Abstract

BACKGROUND

Limited access to contraception and poor compliance are the major reasons for unintended pregnancy in adolescence. This study was designed to compare knowledge of the combined oral contraceptive pill (COCP) in teenage users and non-users. We speculated that consultations between COCP users and their physicians would dispel misconceptions.

METHODS

A cross-sectional survey was undertaken in public clinics affiliated with an academic center. High school-educated female adolescents aged 14-20 years opting for contraception ( n = 254) and Israeli physicians ( n = 114) specializing in Obstetrics, Gynecology and Reproductive Endocrinology participated in the study. Information about past or present COCP use and views of the COCP were recorded by employing a ten-question YES/NO self-completion questionnaire, designed by the researchers.

RESULTS

The prevalence of incorrect beliefs was exceedingly high in the whole adolescent study group and relatively high among the physicians. The prevalence of incorrect beliefs was comparable between COCP users and non-users, regarding the 10 misconceptions investigated. The duration of COCP use did not influence the prevalence of misconceptions about the pill. Age did not serve as a confounding factor for all misconceptions.

CONCLUSIONS

Lack of informative communication between COCP-prescribing physicians and users and mistaken knowledge of the caring physicians may contribute to adolescent ignorance of the COCP. Focusing on adolescent-specific disbeliefs could lead to construction of better educational programs in schools and clinics.

Introduction

The teenage abortion rate in Israel of 10.1/1000 women aged 15–19 years is comparable to that reported in European countries ( Darroch et al ., 2001 ). Two major reasons for unintended pregnancy in adolescence are poor access to contraception and poor compliance ( Emans et al ., 1987 ; Pratt and Bachrach, 1987 ; Goldfarb, 1997 ). Awareness of contraception appears to be high, as 87.2% of female teenagers in Israel used effective contraception at their last intercourse ( Harel et al ., 1997 ), but discontinuation of contraception continues to be a leading cause of unwanted pregnancies in adolescence ( Emans et al ., 1987 ; Pearson et al ., 1995 ). The combined oral contraception pill (COCP) is the most frequently used method of contraception, employed by 44% of sexually active adolescents in Israel and the USA ( Polaneczky, 1998 ; The Alan Guttmacher Institute, 2004 ). Still this rate is lower than that recorded among English (67.2%), French (59.2%) and Swedish (49.9%) sexually active adolescents ( Darroch et al ., 2001 ).

Moreover, drop-outs of 25–66% were reported in adolescent COCP users over a year ( Emans et al ., 1987 ; Dustenberg and Brill, 1990 ). In a more recent study, 42% of COCP users stopped the pill without consulting their providers, with 59% reporting side effects as the main reason for discontinuation ( Rosenberg and Waugh, 1998 ). Specifically, weight gain and acne were reported by a quarter of teenagers who stopped using the pill ( Pratt and Bachrach, 1987 ).

The COCP is the most effective method of contraception for sexually active adolescents. The big discrepancy between the theoretical efficacy (0.1%) and actual use (5–8%) of the pill reflects best versus poor compliance. Poor compliance may be a result of personal fears and perceptions of COCP. Misconceptions and incorrect beliefs may preclude its wide use among teenagers, and lead to discontinuation and increased risk of unwanted pregnancies.

We sought to compare teenagers' incorrect attitudes towards COCP between COCP users (past or current) and non-users, speculating that repeated interaction of COCP users with care givers would abate misconceptions and contribute to expanding knowledge of the patients. We also investigated the prevalence of the same misconceptions about the pill among COCP-prescribing physicians.

Materials and Methods

This was a cross-sectional survey conducted between October 2003 and October 2005 at clinics situated in higher social status communities and affiliated with Hadassah University medical center. Adolescent girls ( n = 254) visiting gynecological clinics and opting for oral contraception were recruited into the study. Inclusion criteria were high school education. Exclusion criteria were reasons other than contraception for taking the pill, such as dysmenorrhea, menorrhagia, irregular cycle, acne vulgaris and hirsutism. Information about past or present COCP use and views of COCP were recorded by employing a ten-question YES/NO questionnaire, constructed by the researchers (Table  I ). Four groups of misconceptions were presented regarding body image, potential side effects, future health risks and method of use. The option of ‘do not know’ was offered as well. A similar questionnaire was offered to 114 Israeli physicians specializing in Obstetrics, Gynecology and Reproductive Endocrinology. The prevalence of a misconception was estimated by the number of wrong answers, whereas the prevalence of uncertainty was determined by the number of subjects responding with ‘do not know’.

Table I.

The original ten-question YES/NO questionnaire, constructed by the researchers to investigate common misconceptions about the COCP

 Question Yes No Do not know 
Body image Does COCP usually cause significant weight gain?    
 Does COCP usually increase appetite?    
 Does COCP usually increase facial acne pimples and body hair?    
Side effects May COCP affect sexual desire?    
 Does COCP usually influence mood?    
Future health risks Does COCP use during adolescence significantly increase breast cancer risk?    
 Does COCP usually cause future infertility?    
 Is COCP dangerous to your health?    
Method of use Can adolescent smokers safely use COCP?    
 Should COCP be stopped every now and then to clean the body?    
 Question Yes No Do not know 
Body image Does COCP usually cause significant weight gain?    
 Does COCP usually increase appetite?    
 Does COCP usually increase facial acne pimples and body hair?    
Side effects May COCP affect sexual desire?    
 Does COCP usually influence mood?    
Future health risks Does COCP use during adolescence significantly increase breast cancer risk?    
 Does COCP usually cause future infertility?    
 Is COCP dangerous to your health?    
Method of use Can adolescent smokers safely use COCP?    
 Should COCP be stopped every now and then to clean the body?    

Statistical analysis

Student' t -test to compare proportions was performed in order to compare prevalence of incorrect answers between COCP users and non-users. Categorical demographic variables of physicians were analysed by chi square test. Misconception score (MS) and uncertainty score (US) were calculated for COCP non-users, current/past-users and physicians using the following formula: MS was the average of incorrect answers, and US was the average of ‘do not know’ replies. Scores comparison between duration of use groups was done using a one way analysis of variance. Data are presented as mean ± SD. A value of P < 0.05 was considered significant.

Results

Two hundred and fifty-four teenagers, aged 14–20 years (17.6 ± 1.6) participated in the study. About half (54.3%) of the subjects were either past or present COCP users ( n = 138). COCP duration of use ranged from one month to 4 years. The mean age of COCP users was 18 ± 1.4 years and 17.1 ± 1.6 years for non-users ( P < 0.0001). Overall, the average of incorrect beliefs was high in the whole study group (MS 4.1), and similar in both COCP non-users and current or past users (MS 4.1 versus 4.2, respectively) (Table  II ). The distribution of MS among teenagers shows that the majority of interviewees had 2–6 out of 10 misconceptions (Fig.  1 ). The prevalence of every misconception was similar between COCP non-users and past/current users, apart from future fertility which was believed to be impaired by the pill by significantly more COCP users than non-users (Table  III ).

Figure 1:

The distribution of misconception and uncertainty about the COCP among teenagers

The misconception score is the average of incorrect beliefs, and uncertainty score is the average of ‘do not know’ replies

Figure 1:

The distribution of misconception and uncertainty about the COCP among teenagers

The misconception score is the average of incorrect beliefs, and uncertainty score is the average of ‘do not know’ replies

Table II.

MS and US scores among COCP users and non-users

 Whole group COCP Non-user COCP user P -value  
MS 4.2 ± 1.9 4.2 ± 1.8 4.1 ± 2.0 0.5 
US 2.1 ± 1.9 2.1 ± 2.0 1.97 ± 1.8 0.5 
Proportion of wrong answers 6.3 ± 2.2 6.4 ± 2.1 6.1 ± 2.3 0.4 
 Whole group COCP Non-user COCP user P -value  
MS 4.2 ± 1.9 4.2 ± 1.8 4.1 ± 2.0 0.5 
US 2.1 ± 1.9 2.1 ± 2.0 1.97 ± 1.8 0.5 
Proportion of wrong answers 6.3 ± 2.2 6.4 ± 2.1 6.1 ± 2.3 0.4 

Data are presented as mean ± SD. MS, misconception score; US, uncertainty score.

Table III.

Prevalence of misconceptions of COCP among teenagers

 Misconception Whole group (%) COCP non-user (%) COCP user (%) P -value a Physician (%) P -value b 
Body image COCP causes weight gain 59.8 62.1 58 0.50 31 <0.0001 
 COCP causes increased appetite 47.6 47.3 47.8 0.93 49 0.85 
 COCP causes acne/hirsutism 32.4 32.2 32.6 0.94 14 <0.001 
Side effects COCP does not affect libido 60.9 66.1 56.6 0.12 23 <0.0001 
 COCP influences mood 55.7 57.1 54.4 0.66 41 <0.05 
Future health risks COCP increases breast cancer risk 32.7 34.5 31.2 0.57 22 0.1 
 COCP causes future infertility 28.7 22.4 34.1 0.03 <0.0001 
 COCP is dangerous to health 11 11.2 10.9 0.93 11 0.98 
Method of use Adolescent smokers cannot use COCP 42.5 41.2 43.5 0.71 24 <0.001 
 Required COCP breaks 40.7 40.9 40.6 0.96 <0.0001 
 Misconception Whole group (%) COCP non-user (%) COCP user (%) P -value a Physician (%) P -value b 
Body image COCP causes weight gain 59.8 62.1 58 0.50 31 <0.0001 
 COCP causes increased appetite 47.6 47.3 47.8 0.93 49 0.85 
 COCP causes acne/hirsutism 32.4 32.2 32.6 0.94 14 <0.001 
Side effects COCP does not affect libido 60.9 66.1 56.6 0.12 23 <0.0001 
 COCP influences mood 55.7 57.1 54.4 0.66 41 <0.05 
Future health risks COCP increases breast cancer risk 32.7 34.5 31.2 0.57 22 0.1 
 COCP causes future infertility 28.7 22.4 34.1 0.03 <0.0001 
 COCP is dangerous to health 11 11.2 10.9 0.93 11 0.98 
Method of use Adolescent smokers cannot use COCP 42.5 41.2 43.5 0.71 24 <0.001 
 Required COCP breaks 40.7 40.9 40.6 0.96 <0.0001 

a Comparison between COCP non-users versus COCP users. b Comparison between COCP users versus physicians.

Age did not serve as a confounding factor for all misconceptions. In relation to future fertility a logistic regression model analysis, including age and COCP use as covariates and the interaction between them, was performed. COCP use only was found to be significant (odds ratio = 1.7, 95% confidence interval 1.02–3.13). The prevalence of doubts regarding COCP (subjects who answered ‘do not know’) ranged from 13.8–27.8%. Overall, the average US was 2.1 in the whole study group, and similar in both COCP non-users and current or past users (US 2.1 versus 1.97, respectively) (Table  II ). The association between COCP use and acne/hirsutism was significantly clearer to subjects who had experience of using the COCP (Table  IV ) (Fig.  2 ). Analysis of the subset of subjects with known duration of COCP use ( n = 153) showed that duration of COCP use was not associated with declining prevalence of COCP misconceptions for body image ( P = 0.18), future health risks ( P = 0.56), method of use (Fig.  2 , P = 0.46) and side effects ( P = 0.18).

Figure 2:

The duration of COCP use was not associated with declining prevalence of COCP misconceptions

Figure 2:

The duration of COCP use was not associated with declining prevalence of COCP misconceptions

Table IV.

Prevalence of uncertainty of the health impacts of COCP among teenagers

 Misconception Whole group (%) COCP non-user (%) COCP user (%) P -value  
Body image COCP causes weight gain 13.8 16.4 11.6 0.27 
 COCP causes increased appetite 17.4 19.6 16.2 0.48 
 COCP causes acne/ hirsutism 15.4 21.7 10.1 0.01 
Side effects COCP does not affect libido 18.1 20.5 16.2 0.38 
 COCP influences mood 26.9 24.1 20.6 0.27 
Future health risks COCP increases breast cancer risk 28.7 30.2 27.5 0.63 
 COCP causes future infertility 22.2 27.6 23.2 0.50 
 COCP is dangerous to health 25.2 17.2 18.4 0.42 
Method of use Adolescent smokers cannot use COCP 18.1 41.2 43.5 0.80 
 Required COCP breaks 18.2 23.6 29.7 0.10 
 Misconception Whole group (%) COCP non-user (%) COCP user (%) P -value  
Body image COCP causes weight gain 13.8 16.4 11.6 0.27 
 COCP causes increased appetite 17.4 19.6 16.2 0.48 
 COCP causes acne/ hirsutism 15.4 21.7 10.1 0.01 
Side effects COCP does not affect libido 18.1 20.5 16.2 0.38 
 COCP influences mood 26.9 24.1 20.6 0.27 
Future health risks COCP increases breast cancer risk 28.7 30.2 27.5 0.63 
 COCP causes future infertility 22.2 27.6 23.2 0.50 
 COCP is dangerous to health 25.2 17.2 18.4 0.42 
Method of use Adolescent smokers cannot use COCP 18.1 41.2 43.5 0.80 
 Required COCP breaks 18.2 23.6 29.7 0.10 

Among the physicians interviewed the MS was 2.2, about half of that of the whole group of adolescents'. No differences in the prevalence of misconceptions were documented regarding the physician's age, gender, subspecialty, seniority and affiliation with an academic center. COCP-prescribing physiecians were significantly more knowledgeable about the pill than COCP users; however, they still held several disbeliefs much like their patients, e.g. COCP increases appetite and breast cancer risk and is dangerous to health (Table  III ).

Comment

Nine out of 10 sexually active teenagers use a contraceptive method, although not always consistently or correctly ( Piccinino and Mosher, 1998 ). The COCP is the method most frequently chosen by adolescent girls ( Polaneczky, 1998 ). However, this population holds many common misconceptions about the pill.

We investigated the doubts and the perception of knowledge about the pill by the prevalence of uncertainties and misconceptions in the teenage community. There is a major difference between the two in relation to risk behavior, as mistaken knowledge (misconception) can result in risk behavior while perceived lack of knowledge (uncertainty) may not. The MS in this study represents erroneous perceived knowledge about hormonal contraceptives, regarding various side effects, future health hazards and method of use. Thus, incorrect knowledge about the accurate use of COCP, its side effects and future health hazards may enhance COCP discontinuation and an unintended pregnancy.

We sought to study the misconception profile during adolescence because adolescents score higher than adults on personality measures associated with risk taking. They are more vulnerable to peer pressure and typically conform to a particular way of acting or thinking ( Brown et al ., 1986 ). Although peer pressure is a key aspect of normal adolescent development, it has been found to be a strong predictor of risk behaviors and potential psychosocial difficulties ( Darcy et al ., 2000 ). Peer influence has also been found to be an important factor in sexual attitudes and contraceptive behavior ( Mirande, 1968 ; Shah and Zelnick 1986 ). At this age, peers influence adolescent contraceptive use in various ways: by modeling pill use; by shaping norms, attitudes and values; and by providing a discussion and support group for COCP users. The debut of sexual intercourse is frequently associated with negative feelings such as anxiety, shame, discomfort, inadequacy and isolation that may be instrumental in motivating young individuals to conform ( Lashbrook, 2000 ).

To our knowledge, the misconception profile of this unique study group has rarely been fully characterized. The subjects in our study have come to the clinic intentionally for contraception counseling and to acquire information about birth control, thus they were highly motivated to use COCP. Engagement in information acquisition activities should have increased their perceived knowledge about the pill. These subjects were high school-educated, sexually active young women who were expected to have higher levels of knowledge about the pill, originating from school sexuality education, medical counseling and peer communication. Nevertheless, exceedingly high levels of misconceptions of COCP were found in this highly selective study group. Moreover, knowledge of the pill was not enhanced with the COCP duration of use. On the contrary, concerns about future fertility were even more prevalent among COCP users than non-users, and doubts regarding the impact of the pill on acne and hirsutism have settled in COCP users probably on the basis of personal experience. COCP in Israel can be used by a teenager (a minor) without notification of her parents or guardians; this adds another alarming aspect to adolescent ignorance.

Of all potential sources of information about the pill, we chose to investigate the COCP-prescribing physicians. Previous studies showed that 51–65% of the patients' information about birth control and its side effects came from medical sources ( Goldfield and Neinstein, 1985 ; Oddens et al ., 1994 ). A lower prevalence of misconceptions was unveiled within the group of physicians compared with COCP users, showing some specific lack of knowledge of the pill in the physicians' community as well as insufficient communication between the caring physician and the patient.

In agreement with former reports ( Greydanus et al ., 2001 ; Ekstrand et al ., 2005 ) discrepancies were evident between adolescent perceptions of weight gain, acne, hirsutism, depression, breast cancer and future infertility risk with use of the COCP and the available scientific evidence.

Misconceptions of body image

Body image is a major concern during adolescence ( Feingold and Mazzella, 1998 ). In a Canadian survey studying concerns of the teenage population, overweight and acne were reported as most worrying to teenagers ( Feldman et al ., 1986 ). In girls, overweight is associated with negative self-esteem, negative mood and anxiety. Moreover, girls appear to be immersed in a subculture where the importance of being slender is emphasized, and where there are frequent discussions about weight loss behaviors ( Moreno and Thelen, 1995 ; Mukai, 1996 ; Paxton, 1996 ). Peer teasing has been found to be related to body dissatisfaction among girls ( Levine et al ., 1994 ; Wertheim et al ., 1997 ). Likewise, acne vulgaris can cause psychosocial health problems including depression, suicidal ideation, anxiety and psychosomatic symptoms, such as pain and discomfort, embarrassment and social inhibition ( Tan, 2004 ).

Weight gain

Our study corroborates others who cited weight gain as a major problem with COCP use ( Gupta, 2000 ). We found exceedingly high prevalence (60%) of teenagers who believed that COCP causes weight gain by increasing appetite, as cited by half of both patients and clinicians. Yet, studies of the low-dose preparations fail to demonstrate a significant weight gain with COCP, with no differences among the various products. As an obvious misconception, weight gain was similar in COCP-treated and placebo groups ( Tan, 2004 ). Slight fluid retention due to the stimulation of renin–angiotensin mechanism by the COCP may account for up to 1–2 kg in about 30% of COCP users. Teenagers gain some weight as they grow, whether they take COCP or not ( Speroff and Fritz, 2005 ).

Acne

One-third of adolescent girls and 14% of physicians believed that COCP actually causes acne and/or hirsutism. In fact, low-dose COCP improves acne regardless of which product is used. The current progestin doses (including the most androgenic levonorgestrel formulations) are usually insufficient to stimulate an androgenic response and provide effective treatment for acne and hirsutism ( Speroff and Fritz, 2005 ).

Misconceptions of future health

Breast cancer

Concern over the relation between COCP use and breast cancer continues to be an issue in the minds of both patients and clinicians ( Goldfield and Neinstein, 1985 ). In our study, one-third of COCP users and a one-fifth of COCP-prescribing physicians believed that the COCP increases breast cancer risk. Indeed, women who began COCP use as teenagers had a 20% statistically significant increased relative risk of breast cancer but ≥10 years after stopping COCP use, there was no increased risk of breast cancer ( Speroff and Fritz, 2005 ). There was no effect of past use or duration of COCP use on the risk of breast cancer, and there was no evidence indicating that a higher dose of COCP increased the risk of breast cancer. Overall, even though the data indicated that young women who begin use before age 20 years have higher relative risks of breast cancer during current use and in the 5 years after stopping, adolescence is a time period when breast cancer is very rare; and, thus there would be only very little impact on the actual numbers of breast cancers, and no major impact on incidence figures ( Speroff and Fritz, 2005 ).

COCP and future reproduction

A major difference in opinion between physicians and teenagers was found in respect of the impact of the pill on future fertility (0 versus 34.1%, respectively, P < 0.0001). Reproduction after discontinuing COCP was once thought to be delayed in early British and American studies using older, higher dose COCP products ( Vessey et al ., 1978 ; Speroff and Fritz, 2005 ). The delay in achieving a pregnancy was presumably due to lingering suppression of the hypothalamic–pituitary reproductive system. Despite the reproductive delay, there was no evidence that infertility was increased by the use of COCP ( Bracken et al ., 1990 ). In fact, in young women, previous COCP use is associated with a lower risk of primary infertility ( Bagwell et al ., 1995 ; Farrow et al ., 2002 ). This opinion discrepancy between physicians and teenagers may point to a lack of informative communication between the physician and the COCP user ( Speroff and Fritz, 2005 ).

Surprisingly, future fertility was believed to be impaired by pill use by significantly more COCP users than non-users (Table  III ). This was the only misconception that prevailed among more COCP users than non-users. This could be explained by higher awareness of potential future reproduction risks when actually taking the pill. Still startling is the finding that although this group of adolescents feared more about potential future infertility, they continued using the pill. The present loss (of unintended pregnancy) might have been more realistic than the possible reproduction loss in the future. Denial may serve as the mechanism that enables these adolescents to continue to take COCP. In this regard, COCP users are perceived as ‘risk takers’ when they engage in behaviors that are potentially detrimental to their future health and wellbeing by their own belief.

COCP and general health

One-tenth of both patients and clinicians thought that COCP is dangerous to health. This is a surprisingly high prevalence of mistrust in a drug with a known risk/benefit ratio within a group of highly-motivated patients, and an alarming accusation of a drug, which is used to avoid a pregnancy, a hazardous condition by itself. The impact of the pill on general health is multi-faceted ( Speroff and Fritz, 2005 ); apart from the prevention of unintended pregnancy and induced abortion, COCP (i) regulates irregular cycles, prevents dysmenorrhea and iron deficiency anemia; (ii) decreases the prevalence of pelvic inflammatory disease and ensuing salpingitis and tubal infertility; (iii) reduces the risk of endometrial and ovarian cancers; (iv) reduces the occurrence of ovarian cysts and endometriosis and (v) increases bone density. These benefits were not indicated in our study group as pivotal to COCP use or initiation. However, they should be discussed with the patients as much as COCP risks.

Misconceptions of method of use

Pill-free intervals

Another great divergence between physicians and teenagers was disclosed on this subject, as the vast majority of doctors knew that there was no rationale for recommending a pill-free interval ‘to rest’ or ‘to clean the body of hormones’, while about 40% of adolescents still believed so. This practice is especially risky because it often results in unintended pregnancies. This discrepancy is another example of a lack of informative communication between the physician and the COCP user.

Smoking

COCP is contraindicated in smokers over the age of 35 because of the increased relative risk of cardiovascular events in women who smoke and use COCP; however, the actual incidence of cardiovascular events is so low at adolescence that the real risk is very low to non-existent in these young women. Surprisingly, roughly a quarter of physicians would have withheld the most effective method of contraception from smoking teenagers.

Misconceptions of side effects

Mood

Low-dose COCP has minimal, if any effect on mood ( Speroff and Fritz, 2005 ). Still more than half of interviewees and 40% of physicians thought that COCP has a deleterious impact on mood.

Libido

Conflicting evidence exists in regards to the possible association between prolonged COCP use and decreased libido. Increased level of sex-hormone-binding globulin as a result of the estrogenic component of the COCP, may lead to low free testosterone levels allegedly associated with poor sexual function and decreased desire ( Bancroft and Sartorius, 1990 ). This potential risk was unknown to two-thirds of teenagers. Even though 77% of physicians suspected the association, this information did not reach over half of COCP users. The lack of effective physician–patient dialogue may be due to the general reluctance among adults to discuss sexuality with teens and the taboo about female sexual desire. COCP users should be warned about the possible impact of COCP on libido in order to address this issue when relevant with the COCP-prescribing physician.

Sexually active teenagers are a high-risk population for an unintended pregnancy. In this study, we showed that the adolescent population is generally ignorant about the pill. We suggest that sexuality education in high schools includes accurate information about COCP and focuses on common perceptions and beliefs. Strategies should be explored for preventing the spread of misinformation to adolescents by family, peers and medical caregivers ( Eisenberg et al ., 2004 ). Sexuality education to groups of adolescents could abate specific misconceptions that are reinforced by peers. Erroneous opinions of the COCP influence personal use and lead to discontinuation. Gynecologists and other health care providers comprise 65% of conveyers of contraceptive information ( Oddens et al ., 1994 ). Our study showed that COCP-prescribing physicians hold significant incorrect opinions of the pill. Additionally, past and current COCP using adolescents still hold unreal perceptions of a causal relation between COCP use and various health issues, reflecting either incomplete knowledge of physicians or lack of effective physician–patient dialogue. Follow-up visits of COCP users should be reserved to discuss the benefits and limits of the pill with the physician ( Nelson, 1996 ). Questions regarding side effects should be answered clearly and accurately by medical personnel. The key to providing contraception to the teenage population is effective communication between the teenager and the most knowledgeable physician. Such a dialogue may improve compliance, minimize anxiety and contribute to reducing unwanted pregnancy rates in this age group.

Acknowledgements

The authors wish to thank Debra S. Goldman-Wohl, PhD for her linguistic assistance.

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