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Mulogo E, Ntaro M, Wesuta A, Namusisi J, Kawungezi P, Batwala V, Matte M. Cost-effectiveness of village health worker-led integrated community case management (iCCM) versus health facility based management for childhood illnesses in rural southwestern Uganda. Malar J 2024; 23:147. [PMID: 38750488 PMCID: PMC11097548 DOI: 10.1186/s12936-024-04962-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 04/24/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND In Uganda, village health workers (VHWs) manage childhood illness under the integrated community case management (iCCM) strategy. Care is provided for malaria, pneumonia, and diarrhoea in a community setting. Currently, there is limited evidence on the cost-effectiveness of iCCM in comparison to health facility-based management for childhood illnesses. This study examined the cost-effectiveness of the management of childhood illness using the VHW-led iCCM against health facility-based services in rural south-western Uganda. METHODS Data on the costs and effectiveness of VHW-led iCCM versus health facility-based services for the management of childhood illness was collected in one sub-county in rural southwestern Uganda. Costing was performed using the ingredients approach. Effectiveness was measured as the number of under-five children appropriately treated. The Incremental Cost-Effectiveness Ratio (ICER) was calculated from the provider perspective. RESULTS Based on the decision model for this study, the cost for 100 children treated was US$628.27 under the VHW led iCCM and US$87.19 for the health facility based services, while the effectiveness was 77 and 71 children treated for VHW led iCCM and health facility-based services, respectively. An ICER of US$6.67 per under five-year child treated appropriately for malaria, pneumonia and diarrhoea was derived for the provider perspective. CONCLUSION The health facility based services are less costly when compared to the VHW led iCCM per child treated appropriately. The VHW led iCCM was however more effective with regard to the number of children treated appropriately for malaria, pneumonia and diarrhoea. Considering the public health expenditure per capita for Uganda as the willingness to pay threshold, VHW led iCCM is a cost-effective strategy. VHW led iCCM should, therefore, be enhanced and sustained as an option to complement the health facility-based services for treatment of childhood illness in rural contexts.
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Affiliation(s)
- Edgar Mulogo
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda.
| | - Moses Ntaro
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Andrew Wesuta
- Bugoye Community Health Collaboration, P.O. Box 149, Kasese, Uganda
| | - Jane Namusisi
- Department of Pediatrics, Mbarara Regional Referral Hospital, P.O. Box 40, Mbarara, Uganda
| | - Peter Kawungezi
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Vincent Batwala
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
- Directorate of Research and Graduate Training, Mbarara University of Science and Technology, P.O. Box 1410, Mbarara, Uganda
| | - Michael Matte
- Bugoye Community Health Collaboration, P.O. Box 149, Kasese, Uganda
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Matte M, Ntaro M, Kenney J, Wesuta A, Kawungezi PC, Bwambale S, Ayebare D, Baguma S, Bagenda F, Stone G, Mulogo E. Assessment of pre-referral treatment for malaria, diarrhea, and pneumonia by rural community health workers in Southwestern Uganda: a cross-sectional study. BMC Health Serv Res 2024; 24:95. [PMID: 38233841 PMCID: PMC10795398 DOI: 10.1186/s12913-024-10598-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/12/2024] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Pre-referral treatment aims to stabilize the child's condition before transferring them to a higher level of healthcare. This study explored pre-referral treatment for diarrhea, malaria and pneumonia in children U5. The study aims to assess pre-referral treatment practices among community health workers (CHWs) for children aged 2 to 59 months diagnosed with malaria, diarrhea, and pneumonia. METHODS Conducted in 2023, this study employed a quantitative retrospective analysis of secondary data gathered from March 2014 to December 2018. Among the subjects, 171 patients received pre-referral treatment, serving as the foundation for categorical data analysis, presenting proportions and 95% confidence intervals across different categories. RESULTS In this cohort, 90 (53%) of the 177 children U5 were male, and age distribution showed 39 (23%), 70 (41%), and 62 (36%) in the 2-11 months, 12-35 months, and 36-60 months categories, respectively. Rapid Diagnostic Test (RDT) malaria results indicated a negative outcome in 83(60%) and positive in 55 (40%) of cases. Symptomatically, 45 (26%) had diarrhea, 52 (30%) exhibited fast breathing, and 109 (63%) presented with fever. Furthermore, 59 (35%) displayed danger signs, while 104 (61%) sought medical attention within 24 h. CONCLUSION The study analyzed a sample of 171 children under 5 years old to assess various characteristics and variables related to pre-referral treatment. The findings reveal notable proportions in gender distribution, age categories, RDT results, presence of diarrhea, fast breathing, fever, danger signs, and timely medical visits. The results highlight the need to strengthen pre-referral treatment interventions and enhance iCCM programs.
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Affiliation(s)
- Michael Matte
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda.
| | - Moses Ntaro
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Jessica Kenney
- Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Boston, MA, 02114, USA
| | - Andrew Wesuta
- Bugoye Community Health Collaboration, Bugoye Health Centre III, PO Box 149, Kasese District, Uganda
| | - Peter Chris Kawungezi
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Shem Bwambale
- Bugoye Community Health Collaboration, Bugoye Health Centre III, PO Box 149, Kasese District, Uganda
| | - David Ayebare
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Stephen Baguma
- Bugoye Community Health Collaboration, Bugoye Health Centre III, PO Box 149, Kasese District, Uganda
| | - Fred Bagenda
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
| | - Geren Stone
- Center for Global Health, Massachusetts General Hospital, 125 Nashua Street, Boston, MA, 02114, USA
| | - Edgar Mulogo
- Department of Community Health, Mbarara University of Science and Technology, PO Box 1410, Mbarara, Uganda
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Okitawutshu J, Signorell A, Kalenga JC, Mukomena E, Delvento G, Burri C, Mwaluke F, Buj V, Sangare M, Luketa S, Brunner N, Lee T, Hetzel M, Lengeler C, Tshefu A. Key factors predicting suspected severe malaria case management and health outcomes: an operational study in the Democratic Republic of the Congo. Malar J 2022; 21:274. [PMID: 36167567 PMCID: PMC9513903 DOI: 10.1186/s12936-022-04296-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 09/17/2022] [Indexed: 12/03/2022] Open
Abstract
Background Evidence suggests that pre-referral Rectal Artesunate (RAS) can be a life-saving intervention for severe malaria in remote settings in Africa. Recognition of danger signs indicative of severe malaria is critical for prompt and appropriate case management. Methods This was an observational study conducted in three Health Zones of the Democratic Republic of the Congo to determine the distribution of dangers signs for severe malaria and assess their impact on RAS use, referral completion, injectable treatment and ACT provision, and health outcomes including death. An individual-level analysis was carried out, using multilevel-mixed effects logistic regression models. Severely ill febrile children < 5 years seeking care from community-based healthcare providers were recruited into a patient surveillance system based on the presence of key danger signs. Clinical and case management data were collected comprehensively over a 28 days period. Treatment seeking was elicited and health outcomes assessed during 28 days home visits. Results Overall, 66.4% of patients had iCCM general danger signs. Age of 2–5 years and iCCM general danger signs predicted RAS use (aOR = 2.77, 95% CI 2.04–3.77). RAS administration positively affected referral completion (aOR = 0.63, 95% CI 0.44–0.92). After RAS rollout, 161 children died (case fatality ratio: 7.1%, 95% CI 6.1–8.2). RAS improved the health status of the children on Day 28 (aOR = 0.64, 95% CI 0.45–0.92) and there was a non-significant trend that mortality was higher in children not receiving RAS (aOR = 1.50, 95% CI 0.86–2.60). Full severe malaria treatment at the RHF including injectable anti-malarial and a course of ACT was highly protective against death (aOR = 0.26, 95% CI 0.09–0.79). Conclusions The main findings point towards the fact that danger signs are reasonably well recognized by health provider at the primary care level, and that RAS could influence positively health outcomes of such severe disease episodes and death. Its effectiveness is hampered by the insufficient quality of care at RHF, especially the provision of a full course of ACT following parenteral treatment. These are simple but important findings that requires urgent action by the health system planners and implementers. Supplementary Information The online version contains supplementary material available at 10.1186/s12936-022-04296-2.
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Affiliation(s)
- Jean Okitawutshu
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland. .,University of Basel, Basel, Switzerland. .,Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo.
| | - Aita Signorell
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Jean-Claude Kalenga
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
| | - Eric Mukomena
- School of Medicine, Department of Public Health, University of Lubumbashi, Lubumbashi, Democratic Republic of the Congo
| | - Giulia Delvento
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Christian Burri
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Fatou Mwaluke
- Clinton Health Access Initiative, Kinshasa, Democratic Republic of the Congo
| | | | | | | | - Nina Brunner
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Tristan Lee
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Manuel Hetzel
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Christian Lengeler
- Swiss Tropical and Public Health Institute, Allschwil, Switzerland.,University of Basel, Basel, Switzerland
| | - Antoinette Tshefu
- Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo
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Bechange S, Roca A, Schmidt E, Gillani M, Ahmed L, Iqbal R, Nazir I, Ruddock A, Bilal M, Khan IK, Buttan S, Jolley E. Diabetic retinopathy service delivery and integration into the health system in Pakistan-Findings from a multicentre qualitative study. PLoS One 2021; 16:e0260936. [PMID: 34910755 PMCID: PMC8673653 DOI: 10.1371/journal.pone.0260936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 11/21/2021] [Indexed: 11/18/2022] Open
Abstract
This paper is based on qualitative research carried out in a diabetic retinopathy (DR) programme in three districts of Pakistan. It analyses the organisation and delivery of DR services and the extent to which the interventions resulted in a fully functioning integrated approach to DR care and treatment. Between January and April 2019, we conducted 14 focus group discussions and 37 in-depth interviews with 144 purposively selected participants: patients, lady health workers (LHWs) and health professionals. Findings suggest that integration of services was helpful in the prevention and management of DR. Through the efforts of LHWs and general practitioners, diabetic patients in the community became aware of the eye health issues related to uncontrolled diabetes. However, a number of systemic pressure points in the continuum of care seem to have limited the impact of the integration. Some components of the intervention, such as a patient tracking system and reinforced interdepartmental links, show great promise and need to be sustained. The results of this study point to the need for action to ensure inclusion of DR on the list of local health departments’ priority conditions, greater provision of closer-to-community services, such as mobile clinics. Future interventions will need to consider the complexity of adding diabetic retinopathy to an already heavy workload for the LHWs.
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Affiliation(s)
- Stevens Bechange
- Sightsavers Pakistan Country Office, Islamabad, Pakistan
- * E-mail:
| | - Anne Roca
- Department of Policy and Programme Strategy, Sightsavers, Haywards Heath, United Kingdom
| | - Elena Schmidt
- Department of Policy and Programme Strategy, Sightsavers, Haywards Heath, United Kingdom
| | | | - Leena Ahmed
- Sightsavers Pakistan Country Office, Islamabad, Pakistan
| | - Robina Iqbal
- Sightsavers Pakistan Country Office, Islamabad, Pakistan
| | - Imran Nazir
- Sightsavers Pakistan Country Office, Islamabad, Pakistan
| | - Anna Ruddock
- Department of Policy and Programme Strategy, Sightsavers, Haywards Heath, United Kingdom
| | - Muhammed Bilal
- Sightsavers Pakistan Country Office, Islamabad, Pakistan
| | | | | | - Emma Jolley
- Department of Policy and Programme Strategy, Sightsavers, Haywards Heath, United Kingdom
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Oliphant NP, Manda S, Daniels K, Odendaal WA, Besada D, Kinney M, White Johansson E, Doherty T. Integrated community case management of childhood illness in low- and middle-income countries. Cochrane Database Syst Rev 2021; 2:CD012882. [PMID: 33565123 PMCID: PMC8094443 DOI: 10.1002/14651858.cd012882.pub2] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The leading causes of mortality globally in children younger than five years of age (under-fives), and particularly in the regions of sub-Saharan Africa (SSA) and Southern Asia, in 2018 were infectious diseases, including pneumonia (15%), diarrhoea (8%), malaria (5%) and newborn sepsis (7%) (UNICEF 2019). Nutrition-related factors contributed to 45% of under-five deaths (UNICEF 2019). World Health Organization (WHO) and United Nations Children's Fund (UNICEF), in collaboration with other development partners, have developed an approach - now known as integrated community case management (iCCM) - to bring treatment services for children 'closer to home'. The iCCM approach provides integrated case management services for two or more illnesses - including diarrhoea, pneumonia, malaria, severe acute malnutrition or neonatal sepsis - among under-fives at community level (i.e. outside of healthcare facilities) by lay health workers where there is limited access to health facility-based case management services (WHO/UNICEF 2012). OBJECTIVES To assess the effects of the integrated community case management (iCCM) strategy on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for children younger than five years of age in low- and middle-income countries. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and CINAHL on 7 November 2019, Virtual Health Library on 8 November 2019, and Popline on 5 December 2018, three other databases on 22 March 2019 and two trial registers on 8 November 2019. We performed reference checking, and citation searching, and contacted study authors to identify additional studies. SELECTION CRITERIA Randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies (CBAs), interrupted time series (ITS) studies and repeated measures studies comparing generic WHO/UNICEF iCCM (or local adaptation thereof) for at least two iCCM diseases with usual facility services (facility treatment services) with or without single disease community case management (CCM). We included studies reporting on coverage of appropriate treatment for childhood illness by an appropriate provider, quality of care, case load or severity of illness at health facilities, mortality, adverse events and coverage of careseeking for under-fives in low- and middle-income countries. DATA COLLECTION AND ANALYSIS At least two review authors independently screened abstracts, screened full texts and extracted data using a standardised data collection form adapted from the EPOC Good Practice Data Collection Form. We resolved any disagreements through discussion or, if required, we consulted a third review author not involved in the original screening. We contacted study authors for clarification or additional details when necessary. We reported risk ratios (RR) for dichotomous outcomes and hazard ratios (HR) for time to event outcomes, with 95% confidence intervals (CI), adjusted for clustering, where possible. We used estimates of effect from the primary analysis reported by the investigators, where possible. We analysed the effects of randomized trials and other study types separately. We used the GRADE approach to assess the certainty of evidence. MAIN RESULTS We included seven studies, of which three were cluster RCTs and four were CBAs. Six of the seven studies were in SSA and one study was in Southern Asia. The iCCM components and inputs were fairly consistent across the seven studies with notable variation for the training and deployment component (e.g. on payment of iCCM providers) and the system component (e.g. on improving information systems). When compared to usual facility services, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (RR 0.96, 95% CI 0.77 to 1.19; 2 CBA studies, 5898 children; very low-certainty evidence). iCCM may have little to no effect on neonatal mortality (HR 1.01, 95% 0.73 to 1.28; 2 trials, 65,209 children; low-certainty evidence). We are uncertain of the effect of iCCM on infant mortality (HR 1.02, 95% CI 0.83 to 1.26; 2 trials, 60,480 children; very low-certainty evidence) and under-five mortality (HR 1.18, 95% CI 1.01 to 1.37; 1 trial, 4729 children; very low-certainty evidence). iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness by 68% (RR 1.68, 95% CI 1.24 to 2.27; 2 trials, 9853 children; moderate-certainty evidence). None of the studies reported quality of care, severity of illness or adverse events for this comparison. When compared to usual facility services plus CCM for malaria, we are uncertain of the effect of iCCM on coverage of appropriate treatment from an appropriate provider for any iCCM illness (very low-certainty evidence) and iCCM may have little or no effect on careseeking to an appropriate provider for any iCCM illness (RR 1.06, 95% CI 0.97 to 1.17; 1 trial, 811 children; low-certainty evidence). None of the studies reported quality of care, case load or severity of illness at health facilities, mortality or adverse events for this comparison. AUTHORS' CONCLUSIONS iCCM probably increases coverage of careseeking to an appropriate provider for any iCCM illness. However, the evidence presented here underscores the importance of moving beyond training and deployment to valuing iCCM providers, strengthening health systems and engaging community systems.
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Affiliation(s)
- Nicholas P Oliphant
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
- School of Public Health, University of the Western Cape, Belleville, South Africa
| | - Samuel Manda
- Biostatistics Unit, South African Medical Research Council, Hatfield, South Africa
- Department of Statistics, University of Pretoria, Hatfield, South Africa
| | - Karen Daniels
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Donela Besada
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
| | - Mary Kinney
- The Global Fund to Fight AIDS, Tuberculosis, and Malaria, Geneva, Switzerland
| | - Emily White Johansson
- International Maternal and Child Health, Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Tanya Doherty
- Health Systems Research Unit, South African Medical Research Council, Tygerberg, South Africa
- School of Public Health, University of the Western Cape, Belleville, South Africa
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Wilson E, Lee L, Klas R, Nesbit KC. Technology and rehabilitation training for community health workers: Strengthening health systems in Malawi. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:833-841. [PMID: 31808218 DOI: 10.1111/hsc.12914] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Revised: 11/14/2019] [Accepted: 11/21/2019] [Indexed: 06/10/2023]
Abstract
Community health workers (CHWs) have been effectively utilised in resource-limited settings to combat a growing demand for health access that cannot be met by the current workforce. The purpose of this study was to evaluate a CHW training programme in Malawi that integrated technology into rehabilitation care delivery. This was a retrospective cross-sectional study of a training programme conducted in December 2018. The participants were a convenience sample of all active home-based palliative care CHWs at St. Gabriel's Hospital (n = 60). The data collected included the following: a written pre- and post-knowledge test, skills competency checklist and a post-training programme survey. Descriptive frequencies described skill competency and quantitative responses from the post-training programme survey. Paired t test (α = 0.05) analysis determined the significance of knowledge acquisition. Themes in the narrative responses in the post-training survey were identified. Both training programme groups showed significantly greater knowledge on the post-test (M = 9.50, SD = 0.861; M = 9.43, SD = 0.971) compared to the pre-test (M = 7.97, SD = 1.351; M = 7.90, SD = 1.900); t(29) = 6.565, p < .001; t(29) = 4.104, p < .001 for Group 1 and Group 2, respectively. All participants demonstrated skill competency in 100% of the skills. All participants responded that the training programme helped them review skills and understand how to use technology 'A lot' on a Likert scale (no, a little, some, a lot). Facilitators of their work included training programmes, phones, communication with the hospital and collaboration amongst CHWs. Barriers included transportation needs, lack of patient care supplies and lack of caregiver compliance. Overall, utilisation of their knowledge and skills from the training programmes helped their patients make improvements in mobility and function that are meaningful to their quality of life in the village. This study highlights the importance of assessing programmes in low-resource settings with a focus on feasibility and developing local capacity.
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Affiliation(s)
- Ellen Wilson
- Kaiser Permanente Vallejo Medical Center, Vallejo, CA, USA
| | - Lydia Lee
- Kaiser Permanente Richmond Medical Center, Richmond, CA, USA
| | - Rachel Klas
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kathryn C Nesbit
- University of California, San Francisco, San Francisco State University, San Francisco, CA, USA
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