Journal of Nursing Education

Research Briefs 

Team-Based Learning in a Community Health Nursing Course: Improving Academic Outcomes

Jane M. Miles, PhD, RN, NEA-BC; Kim L. Larson, PhD, RN, FNAP; Melvin Swanson, PhD



Population health concepts, such as upstream thinking, present challenging ideas to undergraduate nursing students grounded in an acute care orientation. The purpose of this study was to describe how team-based learning (TBL) influenced academic outcomes in a community health nursing course.


A descriptive correlational design examined the relationship among student scores on individual readiness assurance tests (iRATs), team readiness assurance tests (tRATs), and the final examination. The sample included 221 nursing students who had completed the course.


A large positive correlation was found between iRAT and final examination scores. For all students, the mean tRAT score was higher than the mean iRAT score. A moderate positive correlation existed between tRAT and final examination scores.


The study contributes to understanding the effects of TBL pedagogy on student academic outcomes in nursing education. TBL is a valuable teaching method in a course requiring the application of challenging concepts. [J Nurs Educ. 2017;56(7):425–429.]



Population health concepts, such as upstream thinking, present challenging ideas to undergraduate nursing students grounded in an acute care orientation. The purpose of this study was to describe how team-based learning (TBL) influenced academic outcomes in a community health nursing course.


A descriptive correlational design examined the relationship among student scores on individual readiness assurance tests (iRATs), team readiness assurance tests (tRATs), and the final examination. The sample included 221 nursing students who had completed the course.


A large positive correlation was found between iRAT and final examination scores. For all students, the mean tRAT score was higher than the mean iRAT score. A moderate positive correlation existed between tRAT and final examination scores.


The study contributes to understanding the effects of TBL pedagogy on student academic outcomes in nursing education. TBL is a valuable teaching method in a course requiring the application of challenging concepts. [J Nurs Educ. 2017;56(7):425–429.]

Team-based learning (TBL) engages students in the learning process and promotes the development of student learning groups (Michaelson, Parmelee, McMahon, & Levine, 2008). This strategy, which has been recognized as grounded in constructivist education theory (Hrynchak & Batty, 2012), allows the instructor to teach large classes using multiple small groups in the same classroom (Michaelson et al., 2008; Michaelson & Sweet, 2011). As described by Michaelson et al. (2008), the TBL strategy, which originated in the 1970s, consists of three integral phases. In Phase I, students complete a preclass assignment. Phase II occurs during class, and includes an individual readiness assurance test (iRAT), followed by a team readiness assurance test (tRAT). Immediate feedback, clarification, and class discussion following the tRAT are hallmarks of this phase. Phase III is used to integrate and apply the course concepts. Following class, an appeal process is available, whereby teams may appeal a tRAT question if they identify ambiguous or contradictory information and submit evidence from the readings.

Stein, Colyer, and Manning (2016) found that the structure of teams and types of activities in TBL classrooms led to student accountability, and Hettler (2015) reported significant improvement in learning outcomes for low-income and minority students. When fully implemented, the TBL strategy is considered evidence-based teaching because it uses best teaching practices, which include cooperative learning, feedback, reciprocal teaching, whole-class interactive teaching, and visual presentations (Michaelsen & Sweet, 2011). Initial investigations have identified the benefits of TBL in a variety of health fields, including medicine, psychology, pharmacy, and dentistry (Abdelkhalek, Hussein, Gibbs, & Hamdy, 2010; Davidson, 2011; Kuhne-Eversmann, Eversmann, & Fischer, 2008; Shankar & Roopa, 2009; Thomas & McPherson, 2011; Thompson et al., 2007; Willett, Rosevear, & Kim, 2011; Zgheib, Simaan, & Sabra, 2011). Yet, the academic outcomes of TBL have not been well documented in nursing.

Two nursing studies noted the strong theoretical foundations of TBL pedagogy and interactive pedagogies (Mennenga & Smyer, 2010; Ridley, 2007). Other nursing studies have included an evaluation of nursing students' perceptions of TBL (Feingold et al., 2008) and a course comparison of attitudes and team engagement (Clark, Nguyen, Bray, & Levine, 2008). Feingold et al. (2008) found that TBL promoted learner engagement, but students were anxious about group performance affecting team grades. Clark et al. (2008) compared TBL with lecture format and reported higher student engagement in the TBL classrooms, although students were also concerned about their grades due to heavy emphasis on team performance. Limitations of these studies included lack of course comparison and partial implementation of TBL principles. The studies were important initial contributions to the evolution of TBL in nursing education, but they did not examine the effects of this pedagogy on student academic outcomes. Sisk (2011) suggested that future nursing studies address whether TBL improves both learning outcomes and teamwork ability.

Four nursing studies recently evaluated the effect of TBL on academic achievement and team performance (Branson, Boss, & Fowler, 2016; Cheng et al., 2014; Della Ratta, 2015; Park, Kim, Park, & Park, 2014). Of these, only two were conducted in the United States (Branson et al., 2016; Della Ratta, 2015). Using a quasi-experimental design, Cheng et al. (2014) applied the TBL strategy to four different courses in a nursing program in Taiwan and found that TBL improved students' learning behaviors and had a significant effect on academic performance. These investigators measured the outcomes of a group of RN-to-bachelor of science in nursing students enrolled in adult health and maternal and child health nursing courses in comparison with a group of baccalaureate students enrolled in community health and medical–surgical nursing courses. Course-specific measures were not reported; instead, scores from the four courses were merged to determine the overall effect of TBL on academic performance. In a health assessment course, Park et al. (2014) found a significant relationship between TBL strategies and examination scores among nursing students in South Korea. Likewise, in a New York nursing program, Della Ratta (2015) found that students enrolled in a TBL health assessment course scored higher than those from previous classes (formerly lecture based). Finally, Branson et al. (2016) reported that TBL learners in a nursing leadership and management course scored significantly higher on a national standardized management examination compared with students in the same course that was lecture based. The lecture-based course was taught over a regular semester and the TBL course was taught during a summer session. A typical heavier course load during the semester and a shortened time frame during summer session may have been confounding variables, but were not reported. Although these recent studies contribute to understanding TBL outcomes in nursing education, all authors noted major study limitations, such as a heterogeneous convenience sample, nonequivalent course comparisons, and modified use of TBL strategies. In addition, these authors recommended continued research of the TBL strategy on academic outcomes in other nursing education programs.

Due to the modified use of the TBL strategy in past studies and the lack of course-specific outcomes for community health nursing, the purpose of this study was to describe how the full TBL strategy influenced academic outcomes in a core community health course in a U.S. baccalaureate nursing program. The authors first describe the process of incorporating the TBL pedagogy into the course, then present the findings regarding the relationship of TBL with academic outcomes.

Study Background

The TBL pedagogy has been fully implemented in the community health nursing course at the authors' university since 2008. When implementing the TBL strategy, the importance of faculty development and course preparation cannot be underestimated (Elliott, 2014). Recognizing the potential value of TBL, the course coordinator (K.L.L.) sought mentorship from a faculty member who trained in TBL at the university where the pedagogy originated. The mentorship included sharing course syllabi, references, readings from a team-based learning Web site (, and weekly discussions on the philosophy and course preparation. The course coordinator concluded that community health nursing students could benefit from a TBL instructional strategy and mentored two other community health nursing instructors.

The framework for the core community health nursing course integrated an intervention model for public health nursing (Minnesota Department of Health, 2001), with the public health nursing competencies established by the Quad Council of Public Health Nursing Organizations (2011). The course emphasized population health concepts, including upstream thinking, vulnerable populations, and determinants of health. Representing these concepts, topics included global and environmental health, disaster nursing, epidemiology, and health policy.

Population health concepts are challenging for nursing students, as programs often initially concentrate on individual health needs (Education Committee of the Association of Community Health Nurse Educators, 2010). In particular, upstream thinking refers to disease prevention and health promotion and takes a broad view of the economic, political, and environmental factors that lead to poor population health (Martins, 2015). Students must shift their thinking away from an acute care orientation, and the need to facilitate that shift with rigorous and creative teaching contributed to the decision to use the TBL strategy in this course. A clinical component of the course was also designed to facilitate upstream thinking in the direct application of all course concepts, such as community assessment, program planning, implementation, and evaluation. Community service learning projects, such as participation in the Million Hearts Initiative® (Tomaselli, Harty, Horton, & Schoeberl, 2011) fostered a real-world experience in upstream thinking.


This study used a descriptive correlational design (Polit & Beck, 2016) to describe the relationships among student scores on iRATs, tRATs, and the final examination in a community health course using the TBL strategy. The study was conducted from 2011 to 2012. Student grade point average (GPA) was also examined regarding student outcomes.


The study sample (N = 221) included a fall cohort of 106 senior nursing students and a spring cohort of 115 senior nursing students enrolled in the core community health course. The fall cohort graduated prior to the start of the spring cohort, minimizing cross-contamination. The students were assigned to a total of 35 teams, composed of 6 to 7 students per team. The majority of students were women, and 18% were from a racial and ethnic minority group. The average GPA range on admission to this nursing program was 3.4 to 3.7. Informed consent was sought after course completion. The university institutional review board approved the study.

TBL Community Health Course

This course was team taught by two community health faculty and delivered over a 10-week time frame. A midterm test was administered in the fifth week, and a comprehensive final examination was administered in the tenth week. Permanent teams were formed on the first day of class. Following the Michaelson et al. (2008) guidelines, the authors made the team assignments by posing questions to the class, such as “Do you consider yourself creative?” and “Have you lived outside the state?” to ensure a wide range of backgrounds, skills, and abilities within each team. Students who answered questions similarly began forming a line. When all students were in line, they individually selected a number from a limited deck of cards, and the instructor documented the number chosen, forming teams consisting of 6 to 7 students who remained together throughout the course. Immediate documentation was important to maintain the integrity of the random assignment. To support team cohesion, students came to consensus on a team name.

Students attended 5 hours of didactic instruction each week (i.e., 2 class hours every Thursday and 3 class hours every Friday for 10 weeks in the final semester of the senior year). A pre-class assignment was provided for each class day, and each Friday, the three phases of TBL were implemented. The iRAT and tRAT used in Phase I were identical 15-item multiple choice questions that measured comprehension of assigned readings from the required community health nursing textbook. Students used an automated response system for the iRAT. This immediately captured the answers and made faculty aware of gaps in knowledge. During the tRAT, each team engaged in discussion about the answers while faculty walked among the teams to facilitate interaction. Following completion of the tRAT, faculty provided feedback to the entire class on the correct answers. Teams who answered correctly helped in the instruction, known as “whole-class interactive teaching” (Michaelson & Sweet, 2011, p. 45). Teams had the option of implementing the appeal process, using course materials to cite evidence of a better answer. The iRAT and tRAT scoring contributed to 20% of the course grade, with the iRATs weighted at 9% and the tRATs at 11%. This placed emphasis on team performance and followed grading recommendations of Michaelson et al. (2008).

In the second class hour (Phase II), the instructor highlighted key concepts in a brief lecture that included specific attention to those concepts that were not well understood in Phase I. In the third class hour (Phase III), students applied core concepts to a real-life case study using critical thinking, clinical reasoning, and group problem-solving to respond to open-ended questions. For example, with a global health topic, students collaborated to address the risk of contaminated water in a refugee camp, applying the community health nursing process to plan for prevention. While teams discussed the case study, the faculty again walked around the room serving as a resource, facilitating team-work, and clarifying concepts.


The TBL strategy was implemented in the same manner both semesters. The authors found no statistical differences between cohorts and are reporting the combined academic outcomes.

Individual and Team Outcomes

The relationships between iRAT scores and final examination scores and tRAT and final examination scores were investigated using the Pearson product–moment correlation coefficient, a statistical strategy to describe the relationship between two variables (Polit & Beck, 2016). A large positive correlation existed (Cohen, 1988) between the iRAT scores and final examination scores (r = .55, p < .001) and a small positive correlation between tRAT scores and final examination scores (r = .13, p < .052). The mean tRAT score (M = 94.56, SD = 2.52) was significantly higher than the mean iRAT score (M = 82.54, SD = 6.51, t = −27.42, p < .001).

Effect of GPA

Recognizing that a student's past performance may have an effect on subsequent outcomes, the potential effect of GPA was examined as a mediating variable (Bennett, 2000). Using the students' current GPAs, two GPA student categories were retrospectively created, one representing students with a GPA < 3.0, and one representing students with a GPA < 3.0. Using these categories for GPA, it was found that mean iRAT scores were significantly higher in students with high GPAs (M = 84.63, SD = 6.32) than students with low GPAs (M = 79.52, SD = 5.89, t = 5.10, p < .001). No significant differences in tRAT scores existed between high GPA students (M = 94.72, SD = 2.43) and low GPA students (M = 94.34, SD = 2.65, t = 1.11, p = .268). We also observed that final examination scores were significantly higher in students with high GPAs (M = 88.04, SD = 5.32) than students with low GPA's (M = 79.50, SD = 4.88, t = 7.86, p < .001). Using a partial correlation to control for the effect of GPA, the correlation of iRAT with final examination scores decreased from large (r = .55, p < .001) before removing the effect of GPA to moderate (r = .37, p < .001) after controlling for GPA.


Student iRAT scores represent basic comprehension. Therefore, the moderate correlation between iRAT and final examination scores after controlling for the effects of GPA supports the need to track and respond to individual scores from the beginning of the course. Such an early alert of student ability enables instructors to guide students in improved reading and study techniques. This potential use of the iRAT was not identified in previous studies (Branson et al., 2016; Cheng et al., 2014; Park et al., 2014).

Students of varying GPA levels may benefit from TBL in different ways. The small positive correlation between the tRAT and final examination scores may be suggestive of GPA as a mediator (Bennett, 2000). However, in the authors' experience, students with lower GPAs are less likely to verbalize their opinion in a large classroom setting and may benefit from the support and safety offered by team membership. Students with higher GPAs benefit by sharing their knowledge and applying leadership skills within the team. These student characteristics are reflected in the literature (Hettler, 2015). While walking among the teams during team activities, the authors discovered major gaps in understanding and have addressed these misunderstandings immediately. For example, a team struggling with the concept of epidemiological measures did not ask questions during the epidemiology lecture, yet during the application-focused case study, the need for clarification was recognized. If this topic were taught in a traditional classroom setting using only lecture and slides, the opportunity for less confident students to ask questions and gain faculty clarification would be limited.

The TBL strategy affords the opportunity to teach a large size class and still have direct interaction with students. Yoon, Burns, and Michaelsen (2014) reported that TBL can be successful in a wide variety of classroom settings, and that space for faculty to move about the room was important. In the authors' experience, moving about the room was essential to team facilitation and student–faculty interaction. Configuring the room in multiple small teams allowed faculty to become more familiar with the strengths and weaknesses of both the individuals and the teams. This study differed from those by Branson et al. (2016), Cheng et al. (2014), and Park et al. (2014) regarding team member assignment. In those studies, team assignment was determined by faculty, whereas in the current study, team composition was randomly assigned. Although several studies (Clark et al., 2008; Feingold et al., 2008) reported student concern about grades being affected by the TBL strategy, the authors did not find this to be the case. Anecdotal evidence of student appreciation of teamwork was found, and their positive attitude is reflected in the mean tRAT score of 94.56.

Although it is not a specific aspect of the study, it became evident that the integration of the three phases of TBL strategy contributed to optimal student understanding and application of challenging concepts, such as upstream thinking. For any topic area, the Phase II in-class discussion supported validation and clarification of knowledge gained by students during preclass readings. During the subsequent case study, students demonstrated the ability to apply expanded knowledge and think upstream regarding real-world population problems.

The results reflect Elliott's (2014) recommendations for faculty preparation prior to using the TBL strategy, as well as best practices for full implementation of TBL (Michaelsen & Sweet, 2011). These factors strengthened both the course and the current study of academic outcomes.


The primary limitation of the current study was a lack of course comparison. In addition, although student scores were similar across the two semesters, differences in the two cohorts may have existed. Student–faculty interaction during TBL may contribute to academic outcomes; however, this was not measured.


These data contribute to understanding the effects of TBL pedagogy and student academic outcomes in nursing education, specifically in a large U.S. baccalaureate nursing program. Although the data do not demonstrate an obvious positive connection between the TBL strategy and academic outcomes, other benefits of the strategy were recognized. The strategy offers a multifaceted approach to learning and applying complex health concepts. This study should encourage faculty and nursing education programs to pursue the TBL teaching strategy to engage students in team building and the integration of diverse perspectives in their nursing practice.

The authors believe that all student scores may have been negatively affected without use of the TBL strategy and recommend further research of student perspectives of TBL components that are difficult to measure, such as student–faculty interaction during teamwork. In addition, research is needed to identify how TBL contributes to the ability of all students to understand and apply concepts, such as upstream thinking. Such research should consider a mixed-methods design to connect student perspectives of the way that TBL supported the understanding of course concepts. Finally, because the authors did not evaluate the TBL strategy effects on overall course grades, a need for future study exists in this area.


  • Abdelkhalek, N., Hussein, A., Gibbs, T. & Hamdy, H. (2010). Using team-based learning to prepare medical students for future problem-based learning. Medical Teacher, 32, 123–129. doi:10.3109/01421590903548539 [CrossRef]
  • Bennett, J.A. (2000). Mediator and moderator variables in nursing research: Conceptual and statistical differences. Research in Nursing & Health, 23, 415–420. doi:10.1002/1098-240X(200010)23:5<415::AID-NUR8>3.0.CO;2-H [CrossRef]
  • Branson, S., Boss, L. & Fowler, D.L. (2016). Team-based learning: Application in undergraduate baccalaureate nursing education. Journal of Nursing Education and Practice, 6, 59–64. doi:10.5430/jnep.v6n4p59 [CrossRef]
  • Cheng, C.-Y., Liou, S.-R., Hsu, T.-H., Pan, M.-Y., Liu, H.-C. & Chang, C.-H. (2014). Preparing nursing students to be competent for future professional practice: Applying the team-based learning-teaching strategy. Journal of Professional Nursing, 30, 347–356. doi:10.1016/j.profnurs.2013.11.005 [CrossRef]
  • Clark, M.C., Nguyen, H.T., Bray, C. & Levine, R.E. (2008). Team-based learning in an undergraduate nursing course. Journal of Nursing Education, 47, 111–117. doi:10.3928/01484834-20080301-02 [CrossRef]
  • Cohen, J.W. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Lawrence Erlbaum Associates.
  • Davidson, L.K. (2011). A 3-year experience implementing blended TBL: Active instructional methods can shift student attitudes to learning. Medical Teacher, 33, 750–753. doi:10.3109/0142159X.2011.558948 [CrossRef]
  • Della Ratta, C.B. (2015). Flipping the classroom with team-based learning in undergraduate nursing education. Nurse Educator, 40, 71–74. doi:10.1097/NNE.0000000000000112 [CrossRef]
  • Education Committee of the Association of Community Health Nurse Educators. (2010). Essentials of baccalaureate nursing education for entry-level community/public health nursing. Public Health Nursing, 27, 371–382. doi:10.1111/j.1525-1446.2010.00867.x [CrossRef]
  • Elliott, S. (2014). Using a modified team-based learning approach to teach nursing students about communicable disease control and community health nursing. Journal of Nursing Education, 53, 651–653. doi:10.3928/01484834-20141027-01 [CrossRef]
  • Feingold, C.E., Cobb, M.D., Givens, R.H., Arnold, J., Joslin, S. & Keller, J.L. (2008). Student perceptions of team learning in nursing education. Journal of Nursing Education, 47, 214–222. doi:10.3928/01484834-20080501-03 [CrossRef]
  • Hettler, P.L. (2015). Student demographics and the impact of team-based learning. Internal Advances in Economic Research, 21, 413–422. doi:10.1007/s11294-015-9539-7 [CrossRef]
  • Hrynchak, P. & Batty, H. (2012). The educational theory basis of team-based learning. Medical Teacher, 34, 796–801. doi:10.3109/0142159X.2012.687120 [CrossRef]
  • Kuhne-Eversmann, L., Eversmann, T. & Fischer, M.R. (2008). Team- and case-based learning to activate participants and enhance knowledge: An evaluation of seminars in Germany. Journal of Continuing Education in the Health Professions, 28, 165–171. doi:10.1002/chp.175 [CrossRef]
  • Martins, D.C. (2015). Thinking upstream: Nursing theories and population-focused nursing practice. In Nies, M.A. & McEwen, M. (Eds.), Community/public health nursing (6th ed., pp. 36–48). St. Louis, MO: Elsevier.
  • Mennenga, H.A. & Smyer, T. (2010). A model for easily incorporating team-based learning into nursing education. International Journal of Nursing Education Scholarship, 7, 1–14. doi:10.2202/1548-923X.1924 [CrossRef]
  • Michaelson, L.K., Parmelee, D.X., McMahon, K.K. & Levine, R.E. (2008). Team-based learning for health professions education: A guide to using small groups for improving learning. Sterling, VA: Stylus.
  • Michaelson, L.K. & Sweet, M. (2011). Team-based learning. New Directions for Teaching and Learning, 128, 41–51. doi:10.1002/tl.467 [CrossRef]
  • Minnesota Department of Health, Division of Community Health Services, Public Health Nursing Section. (2001). Public health interventions: Applications for public health nursing practice. St. Paul: Minnesota Department of Health.
  • Park, H.R., Kim, C.J., Park, J.W. & Park, E. (2014). Effects of team-based learning on perceived teamwork and academic performance in a health assessment subject. Collegian, 22, 299–305. doi:10.1016/j.colegn.2014.05.001 [CrossRef]
  • Polit, D.F. & Beck, C.T. (2016). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
  • Quad Council of Public Health Nursing Organizations. (2011). Quad Council competencies for public health nurses. Retrieved from
  • Ridley, R.T. (2007). Interactive teaching: A concept analysis. Journal of Nursing Education, 46, 203–209.
  • Shankar, N. & Roopa, R. (2009). Evaluation of a modified team based learning method for teaching general embryology to 1st year medical graduate students. Indian Journal of Medical Science, 63, 4–12. doi:10.4103/0019-5359.49076 [CrossRef]
  • Sisk, R.J. (2011). Team-based learning: Systematic research review. Journal of Nursing Education, 50, 665–669. doi:10.3928/01484834-20111017-01 [CrossRef]
  • Stein, R.E., Colyer, C.J. & Manning, J. (2016). Student accountability in team-based learning classes. Teaching Sociology, 44, 28–38. doi:10.1177/0092055X15603429 [CrossRef]
  • Thomas, M.D. & McPherson, B.J. (2011). Teaching positive psychology using team-based learning. The Journal of Positive Psychology, 6, 487–491. doi:10.1080/17439760.2011.634826 [CrossRef]
  • Thompson, B.M., Schneider, V.F., Haidet, P., Levine, R.E., McMahon, K.K., Perkoski, L.C. & Richards, B.F. (2007). Team-based learning at ten medical schools: Two years later. Medical Education, 41, 250–257. doi:10.1111/j.1365-2929.2006.02684.x [CrossRef]
  • Tomaselli, G.F., Harty, M., Horton, K. & Schoeberl, M. (2011). The American Heart Association and the Million Hearts Initiative: A presidential advisory from the American Heart Association. Circulation, 124, 1795–1799. Retrieved from doi:10.1161/CIR.0b013e3182327084 [CrossRef]
  • Willett, L.R., Rosevear, G.D. & Kim, S. (2011). A trial of team-based versus small-group learning for second-year medical students: Does the size of the small group make a difference?Teaching and Learning in Medicine, 23, 28–30. doi:10.1080/10401334.2011.536756 [CrossRef]
  • Yoon, M.H., Burns, C.M. & Michaelsen, V.E. (2014). Team-based learning in different classroom settings. Medical Science Educator, 24, 157–160. doi:10.1007/s40670-014-0024-3 [CrossRef]
  • Zgheib, N.K., Simaan, J.A. & Sabra, R. (2011). Using team-based learning to teach clinical pharmacology in medical school: Student satisfaction and improved performance. Journal of Clinical Pharmacology, 51, 1101–1111. doi:10.1177/0091270010375428 [CrossRef]

Dr. Miles is Assistant Professor, Marquette University College of Nursing, Milwaukee, Wisconsin; Dr. Larson is Associate Professor and Dr. Swanson is Professor and Chief Statistician, East Carolina University College of Nursing, Greenville, North Carolina.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Jane M. Miles, PhD, RN, NEA-BC, Assistant Professor, Marquette University College of Nursing, Clark Hall 365, Milwaukee, WI 53201; e-mail:

Received: July 24, 2016
Accepted: February 15, 2017


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