“I Can’t Go Far”: Perceptions and Experiences of Heart Failure Patients Regarding Physical Activity: A Qualitative Study Using Semistructured Face-to-Face Interviews

Abstract

Background

Participation in regular physical activity (RPA) is beneficial to the quality of life and life expectancy of patients with chronic heart failure (CHF). However, it is inadequate in many patients.

Aims

To determine the factors that influence the practice of RPA in patients with CHF managed in general practice.

Method

This was a qualitative study using semistructured, individual face-to-face interviews. Patients with CHF (New York Heart Association Stages 1–3) capable of participating in RPA were enrolled by their general practitioner. A longitudinal and transversal inductive thematic analysis was performed by two researchers.

Results

Five themes emerged from the 19 interviews that were conducted. Poor knowledge of the disease and the benefits of participating in RPA, as well as the lack of motivation or enjoyment, in particular due to the absence of previous participation, were considered significant obstacles. Fear associated with CHF or other comorbidities was also an obstacle. Attendance at a rehabilitation center, family and social circles, and having a pet all appeared to be beneficial. Family and friends were important for motivating the patient to participate in an activity but could also be an obstacle when they were overprotective.

Conclusion

This study helps highlight the difficulties for patients with CHF associated with participation in RPA. Despite the obstacles, there are enabling factors on which the general practitioner may rely to motivate their patients.

Keywords

chronic heart failure physical activity general practitioners qualitative research individual interviews

The incidence of chronic heart failure (CHF) increases progressively with age, reaching more than 10% in patients aged ≥70 years (Ponikowski et al., 2016). CHF has major consequences, both physically and psychologically (Di Palo, 2020). On average, 50% of patients who are diagnosed with CHF are readmitted to hospital within a year of initial hospitalization, and 50% to 75% of patients die within 5 years of diagnosis (Al-Omary et al., 2018; Roger, 2013; Tribouilloy et al., 2010; Tuppin et al., 2014). CHF seriously impairs quality of life (Alpert et al., 2017; García-Olmos et al., 2019), and living with it can be frightening, restrictive, and distressing (Jeon et al., 2010; Pattenden et al., 2007). Patients’ daily lives are marked by a decrease in physical capacity (Churilla et al., 2016) and unpredictable fatigue with fluctuating intensity, leading to limitations in the performance of daily and social activities, increased dependence on others, and a loss of self-esteem, identity, and intellectual function (Jeon et al., 2010; Schjoedt et al., 2016). Patients also experience depression, which occurs more frequently among patients with CHF (Sbolli et al., 2020). Depression is not only inextricably linked to other symptom domains (Rumsfeld et al., 2003) but also negatively affects the burden of symptoms, hospitalization rate, and mortality in patients with CHF (Greco et al., 2004).

Regular exercise has a beneficial effect on all-cause death and hospitalization, cardiovascular death, readmission rates, quality of life, and depression scores in patients with CHF (Albert et al., 2015; Blumenthal et al., 2012; Smart & Marwick, 2004). Regrettably, few patients comply fully with exercise recommendations (Blumenthal et al., 2012; Smart & Marwick, 2004; van der Wal et al., 2006). Only half of all patients from a 2006 study who understood the importance of engaging in some form of exercise reported doing so (van der Wal et al., 2006). Noncompliance with nonpharmacological recommendations (like exercise) in CHF patients is associated with adverse outcomes (van der Wal et al., 2010), whereas patient education and counselling have proved beneficial Motivation results in a change in self-efficacy, which in turn results in increased physical activity (Klompstra et al., 2018). The motivation to be physically active is important, but not sufficient on its own. In order to change behavior in terms of physical activity, patients must be able to adopt a self-care approach. Self-care, defined as a decision-making process in the selection of behaviors that result in maintained physiological stability (Riegel et al., 2009), is fundamental for improving health outcomes in patients with CHF (Moser et al., 2012; Riegel et al., 2009). Patients who report more effective self-care have a better quality of life, with lower mortality and readmission rates (Jaarsma et al., 2017). Comorbid conditions, depression, anxiety, age, and impaired cognition are all factors that make self-care difficult for CHF patients (Riegel & Carlson, 2002). Regular physical activity (hereafter, RPA) in patients with CHF has been studied only rarely in primary care, especially in France. In a self-care approach, it is useful, first, to recognize any potential barriers before preparing patients for exercise (Riegel & Carlson, 2002). Primary care physicians need to understand reasons why patients can either adapt or fail to do so. We were therefore particularly interested in patients with CHF in primary care to address this issue from a self-care perspective.

The aim of our study was to determine the factors that influence the practice of RPA in patients with CHF who are managed in general practice.

Method

Study Type

We performed a qualitative approach using semistructured individual interviews to explore behaviors toward physical activity in patients with CHF. This method was chosen to maximize the amount of data gathered in answering the questions raised. Data were collected through semistructured individual interviews to record the perceptions and experiences of patients with CHF with regard to their participation in RPA, based on their own lifestyles (Britten, 1995). We followed the recommendations of the Consolidated Criteria for Reporting Qualitative Studies (Tong et al., 2007).

Study Sample

Patient recruitment was undertaken in both rural and urban areas within the Auvergne region. However, 10 general practitioners (GPs) were selected randomly from the most recent edition of the phonebook for the Auvergne area. We attempted to obtain maximum variability in GPs’ characteristics (including sex, age, and rural or urban practice). Seven GPs agreed to participate, while three declined owing to a lack of time. The seven GPs were contacted by telephone or were met face-to-face to explain the objectives of the study and the characteristics of the patients sought. The GPs contacted patients with CHF (New York Heart Association [NYHA] Class I–III) based on the criteria provided by the researchers. Patients who gave their consent were contacted by telephone to organize an appointment for a personal interview.

The sampling was performed while looking for maximum diversity based on the following criteria: sex, age, marital status (in a couple/single), habitat (urban/rural), professional activity, time since CHF diagnosis, left ventricular ejection fraction, and participation in a therapeutic education program. These characteristics were specified by the researchers to inform the GPs as recruitment progressed.

Interview Guide

An interview guide was produced after consultation with a cardiologist, GPs, and patients. It evolved throughout the study, notably with the inclusion of questions that concerned the patient’s social group or their activities prior to the onset of their cardiovascular problems (see Supplemental Table 1).

Data Collection and Analysis

All interviews were carried out at the patient’s home, recorded using a digital voice recorder, and transcribed in full with anonymization. The interviews were carried out by a researcher trained in qualitative research but with little experience of interviewing. After transcription, the interviews were analyzed using a straightforward inductive thematic approach (Braun & Clarke, 2006; Thomas, 2006) for explanatory purposes and derived from the Grounded Theory (Paillé & Muchielli, 2012). The material from the interviews was proofread several times after each transcription, and the transcriptions were encoded independently by the interviewer (MB) and a more experienced investigator (PV) to increase both the internal and the external validity. These two investigators pooled their codes independently according to some main themes in order to construct the analytical framework prior to a comparison of all their codes and themes. In cases of disagreement, a consensus was sought with additional analysis by the third investigator (EC). A cross-sectional analysis was also performed to classify the patients. The results of the study were presented to the patients for validation.

Ethical Issues

Prior to each interview, an information sheet was provided to the patient, explaining the aims of the study, the terms of confidentiality, the patient’s rights, and anonymization. Written consent was obtained from participants for their involvement and for the recording of their interview. The study received a favorable opinion from the Ethics Committee, CPP Sud-Est VI, reference 2020/CE 07.

Results

Indeed, 22 patients were recruited by seven GPs, and 19 interviews were carried out, with an average duration of 28 minutes, between September and November 2019. Three patients refused to participate for various reasons (holiday abroad, death of a relative, or planned surgery). A sufficiency of data was reached after 16 interviews, as confirmed by 3 additional interviews that provided no further data, for a total of 19 interviews analyzed. The characteristics of the GPs involved in the recruitment of the patients are shown in Table 1, and those of the participants are shown in Table 2. The key factors are summarized in Table 3. In total, five themes emerged from the analysis of the interviews.

Table 1.

Characteristics of General Practitioners.

Characteristics of general practitioners	N (%)
Gender
Female	3 (42.9)
Male	4 (57.1)
Age, years
30–39	2 (28.5)
40–49	2 (28.5)
>50	3 (43)
Activity location
Urban	4 (57.1)
Rural	3 (42.9)
Nature of practice
Solo	1 (14.3)
Group	6 (86.7)

Table 2.

Characteristics of the Study Population.

Characteristics of participants	N (%)	Participant number
Gender
Female	10 (52.6)	P2, P5, P6, P7, P9, P10, P12, P13, P15, P19
Male	9 (47.4)	P1, P3, P4, P8, P11, P14, P16, P17, P18
Age, years
35–54	3 (15.8)	P1, P4, P12
55–74	4 (21)	P3, P6, P13, P15
75–94	12 (63.2)	P2, P5, P7, P8, P9, P10, P11, P14, P16, P17, P18, P19
Marital status
Married	8 (42.1)	P1, P2, P3, P6, P8, P11, P16, P 17
Unmarried/divorced	5 (26.3)	P4, P9, P10, P12, P13
Widowed	6 (31.6)	P5, P7, P14, P15, P18, P19
Highest level of education
Primary	10 (52.6)	P2, P3, P5, P6, P7, P9, P13, P16, P17, P19
Secondary	7 (36.8)	P4, P8, P 10, P11, P14, P15, P18
College/university	2 (10.6)	P1, P2
Location
Urban	7 (36.8)
Rural	12 (63.2)
Cardiac rehabilitation program
Yes	6 (31.6)	P4, P6, P7, P12, P15, P19
No	13 (68.4)	P1, P2, P3, P5, P8, P9, P10, P11, P13, P14, P16, P17, P18
Left ventricular ejection fraction
≥40	14 (73.7)	P1, P3, P4, P5, P7, P8, P9, P10, P12, P13, P14, P16, P17, P18
≤40%	5 (26.3)	P2, P6, P11, P15, P19
New York Heart Association stage
Stage 1	4 (21.1)	P4, P6, P7, P12
Stage 2	10 (52.6)	P1, P2, P5, P10, P11, P14, P15, P16, P17, P19
Stage 3	5 (26.3)	P3, P8, P9, P13, P18

Table 3.

Factors That Encourage and Factors That Limit Regular Activity.

Factors	Patient with regular physical activity	Patient without regular physical activity
Related to the disease	Lack of functional symptoms (NYHA Stage 1)	Limited by the symptoms (NYHA Stages 2 and 3)
Related to the disease	Lack of comorbidities	Disabling comorbidities, e.g., arthritis, COPD
Related to the patient	Being motivated	Lack of enjoyment and motivation for physical activity
	Having a dog	Isolation
	Participating in RPA before the disease	Sedentary behavior
	Motivating family or social circles	Concern of the family or professional circles
Related to the doctor	Good knowledge of the disease	No or little knowledge of the disease and/or in denial
	Received specific advice on RPA	No idea of what is feasible RPA (type, intensity, duration)
	Stayed in a cardiac rehabilitation center	Did not stay in a cardiac rehabilitation center

RPA = regular physical activity; NYHA = New York Heart Association; COPD = chronic obstructive pulmonary disease.

Lack of Knowledge of Their Disease

Most interviewees were unable to explain CHF clearly. They justified this lack of knowledge by noting that the health care professionals had not provided them with an explanation, or that it was too difficult to remember, with complicated medical terms.

I don’t know, I have a problem with a . . . valve, isn’t it? [ . . . ] I go to my doctor’s, he treats me, I don’t ask too many questions. It is not that I am afraid, it just doesn’t interest me. I can’t keep the medical terms in my head. (P1)

Most patients acknowledged that they did not wish to know too much about their disease and had not performed any documentary research, including those who complained of a lack of explanation.

I don’t have the internet anyway, but I have not sought out specific information about my disease. (P9)

Ten (53%) of the participants did not consider their disease to be serious, despite a description of some troublesome symptoms in their daily life. Most did not make the link between their breathlessness and their cardiac impairment. Patients who refused to learn more about their illness or to consider its severity referred to their illness as a threat. Several doubted their ability to engage in RPA.

When I walk, I have to stop a little. [ . . . ] No, for me, it isn’t something serious, I am not worried at all. [ . . . ] I have gained 10 kg in 20 years. Maybe that is what is causing this breathlessness. But I don’t think it is particularly important. (P10)

Knowing the Benefits of RPA

The importance of treatment, diet, and absence of alcohol or tobacco consumption were identified as beneficial to participants. Although all NYHA Class I patients reported having engaged in RPA, most participants did not see physical activity as a beneficial element in the management of CHF.

My GP saw in my folder that I still drink some alcohol. . . . He calls it toxic. He told me that it would be good to stop drinking, but he did not mention doing sports. (P1)

They explained that breathlessness and fatigue hindered their participation in RPA, and as a result they did not push themselves.

For sure, with a shortness of breath like this, I am not going to bother going into the woods. Nor do other things. I didn’t even do much in the garden this year. (P17)

However, half the interviewees explained that neither their GP nor their cardiologist advised them to practice RPA. Some even admitted that they would be more active if it were recommended. They regretted not having more specific instructions and not knowing whether there was a RPA that would be especially beneficial. They also wondered about the duration and intensity of this activity.

No, he did not talk to me about participating in a physical activity. He just performed a technical check-up on my heart. You know, they are a little swamped. We could not talk the way we are now. (P10)

An exercise bike? Would that be possible? Would the effect be the same as a road bike? Yes, it’s feasible, I might like that. (P13)

The patients who had stayed in a cardiac rehabilitation center were more aware of the benefits of RPA, particularly for breathlessness. They expressed a greater confidence in their ability to perform RPA. The advice given on the continuation of the activity at home and the reassuring aspect of rehabilitation supervised by health care professionals were also highlighted. They all declared a regular and quantified physical activity such as walking, cycling, running, individually or in a sports club.

I go at least 3 times a week. At the rehabilitation center, they told me that was the basics; sessions of at least half-an-hour, without overdoing it. If I cannot go one day, I go another day. I walk. Cycling is good too, it’s good for the cardio, that’s what they told me. So, I’m doing it in a gym. I registered at the gym, and I like it. (P4)

Friends and Family Are Important for the Patient

The majority of participants acknowledged that friends and family were an important source of motivation. Transportation difficulties, and a fear of bothering friends and family on a regular basis were highlighted, if only to undertake a simple activity like walking. However, participation in RPA with someone else or as part of a group appeared particularly stimulating and could also solve transportation difficulties. A lack of relationships, or loneliness, was highlighted by some as discouraging, especially for those living in rural areas.

I have a son who is going to live close to me, he walks a lot with his wife. Maybe I will walk a little more. I will not be able to follow them but when they’re here I walk with them. But not on my own. (P14)

Yes, for example, if I was registered at a gym. I’d like that a lot. But it’s far, I cannot go there. I can’t drive. My daughters can’t come and pick me up on an evening. When they have finished their day, they have their children, they have their own lives. (P15)

Ownership of a dog was described as a stimulant and a reason for going for a walk, sometimes several times a day.

I do not go on long walks, but one little walk with my dog. I go every day. She asks for it, she leads me in the end. I walk for half-an-hour. Each time, I take her out 2 or 3 times a day. (P19)

However, friends and family could occasionally be an impediment. A few interviewees mentioned the overprotective nature of their family and friends, especially of their partner. Their concern was raised as a strong impediment to the practice of RPA.

My wife does not want me to go fishing on my own because she is very anxious by nature, and she is scared that I could pass-out. So, I always need to ask someone else, it’s annoying. . . . (P3)

One patient described the supportiveness of their professional circle as a factor that prevented them from experiencing any difficulty at work.

Lack of Motivation

“Lack of enjoyment,” “feeling lazy,” and “lack of will” were terms used to justify the lack of motivation by some patients.

I am not a fan of walking. [ . . . ] I had an exercise bike but I didn’t move forward on the bike so I didn’t see the point. But I know, I am probably lazy. (P14)

Those who were active in their hobbies or sport before their heart condition were more likely to remain so, and understood the benefits of RPA.

We have always gone hiking. We used to go backpacking for a full day. We still do. So I find that it helps a lot because I can still climb. (P2)

The few patients who became more active were those who had benefitted from a stay in a cardiac rehabilitation center. Weather conditions were often mentioned to justify the abandonment of RPA, which was made difficult either by heat or rain. For others, it was lack of time due to their professional life.

If I don’t do any sport, it’s because I don’t have the time. I mean, I don’t make the time. (P1)

Concerns Related to Health Status

Discovery of their heart problem had led patients to be apprehensive about RPA. The explanations of different health care professionals were even seen as alarming, making them afraid of physical overexertion. One patient mentioned the fear of damaging their implantable defibrillator during an activity that carried a risk of injury. Older participants stated their fear of hurting themselves by falling.

I can’t walk a lot, you see, I can’t go far. I don’t know. Am I scared? I think that, without realizing it, yes. I have a neighbor not far away that I like, well I am a little scared of going to their home. (P5)

Well, choosing a circuit is good. But when I’m walking alone, if something breaks, I think “what am I going to do,” we can fall, a car can hit us. There’s not only walking, I hesitate to take a bike . . . I have a friend, he fell at the level crossing, and then he wanted to ride his bike again and he fell again, he broke his hip. I said to myself “you have to know how to stop.”

Those who had followed a rehabilitation program were more self-confident.

They told me (at the rehabilitation center) that the thing that helped me recover was that I was not afraid. Because there are a lot of people who set themselves limits, since they know that it is the heart, they don’t want to overdo it at sports because they are scared, specifically of having a heart attack or something else. (P4)

The presence of related conditions that do not, in theory, prevent participation in RPA was raised a few times by some patients to justify their sedentary behavior. Respiratory diseases, kidney failure, prostate cancer, depression and, primarily, osteoarthritic impairments of the legs were described. Sometimes CHF was secondary to these comorbidities.

The knee, for example, I have synovitis. It’s a new thing. It bothers me a lot. But my problem is mainly renal. It’s getting worse, so the heart is kind of secondary for me. (P10)

Patients mentioned the side effects of their treatment, in particular low blood pressure, as a factor that made all RPA difficult.

The cardiologist told me that everything was fine. He told me to walk and move . . . I’m not out of breath but I don’t have too much blood pressure, I always tend to have small drops in blood pressure. (P7)

Discussion

Our study revealed several obstacles to participation in RPA as described by patients with CHF. One of the most important was a lack of knowledge about their disease and of the benefits of RPA. The benefits and types of RPA were not explained fully to participants during follow-up. A qualitative investigation in the United States also revealed a lack of knowledge in patients of their disease, as well as a lack of information provided by doctors (Albert et al., 2015). We can relate this lack of knowledge in patients to the fear of hurting themselves or collapsing, both described by interviewees as limiting factors, as were the symptoms of CHF themselves. The presence of related conditions complicates the pursuit of RPA and can mean that CHF becomes of secondary importance. The limitations imposed by associated comorbidities, the symptoms related to CHF (including fatigue and breathlessness), and the lack of perceived benefits have all been highlighted as obstacles to participation in RPA (Tierney, Elwers, et al., 2011). Fear was also described as a factor by Albert et al (2015). This is a barrier found in people in the precontemplation stage (Tierney, Elwers et al., 2011) of the self-change model of Prochaska and DiClemente (1983). With regard to the extended parallel process model (Gore & Bracken, 2005), the lack of knowledge or the refusal to learn more about the disease can be related to a denial reaction due to “fear appeal” (CHF condition). This supposes that patients doubt their ability to engage in RPA (i.e., “low perceived self-efficacy”) and/or whether RPA is effective (i.e., “low perceived response efficacy”).

Our study also reveals levers, which mirror the barriers, described by patients who engage in RPA. These factors are summarized in Table 3. For example, isolation represents a major obstacle to participation in RPA; in contrast, family and social circles or owning a pet can be highly beneficial. Indeed, a whole network may be organized to help motivate patients. However, families, and partners in particular, are sometimes overprotective of patients for fear that the disease will progress, and they may hold them back from participation in RPA. In a literature review of qualitative studies, the importance of the family and social circles and the initial level of activity was also shown (Strachan et al., 2014). Two meta-analyses have shown that contributions from the social network and professional support were enabling factors for self-care (Albert et al., 2015; Strachan et al., 2014).

Another barrier is the difficulty for people who do not usually do any sport to change their habits following the onset of heart problems. For the patients involved in our study, residence in a cardiac rehabilitation center appears to be a motivating factor for RPA. These patients are aware of the importance of RPA and more inclined to make it part of their daily routine, including those who are not very active. This was confirmed by others studies (Anderson et al., 2017), and is probably associated with therapeutic education sessions (Meng et al., 2016) provided in the rehabilitation program specific to each patient. The efficiency of the support strategies for continuing RPA over time still needs to be proven (Tierney, Mamas, et al., 2011). It is likely that the lack of social support during the transition from supervised exercise to home exercise is responsible for the loss of both motivation and the beneficial effects of physical activity, especially on quality of life (Riegel et al., 2009). Motivation is an important factor, particularly in view of its association with the perception of self-efficiency (Dontje et al., 2014; Klompstra et al., 2018). In reference to the extended parallel process model (Gore & Bracken, 2005), the reason why patients who stayed in cardiac rehabilitation seem more aware of the benefits of RPA and more engaged in it may be their belief that they can do it (i.e., high perceived self-efficacy and response efficacy). They are therefore motivated to control the disease and to think consciously about ways to remove or reduce the symptoms and consequences of CHF.

Our study has some possible limitations. First, it is important to note that even if the sample is diverse in terms of age, geographical location, family situation, socioeconomic status, and NYHA stage, it was drawn from the patient population of GPs in one region of France only. Furthermore, some GPs may have unconsciously selected patients with whom they had a good relationship. The applicability of our findings in other patient populations may therefore be somewhat limited. Nevertheless, we believe that these results are generalizable at least to some extent in countries with similar health care systems. Second, despite efforts to make participants feel comfortable by conducting interviews at home, it is possible that they may have responded in ways perceived to be socially acceptable, thereby retaining some information of interest. Third, the fact that the interviews were carried out by a researcher trained in qualitative research but with little experience of conducting interviews may be another limitation.

The validity of the findings is supported by several factors. External validity was promoted by careful selection of a varied panel of participants. All interviews were carried out in patients’ homes, which helped them feel more at ease. Triangulation of the data, which helped limit the scope for personal interpretation, and the validation of the data by 18 of the 19 participants (one patient was unable to validate the data because she was in hospital) increased the internal validity of the investigation. No new data emerged during this process.

For practice, GPs need to bear in mind that CHF is a chronic disease that requires changes and adjustments to be made on a daily basis. The existence of numerous barriers to participation in RPA reported by patients points to the necessity, having provided them with the required information, to develop their therapeutic education (Albano et al., 2014) and encourage skills of self-care (Jaarsma et al., 2017; Riegel & Carlson, 2002). Awareness and use of personal strengths has been identified as an important part of enabling people to live well with chronic disease (Riegel et al., 2012). This study extends our understanding of subjective evaluation and application of personal strengths in people with CHF. Interactions and relationships with health care providers play a substantial role in patients’ capacity for CHF self-care (Currie et al., 2015). According to patients’ life plans, GPs can help them by acknowledging individual barriers and motivators. The mobilization of patients’ personal strengths contributes to the promotion of their optimal self-management and well-being.

Based on the results of our study, a questionnaire could be constructed and administered to a large population of patients in general practice. This would allow the determination of the level of physical activity and the different profiles of patients engaging in PRA. GPs could then identify patients who should be particularly encouraged to promote their self-management. These data could also be used to develop and evaluate a web-based application for home-based exercise programs.

Conclusions

Our study helps us understand why patients with CHF in general practice do not undertake RPA. They need health care professionals, including GPs and cardiologists, to explain the disease and the benefits of RPA, and to provide practical advice. In order to foster an attitude of self-care, it seems essential for GPs to provide reassurance, explain the facilitating factors, and encourage self-motivation.

Supplemental Material

sj-docx-1-heb-10.1177_10901981211053247 – Supplemental material for “I Can’t Go Far”: Perceptions and Experiences of Heart Failure Patients Regarding Physical Activity: A Qualitative Study Using Semistructured Face-to-Face Interviews

Supplemental material, sj-docx-1-heb-10.1177_10901981211053247 for “I Can’t Go Far”: Perceptions and Experiences of Heart Failure Patients Regarding Physical Activity: A Qualitative Study Using Semistructured Face-to-Face Interviews by Elodie Charuel, Martial Bernard, Hélène Vaillant Roussel, Benoit Cambon, Thibault Ménini, Elodie Lafarge, Frédéric Dutheil and Philippe Vorilhon in Health Education & Behavior

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Philippe Vorilhon

Supplemental Material

Supplemental material for this article is available online at .

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