
1
8
]
,
wh
ich
is
wid
ely
u
s
ed
in
th
e
s
o
cial
s
cien
ce
s
,
an
d
a
p
o
wer
esti
m
ate
o
f
0
.
8
,
with
an
alp
h
a
o
f
0
.
0
5
.
I
n
th
e
f
in
al,
th
er
e
was 1
5
4
s
am
p
le
b
e
r
ec
r
u
ited
i
n
th
is
s
tu
d
y
with
2
0
% a
ttritio
n
r
ate.
2.
3
.
I
ns
t
rum
ent
T
h
e
r
esear
ch
er
u
s
ed
a
ce
n
s
u
s
.
T
h
e
s
o
cio
-
d
em
o
g
r
a
p
h
ic
q
u
esti
o
n
in
clu
d
es
1
4
item
s
.
T
h
ese
it
em
s
co
v
er
g
en
d
er
(
m
ale
an
d
f
em
ale)
,
a
g
e,
lev
el
o
f
ed
u
ca
tio
n
(
d
ip
lo
m
a
,
b
ac
h
elo
r
'
s
,
m
aster
'
s
,
an
d
ab
o
v
e)
,
len
g
t
h
o
f
wo
r
k
as a
n
u
r
s
e,
p
o
s
itio
n
(
n
u
r
s
e
lev
el
1
to
5
)
,
an
d
wo
r
k
in
g
ar
ea
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
SS
N
:
2
2
5
2
-
8
8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
15
,
No
.
1
,
M
ar
ch
20
26
:
1
2
6
-
1
31
128
T
h
e
h
o
s
p
ital
s
u
r
v
ey
o
n
p
atie
n
t
s
af
ety
cu
ltu
r
e
(
HSPS
C
)
d
ev
elo
p
ed
by
th
e
Ag
en
c
y
f
o
r
Hea
lth
ca
r
e
R
esear
ch
an
d
Qu
ality
(
AHRQ)
U.
S.
Dep
ar
tm
en
t
o
f
Hea
lth
a
n
d
Hu
m
an
Ser
v
ices
(
2
0
1
6
)
u
s
ed
o
p
er
atio
n
ally
to
m
ea
s
u
r
e
p
er
ce
p
tio
n
s
o
f
t
h
e
s
af
ety
cu
ltu
r
e.
T
h
is
in
s
tr
u
m
en
t
c
o
n
s
is
ts
o
f
1
2
co
m
p
o
s
ites
o
f
s
a
f
ety
cu
ltu
r
e
with
a
to
tal
o
f
4
2
item
s
r
ated
o
n
a
5
-
p
o
in
t
L
ik
er
t
s
ca
le
r
a
n
g
in
g
f
r
o
m
"5
=
s
tr
o
n
g
ly
ag
r
ee
"
to
"1
=
s
tr
o
n
g
ly
d
is
ag
r
ee
"
o
r
a
5
-
p
o
i
n
t f
r
eq
u
en
cy
s
ca
le
wh
er
ein
5
=
alwa
y
s
an
d
1
=
n
ev
er
b
ef
o
r
e.
2.
4
.
P
r
o
ce
du
re
T
h
e
r
esear
ch
e
r
ap
p
r
o
ac
h
ed
t
h
e
Kar
awa
n
g
h
o
s
p
ital
f
o
r
p
er
m
is
s
io
n
to
co
n
d
u
ct
t
h
e
s
tu
d
y
a
f
ter
o
b
tain
in
g
a
letter
o
f
p
er
m
is
s
io
n
f
r
o
m
L
in
c
o
ln
Un
i
v
er
s
ity
C
o
lleg
e
to
co
n
d
u
ct
th
e
s
tu
d
y
in
I
n
d
o
n
esia.
T
h
e
r
esear
ch
er
b
eg
i
n
s
co
llectin
g
d
ata
af
ter
r
ec
eiv
in
g
a
letter
o
f
ap
p
r
o
v
al
f
r
o
m
e
ac
h
h
o
s
p
ital'
s
E
th
ical
C
o
m
m
ittee.
T
h
e
r
esear
ch
er
n
ee
d
e
d
p
er
m
i
s
s
io
n
f
r
o
m
th
e
h
ea
d
n
u
r
s
e
to
m
ak
e
th
e
s
tu
d
y
'
s
p
u
r
p
o
s
e
an
d
elig
ib
ilit
y
cr
iter
ia
clea
r
to
p
o
ten
tial
s
u
b
jects
b
ef
o
r
e
b
e
g
in
n
in
g
th
e
r
ec
r
u
itm
en
t
p
r
o
ce
s
s
.
T
h
e
n
o
tifie
d
co
n
s
en
t
f
o
r
m
was
d
is
tr
ib
u
ted
an
d
co
llected
at
th
e
en
d
o
f
th
e
war
d
m
ee
tin
g
d
u
r
in
g
th
e
tim
e
allo
tted
.
So
m
e
ex
p
lan
atio
n
s
ab
o
u
t
p
ar
ticip
an
t
p
r
o
tectio
n
,
in
clu
d
in
g
an
o
n
y
m
ity
,
th
e
u
n
n
am
ed
s
ig
n
atu
r
e
b
o
x
to
en
s
u
r
e
co
n
f
id
en
tiality
,
an
d
a
s
tatem
en
t
th
at
all
in
f
o
r
m
atio
n
p
r
o
v
id
e
d
is
f
o
r
ac
ad
em
ic
p
u
r
p
o
s
es
o
n
ly
,
ar
e
in
clu
d
e
d
in
th
e
in
f
o
r
m
e
d
co
n
s
en
t.
Af
ter
o
b
tain
in
g
in
f
o
r
m
e
d
co
n
s
en
t,
th
e
r
esear
ch
er
d
is
tr
ib
u
ted
th
e
s
u
r
v
ey
to
th
o
s
e
wh
o
h
ad
ag
r
ee
d
to
p
ar
ticip
ate.
Par
ticip
an
ts
m
a
y
also
o
p
t
o
u
t
o
f
th
e
s
tu
d
y
if
th
ey
f
in
d
it
b
u
r
d
en
s
o
m
e.
T
h
e
q
u
esti
o
n
n
air
e
is
co
m
p
letely
an
o
n
y
m
o
u
s
an
d
d
o
es
n
o
t
ask
f
o
r
an
y
p
er
s
o
n
al
in
f
o
r
m
atio
n
ab
o
u
t
th
e
r
esp
o
n
d
en
t,
an
d
all
q
u
esti
o
n
n
air
es we
r
e
r
etu
r
n
ed
to
th
e
r
esear
ch
e
r
in
s
ea
led
en
v
e
lo
p
es.
2.
5
.
Da
t
a
a
na
ly
s
is
Descr
ip
tio
n
s
o
f
d
em
o
g
r
ap
h
ic
ch
ar
ac
ter
is
tics
an
d
p
atien
t
s
af
ety
cu
ltu
r
e
p
r
ac
tice
wer
e
m
ad
e
u
s
in
g
d
escr
ip
tiv
e
s
tatis
tics
an
d
f
r
eq
u
en
cy
d
is
tr
ib
u
tio
n
s
to
ac
co
u
n
t
f
o
r
s
ex
d
if
f
er
en
ce
s
in
th
e
d
is
tr
ib
u
tio
n
o
f
t
h
ese
v
ar
iab
les.
A
ch
i
-
s
q
u
ar
e
tes
t
an
d
an
in
d
ep
en
d
en
t
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-
test
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eter
m
i
n
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y
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er
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ce
s
in
p
atien
t
s
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ety
c
u
ltu
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e
p
r
ac
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th
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A
p
-
v
alu
e
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f
0
.
0
5
in
d
ic
ated
th
at
th
e
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esu
lt
was s
tatis
t
ically
s
ig
n
if
ican
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T
h
e
s
tatis
t
ical
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aly
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r
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ied
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u
t
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s
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g
SP
SS
v
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2
3
.
0
(
SP
SS
I
n
c.
,
C
h
icag
o
,
I
L
,
USA)
.
3.
RE
SU
L
T
S
3
.
1
.
De
m
o
g
r
a
ph
ic
cha
ra
ct
er
is
t
ics
T
h
e
m
ea
n
ag
e
o
f
f
em
ale
an
d
m
ale
p
ar
ticip
an
ts
was
3
4
.
2
1
±
1
4
.
0
7
an
d
3
6
.
2
9
±
1
2
.
5
1
y
ea
r
s
o
ld
,
r
esp
ec
tiv
ely
(
T
ab
le
1
)
.
I
n
th
e
s
am
p
le
o
f
m
ales
,
th
e
m
ajo
r
ity
o
f
th
em
(
5
4
.
7
%)
h
ad
a
d
ip
lo
m
a
d
eg
r
ee
,
5
3
.
3
%
m
ar
r
ied
,
7
6
%
n
u
r
s
e
lev
el
1
t
o
2
,
4
2
.
7
%
wo
r
k
in
g
at
in
p
atien
ts
u
n
it,
an
d
h
ad
wo
r
k
in
g
ex
p
er
ien
ce
f
o
r
ab
o
u
t
1
9
.
0
1
±
6
.
5
5
y
ea
r
s
.
W
h
ile
in
th
e
f
em
ale
s
am
p
le,
th
e
m
ajo
r
it
y
o
f
th
em
(
5
1
.
7
%)
h
a
d
a
d
ip
l
o
m
a
d
eg
r
ee
,
7
8
.
6
%
m
ar
r
ied
,
5
2
.
4
%
n
u
r
s
e
lev
el
1
to
2
,
5
3
.
8
%
wo
r
k
in
g
at
i
n
p
ati
en
ts
u
n
it,
a
n
d
h
ad
wo
r
k
in
g
ex
p
er
ien
ce
f
o
r
ab
o
u
t
1
7
.
9
3
±
5
.
6
4
y
ea
r
s
.
A
g
e,
m
a
r
ital
s
tatu
s
,
an
d
wo
r
k
i
n
g
p
o
s
itio
n
wer
e
s
ig
n
if
ican
tly
d
if
f
e
r
en
t
b
etwe
en
m
ales
an
d
f
em
ales
(p
<
0
.
0
5
)
.
T
ab
le
1
.
Dem
o
g
r
ap
h
ic
co
m
p
ar
is
o
n
b
etwe
en
m
ale
an
d
f
em
ale
(
n
=
2
2
0
)
V
a
r
i
a
b
l
e
s
To
t
a
l
M
a
l
e
F
e
mal
e
p
-
v
a
l
u
e
n
=
2
2
0
(
%)
n
=
7
5
(
%)
n
=
1
4
5
(
%)
A
g
e
,
M
e
a
n
±
S
D
3
5
.
7
6
±
1
3
.
4
5
3
6
.
2
9
±
1
2
.
5
1
3
4
.
2
1
±
1
4
.
0
7
0
.
0
0
1
Ed
u
c
a
t
i
o
n
l
e
v
e
l
D
i
p
l
o
m
a
I
I
I
1
1
6
(
5
2
.
7
)
4
1
(
5
4
.
7
)
7
5
(
5
1
.
7
)
0
.
2
3
8
B
a
c
h
e
l
o
r
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0
0
(
4
5
.
5
)
3
3
(
4
4
.
0
)
6
7
(
4
6
.
2
)
M
a
s
t
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r
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4
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1
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8
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1
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t
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1
4
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8
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6
)
0
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0
3
2
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n
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e
6
6
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3
0
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0
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3
5
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6
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3
1
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W
o
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4
N
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r
se
l
e
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e
l
2
-
5
8
7
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3
9
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6
)
1
8
(
2
4
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0
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6
9
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4
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6
)
W
o
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k
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n
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n
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n
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t
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p
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1
1
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3
2
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4
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7
8
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O
u
t
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t
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t
d
e
p
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r
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4
5
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2
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1
8
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7
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Emerg
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W
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y
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3
4
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5
5
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9
3
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6
4
0
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3
1
7
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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2252
-
8
8
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6
S
ex
d
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s
o
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p
a
tien
t sa
fety
cu
ltu
r
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p
r
a
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a
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es in
K
a
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(
Lil
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S
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i
)
129
3
.
2
.
Sex
diff
er
ence
s
in
pa
t
ie
nt
s
a
f
et
y
cult
ure
pra
ct
ice
Fem
ales
r
ep
o
r
ted
h
av
in
g
a
h
i
g
h
er
o
v
er
all
s
co
r
e
o
f
p
atien
t
s
af
ety
cu
ltu
r
e
p
r
ac
tices
th
an
m
ales
(
3
.
6
5
(
SD
=
1
.
1
2
v
s
.
3
.
1
1
(
SD
=
1
.
4
3
)
,
p
-
v
alu
e
=
0
.
0
0
1
)
(
T
ab
le
2
)
.
Acc
o
r
d
in
g
to
p
atien
t
s
af
ety
cu
ltu
r
e
p
r
ac
tice
d
o
m
ain
,
team
wo
r
k
(
4
.
2
1
(
SD
=
1
.
3
5
)
v
s
.
3
.
7
8
(
SD
=
1
.
7
6
)
,
p
-
v
alu
e
=
0
.
0
0
1
)
,
r
esp
o
n
s
e
to
er
r
o
r
(
3
.
5
6
(
SD
=
1
.
9
3
)
v
s
.
3
.
3
1
(
SD
=
1
.
9
3
)
,
p
-
v
alu
e
=
0
.
0
0
1
)
,
a
n
d
c
o
m
m
u
n
icatio
n
o
p
en
n
ess
(
3
.
8
8
1
.
5
6
v
s
.
2
.
3
5
(
SD
=
0
.
9
2
)
,
p
-
v
alu
e
=
0
.
0
0
1
)
wer
e
h
ig
h
er
am
o
n
g
f
em
ale
th
a
n
m
ale
.
W
h
ile
th
e
o
th
er
d
o
m
ain
s
u
c
h
as
s
taf
f
in
g
an
d
wo
r
k
p
ac
e,
o
r
g
a
n
izatio
n
a
l
lear
n
in
g
–
co
n
tin
u
o
u
s
im
p
r
o
v
em
en
t,
r
e
s
p
o
n
s
e
to
er
r
o
r
,
s
u
p
er
v
is
o
r
,
m
an
ag
er
,
o
r
clin
ical
lead
er
s
u
p
p
o
r
t
f
o
r
p
atien
t
s
af
ety
,
co
m
m
u
n
icatio
n
ab
o
u
t
e
r
r
o
r
,
co
m
m
u
n
icatio
n
o
p
e
n
n
ess
,
r
ep
o
r
tin
g
p
atien
t
s
af
ety
ev
en
ts
,
h
o
s
p
ital
m
an
a
g
em
en
t
s
u
p
p
o
r
t
f
o
r
p
atien
t
s
af
e
ty
,
an
d
h
an
d
o
f
f
s
an
d
in
f
o
r
m
at
io
n
ex
ch
a
n
g
e
,
wer
e
n
o
t sig
n
if
ican
tly
d
if
f
er
en
t
b
et
wee
n
m
ales
an
d
f
em
ales
.
T
ab
le
2
.
Sex
d
if
f
er
e
n
ce
in
p
ati
en
t saf
ety
cu
ltu
r
e
p
r
ac
tice
(
n
=
220)
V
a
r
i
a
b
l
e
s
M
a
l
e
F
e
mal
e
p
-
v
a
l
u
e
M
e
a
n
SD
M
e
a
n
SD
P
a
t
i
e
n
t
s’
saf
e
t
y
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u
l
t
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r
e
3
.
1
1
1
.
4
3
3
.
6
5
1
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1
2
0
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0
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D
o
ma
i
n
sc
o
r
e
Te
a
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k
3
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8
1
.
7
6
4
.
2
1
1
.
3
5
0
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0
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S
t
a
f
f
i
n
g
a
n
d
w
o
r
k
p
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c
e
3
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4
2
1
.
5
6
3
.
4
9
1
.
4
0
0
.
4
8
5
O
r
g
a
n
i
z
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t
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l
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p
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2
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4
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H
o
sp
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H
a
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4
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1
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3
0
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3
1
8
4.
DIS
CU
SS
I
O
N
T
h
is
s
tu
d
y
f
o
u
n
d
th
at
n
u
r
s
es
h
ad
a
m
o
d
er
ate
lev
el
o
f
p
ati
en
t
s
af
ety
cu
ltu
r
e
p
r
ac
tices.
T
h
is
s
tu
d
y
r
ef
lects
th
at
n
u
r
s
es
n
ee
d
to
d
o
b
etter
p
r
ac
tice
to
war
d
p
atien
t
s
’
s
af
ety
b
u
t
s
o
m
e
h
o
w
n
ee
d
t
o
im
p
r
o
v
e
in
o
r
d
er
to
ac
h
iev
e
g
o
o
d
q
u
ality
o
f
ca
r
e.
I
n
T
u
r
k
ey
,
th
e
av
er
a
g
e
to
tal
s
co
r
e
o
f
n
u
r
s
es
o
n
th
e
p
atien
t
s
af
ety
cu
ltu
r
e
was
2
.
5
8
(
SD
=
0
.
3
9
)
,
with
t
h
e
h
ig
h
est
s
co
r
e
o
n
t
h
e
em
p
lo
y
ee
b
eh
av
io
r
s
u
b
s
ca
le
an
d
th
e
l
o
west
s
co
r
e
o
n
th
e
ad
v
er
s
e
ev
e
n
t
r
e
p
o
r
tin
g
s
y
s
tem
s
u
b
s
ca
le
[
8
]
,
[
1
9
]
.
C
o
n
d
u
c
ted
a
m
eta
-
an
aly
s
is
o
f
1
1
d
es
cr
ip
tiv
e
s
tu
d
ies
o
n
h
o
s
p
ital
s
taf
f
an
d
d
is
co
v
er
e
d
t
h
at
o
n
ly
8
.
3
%
an
d
to
3
2
.
3
%
o
f
r
esp
o
n
d
en
ts
h
a
v
e
ex
ce
llen
t
o
r
v
er
y
g
o
o
d
p
atien
t
s
af
ety
cu
ltu
r
e,
r
esp
ec
tiv
ely
.
F
o
r
ex
am
p
le,
a
B
r
az
ilian
s
tu
d
y
f
o
u
n
d
th
at,
asid
e
f
r
o
m
th
e
r
e
co
g
n
itio
n
o
f
s
tr
ess
,
th
e
p
er
ce
p
tio
n
o
f
s
af
ety
clim
a
te
d
if
f
er
ed
s
ig
n
if
ica
n
tly
ac
r
o
s
s
t
h
e
ca
teg
o
r
ies
in
an
o
th
er
s
tu
d
y
,
an
d
th
at
t
h
er
e
is
a
co
r
r
elatio
n
b
etwe
en
th
e
f
iv
e
SAQ
d
o
m
ain
s
an
d
th
e
v
ar
iab
les
tim
e
o
f
ex
p
er
ien
ce
an
d
in
t
en
tio
n
to
leav
e
th
e
p
r
o
f
ess
io
n
.
An
E
g
y
p
tian
s
tu
d
y
f
o
u
n
d
th
at
m
o
r
e
th
an
h
alf
(
5
7
.
9
%)
o
f
r
esp
o
n
d
en
ts
b
eliev
ed
th
at
p
atien
t
s
af
ety
was
in
ad
eq
u
ate.
Six
ty
-
th
r
ee
p
er
ce
n
t
o
f
n
u
r
s
es
b
eliev
ed
th
at
ad
v
er
s
e
ev
e
n
ts
n
ev
er
o
cc
u
r
r
ed
,
a
n
d
f
if
ty
-
f
o
u
r
p
er
ce
n
t
o
f
t
h
em
d
id
n
o
t
f
o
r
m
ally
r
ep
o
r
t
an
y
a
d
v
er
s
e
e
v
en
t
s
[
2
0
]
.
T
h
is
s
tu
d
y
f
o
u
n
d
th
at
f
em
ale
n
u
r
s
es
wer
e
m
o
r
e
lik
ely
to
p
r
ac
tice
p
atie
n
t
s
af
ety
cu
ltu
r
e
th
a
n
m
ale
n
u
r
s
es.
Fem
ale
team
wo
r
k
m
ay
b
e
a
f
ac
to
r
in
th
is
p
atien
t
s
af
ety
c
u
ltu
r
e
d
is
cr
ep
a
n
cy
[
2
1
]
,
[
2
2
]
.
I
n
o
u
r
s
tu
d
y
,
w
e
f
o
u
n
d
th
at
f
em
ale
n
u
r
s
es
wer
e
m
o
r
e
lik
ely
th
an
th
eir
m
ale
co
u
n
ter
p
ar
ts
to
co
ll
ab
o
r
ate.
Acc
o
r
d
in
g
to
o
u
r
f
in
d
in
g
s
,
th
ese
v
a
r
iab
les
h
av
e
a
s
ig
n
if
ican
t
im
p
ac
t
o
n
h
o
w
p
eo
p
le
in
ter
ac
t
with
in
a
n
d
ac
r
o
s
s
p
r
o
f
ess
io
n
al
g
r
o
u
p
s
.
T
r
ad
itio
n
al
r
o
les,
n
o
r
m
s
,
an
d
s
ter
eo
ty
p
es
o
f
g
en
d
er
[
2
3
]
af
f
ec
t
b
o
th
m
en
a
n
d
wo
m
e
n
in
d
i
f
f
er
en
t
wa
y
s
.
T
h
er
e
m
ay
b
e
s
er
io
u
s
co
n
s
eq
u
en
ce
s
f
o
r
team
wo
r
k
if
th
e
d
if
f
er
en
t
ex
p
e
r
ien
ce
s
o
f
wo
m
en
an
d
m
en
lead
to
a
cu
ltu
r
e
th
at
en
co
u
r
ag
es
m
ed
ical
er
r
o
r
s
an
d
ad
v
er
s
e
ev
en
ts
b
y
u
n
d
e
r
m
in
in
g
team
m
o
r
ale,
co
m
m
u
n
icatio
n
,
a
n
d
p
s
y
ch
o
lo
g
ical
s
af
ety
[
2
4
]
-
[
2
6
]
.
R
eg
ar
d
less
o
f
th
eir
p
o
s
itio
n
in
th
e
tr
ad
itio
n
al
h
ier
ar
ch
ical
s
tr
u
ctu
r
e
,
wo
m
en
an
d
m
en
in
all
p
r
o
f
ess
io
n
s
f
elt
th
at
m
en
wer
e
t
r
ea
ted
with
m
o
r
e
r
esp
ec
t th
a
n
th
eir
f
e
m
ale
co
lleag
u
es.
Fem
ale
n
u
r
s
es
co
m
m
u
n
icate
d
m
o
r
e
o
p
en
ly
th
an
m
ale
n
u
r
s
es.
I
t
i
s
cr
itica
l
f
o
r
em
p
lo
y
e
es
to
f
ee
l
em
p
o
wer
ed
to
s
p
ea
k
u
p
wh
e
n
th
ey
o
b
s
er
v
e
s
o
m
eth
in
g
th
at
co
u
ld
jeo
p
ar
d
ize
p
atien
t
c
ar
e
with
o
u
t
f
ea
r
o
f
r
ep
er
cu
s
s
io
n
s
f
r
o
m
th
o
s
e
in
p
o
s
itio
n
s
o
f
au
th
o
r
ity
(
AHRQ,
2
0
0
9
)
.
T
h
e
ef
f
ec
tiv
en
ess
o
f
an
o
r
g
a
n
izatio
n
'
s
co
m
m
u
n
icatio
n
p
r
o
ce
s
s
ca
n
b
e
af
f
ec
ted
b
y
c
u
ltu
r
al
a
n
d
g
en
d
er
d
if
f
er
en
ce
s
[
2
7
]
.
Hea
lth
in
f
o
r
m
a
tics
'
to
p
tab
le
s
h
o
u
ld
in
clu
d
e
th
e
s
tu
d
y
o
f
h
o
w
p
eo
p
le
c
o
m
m
u
n
ica
te
in
h
ea
lth
ca
r
e
f
o
r
two
r
ea
s
o
n
s
:
im
p
r
o
v
in
g
co
m
m
u
n
icatio
n
an
d
b
etter
u
n
d
er
s
tan
d
in
g
th
e
f
u
n
ctio
n
o
f
in
f
o
r
m
atio
n
s
y
s
tem
s
[
2
8
]
.
Mo
r
e
a
n
d
m
o
r
e
ef
f
o
r
ts
ar
e
b
ein
g
m
a
d
e
to
e
n
s
u
r
e
th
at
h
ea
lth
ca
r
e
s
y
s
tem
s
ar
e
"c
u
ltu
r
ally
co
m
p
ete
n
t"
s
o
th
at
p
atien
ts
f
r
o
m
v
ar
io
u
s
cu
ltu
r
al
an
d
li
n
g
u
is
tic
b
ac
k
g
r
o
u
n
d
s
ca
n
r
ec
eiv
e
ca
r
e
th
at
is
tailo
r
ed
to
th
eir
s
p
ec
if
ic
n
ee
d
s
[
2
9
]
,
[
3
0
]
.
Hea
lth
ca
r
e
o
r
g
an
izatio
n
s
m
u
s
t
k
n
o
w
wh
ich
attitu
d
es
an
d
b
eh
av
io
r
s
ar
e
ap
p
r
o
p
r
iate
f
o
r
p
a
tien
ts
in
o
r
d
er
to
estab
lis
h
an
d
m
ain
tain
a
h
ea
lth
y
c
u
ltu
r
e
o
f
s
af
ety
[
3
1
]
.
Evaluation Warning : The document was created with Spire.PDF for Python.
I
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:
2
2
5
2
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8
0
6
I
n
t J Pu
b
lic
Hea
lth
Sci
,
Vo
l.
15
,
No
.
1
,
M
ar
ch
20
26
:
1
2
6
-
1
31
130
5.
CO
NCLU
SI
O
N
T
h
is
s
tu
d
y
f
o
u
n
d
th
at
p
atien
t
s
af
ety
cu
ltu
r
e
am
o
n
g
n
u
r
s
es
was
r
ep
o
r
ted
m
o
d
er
ate.
Fem
a
le
r
ep
o
r
ted
to
h
av
e
h
ig
h
er
o
v
er
all
s
co
r
e
o
f
p
atien
t
s
af
ety
cu
ltu
r
e
p
r
ac
tic
es
th
an
m
ale.
Acc
o
r
d
in
g
to
p
a
tien
t
s
af
ety
cu
ltu
r
e
p
r
ac
tice
d
o
m
ain
,
team
wo
r
k
,
r
esp
o
n
s
e
to
e
r
r
o
r
,
a
n
d
c
o
m
m
u
n
icatio
n
o
p
e
n
n
ess
wer
e
h
ig
h
er
am
o
n
g
f
em
ale
th
an
m
ale.
Nu
r
s
es m
u
s
t b
e
tr
ain
ed
an
d
p
r
o
f
ess
io
n
al
co
m
m
u
n
icati
o
n
im
p
r
o
v
ed
as a
m
ea
n
s
o
f
en
s
u
r
in
g
b
etter
p
atien
t
s
af
ety
.
Patien
t
s
af
ety
cu
ltu
r
es
v
ar
y
wid
ely
ac
r
o
s
s
h
o
s
p
itals
,
u
n
its
,
an
d
co
u
n
tr
ies,
as
ev
id
en
ce
d
b
y
th
e
g
r
o
win
g
n
u
m
b
er
o
f
s
tu
d
ies th
at
h
av
e
lo
o
k
ed
at
th
is
is
s
u
e
in
d
ep
t
h
.
CO
NF
L
I
C
T
O
F
I
N
T
E
R
E
S
T
ST
A
T
E
M
E
NT
All a
u
th
o
r
s
d
ec
lar
e
n
o
co
n
f
lict o
f
in
ter
est.
RE
F
E
R
E
NC
E
S
[
1
]
K
e
m
e
n
t
e
r
i
a
n
K
e
s
e
h
a
t
a
n
R
I
,
“
P
r
o
f
i
l
k
e
s
e
h
a
t
a
n
I
n
d
o
n
e
s
i
a
t
a
h
u
n
2
0
1
7
,
”
2
0
1
7
.
[
O
n
l
i
n
e
]
.
A
v
a
i
l
a
b
l
e
:
h
t
t
p
s
:
/
/
k
e
m
k
e
s.
g
o
.
i
d
/
a
p
p
_
a
sse
t
/
f
i
l
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