Family Health Promotion Assessment and Initiative Application of the Developmental Model of Health and Nursing (DMHN)

FamilyHealth Promotion Assessment and Initiative: Application of theDevelopmental Model of Health and Nursing (DMHN)

Thepromotion of the health of a family is a procedure through whichfamily members perform towards the sustenance and improvement ofemotional, spiritual, social, and physical good of the members ofthat family (Ford-Gilboe, 2002). This is when family members createpositive patterns of decision making and troubleshooting issuesconcerning their health matters. These patterns are integrated withintheir way of life patterns and the way which the close relativesreact to difficulties of diseases and health (Allen &amp Warner2002). The family members play significant roles in managing chronicdiseases of kids, (Knafl et al. 1996, 2000 Chambers 2000) and familymembers have a considerable impact to health methods and health ofkids. Therefore, family members should be at the center in theprocedure of promoting health among its members. This is regardlessof family members’ situation or the family structure ororganization.

Thefamily is perceived to be a requisite partner in the promotion ofhealth. The nursing staff, in their day to day routine, gets engagedin family members’ healthcare. The intent of the nursing staff isto appraise the family’s health as being an inclusive andmulti-layered experience. The nursing staffs act as important playersin the promotion of solidarity founded on family oriented approachesthat involve balancing the instruction to family members’ livestogether with protecting their privacy. This paper presents a case onthe use of Development Model of Health and Nursing, commonly referredto as the McGill Model, to evaluate the health needs of a certainfamily health needs. This document will illustrate how the McGillModel will be useful to promote the health of a single father and histwo sons who he is bringing up single handedly.

Mr.M’s family case will evince the validity of the use of McGill modelin the promotion of health. Earlier research has shown that familiesthat fathers as the only parent lack social support and there is theoverload of responsibilities on the father for him to accomplish allof them. The paper will show the challenges that Mr. M is faced within a bid to provide a satisfying life for his sons, aged 18 and 9. Bythe use of the McGill model, the paper will show a step to steptransition of the family’s earlier health condition to an improvedone. The procedure embarks on the family members’ strengths andweaknesses, their challenges and their hopes and ambitions. Thestrengths of the dad turn out to be the greatest predictors ofsuccess in the promotion of his family’s health. His strength andambition are internal factors that are unbeatable by other variablesfrom the external environment.

McGillModel

Inthe past, many theorists in the nursing field have developed variousconceptual model that attempt to offer formal explanations andsolutions for issues pertaining to the promotion of health conditionsof families and residents. The cornerstones of such conceptualexplanations are usually nursing principles, health, the environment,and the individuals or groups in context (Fawcett, 2004). The McGillmodel is one such conceptual model that has brought a revolution inthe nursing field. This model was developed by Moyra Allen as theDevelopmental Model of Health and Nursing (Allen &amp Warner, 2002). This model is based on the interactions that ought to be inexistence between individuals, families and nurses in the medicalfield. It puts into consideration the fact that nursing is aimed atpromoting the health of families and residents by interacting withthem to aid them in attaining their goals in life. Health promotionought to be conducted with utmost collaboration of all the involvedparties for best results. The nurse is endowed with theresponsibility of helping families in the exploration of issues thatinfluence their daily lives. The goal of the nurse is to acknowledgethe capabilities and strengths of their clients and their families.The nurse has also to work closely and actively work with theparticipants so as to nurture, develop, strengthen and maintain thepotential harbored by all members. The Developmental Model of Healthand Nursing (DMHN) model extends the principles championed by theMcGill’s model. The model supposes that the goals of healthpromotion are achievable when the health potential of the families incontext is supported. Support is through motivation, resources andthe strengthening of the family bond.

Theontology of personhood is a major consideration in the DMHN model.The theorists acknowledged that every individual has inherent freedomwith regard to his or her involvement on health matters pertaining tohim or her they ought to be involved in all necessary decisionmaking and they are responsible for making the right choices fortheir own sake. The DMHN model considers all individuals as mindful,reflective, reciprocal and flexible human beings there arearchitects of their own experiences (Allen &amp Warner, 2002). Humanbeings are constantly designing their lives towards attachment withothers, coping with them and the environment, andregulatingthemselves by setting limits, both consciously and sub-consciously(Gottlieb &amp Gottlieb, 2007). These components are importantaspects of human survival.

TheDMHN model explains that human beings are inseparable from theenvironments in which they dwell. The nurse is, therefore, expectedto facilitate a better understanding of the environment which enablesthe individuals and families reconcile with and adapt to theirenvironments (Gottlieb &amp Gottlieb, 2007). The model explains thatevery individual is a being that is invariably situated in the familycontext and it is the family that is their major unit of concern. Inthis light, it becomes important for the nurse to be mindful of theindividual’s family relations. This kind of screening is importantas the nurse will be able to identify the kind of relationship thatis in existence between them it could be reciprocal and the nurseought to alter that first. The DMHN model concludes that humans livein networks of meaningful relationships that influence theirexperiences and development.

  1. INTEGRATION OF DMHN MODEL IN FAMILY CARE: MR. M’S FAMILY

TheM family comprises of a father and two sons: Mr. M, B and C. B is 18years old, and is presently in high school for his final year. C ishis brother, 9 years of age and is currently in his third grade inschool. They both perform averagely in school and though theirteachers claim that there is a lot of improvement room for them asthey do not unleash all their potential. Mr. M is a widower who losthis wife two years ago. Mrs. M succumbed to cancer regardless of theexpensive treatment they sought for her. The chronic illness of Mrs.M left the family in financial problems and they can merely providefor their needs. Mr. M currently works as a mechanic in a neighboringgarage where he gets little income for their basics at home. He isprofoundly concerned about his boys. He seems isolated and lonelyafter the death of his spouse. He attends church sometimes and rarelygoes out. He has a few friends. Furthermore, he is perturbed by hismature son’s habit of alcohol consumption and substance use. He hasa sweetheart and a lot of the times he remains at his place. He isextremely helpful and allows him with his consuming issue. Mr. M andthe sweetheart get along remarkably well. He is happy about theirconnection.

2.1THE HEALTH PROFESSIONAL CONNECTIONS WITH FAMILY MEMBERS

Threediscussions were done by me as a health professional. I handled tospeak with Mr. M. though his older son failed to attend, while theyounger one only joined the 2nd and the third meetings. In accordancewith the meetings, I established that Mr. M is attentive to themedical appropriate care needs involving his children (Herrmann etal. 1998). I used an issue-focused strategy to set up the medicalappropriate care needs of M family members. He is a dad who does notrely on public networking sites that would have assisted him indealing with his health problems and the difficulties of being afather. This leads him to have a weak assistance system that makeshim to be alone at most times. He is always in problems such aseconomical problems, concerned with his individual medical issues ofserious hypertension, and dealing with family members’ pressure. All this difficulties make it hard for him in being in a position tooffer effective fatherhood and parenting (Burke &amp Liston 1994).

Understandingthe responsibilities of being a father is critical for Mr. M. I tookthe further step of inquiring about the family members’ encountersand how much Mr. M’s was able to tackle them, with the lack of hisspouse, in aiding to promote the entire family members health. TheDMHN model (Ford-Gilboe 2002a Allen &amp Warner 2002) provides uswith a viewpoint that will aid in the promotion of Mr. M family’s.The DMHN model emphasizes on family members’ sturdiness as a way toobtain valuable health. This implies that health should be consideredto be a major aspect in the lives of M family and has formed a greatpart of the way of life of this family (Allen &amp Warner, 2002). Itis also true that the actions that impact on the member’s healthdevelop over a long period of time and are nurtured through theeveryday routine of this family member’s way of life. Ford-Gilboeet al. (2000),intheir research of single parent family members have offeredassistance to the theoretical connection found in the DMHN model orMcGill Design. They evince that health prospective, also known asdurability, is the core aspect that various types health promotion inthe people’s way of life methods and is also the key to theachievement of health performance.

Inaccordance with the DMHN model it is possible to set up informationconcerning M family members’ health and its promotion. Depending onthis model, the health of children members is by four distinctfactors that are interrelated. These are health prospective, healthperformance, health positioning, and health behavior proficiency(Ford- Gilboe, 2002). The central aspect of this theory is healthperformance, which avails a procedure of active participation onfamily members’ health problems. Within this procedure, familymembers set up waysof making use of their strong points and todeal with difficulties they face on an everyday foundation. They alsomake use of their sources in order to obtain the families andindividual growth. Mr. M and his close relatives do not demonstrategreat levels of health performance. This is because they are notdefinitely engaged or even interestedin problems concerning theirhealth. John who joined the meeting said that most age of worried ofhis growth, and the family members’ difficulties impact him in theschool. He sometimes goes to high school without anything for hisstomach and he remains at home so that he can do other little jobs tobring meals to the table. This is especially because he seemsremorseful leaving his dad alone at home.

Also,the impairment of his dad to walk Makes B to seem like it is aspectof his duty to make sure that somebody is always around to look afterhim. For his dad, he is engaged with economical difficulties. Themonthly earnings from the garage all go to paying B’s education.There is, therefore, difficulty in paying for utility expenses,buying meals and other basic necessities. M family members isprimarily a low-income family members that is with exclusivedifficultieson health issues. The exertion is to improve orsustain the overall mental and actual physical wellbeing of thefamily members. This is mainly in the situation that the elder son isinto alcohol addiction, and the pressure that the dad has towards theeconomical difficulties is challenging to the members of M familymembers have to deal. There is also the task on the need to recoverfrom the serious hypertension that faces Mr. M.

Thehome visit to the group of M is a no-cost public service and healtheducation program that is designed to help the close relatives andevery individual. The objective of this home check is to provideassistance to the individual dad, Mr. M, who has lost his spouse. Hecomes from a low- earnings economic position for he does not workmuch. The aim of the check is to link the close relatives to theappropriate medical care providers and drug misuse and preventionmeasures. In this check, I am also is mandated to make sure that thefamily members are coping well to changes in the family after thelack of one of the friend who was also the bread winner. I am,further, bestowed with the responsibility to increase informationregarding parenthood to Mr. M. This is based on the best approach andstrategy to use to help his close relatives with improved healthgrowth.

Thefirst visit to M family home was about engagement. I introducedmyself to Mr. Mwhom I at home. I discussed with him on issuesconcerning his family members’ health and described the wholeprocedure for their home visits. I Mr. M that I was planning to holddiscussions with all his close relatives so that they can help himand his sons to tackle the difficulties he encounters as a father andto highlight the health needs of all members in this family. Iinformed Mr. M that he was free to air out all the challenges duringthat time. I together with Mr. M scheduled their first meeting periodfor the coming week on Tuesday at 3.00 pm. The following visit wouldrally around medical issues together with other responsibilities ofthe family. By the end of the first encounter period with Mr. M, Ihad managed to create a trustconnection between us.

2.2ASSESSMENT

McGillDesign guides into the five inquiry questions that entail of thismodel, as follows:

Whatis the family dealing with?

Mfamily members have a wide range of difficulties to face. This familyis characterized by low earnings and it, therefore, encounterseconomical problems. The son’s schooling requires the largest chunkof Mr. M’s earnings. The family depends on little earnings that Mr.M gets from his part time job as a mechanic in a neighboring garage.He contributes to the household costs, but often is overwhelmed byhis medical condition that he does not go to work.

Mr.M encounters individual problems concerning his health. He has backproblems and hypertension and is almost disabled. He is with troublesmost of time because of his economic problems, solitude, and problemsof his eldest son’s alcohol consumption routines. He is not socialand does not involve himself in organizations and has a very fewnumber of friends.

Thefamily is then faced with the challenge task of alcohol addiction. Bis into drug and excessive drinking. This could be a failing ofdealing up with the task of lack of his mother and lack ofappropriate fatherhood from his only parent. B is with the lack ofpsychological well-being. He is struggling with his academic career,but with no adequate sources. He struggle with his father’s medicalcondition which could be a source of his average performance inschool.

Whatis important to the family members and broader problems that mightexplain the family’s focus?

Thefamily is working together, physically and psychologically, inhelping Mr. M in his medical condition. For instance, B is willing toremain with his dad instead of attending classes for the sake of hisfuture life. This is despite his other responsibilities such as hisjob. The aim of this family members is to achieve emotional andhealth to all members. Mr. M struggles to see his children go throughthe education system and tries to strain to work even when hi healthis deteriorated. On the other hand, the children are sympathetic withtheir father and are willing to give up their studies for his sake.Their psychological health is deteriorated and this calls for specialprofessional care they could end up losing in both ends. Theirstudies are important and so is the physical health of their onlyparent. However, they still try to hold on and instead try to balancetheir activities to suit both of their prime needs.

Howare they going about that?

Thefamily members recognize the significance of offering assistance toone another. John is also helpful towards his dad the dadfacilitates his sons’ education.Each of these members has achance to demonstrate assistance. B manages his dad after schoolhours. On the days that his dad shows signs of intense backache, hedecides not to go to school so as to provide his dad with the neededassistance. He does housekeeping and other chaos such as cleaningthe floors and washing clothes. B cooks and sweeps the floor on aregularly. B is also helpful he purchases mealssuch asvegetables and milk on a from time to time. When he gets some extracoins on a bad day, he drinks too much to a point of loosing cash. Healso purchases drugs for his sickly dad when he gets worse.

Whatare their prospective sources and how do they best learn?

Thefamily members has great prospective to do what is best for each oneof them. They can provide each other with moral and ethicalassistance and yearn to be definitely engaged. This will enable thefamily members understand ways of dealing with the difficulties thatimpact their health. This is possible when each of the memberscreates use of their sources and strong points to achieve theobjectives of their family as well as their individual objectives. With effective use of sources, proactive participation, and activecommitment, on the issues of health, M’s family is able to set up aproblem-solving approach that will help them to manage healthdifficulties.

Oneof the most significant sources is the family members’contribution. Mr. M focuses on demonstrating control and power overhis way of life and that of his children by instilling beneficialthoughts to his kids by his thinking positively and helping his sonsto follow suit. Family members are also to be convinced to provide Bwith the assistance he needs with the aim of helping him out of hisalcohol and drug consuming routines. Money for the family membersshould be well planned so that Mr. M can start a little businessentity just near his home. This is an enterprise that he thinks hecan manage best such as a shop or food market. These are businessesthat need little capital while others require huge sums of money butMr. M can begin with the earlier. The company can also be boostedthrough inexpensive loans. Mr. M will also be encouraged to joinother organizations in the society that encourage and help widowerslike him. With such measures, he will preoccupy himself withsignificant actions and free himself from solitude and worrisomethoughts.

Whatother sources could still be mobilized

Othersources consist of having coaches and guides who act as champions tothe success of the family members. This implies that S and B can bereferred to guides who will direct them and give them optimism abouttheir lives and the medical condition of their father. The use ofcounselors will help develop the psychological health of the familymembers. It will change their perceptions about the challenges theyare facing and they will learn how to live with them. The coacheswill also act as friends who will act as avenues for the familymembers to air their views and socialize with this will minimize thesolitude phenomenon that characterizes the family at present. Theguides will give the family members the right directions on how bestthey ought to offer their support and contribution to the well-beingof the family. It is noteworthy that failure to understand how toproperly contribute may culminate the existent problems instead ofhelping solve them. Family contribution is an integral aspect inhealth performance because it determines the prospective of thefamily members to obtain great health (Ford-Gilboe 2002).

Thehealth prospective of the family members functions as a reservoir ofthe members abilities and this consist of motivation, sources anddurability among them (Ford Gilboe, 2002, Allen &ampWarner 2002). The strong points of these close relatives are aspect of theirinternal abilities that demonstrate the patterns of family members’relations and their individual characteristics (Ford-Gilboe, 2002).The resilience of the Mr. M as a single parent can be seen in hisgreat degree of hope, vision, and foresight his strength will meanthat he can have a suitable detailed strategy that creates abeneficial environment for the growth and development of his family.He is liable for providing his kids with a right passage to adulthood through cultivating their ethical sensibilities, skills, andassigning them with obligations. With the little source that Mr. Mhas, he can manage to nurture beneficial feelings and direction tohis family through the adoption of new traditions to favor hiscrucial care giving.

Anadditional source that the close relatives need is strength.Resilience is a very important virtue that each individual of thefamily ought to create. This is because it is a way of individualdurability that allows one to cope with the challenges that lifepresents. Resilience is an aspect that can lead to positive healthprospects. Resilience is a multifaceted term that has variousinterpretations in different kinds of perspectives. Resilience is anaspect that shows individual potential, procedure and results(Woodgate, 1999). Studies on sturdiness in adolescents and children(Lindenbergetal.1998, Resnick, 2000), have shown that it is acharacteristic that occurs from the effects of dwelling in poorenvironmental conditions. Studies among mature men on resilience haveevinced that this is an aspect that occurs from their individualpotential. Development and Growth of resilience is a phase that willsupport an individual to deal with challenging situations in life,and the everyday normative stresses such as, in single-parenting(Ford-Gilboe et. al., 2000) and lack of friendship, characterized bysolitude (Wagnild &ampYoung, 1990). The attainment of resiliencedefines the capability of an individual to make it through thechallenges in their everyday life. For the situation of Mr. M andhis kids, they have the capability to create resilience as one oftheir fundamental sources for it will help them practicedetermination, and have a balanced viewpoint towards living theirlives. They will develop a sense of self reliance, self purpose andrealize that each one of them has a special path in the destinationsof their lives.

Accordingto O’Leary (1998), resilience is a characteristic that allows oneto move far beyond survival and recovery to deal with the actualrealities of life’s diversities. Resilience from the father’sside indicates the realization of beneficial health performance toeveryone members. Resilience is also seen on the children’s partthey are hard working and are willing to go to limits to help intheir family matters and especially their father’s health.

2.3GOALS

Theprimary purpose of M family members is to attain aptitude in healthybehavior. This implies thatthe health action result can beestablished through the efficacy of the family members to pursue andsustain life patterns alterations that are relevant to each one ofthem (Ford-Gilboe, 2002). Acquisition of health promotion in thefamily’s way of life calls for a multidimensional pattern ofactions and perceptions that are self instigated. These changes serveto sustain and enhance the level of self-actualization, that ofhealth level and also an individual’s personal fulfillment.

Theintention of the family members is to create beneficial self-conceptthrough adapting healthy ways of living strategies. They are aimingat achieving public and self-efficacy assistance. They also aim atattaining quality public and actual physical environment and healthyway of life methods. The father aims at healing his back from painsand suppressing his hypertension. He also aims at ensuring that hissons go through school and excel academically. He wants to see themgraduate from boys to men who will be successful in life and imparton other people’s lives by giving back to the society.

2.4THE FAMILY’S HEALTH PLAN

Thissection aims at providing a strategy that facilitates developmental,growth seeking activities with a pragmatic objective and the specificapproaches that might be mobilized for fellow family members toachieve their potential for the health that is significant to them.The M family should have the aspiration to support one another inorder to set up a dependable, independent, responsible kind of way oflife among themselves. They ought to have open patterns ofcommunication that will help them to solve problems as a unit(Gottlieb, Feeley &amp Dalton, 2005). The family and I will continueto act together in making resolutions necessary for individualizedappropriate care through the suitable assistance channels andstructures. This is with the aspiration of presenting the wholefamily with an, exceptionally, best way of promoting health care. Idid not simply concentrate on an individual without first probing theindividual within the point of view of other family members. This isbecause the family unit acts as a component of appropriate care(Allen &amp Warner, 2002).

Empowermentcollaboration is also another vital consideration for M’s familymembers. Empowerment collaboration happens between the family membersand the health specialist based on a reliable, respectful, and mutualconnection (Gottlieb, Feeley &amp Dalton, 2005). Within this bond,they can discuss information, experience, among other things, andthis helps in fostering understanding amongst them this way theydevelop together as associates in promotion of family health. Thisway of bonding ensures that family members are understood, heard andsupported within the predictable and unanticipated actions in theirlives. Family members will be with reference and advice from anexpert on how to make their way through life’s difficulties. Theobjective is to empower M’s family members through the recognitionthe problems the family unit encounters. It is important to respectand acknowledge the part of the family grievances within appropriatemedical care circumstances. The value of the evaluation is to conferthe family members’ part and that of the health professional. Italso aids to determine the extent to which the family members’desires are to be engaged (Gaudine, 2005).

TheDMHN model focuses on the founding of an empowering collaborationwithin the abilities and health conditions of the family members.This includes theprospective for fellow loved family members totransform and grow. It is obligatory for the health expert to reviewthe event perspective by determining what kind of assistance is mostappropriate for for the nursing staff to execute in a bid to back upand fortify the family. Family members’ health assessment shouldcomprise of information that addresses the discernment of the familymembers towards various actions in their way of life, family members’structure, the surroundings’ conditions, and the sturdiness ofchildren members. The identification of these factors leads to thereasons for establishing the exclusive problems of the family membersand to establish the probable resolutions to the family members’difficulties (Gottlieb, Feeley &amp Dalton, 2005).

Iwas able to identify the sources and the kind of support the familymembers require to help them deal with their way of lifedifficulties. I classified them into three main categories:interfamilial, extra familial, and interfamilial. The support can befrom within the family members where members help one another aspartners. In this case, individual members of the family members needto be given a chance to air out their needs and experiences becausethis avails a channel to set up the sources to deal with the needsthey express. Support comes from information, encouragement, andinterpersonal relationships that people have within their families.

Thereshould be a strategy for nursing staff by ensuring that they areprovided with a considerable amount of time and resources after longwork at their workplaces so as to facilitate the family-centeredpractices. The nursing staff also ought to be knowledgeable,skillful, and possess appropriate judgment on the needs of familymembers (Gottlieb, Feeley &amp Dalton, 2005). The nursing staff hasto always be provided with appropriate sources such as staffing andtime to create and implement family based strategies and methods andcreate applications that aid performance and enhancement of people’sways of life, as well as creating a balance.

  1. CONCLUSION

Thispaper has critically analyzed the medical care needs of M familymembers based on the DMHN model. The model provides a viewpoint thatenables us to understand areas of health marketing in a given familymembers. Primary is to set up the durability of this family members.The close relatives can gain durability for them to succeed in allchanging actions in way of life. Durability will help the family todevelop resilience towards the pursuit for their goals. Challengesare part of life and it takes durability and perseverance to overcomethem. It is sad to find that one could give up on something yet therewas a looming solution. Mr. M and his sons ought not to give up ontheir dream of promoting their health even though it takes them along time to achieve it. Optimism enhances the speed in whichpositive changes to their health life will take place. As a healthprofessional, I am working closely with them to see to it that theydo not give up yet.

Mr.M’s Family is now on its verge to recovery and with my assistance,it is going to grow and develop well health wise. B and S are nowcommitted to their school work than it was before. They also workgreatly after work to aid their father in conducting duties andchores around the home. The step to step guidance I have offered themis imparting positively into their lives as Mr. M is even respondingbetter to medication for his back pains and hypertension. I envisiona cohesive M family and have begun to advice B on how he could stopdepending on drugs and alcohol as a remedy for his problems at home.His teachers are optimistic too and are happy about his behavioralchange. His performance in curricular and extracurricular activitiesis improving greatly over the past month.

Mr.M. is set to join a communal organization that deals with singleparenting and the benefits he could get from it are immeasurable. Hewill learn how to assume the responsibilities of both parents evenwith the absence of his children’s mother. In a recent discussionwith him, he is now even optimistic that he could remarry so as tohave a companion to share his life with one who would aid inbringing up his sons. In the organization, Mr. M will acquire newfriends who will be beneficial in that they will help him kill hisboredom and solitude. Embarking on his strengths, Mr. M is alsopersistent of the idea of setting up a small business venture to helpin supplementing his income at the garage. He is even of the ideathat after the business has established itself, he will relinquishhis mechanic career since it is complicating his recuperation andresponse to medicine.

Mr.M’s family has identified its members’ strengths and weaknessesand is on its way to the correction of their weak points as well asmajoring on the strengths for promotion of health purposes. Selfrealization is a major milestone in the definition of the course thatought to be taken in improving the health of Mr. M’s family. Theyhave therefore begun well, with my help, and with time they willlearn how to enhance their strengths and minimize their weaknesses.For instance, the love that binds the family together acts as a greatpillar. It plays the supportive role towards the achievement of theirhealth goals and objectives. The love leads to sacrifices and theseare good if they are properly informed and well planned for. There isalso the weakness of financial strain. This could be minimizedthrough proper planning of what they get instead of wasting it onalcohol and other irrelevant things. Mr. M will also start a shopthat will help in the provision of basic needs, pay for hismedication, and support his sons through school. The family memberswill be more settled and there will be composure to facilitateforward thinking and innovation.

Theapplication of the DMHN model has facilitated the optimism within Mr.M’s family. It is another of the many successes that the use of thetheory could have. It is, therefore, important that the theory ischampioned and put to practice. The theory performs better thanothers that had been developed in the past. The scholars have made animportant mark in the health care industry and more modifications ofthe theory should be made to improve its propositions andeffectiveness.

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