|Year : 2018 | Volume
| Issue : 2 | Page : 86-94
Developing a culturally sensitive mental health intervention for asylum seekers in the Netherlands: A pilot study
Ortal Slobodin1, Samrad Ghane2, Joop T.V.M De Jong3
1 i-psy (inter-cultural psychiatry), Amsterdam; Department of Education, Ben-Gurion University, Beer-Sheva, The Netherlands
2 i-psy (inter-cultural psychiatry), Amsterdam, The Netherlands
3 Amsterdam Institute for Social Science Research, University of Amsterdam; School of Medicine, Boston University, Boston, MA, United States
|Date of Web Publication||30-Jul-2018|
Department of Education, Ben-Gurion University, Beer-Sheva 84105
Source of Support: None, Conflict of Interest: None
Introduction: This pilot study investigated asylum seekers’ needs and expectations in the mental health field to develop a culturally sensitive psychosocial intervention. Method: Participants were residents of a certain asylum-seekers centre in the Netherlands, with most of them from the Middle East crisis. Needs and expectations were identified using therapy expectations questionnaire (11 participants) and two focus groups (17 participants). Results: Participants associated mental health problems with post-migration stressors more often than with past traumatic experiences. Often, health problems were silenced due to shame, guilt, anxiety and the fear of negative stigma. Individuals and communities were limited in their ability to provide support for those suffering from psychosocial distress due to heavy stigma and the burden of multiple stressors. Conclusion: We underscore the importance of considering the local knowledge of mental health in developing emergency interventions and emphasise the need to reach beyond the trauma-focused approach to strengthen capacities within the community.
Key implications for practice
- Developing a culturally sensitive mental health intervention for asylum seekers requires local knowledge of mental health issues
- Mental health interventions in emergencies should reach beyond the individualistic trauma-focused approach to address the whole context of forced displacement
- Because armed conflict often leads to a disruption of the social ecology of a community, mental health interventions should build on existing local support and services and strengthen capacities within the community.
Keywords: Asylum seekers, culture adaptation, focus group, intervention, needs, trauma
|How to cite this article:|
Slobodin O, Ghane S, De Jong JT. Developing a culturally sensitive mental health intervention for asylum seekers in the Netherlands: A pilot study. Intervention 2018;16:86-94
| Introduction|| |
The marked increase in forced migration has led to a significant growth in research on the mental health of populations affected by armed conflict (Miller & Rasmussen, 2017). Studies with asylum seekers and refugees suggested that the psychological and social impacts of emergencies may be acute in the short term, but they can also undermine mental health and psychosocial well-being in the long term (Kirmayer et al., 2011; Priebe et al., 2013; Shawyer et al., 2017). Importantly, evidence suggests that the mental health impact of armed conflict is further exacerbated by post-migration stressors, such as economic difficulties, discrimination, enculturation, parenting and employment (Fazel et al., 2011; Saechao et al., 2012; Siriwardhana et al., 2014).
Following the Asian tsunami in 2004, mental health and psychosocial support (MHPSS) had become a common feature of many emergency humanitarian responses (Miller & Rasco, 2004) and was positioned as a top priority from the very beginning of the emergency response. However, the lack of multi-sectoral, inter-agency consensus as to the definition and selection of mental health interventions in emergency settings contributed heavily to poor coordination across sectors, fragmented services and alarming inconsistency (Başoğlu, 2006; Bernal & Sáez-Santiago, 2006). One of the major reasons for confusion and debate in the field is the inconsistent definition of the term ‘psychosocial interventions’. While the term ‘psychosocial interventions’ covers a wide range of intervention strategies (such as the provision of psychological or medically therapeutic services, psycho-education, interpersonal skills, social activities to support the expression of feelings and thoughts, supportive practices for child development and the provision of psychology-oriented skills training for personnel), the underlying theoretical principles, methodologies, tools or processes considered to be the active ingredients in these interventions remained elusive (Galappatti, 2003). Williamson & Robinson (2006), therefore, highlighted the need for an alternative conceptualisation and communication of psychosocial interventions that involve a wider set of actors. Accordingly, it would be more useful to think of interventions that contribute towards well-being than it is to try to develop a system for determining whether a particular intervention should be considered ‘psychosocial’ or not.
Another dilemma in choosing a therapeutic direction with forced migrants is whether the standard trauma-focused interventions (e.g. cognitive-behavioural therapy; CBT) are suitable for this population, or whether a stabilisation phase is preferable. Despite strong evidence (for review refer Slobodin & de Jong, 2015) for the efficacy of trauma-focused interventions, such as CBT (Hinton et al., 2005; Hinton et al., 2008) and narrative exposure therapy (Neuner et al., 2008; Ruf et al., 2010) in refugee samples, others argue that the high levels of uncertainty and the ongoing threat of further trauma may limit the acceptability and effectiveness of these interventions (NICE, 2005).
Moreover, the field of MHPSS has been polarised for many years into multiple camps, which greatly differed conceptually and theoretically (Wessells & van Ommeren, 2008). Generally, the health sector was divided into two different approaches. The first approach used a medical model of post-traumatic stress disorder (PTSD) and focused on freestanding supports such as counselling, psychotherapy and medication. The other approach used a public health model that considered all mental disorders and involved general mental health services (World Health Organization, WHO, 2003). Likewise, the social welfare sector was divided into the medical model of PTSD and a community-based approach, using non-clinical processes such as support groups. Taken together, the absence of consensus about the appropriate practices combined with a weak base of evidence has enabled poorly implemented MHPSS to occur (Allden et al., 2009; De Jong et al., 2015).
In 2007, an important step towards achieving a consensus was taken when the Inter-agency Standing Committee (IASC) published a practical guidance on tiered action in emergency settings (Wessells & van Ommeren, 2008). These guidelines are a milestone for the MHPSS field, because they are the first inter-agency consensus about what are the essential first steps to be taken in an emergency. Together with presenting actions that should be the minimum response in emergency settings, the IASC guidelines emphasise the scientific and ethical imperative of developing culturally sensitive approach in all areas of MHPSS including inter-agency cooperation, assessment tools, training, monitoring and evaluation (also refer De Jong 2002, 2007; Hinton & Jalal, 2014; The Sphere Project, 2011). Understanding socio-cultural contexts requires ethnographic information on cultural resources, norms, roles and attitudes (e.g. mourning practices, attitudes towards mental disorder and gender-based violence and help-seeking behaviour), to allow a better identification of needs and assist in intervention selection (WHO, 2010).
Consistent with this view, Jordans, Tol, and Komproe (2011) presented a research strategy aimed at facilitating informed decision making for selecting interventions within low- and middle-income countries. Because this strategy relies on the global and local knowledge of mental health issues, it can be easily applied to emergency contexts. The model assumes that because evidence-based treatment from high-income setting cannot be simply transferred to low- and middle-income countries (Chatterjee et al., 2008; Patel, 2009), there is a need for a preliminary adaptation stage that is comprises four phases: (a) a qualitative phase to assess needs and determine tentative intervention objectives; (b) a global expert panel to identify and prioritise intervention modalities for low-resource settings; (c) a systematic literature review and the distillation of practice elements from evidence-based treatments and (d) stakeholder meetings to explore the socio-cultural feasibility and acceptability of the developed intervention. Guided by this model, this paper describes the first phase, a qualitative phase of assessing needs among recently arrived asylum seekers in the Netherlands, to enhance cultural awareness and support the need for intervention (Filippi et al., 2014; Lewis-Fernández et al., 2013). Information on needs and expectations from therapy was collected with the help of two methodologies: questionnaires and focus groups.
| Method|| |
The study involved residents belonging to a certain asylum-seekers centre in the city of Almere in the Netherlands, which was characterised by a relatively large population of asylum seekers. The centre provides a temporary shelter for asylum seekers until the immigration service reaches a decision on their request for asylum. This facility is provisioned by the Dutch Central Agency for the Reception of Asylum Seekers (COA). The centre of Almere hosts 500–800 people from different origins, in particular from Syria and Eritrea, but also from Iraq, Afghanistan and Armenia. Data collection was conducted in two sites. Questionnaires were completed by asylum seekers attending a public Dutch mental health organisation, which specialises in culturally sensitive treatment for ethnic minorities (‘i-psy’, intercultural psychiatry). Focus group interviews were conducted in the asylum seekers centre in Almere.
All participants were residents of the asylum-seekers centre in Almere. Questionnaires regarding therapy expectations were completed by 11 asylum seekers (9 men and 2 women) who attended a mental health service near the asylum-seekers centre. These patients originated from different countries including Iran, Afghanistan, Sierra Leone and Eritrea. The focus groups included Syrian asylum seekers. The first group comprised 5 men and 2 women, and the second had 10 men. The majority of the participants were in the age group of 18–30 years [Table 1].
Expectations from therapy questionnaire − This questionnaire was adapted from The Milwaukee Psychotherapy Expectations Questionnaire, a validated measure of clients’ expectations about the components and the effects of therapy (Norberg et al., 2011). The questionnaire measures three separate types of expectations: role, outcome and process. Role expectations refer to the client’s expectations for the clinician’s role or interpersonal style during treatment; outcome expectations reflect expected improvement from therapy, whereas process expectations pertain to the content of sessions (Aubuchon-Endsley & Callahan, 2014). In addition, items that were previously identified as relevant needs in refugee population (e.g. support in parenting and family relation) (Jordans et al., 2011) were included. Items were scored on a Likert scale, ranging from 0 (not at all) to 10 (very much so). The questionnaire was translated from English to Arabic and French using translation back-translated method. To our knowledge, this tool was not previously used in refugee or asylum-seekers groups.
Focus groups − The two groups were presented with a series of questions regarding the community’s needs in the psychosocial field as well as attitudes towards mental health problems and services, for example, what are the signs of psychosocial distress?; how does the community cope with mental health problems?; what is the best way to help people? and does talking to other people help? The total duration of group discussion was 90 min. Data analysis was based on written notes.
Questionnaires regarding expectations from therapy were delivered by graduate students at the intake phase. In a few cases, questionnaires were presented by the therapist at the initial phase of the treatment. All therapists received explanations about the purposes of the study by the principle investigators to enhance cooperation. Questionnaires required 20 min to complete.
Focus groups − To establish homogenous language/ethnic focus groups, invitations to participate were sent to Syrian asylum seekers, who were the largest ethnic group in the Almere centre of asylum seekers at the time of the study.
Invitations to participate in the focus groups were randomly sent by the medical team to the e-mail addresses of 50 adult Syrian residents of the asylum-seekers centre. The invitation letter included information about the objectives of the focus group, which was exploring mental health problems, as well as identifying needs and learning about the coping strategies of the community. The letter also included a guarantee of data confidentiality and the contact details of the principle investigators. Participation in the focus group was voluntary. All individuals who showed up for the meeting were included in the group. Focus group interviews were conducted with the assistance of a Dutch to Arabic translator.
The analysis of focus groups’ data represents Colaizzi’s (1978) process for phenomenological analysis (Speziale & Carpenter, 2007). The first step included a detailed reading of the transcript to obtain a general idea about the whole content. In the second step, transcripts were read and re-read to extract words and sentences relating to asylum seekers’ experiences. When each transcript had been prepared in this way, the segments of text were then given the descriptive label of ‘significant statement’. At step 3, the highlighted significant statements were then physically cut and sorted into groups of similar ideas that were pasted together to begin formulating meanings (Colaizzi, 1978).
At step 4, meanings from the significant statements and phrases from the interview were formulated and organised into themes. At step 5, the emergent themes were organised. Finally, the results of the data analysis were integrated into an exhaustive description of asylum seekers’ experiences (Speziale & Carpenter, 2007).
| Results|| |
Expectations from therapy questionnaire
[Table 2] describes the response distribution in items measuring expectation from therapy. As can be seen in the table, the most desired outcome of patients was that the therapist will help them to ease their distress and get active. Most participants also expected that the therapist will assist them in solving everyday problems and organise their daily lives. Some patients expected that the therapist will help them to find a job and arrange their residency permit. From the process domain, participants looked for a safe place where they could explore their difficulties. Importantly, most participants appreciated help focusing on symptoms associated with their adverse past.
Three themes emerged in the focus group discussions: the loss of identity, feelings of uncertainty and helplessness and negative attitudes towards mental health issues. [Table 3] shows the themes and the formulated meanings according to step 4 in Colaizzi’s (1978) process.
Identity loss: Participants in the focus groups pointed to a devastating loss of self-resources and assets that once constituted their sense of identity, including relationship, education, profession, belongings and social status. They felt as if they lost their unique existence as individuals and became one of many unwanted people that the government has to handle. The experiences of ‘being a number/a case’ or ‘being invisible’ emphasise the extreme disruption of identity and reflect the massive exclusion of asylum seekers from the host society. Such severe identity crisis was associated with negative self-esteem and feelings of worthlessness, as indicated in one of the participants’ text:
In Syria, I was a famous artist, everybody knew me. Here, we are only numbers. I am a subject, treated as one. We have no future, no work and no information about when the rest of the family arrives. This is what makes people crazy.
Helplessness and uncertainty: Participants described their daily lives as empty from activities and full of waiting, thinking and worrying. The experience of being passive and the lack of control were often described as a major source of psychological distress. Uncertainty was related to multiple stressors including whether a residency permit will be approved, where they would be transferred, whether and when a family reunion will occur and what will happen if their application would be rejected. The asylum procedure was a puzzling phenomenon for most respondents. It lacked transparency and seemed to work without rationale. Their vague futures combined with the absolute powerlessness in the decision were associated with feelings of anxiety and anger. A young man, who studied engineering in Syria said:
I am an educated man. I had a promising future. Here, I have no idea what will happen to me. I do not know whether I will stay here and whether I could ever continue my studies. Everybody tells us: “you have to be patient”, but waiting is impossible. I can’t sit all day and do nothing. I am not used to it and it makes me crazy.
Participants indicated that their inability to work and contribute to the society (and somehow even compensate for the burden of asylum seeking) strongly harmed their well-being. The feelings of helplessness were also associated with unrealistic expectations from life in the host country:
We used to think that we left hell and came to paradise. We had an image … 99% of the people who came to Europe expect paradise. They believe that Europe must treat us, that we are entitled because we are refugees. But then we realize that this is not the case and the disappointment is enormous.
Negative attitudes towards mental health problems: Discussing the various manifestations of mental problems with focus group participants revealed that psychological distress may be expressed in multiple behavioural (too quiet, orientations problems, he is not himself anymore), physical (reduced appetite, lack of sleep, shaking), social (no eye contact, avoiding social interactions) and cognitive (thinking too much, concentration problems) trajectories.
Sharing mental health problems was associated with heavy stigmatisation and shame. Importantly, the question of ‘how do you know that someone has mental health problems?’ was frequently answered by: ‘Probably, I would not have known’. One participant commented that even the invitation letter for the focus group, which was signed by a psychologist, resulted in a negative judgment from others. Therefore, most people, especially men, were trying to minimise and avoid the expression of mental pain. As one of the participants described:
In the Middle East, men should be strong and respected, so you don’t show any sign for weakness. Men should not act this way. Sometimes mental health problems appear as physical problems, which are considered less shameful.
Often, mental problems were exposed in a very late stage (‘after explosion’), probably after the initial distress had been complicated. Related to these burdens, there was a strong impression that people were seriously limited in their ability to support those with mental health problems. Participants indicated that even if they wished to talk to someone, their wish will be most probably rejected. This is because psychological distress is associated with abnormal behaviour (‘craziness’) or because people are overburdened with their own problems. A repeated theme was that people are indifferent to each other’s suffering. There was a sense of emotional alienation that led to social disconnectedness between community members. One participant explained why he can’t find any comfort in others:
No one can understand you. Everyone went through something, but tortures, bombs, bullets 5–10 cm from your body, feel different. No one can relate to your own experience, they just say: ‘good that you survived, take care next time’.
These words exemplify how people are isolated and detached in their own traumatic past, believing that no one can understand or support their pain.
| Discussion|| |
The aim of the current pilot study was to investigate asylum seekers’ needs and expectations in the mental health field to allow the development of culturally sensitive intervention. Questionnaires and focus group data pointed to several main themes. First, mental health problems were more frequently associated with post-migration stressors (identity loss, uncertainty and helplessness) than with past traumatic experiences. Second, mental health problems and the use of mental health services were silenced among asylum seekers due to shame, guilt, anxiety and the fear of negative stigma. Together with the urge to minimise psychological distress, participants often expressed their readiness to process adverse experiences in therapeutic settings. Finally, individuals and communities were limited in their ability to provide support for those suffering from psychosocial distress due to the heavy stigma related to mental health issues and the burden of multiple stressors. Consistent with previous findings (Hallas et al., 2007; Ryan et al., 2008), participants in this study associated their mental health problems with adverse stressors during the post-migration period rather than with pre-migration traumatic episodes. This finding posits that prolonged periods of uncertainty, fear and boredom during the post-migration period may have an extreme effect on asylum seekers’ well-being. A study with Iraqi asylum seekers in the Netherlands showed that the duration of the asylum procedure is an important risk factor for psychiatric problems; those who stayed longer than 2 years in the asylum-seekers centre suffered from higher levels of anxiety, depression and somatoform disorders than those who stayed for <6 months (Laban et al., 2004). Similar results were reported in a study among torture survivors in the United States, which found that participants receiving services after 1 year of resettlement were more likely to experience PTSD and depression than participants receiving services within 1 year (Song et al., 2015). Van et al., 2001 suggested that the threat of being exiled was so overwhelming, anonymous and uncontrolled that people felt they have become objects, numbers or ‘cases’. In this context, frustration with the asylum procedure was seen as an attempt to maintain a sense of continuity between being victims of war or human rights violations and a socially excluded minority in the host country.
Consistent with previous research (Hassan et al., 2015), focus group data suggested that the psychosocial distress of asylum seekers may be further complicated by the heavy stigma associated with mental health problems. Stigma and discrimination in relation to mental illnesses have been described as having worse consequences than the conditions themselves (Thornicroft et al., 2016). Stigma not only hinders help-seeking behaviour, but also results in social isolation, low self-esteem and limited opportunities in employment and education (Marquez & Walker, 2016; Shannon et al., 2015; Weine, 2011). Difficulty in discussing mental health issues among the asylum-seekers community was previously associated with multiple reasons including a history of political repression, the belief that talking does not help, fear that information will be spread throughout government agencies or within the ethnic community, the avoidance of symptoms and shame (Drummond et al., 2011; Wong et al., 2006). A common strategy to minimise the stigma associated with mental health services is to incorporate them into broad-based community settings, such as schools, primary prevention or case management programs (Beehler et al., 2012; Birman et al., 2008; Kataoka et al., 2003). Other strategies include mental health programs that are provided by trained refugee staff (Kieft et al., 2008) or integrating mental health services with culturally appropriate services (Gong-Guy et al., 1991). The World Bank Group (2016) suggested that anti-stigma campaigns as well as peer-to-peer support models can help break down stigma and raise awareness. Peer-to-peer models engage those recovering from mental health problems in helping others and encourage them to take on visible, proactive roles in their communities. A recent review provided evidence that social contact is the most effective type of intervention to improve stigma-related knowledge and attitudes mainly in the short term (Thornicroft et al., 2016). Nevertheless, the scarcity of evidence on interventions to reduce stigma, especially in low-income countries, calls for future research.
Interestingly, our findings suggest that together with the urge to silence psychosocial distress, participants expressed their readiness to process adverse experiences in therapeutic setting.
Similar attitudes were observed in a phenomenological study of Vincent et al., 2013, who examined the asylum seekers’ experiences of trauma-focused CBT. Participants in their study experienced a significant fragmentation anxiety towards the treatment and expressed a deep conflict between the tendency to avoid their traumatic experiences and the wish to engage in therapy. Such ambivalence between minimising pain and disclosing it is a common aspect of working with forced migrants, in whom silence may protect the self and others from the overwhelming impact of trauma. Moreover, silence may function as a device of meaning making, identity reconstruction or a medium to express the incomprehensible (Ghorashi, 2008; Puvimanasinghe et al., 2015). Understating this ambivalence in a cultural context is important not only for intervention selection, but also as a basis for therapeutic dialogue.
In addition, we observed a limited ability among the individuals and communities to support those suffering from mental health problems. Beyond the fear of negative stigma, the burden of multiple stressors limited people’s capacity for mutual concern and support. Consequently, the feelings of shame and isolation surrounded mental health issues. Although it is clear that people in emergencies will benefit from help in accessing greater community and family supports (Hobfoll & de Jong, 2014), providing a community-based intervention in emergency settings poses a real challenge for MHPSS providers. In most emergencies, there are massive disruptions of family and community networks due to loss, displacement, family separation, community fears and distrust (Silove et al., 2017). Armed conflict may also disrupt the cultural values and traditions that have previously provided a sense of unity and identity to communities (Strang & Ager, 2003). According to the IASC guidelines, useful responses in the community level include family tracing and reunification, assisted mourning and communal healing ceremonies, mass communication on constructive coping methods, supportive parenting programs, formal and non-formal educational activities, livelihood activities and the activation of social networks, such as through women’s groups and youth clubs (IASC, 2007). Drawing on the conservation of resources theory (Hobfoll, 1998), Strang and Ager (2003) argued that the psychosocial well-being of a community is dependent on the ability to deploy resources effectively to re-establish meaning and agency. Therefore, any intervention that leads to long-term dependence on external support is not effective in building psychosocial well-being. Instead, mental health interventions should be driven as much as possible by the initiative of the affected population.
A specific recommendation of the WHO (2010) to increase the utilisation of mental health interventions in communities with limited resources is to implement task shifting. Through shifting tasks, interventions that are originally provided by specialised services may be conducted in primary or community settings (Van Ginneken et al., 2013). To address the need for task shifting, the WHO (2016) has developed a range of mental health interventions, which are intended to be delivered by lay counsellors or peer refugees who have not received specialised mental health training. These interventions, such as Problem Management Plus (PM+), include multiple structured practical steps (problem solving, increasing activity level and stress management), which can be useful for a range of emotional problems. Currently, several European groups (EU STRENGTHS program) translate and adapt the WHO interventions and training programs for use with Syrian refugees across Europe and countries bordering Syria (Sijbrandij et al., 2017). The objective of this program is to strengthen national and local healthcare systems by integrating mental health services into primary and community care systems. The interventions will be delivered through individual or group face-to-face or smartphone formats by either peer refugees or local non-professional helpers who will receive training and supervision from local mental healthcare professionals (Sijbrandij et al., 2017).
Lastly, some participants in the current study expressed their wish that the therapist would help them solve the practical aspects of their lives, such as finding a job and arranging a residency permit. These expectations are sometimes considered by mental health professionals as unrealistic, unethical, conflicting with therapeutic roles or the blurring of provider–client boundaries (Century et al., 2007). However, given the complexity of problems in asylum-seekers community and the inter-relatedness of therapeutic interventions in the field, there is a need to consider the ethical dilemmas that these patients raise for professionals (NICE, 2005). Savin & Martinez (2006) advocate a more flexible model of ethics, whereby clinicians use a graded risk-assessment approach to determine what is the most acceptable and defensible therapeutic course of action. Practitioners who focus on addressing emotional issues to the point of excluding pragmatic issues are perceived as unresponsive to refugees’ needs (Kinzie et al., 1980). In contrast, therapists’ practical support is often perceived as a sign of genuine care (Jensen et al., 2013).
This study should be considered under certain limitations. The most important ones are the small sample size, the gender imbalance and the fact that only two focus groups were included in the qualitative part. Taken together, these shortcomings clearly limit our ability to draw firm conclusions about the various needs and preferences of asylum seekers. Moreover, it is possible that because participation in the focus group was voluntary, certain demographic or clinical groups of asylum seekers were underrepresented in this sample. For example, the relatively little interest in family and parenting skills might be related to the young age of most participants. Finally, information regarding expectations from therapy questionnaires was collected in the intake phase of receiving mental health treatment and may, thus, be influenced by social desirability. Because this research remains at the preliminary stages, further qualitative and quantitative research with larger samples is needed to validate and generalise our results.
| Conclusion|| |
Armed conflict often leads to a disruption of the social ecology of a community, where interpersonal relations and cultural systems cease to function. Such ‘assault on meaning’ (Alcock, 2003) underscores the clinical and ethical importance of considering culture as a key resource area in the psychosocial well-being of individuals and communities. Culturally informed interventions in emergency settings require a local understanding of mental health issues (e.g. the interpretations of the causes and the effects of the emergency, the cultural idioms of distress, protective and resilience factors and the utilisation of mental health services) as well as the expectations and preferences of the affected population. To promote the community’s capacity to mediate adversity and minimise dependency on external support, MHPSS should build on existing local support and services and strengthen capacities within the community. Due to its reliance on the local knowledge of mental health issues, this guiding framework is not restricted to a European context but rather could be integrated in a sustainable way into various cultural and geographical emergency settings.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]
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