benefits and deficiencies in the interventions, including which aspects of the program need modification.  Evaluation also provides unanticipated information that may be of benefit to program improvement.  It also communicates facets of the program to key stakeholders, who must be part of the ongoing evaluation process.  Dissemination of findings in scientific journals is also a key issue, as the sharing on information on which prevention measures work is essential to modification of existing strategies68.

            Evaluation components include setting achievable goals and objectives and must be integrated into the program from its onset.  The objectives must be specific, measurable, attainable, relevant, and time based.  Evidence based interventions must be evaluated to be found safe, ethical, feasible, and effective69. 

           

A National Strategy for Suicide Prevention

 

Recognizing the public health approach to suicide prevention, and following from guidelines of the World Health Organization, the United States has created a partnership between public and private agencies to address this issue.  The formulation of this partnership included the US Department of Health and Human services, the Centers for Disease Control and Prevention, the Health Resources and Service Administration, the Indian Health Service, the National Institute of Mental Health, the Office of the Surgeon General, and the Substance Abuse and Mental Health Services Administration, and the Suicide Prevention Advocacy Network, as well a public advocacy organization that includes suicide survivors, community activists, and health and mental health clinicians.

            The Surgeon General’s Call to Action70 has created a framework for addressing this public health concern, AIM: Awareness, Intervention, and Methodology.  Assessing that mental and substance abuse disorders generate the greatest risk for suicide, there has been a focus for better methods of detecting and treating these disorders.  In addition to these key elements, other areas of focus will be constructive public health policy, measurable objectives, implementation of monitoring and evaluation procedures for the objectives, and providing appropriate resources to agencies designated to carry out the Surgeon General’s recommendations. 

            The National Strategy For Suicide Prevention (NSSP), created from the Surgeon General’s Call to Action can be characterized as “a catalyst for social change with the power to transform attitudes, policies, and services…It strives to promote and provide direction to efforts to modify the social infrastructure in ways that will affect the most basic attitudes about suicide and its prevention, and that will also change judicial, educational, and health care systems”71.  The following are the goals of the National Strategy for Suicide Prevention:

1. Promote Awareness that suicide is a public health problem that is preventable

2. Develop Broad Based Support for Suicide Prevention

3. Develop and implement strategies to reduce the stigma associated with being a         consumer of mental health, substance abuse, and suicide prevention strategies

4. Develop and implement suicide prevention programs

5. Promote efforts to reduce access to lethal means and methods of self harm

6. Implement training for recognition of at-risk behavior and delivery of effective treatment

7. Develop and promote effective clinical and professional practices

8. Improve access to community linkages with mental health and substance abuse disorders

9. Improve reporting and portrayals of suicidal behavior, mental illness, and substance abuse services

10. Promote and support research on suicide and suicide prevention

11. Improve and expand surveillance system

            Finland was the first nation to implement the National Strategy for Suicide Prevention, beginning in 1986.  A 20 percent reduction in suicide rates between 1991-1996 were credited to the implementation of the plan, and the United Nations and World Health Organization has used Finland’s program as a model for suicide prevention72.  In 1999 the suicide rate was recorded as 9% below the nation’s rates prior to program implementation.  The Suicide Prevention Project in Finland not only sought to reduce suicide, but also to promote mental health within the country.  Strategies included improving collaboration between health agencies as well as enhancement of protective factors such as improvement of living conditions and enrichment of individuals’ personal resources.  Following from the public health model of improved coordination and communication between community agencies, the Finnish program built a national network of professional contact persons that included health professionals, social service personnel, clergy, police, and rescue departments. Mental health research was also a strong component of the program.  A more concerted national depression treatment program was also initiated, targeted to all age groups, that included not only basic services but also specialized care. Additionally, the ways in which media depicted suicide were also affected through education programs focusing on mental illness and suicide. For a more detailed examination of Finland’s program, see Beskow et al 199973.

The United States Air Force, in response to suicide being the second leading cause of death among its members, implemented a comprehensive suicide prevention program modeled on a public health approach to suicide prevention from 1996-199774.  This approach, called LINK, not only focused on individual psychiatric issues, but also emphasized the community and social elements of suicide, and sought to affect suicide risk factors, but also promote positive mental health.  This strategy follows from the United Nations and World Health organization recommendations75.  Key components of the Air Force’s program included promotion of early mental health interventions, coordination of services among various agencies in the organization, decreasing stigma associated with help-seeking, and the promotion of protective factors such as social support and teaching effective coping skills.  Staff were trained in suicide awareness, policy changes were made following from epidemiological data collection, and a database was created that effectively monitored suicide attempts and completions among personnel and their families. 

            There was also a strong move to change the culture of the Air Force, which placed the responsibility of the well-being of staff on all members of the organization, and not on the individual or select social services.  Additionally policy changes were made that encourage help-seeking behavior; new confidentiality policies were established which protected individuals within the confines of doctor patient relationships.  Collaborative efforts within the organization’s existing services were also viewed as a significant element within the program.  Six agencies within the Air Force were seen as critical for the prevention of suicide and the promotion of mental health, given that risk factors have no clear demarcation and there is overlap within the areas of risk.  These agencies included the chaplains, family advocacy, family support, health promotion and health wellness centers, child and youth programs, and mental health services.  This coordination is managed under the Integrated Delivery System and delivers services among broad aspects of military life such as work sites, community sites, and schools.

The results of this program implementation, utilizing an integrated, public health approach were successful.  Between 1994-1998, suicide rates decreased from 16.4 per 100,000 to 9.4 per 100,000 (p<0.002).  Within the first 8 months of 1999, the estimated rate of suicide is 2.2 per 100,000. This rate is approximately 80% lower than the lowest annual rate since 198076.   The significance of the Air Force’s prevention program is that it incorporated the entire community, and did not just focus on the health services system to detect and treat those at risk of suicide.  This community focus bolstered pre-existing protective factors and attempted to change the culture of the community to be more responsive, as well as diminish the impact of risk factors for suicide77. Following from the public health model, the Air Force continues to assess its data for program modification, and has also created an epidemiological data base and surveillance system.  This system collects social, psychological, economic, behavioral, and relationship factors surrounding suicide attempts and completions among non-active and active duty members78.

            In reviewing the Air Force’s program, it must be taken into account that these changes occurred within a controlled environment, where individuals have access to basic services, have housing provided for them, there is a higher level of education among the personnel, there is less use of illegal drugs, there is less prevalence of mental illness, and there are personnel who take personal responsibility for the well-being of the members of the Air Force. Additionally, a casual relationship between program implementation and decreased suicide rates was not conclusively established. Finally, key components of the program have not been identified that may have contributed to the decline in suicide rates79.  Given this, however, “This study highlights that suicide is a preventable health problem and demonstrates the importance of using multiple agencies to address the issue.  It also indicates that a community-wide, multiple strategy program can be planned an implemented and can contribute to reducing self-directed violence.”80

 

Conclusions

            Suicide, now defined as a public health issue by the United States, must be approached as such.  An approach that relies on clinicians to manage and reduce risk in suicidal patients has limited applications, as the prediction of suicidal behavior, has been characterized as “dismal” by some researchers81.  Additionally, Knox et al82 state, “[Clinicians] have promoted, however unwittingly, the social isolation of the community problems of suicidal behaviors….exploring the nature of protective factors requires engaging the public health community, and opportunity not yet exploited.” 

            The program of the US Air Force and Finland’s National Strategy for Suicide Prevention offers promising approaches to suicide prevention utilizing a public health approach.  Regardless of some of the methodological issues inherent in these programs, the broad coalition of resources that were coordinated for both programs appeared to have had an impact.  As suicide is a multifaceted event, a multifaceted approach is warranted that incorporates not only professional services, but also a change in the attitudes and awareness within a community or organization.  “Suicide and suicidal behaviors can be reduced as the general public gains more understanding about the extent to which suicide is a problem, about the ways in which it can be prevented, and about the roles individuals and groups can play in prevention efforts.”83

            Within areas of research, the stages of the public health approach to suicide must be refined.  Especially important is the issue of surveillance, particularly for suicide attempts.  As previous history of suicide attempts is a risk factor for future attempts, a data base to monitor community rates of suicide attempts is essential.  The relationship between risk factors and protective factors is largely unknown.  Adding variables of ethnicity, age, and gender further complicate the areas of risk and protective factors.  Research is needed that addresses these issues.  Interdisciplinary research is essential in areas of risk and protective factors.  The social, cognitive, cultural, and biological must all be addressed within the areas of research.  Programs that are initiated must be done so with built-in mechanisms for measuring outcomes.  Without the ability to monitor program effectiveness, modifications can not be made in prevention strategies.  Also at issue in evaluation and monitoring of prevention strategies are costs.  Are the programs utilizing resources effectively?       

            Although the challenges are enormous, considering the magnitude of suicide within the nation and the world, the methodological challenges to research and appropriate preventive measures, as well as the difficulties in coordination of resources, suicide is a public health issues that must be addressed.  It is a preventable occurrence, and innovative programming has demonstrated that when done appropriately, it can make an impact on rates of suicide.  Perhaps the most encouraging sign that this problem can be addressed, given the challenges, is that suicide is becoming a health problem that is increasingly in the government’s and public’s awareness.  An awareness and understanding of the significance of the problem is the first step in creating strategies to reduce rates of suicide. 

 

 

References

 

 

  1. US Public Health Service, The Surgeon General’s Call to Action to Prevent Suicide.  Washington, DC: 1999.
  2. Desjarlais, Robert; L. Eisenberg, B. Good, A. Kleinman.  1995.  World Mental Health: Problems and Priorities in Low Income Countries.  New York: Oxford University Press.
  3. Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds. Reducing Suicide: A National Imperative. 2002.  Washington, DC: The National Academie Press.
  4. Conwell, Yeates; Duberstein, Paul R.; Caine, Eric D.  Risk Factors for Suicide in Later Life.  Biological Psychiatry.  2002; 52: 193-204.
  5. NCIPC (National Center for Injury Prevention and Control). 2000. Web-Based Injury Statistics Query and Reporting System. [Online].  Available: http://www.cdc.gov/ncipc/wisqars/ [accessed April 10, 2004].
  6. Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds. Reducing Suicide: A National Imperative. 2002.  Washington, DC: The National Academie Press.
  7. Murphy, S.L. 2000.  Deaths: Final Data for 1998.  National Vital Statistics Reports, 48(11): 1-105.
  8. Maris, Ronald W. Suicide. The Lancet, 2002;  360: 319-326.
  9. McIntosh, J. AAS 2001 Statistics
  10. US Department of Health and Human Services.  Prevention ’84-’85.  Washington, DC: US Government Printing Office, 1985. In McGinnis, J. Michael.  Suicide In America-Moving Up the Public Health Agenda.  Suicide and Life Threatening Behavior. 1987; 17(1): 18-32.
  11. 2002 Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

Reducing Suicide: A National Imperative.  Washington, DC: National Academy Press.

      12.  2002 Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

Reducing Suicide: A National Imperative.  National Academy Press, Washington,                           DC.

       13. 2002 Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

Reducing Suicide: A National Imperative.  National Academy Press, Washington,                           DC.

14. O’Carol, PW; Berman, AL; Maris RW; Moscicki EK; Tanney, BL; Silverman, M

1996.  Beyond the Tower of Babel: A nomenclature for suicidology.  Suicide and                Life Threatening Behavior. 26(3):237-252.

       15. Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.                                                                                           

      Reducing Suicide: A National Imperative.  Washington, DC: National Academy                  

              Press.

        16. Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

        Reducing Suicide: A National Imperative.  Washington, DC: National Academy

        Press.

 

17.   Maris, Ronald W. Suicide. The Lancet.  (360): July 27, 2002: p.319-326.                                     

18.   Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

  Reducing Suicide: A National Imperative.  Washington, DC: National Academy                      

               Press.     

      19.   Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

  Reducing Suicide: A National Imperative.  Washington, DC: National Academy                       

  Press.

20.   Moscicki, E.  Epidemiology of Suicide.  In Goldsmith S., ed. Risk Factors for                                                  

        Suicide.  Washington, DC: National Academy Press. 2001. p 1-4.  

21.   Angst, J., Angst F., Stassen, HH. 1999.  Suicide Risk in Patients with Major             

        Depressive Disorder.  Journal of Clinical Psychiatry. (60) Suppl.2 p.57-62.

      22.   Moscicki, E.  Epidemiology of Suicide.  In Goldsmith S., ed. Risk Factors for

        Suicide.  Washington, DC: National Academy Press. 2001. p 1-4.

      23.   Moscicki, E.  Epidemiology of Suicide.  In Goldsmith S., ed. Risk Factors for

        Suicide.  Washington, DC: National Academy Press. 2001. p 1-4.

      24.   Moscicki, E.  Epidemiology of Suicide.  In Goldsmith S., ed. Risk Factors for

        Suicide.  Washington, DC: National Academy Press. 2001. p 1-4.

      25.   US Public Health Service, The Surgeon General’s Call To Action To Prevent

        Suicide. Washington DC: 1999.

      26.   Blumenthal, SJ. Suicide: A Guide to Risk Factors, Assessment, and Treatment of                      

              Suicidal Patients. Medical Clinics of North America.  1988. (72): 937-71.

27.    US Public Health Service, The Surgeon General’s Call To Action To Prevent             

         Suicide.  Washington, DC: 1999.

      28.    US Public Health Service, The Surgeon General’s Call To Action To Prevent

         Suicide. Washington, DC:1999.

      29.    Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

          Reducing Suicide: A National Imperative.  Washington, DC: National                              

          Academy Press.

       30.    Gordon, R.S. An Operational Classification of Disease Prevention. 1983.

          Public Health Reports (98): 107-109.

        31.   Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

           Reducing Suicide: A National Imperative.  Washington, DC: National                                               

           Academy Press.

        32.    Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.                   

           Reducing Suicide: A National Imperative.  Washington, DC: National

           Academy Press.

33.   Silverman, M; Maris, RW. 1995. The Prevention of Suicidal Behaviors: An                                    

           Overview.   Suicide and Life Threatening Behavior. 25(1): 10-21.

34.    Silverman, M; Maris, RW. 1995. The Prevention of Suicidal Behaviors: An                                   

           Overview. Suicide and Life Threatening Behavior. 25(1): 10-21.

35.    Silverman, M; Maris, RW. 1995. The Prevention of Suicidal Behaviors: An                                   

           Overview. Suicide and Life Threatening Behavior. 25(1): 10-21.

   36.    Lester, D. 1990 The Effect of Detoxification of Domestic Gas in

            Switzerland on Suicide Rate. Acta Psychiatrica Scandinavia (82): 383-384

 

      37.   Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public.

              Health Perspective. 25(1): 82-91.

38.   Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

              Reducing Suicide: A National Imperative.  Washington, DC: National

              Academy Press.

39.    Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public.

              Health Perspective. 25(1): 82-91.

40.    Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public.

              Health Perspective. 25(1): 82-91.

41.   McGinnis, JM. 1987. Suicide in America-Moving Up the Public Health                                                                       

        Agenda. Suicide and Life Threatening Behavior. 17(1):18-32.

42.      Satcher, D. 1998. Bringing the Public Health Approach to the Problem of

              Suicide. Suicide and Life Threatening Behavior 28(4):325-7.

            43.   Knox, K; Conwell Y; Caine, E. 2004. If Suicide is a Public Health Problem,           

                    What Are We Doing to Prevent It? American Journal of Public Health.

                     94(1):37-44.

           44.    Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public   

                    Health Perspective. 25(1): 82-91.

            45.   Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public   

              Health Perspective. 25(1): 82-91.

46.  Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

  Reducing Suicide: A National Imperative.  Washington, DC: National                               

 Academy Press.

47.  Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public   

             Health Perspective. 25(1): 82-91.

            48.  Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds. 

             Reducing Suicide: A National Imperative.  Washington, DC: National.

             Academy Press.

            49.  US Public Health Service, The Surgeon General’s Call To Action To Prevent     

             Suicide. Washington DC: 1999.

            50.  US Public Health Service, The Surgeon General’s Call To Action To Prevent      

             Suicide. Washington DC: 1999.

            51.  US Public Health Service, The Surgeon General’s Call To Action To Prevent     

             Suicide.Washington DC: 1999.

            52.  Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds. 

             Reducing Suicide: A National Imperative.  Washington, DC: National.

             Academy Press.

            53. Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

            Reducing Suicide: A National Imperative.  Washington, DC: National               

            Academy Press.

            54. Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public                                                                   

           Health Perspective. 25(1): 82-91.

           55. Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public

     Health Perspective. 25(1): 82-91.

           56. Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public

     Health Perspective. 25(1): 82-91.

           57. Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public

                 Health Perspective. 25(1): 82-91.

           58. Conwell, Yeates; Duberstein, Paul R.; Caine, Eric D.  Risk Factors for Suicide

                  in Later Life.  Biological Psychiatry.  2002; 52: 193-204

           59. Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

            Reducing Suicide: A National Imperative.  Washington, DC: National

            Academy Press.

     60.  Pfeffer, Cynthia. 2001. Youth Suicide: prevention through risk management       

           Clinical Neuroscience Research. 1: 362-365.

           61. Pfeffer, Cynthia. 2001. Youth Suicide: prevention through risk management       

           Clinical Neuroscience Research. 1: 362-365.

           62. Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public           

                 Health Perspective. 25(1): 82-91.

           63. Potter, L; Powell, K; Kachur, SP. 1995. Suicide Prevention from a Public                                               

                Health Perspective. 25(1): 82-91.

           64. Knox, K; Conwell Y; Caine, E. 2004. If Suicide is a Public Health Problem,           

                 What Are We Doing to Prevent It? American Journal of Public Health.

                 94(1):37-44.

           65. McGinnis, JM. 1987. Suicide in America-Moving Up the Public Health       

            Agenda. Suicide and Life Threatening Behavior. 17(1):18-32.

           66. US Public Health Service, The Surgeon General’s Call To Action To Prevent

           Suicide.  Washington DC: 1999.

           67. SPAN USA, Inc. 2001. Suicide Prevention: Prevention Effectiveness and     

                 Evaluation. SPAN USA: Atlanta, GA.

           68. SPAN USA, Inc. 2001. Suicide Prevention: Prevention Effectiveness and

                Evaluation. SPAN USA: Atlanta, GA.

           69. SPRC (Suicide Prevention Resource Center) [Online]. (2003). The Public       

                 Health Approach to Prevention. Available from:

                 http://www.sprc.org/suicideprevention/phapproach.asp

           70. US Public Health Service, The Surgeon General’s Call To Action To Prevent      

                 Suicide.  Washington DC: 1999.

           71. National Mental Health Information Center. National Strategy for Suicide

                 Prevention: Goals and Objectives for Action. (2000). Available from:

                 http://www.mentalhealth.org/publications/allpubs/SMA01-3517/intro.asp

           72. Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

            Reducing Suicide: A National Imperative.  Washington, DC: National

            Academy Press.

           73. BeskowJ; Kerkhof, A; Kokkola, A; Uutela, A. 1999. Suicide Prevention in

     Finland 1986-1996: External Evaluation by an International Peer Group.  

     Helsinki: Ministry of Social Affairs and Health.

           74. Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

            Reducing Suicide: A National Imperative.  Washington, DC: National      

            Academy Press.

           75. United Nations. 1996. Prevention of Suicide: Guidelines for the Formulation     

            and Implementation of National Strategies. New York: United Nations.

     

   76. Litts, DA; Moe, K; Roadman CH; Janke, R; Miller, J. 2000. From the Centers o

          of  Disease Control and Prevention. Suicide prevention among active duty Air      

          Force personnel-United States, 1990-1999. Journal of the American Medical

         Association. 283(2): 193-194.

        77. Litts, DA; Moe, K; Roadman CH; Janke, R; Miller, J. 2000. From the Centers of

        Disease Control and Prevention. Suicide prevention among active duty Air Force

        personnel-United States, 1990-1999. Journal of the American Medical

        Association. 283(2): 193-194.

        78. Goldsmith, SK; Pellmar, TC; Kleinman, AM; Bunney, WE, eds.

        Reducing Suicide: A National Imperative.  Washington, DC: National Academy

        Press.

  79.  Litts, DA; Moe, K; Roadman CH; Janke, R; Miller, J. 2000. From the Centers

         of Disease Control and Prevention. Suicide prevention among active duty Air       

         Force personnel-United States, 1990-1999. Journal of the American Medical

         Association. 283(2): 193-194.

  80.  Litts, DA; Moe, K; Roadman CH; Janke, R; Miller, J. 2000. From the Centers

         of Disease Control and Prevention. Suicide prevention among active duty Air       

         Force personnel-United States, 1990-1999. Journal of the American Medical

         Association. 283(2): 193-194.

81.    Silverman, M; Maris, R. 1995. The Prevention of Suicidal Behaviors: An                   

Overview. Suicide and Life Threatening Behavior. 25(1): 10-21.

        82.   Knox, K; Conwell Y; Caine, E. 2004. If Suicide is a Public Health Problem,           

                What Are We Doing to Prevent It? American Journal of Public Health.

                94(1):37-44.

        83.   SPRC (Suicide Prevention Resource Center) [Online]. (2003). The Public       

                Health Approach to Prevention. Available from:

                http://www.sprc.org/suicideprevention/phapproach.asp

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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