Knowledge, attitudes, and practices regarding prostate cancer and early screening among middle-aged and elderly Chinese men: a cross-sectional study

Introduction

Prostate cancer, a prevalent malignancy affecting men worldwide, has become increasingly common, as evidenced by the rising incidence rates globally (1). Approximately 1 in 8 men is expected to receive a prostate cancer diagnosis during their lifetime, with over 400,000 men currently living with or beyond the disease, underscoring its substantial impact on male health (2). Global cancer statistics from 2020 highlight the prominence of prostate cancer, ranking it among the top three cancers in both morbidity and mortality for men (3). In Asian countries, including China, prostate cancer incidence has historically been lower than in Western populations but has shown a steady increase in recent years, largely due to population aging and improved detection. According to GLOBOCAN 2020, prostate cancer ranks among the top ten cancers for Chinese men, and its incidence continues to rise annually. Prostate cancer is the leading cause of new cases and the second leading cause of male cancer-related deaths (4). This surge in prostate cancer cases has heightened the urgency of addressing this significant public health concern (5). The increasing incidence is partially attributed to heightened awareness and the greater uptake of prostate cancer screening (6). However, evidence regarding the uptake of prostate cancer screening among Chinese men, particularly those who are middle-aged and elderly, remains limited, highlighting the need for population-specific data. Early screening, using methods such as serum prostate-specific antigen (PSA) testing and magnetic resonance imaging (MRI), has become a crucial strategy in reducing the morbidity and mortality associated with prostate cancer. Digital rectal examination (DRE), while historically recommended, remains controversial due to men’s frequent reluctance to undergo this procedure (7). In addition, in line with recent trends noted by international experts, DRE has been gradually falling out of favor in several Western countries, where the emphasis is shifting toward multiparametric MRI and emerging artificial intelligence (AI)-assisted imaging techniques for early prostate cancer detection. Our study specifically examines men’s perceptions and attitudes toward DRE in addition to other screening methods. This underscores the importance of proactive screening measures in enhancing early detection and facilitating timely intervention for those at risk of prostate cancer.

Understanding individuals’ awareness, attitudes, and behaviours regarding prostate cancer and its early screening is essential, with knowledge, attitudes, and practices (KAP) serving as fundamental dimensions for exploring these dynamics. Structured survey methods for KAP assessments provide a systematic framework to examine the nuanced aspects of men’s perceptions and actions related to prostate cancer. These studies are integral for investigating individuals’ understanding, perceptions, and behaviours on specific health-related topics and are valuable tools in this regard (8). Grounded in health literacy principles, the model suggests that knowledge positively influences attitudes, which, in turn, shape individual practices (9). This approach aids in identifying public understanding of prostate cancer, as well as attitudes and behaviors towards screening and preventive measures. It supports the implementation of more effective awareness campaigns to increase public attention and awareness. Furthermore, this model helps identify factors hindering early screening and offers actionable recommendations for improvement. Given that prostate cancer is a common malignant tumour in the urinary system, especially among middle-aged and elderly males, with high incidence and mortality rates, focusing on KAP studies in this demographic is crucial. Such research is vital for understanding and addressing the specific needs and awareness levels of this age group, ultimately contributing to the development of more effective prevention, diagnosis, and treatment strategies for prostate cancer.

Despite the recognized importance of prostate cancer screening, research on KAP regarding prostate cancer screening among Asian populations, particularly in China, remains limited. This study therefore aims to address this critical gap in the existing research knowledge base. Most existing studies have focused on Western populations, with fewer investigations specifically examining the cultural and demographic factors that influence Chinese men’s attitudes and practices toward prostate cancer screening. This gap in knowledge is particularly significant given the cultural barriers and healthcare system differences that may affect screening behaviors in Asian contexts. Cultural perceptions, embarrassment associated with DRE, limited awareness campaigns, and unequal access to specialized medical resources represent major barriers to prostate cancer screening uptake in many Asian populations, including China. Prostate cancer has shown a gradual increase in incidence among Asian men in recent years, reflecting changes in aging demographics and lifestyle patterns. However, awareness and screening participation remain relatively low, often hindered by limited health education, embarrassment related to DRE, and restricted access to screening services. Therefore, there is a clear need for targeted research to understand the specific KAP patterns among middle-aged and elderly Chinese men and to develop culturally appropriate interventions for this population.

Although several studies have explored KAP regarding prostate cancer screening globally, research focusing on Chinese or broader Asian male populations remains limited. Existing studies in Asia often concentrate on cervical or breast cancer KAP, with few addressing prostate cancer specifically. Additionally, most current studies do not provide a detailed analysis of how KAP interact among middle-aged and elderly men. This gap underscores the importance and necessity of this study to provide evidence-based data for designing targeted educational and screening strategies in China.

Informed by the KAP framework and health behavior models such as the Health Belief Model and the Theory of Planned Behavior, it is generally posited that knowledge shapes attitudes, which in turn influence health practices. This rationale provides theoretical support for applying mediation analysis to examine potential pathways from knowledge to practice through attitudes in the context of prostate cancer screening (8-10). In response to the global prevalence of prostate cancer and the lack of targeted research in this area, this study aims to investigate the KAP of the middle-aged and elderly male population regarding prostate cancer and early screening. The ultimate goal is to enhance public health strategies by promoting informed decision-making and proactive involvement in prostate cancer awareness and timely screening. We present this article in accordance with the SURGE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-503/rc).

Methods

Study design and participants

This cross-sectional study, conducted between September and November 2023, employed convenience sampling to select middle-aged and elderly male participants who visited the urologic surgery clinic and voluntarily agreed to participate. The inclusion criteria were individuals aged ≥35 years with the capacity to provide informed consent. Exclusion criteria included individuals who did not consent to participate. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the First People’s Hospital of Changzhou (No. 2023-166), and written informed consent was obtained from all participants.

Procedures

This questionnaire was self-developed based on the KAP theoretical framework, as no validated KAP instruments specifically addressing prostate cancer or PSA screening were identified in the existing literature. Similar KAP studies on cancer prevention and screening have commonly employed self-designed questionnaires tailored to their research contexts. A survey using a self-designed questionnaire was administered to a sample of middle-aged and elderly males. The design of the questionnaire was informed by the National Comprehensive Cancer Network (NCCN) Guidelines 2017, 2nd Edition, Prostate Cancer MS-11, the NCCN Guidelines 2019, 2nd Edition, Early Detection of Prostate Cancer MS-12, and relevant literature (10). The questionnaire was revised based on feedback from three experts: two chief physicians from the Department of Oncology and one chief physician from the Department of Urology, all of whom are professors and doctoral supervisors. A pilot study involving 54 responses was conducted, with the reliability test yielding a Cronbach’s α of 0.884, with Cronbach’s α coefficients of 0.938, 0.700, and 0.808 for the KAP domains, respectively. indicating strong internal consistency. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.914 (P<0.001), indicating excellent suitability for factor analysis. Furthermore, validity analysis is currently being supplemented to strengthen the psychometric evaluation: root mean square error of approximation (RMSEA) =0.076, incremental fit index (IFI) =0.916, Tucker-Lewis index (TLI) =0.901, comparative fit index (CFI) =0.916.

The final questionnaire, administered in Chinese, included four dimensions of information collection, comprising a total of 38 items. Basic information comprised 14 items. The knowledge dimension included 10 items, with a scoring system where “very familiar” was assigned 2 points, “heard about it” 1 point, and “not sure” 0 points. The possible score range was 0–20 points, with a score exceeding 70% of the total indicating good knowledge. The attitude dimension comprised 7 items, rated on a five-point Likert scale. Items 4, 5, 6, and 7 were scored from 5 to 1 point, while items 1, 2, and 3 were scored from 1 to 5 points. The possible score range was 7–35 points, with scores from 7–18 indicating a negative attitude, 19–25 a neutral attitude, and 26–35 a positive attitude. The practice dimension also included 7 items, rated on a five-point Likert scale, with scores ranging from 5 to 1 point. The possible score range was 7–35 points, with scores from 7–18 indicating negative practices, 19–25 representing moderate practices, and 26–35 indicating positive practices.

To facilitate questionnaire distribution, the WeChat-based “Sojump (https://www.wjx.cn/)” Mini Program was used to create an online survey and generate QR codes for seamless data collection. Participants scanned the QR code, logged in via WeChat, and completed the questionnaire. Quality assurance measures included allowing each IP address to submit only once, making all items mandatory, and setting a response time threshold of less than 60 seconds. The research team carefully assessed the completeness, internal coherence, and reasonableness of all responses. Questionnaires with illogical responses or uniform answers across KAP sections were deemed invalid.

For participants unfamiliar with WeChat, paper questionnaires were provided. The questionnaire was designed with neutral and objective language to avoid bias, and concise to prevent participant fatigue or loss of interest.

Throughout the questionnaire completion process, professional researchers provided additional explanations to participants who encountered difficulties, ensuring a clear understanding of the questionnaire’s purpose, questions, and options. All explanations were delivered following standardized written guidance, and all investigators received prior training to minimize variability and reduce interviewer bias. Three additional research assistants, graduate students, and residents in medical oncology, with solid professional knowledge of prostate cancer, were prepared for the investigation. They were professionally trained by the study sponsors to consistently provide accurate answers to participants’ queries.

Upon collection, each questionnaire was thoroughly reviewed by research assistants and researchers to ensure data integrity. Any ambiguous questionnaires were discussed to determine their inclusion in the study. Contact information for all participants was retained for potential follow-up. During data cleaning, the following criteria were used to classify a questionnaire as invalid: (I) lack of consent; (II) response time less than 60 seconds; (III) participants aged under 18 years; (IV) illogical answers; (V) incomplete responses to necessary information; and (VI) selecting the same option for all questions in any section of the questionnaire.

Sample size calculation

Sample size was calculated using the formula for cross-sectional studies: α =0.05, n=(z1−α/2δ)2×p×(1−p), where z1−α/2=1.96 when α =0.05, the assumed degree of variability of P=0.5 maximises the required sample size, and δ is admissible error (which was 5% here). The theoretical sample size was 480 which includes an extra 20% to allow for subjects lost during the study.

Statistical analysis

Statistical analysis was performed using SPSS 26.0 (IBM Corp, Armonk, NY, USA). Structural equation modelling (SEM) was used to examine the theoretical relationships among variables. Descriptive statistics, including mean ± standard deviation, were used for quantitative variables, while inter-group comparisons were conducted using analysis of variance (ANOVA). Categorical variables were described by frequencies and percentages. Chi-squared and Fisher’s exact tests were used for comparisons in the knowledge and attitude sections. SEM and mediation analysis were employed to investigate the relationships between sociodemographic data and KAP, as well as the pathways among individual KAP components. All statistical tests were two-tailed, with a P value of less than 0.05 considered statistically significant. Based on the KAP framework and established health behavior theories, we hypothesized that knowledge may exert both direct and indirect effects on practice through attitudes. Therefore, SEM with mediation analysis was employed to test these theoretical pathways.

Results

Demographic characteristics

Initially, a total of 616 responses were collected. After data cleaning, 518 valid questionnaires remained. The mean age of participants was 59.47±14.84 years. Among them, 241 (46.53%) had prostate disease, 79 (15.25%) had prostate cancer, 250 (48.26%) had undergone early screening for prostate cancer, and 100 (19.31%) had a relative with prostate disease or prostate cancer. The mean scores for KAP were 7.58±5.67 (possible range, 0–20), 25.27±2.27 (possible range, 7–35), and 26.11±3.94 (possible range, 7–35), respectively. Analysis of sociodemographic characteristics revealed that participants with a high school or technical school education had higher knowledge and attitude scores (P=0.001 and P<0.001), while those with a junior high school education had higher practice scores (P<0.001). Participants who were married and had children also had higher practice scores (both P<0.001). Additionally, unemployed individuals (both P<0.001), those with prostate disease (both P<0.001), and those who had previously undergone prostate cancer screening (both P<0.001) were more likely to have higher knowledge and practice scores, which may be partly attributed to their prior exposure to health information and clinical guidance during screening visits. Moreover, individuals with prostate cancer (all P<0.001) and those with a family history of prostate disease or cancer (P<0.001, P<0.001, and P=0.01) had higher KAP scores (Table 1).

KAP dimensions

The two questions with the highest number of participants selecting “Very familiar” or “Heard of” were: “The incidence of prostate cancer is higher in elderly men and those with a family history” (K3) with 90.16%, and “Prostate cancer can cause complications such as difficulty urinating and diminished sexual function” (K1) with 78.38%. Conversely, the two questions with the highest number of participants selecting “Unclear” were: “Dietary habits that primarily include meat and dairy products may increase the risk of prostate cancer compared to diets mainly consisting of rice, soy products, and vegetables” (K4) with 60.04%, and “Obesity increases the risk of prostate cancer” (K5) with 59.85% (Table S1). Regarding attitudes towards prostate conditions, 43.63% expressed feelings of worry, fear, and anxiety about prostate cancer (A1). Additionally, 54.63% did not perceive DRE as shameful (A3). Furthermore, 76.83% and 73.36% respectively agreed on the importance of early screening (A4) and the necessity for regular early screening in high-risk groups (A5). Notably, 46.33% believed that hospitals did not provide sufficient education about early screening for prostate cancer (A7) (Table S2). In terms of practice, participants showed limited engagement in acquiring relevant knowledge (P1) and participating in early screening activities (P6), with only 29.34% and 31.27% frequently engaging in these practices, respectively. Conversely, a more proactive approach was observed in other areas, with 69.69% frequently paying attention to dietary nutrition and balance (P2), 71.24% maintaining a positive and optimistic mindset (P3), and 70.08% frequently attending to rest and personal hygiene (P4) (Table S3).

Pearson correlation analysis

In the Pearson correlation analysis, significant positive correlations were found between knowledge and attitude (r=0.369, P<0.001) and between knowledge and practice (r=0.207, P<0.001) (Table S4). The 70% of the highest scores for the practice dimensions were used as the cut-off value to divided the groups, and the number of participants above the cut-off value was 333 (64.29%).

Multivariate logistic regression analysis

Multivariate logistic regression showed that knowledge score [odds ratio (OR) =1.066; 95% confidence interval (CI): 1.010–1.124; P=0.02], currently smoking (OR =1.972; 95% CI: 1.087–3.578; P=0.03), and with previous prostate cancer early screening (OR =0.235; 95% CI: 0.142–0.391; P<0.001) were independently associated with proactive practice (Table S5).

SEM and mediation analysis

The SEM and mediation analysis, as illustrated in Table S6 and Figure 1, along with the assessment of direct and indirect effects (Table 2), revealed that knowledge directly impacts both attitude (r=0.154, P<0.001) and practice (r=0.203, P<0.001). No discernible indirect effect of knowledge on practice was observed. Additionally, neither the direct nor indirect effects between attitude and practice were found to be statistically significant.

Figure 1 Mediation analysis based on structural equation modelling.

Discussion

The study reveals that middle-aged and elderly men exhibit insufficient knowledge, while showing positive attitudes and proactive practices regarding prostate cancer and its early screening. Based on these findings, one of the most urgent targets for intervention is the insufficient hospital-based education about early prostate cancer screening, as nearly half of participants reported a lack of such information. Strengthening hospital-led health education should therefore be prioritized, alongside efforts to highlight dietary risks and address common misconceptions. Such interventions aim to enhance overall knowledge and encourage proactive practices among middle-aged and elderly men concerning prostate cancer and early screening. Furthermore, the multivariate logistic regression analysis revealed that knowledge score, current smoking status, and prior prostate cancer early screening experience were significantly associated with proactive preventive practices. This suggests that enhancing relevant knowledge not only increases the acceptance of early screening but also positively influences non-screening behaviors, particularly among individuals who currently smoke. Interestingly, the finding that current smoking status was associated with more proactive practice behaviors appears counterintuitive and contradictory to common public health understanding and previous literature. First, this association might be confounded by other factors not fully accounted for in the model, such as increased interactions with the healthcare system due to smoking-related comorbidities, which could lead to greater exposure to health education and screening promotion (11). Second, smokers may receive more frequent health warnings and check-ups, potentially motivating them to adopt certain preventive behaviors despite their continued smoking. Third, this result could also be due to random statistical variation or residual confounding that could not be completely eliminated in this cross-sectional analysis. Future studies should further explore this unexpected association using longitudinal designs and additional control variables to clarify the underlying mechanisms.

The findings underscore existing knowledge gaps among the middle-aged and elderly male population regarding prostate cancer and its early screening. Using the top 70% of scores in the practice dimension as a grouping standard further elucidated the roles of higher knowledge scores, current smoking, and previous screening experience in promoting proactive preventive behaviors. This data-driven grouping method supports the positive association between knowledge score and preventive behaviors, providing clearer evidence for future studies to adopt similar grouping standards and evaluation methods. Despite displaying positive attitudes and proactive practices, the identified knowledge deficits raise concerns about their potential impact on informed decision-making and preventive behaviours. This is consistent with prior research that highlights the critical role of knowledge in shaping participation in cancer screening (12). The logistic regression results from this study further validate the impact of knowledge scores on proactive preventive behaviors. The association between educational attainment and higher KAP scores aligns with established literature, where higher education is consistently linked to improved health-related knowledge and behaviours (13). Additionally, the distinct patterns observed in KAP scores related to smoking status and alcohol consumption emphasise the need for tailored interventions that consider lifestyle factors. Moreover, patients’ knowledge, attitudes, and especially practices are also shaped by the tendencies and approaches of their attending urologists. Prior research has documented differences in guideline adherence and practice patterns among urologists in various countries, highlighting the importance of physician-related factors in interpreting patient behaviors and designing interventions (14-16). These findings are consistent with studies recognising the influence of lifestyle choices on health-related knowledge and practices (17). Furthermore, participants with a history of prostate disease or cancer, and those who had undergone prior early screening, exhibited higher KAP scores. The multivariate logistic regression findings further support this association, revealing a significant influence of prior screening experience on preventive behaviors (P<0.001), particularly in positively affecting practice scores. This reaffirms the positive impact of personal health experiences and proactive screening practices on overall awareness and engagement, corroborating findings from other cancer-related studies (18,19).

The correlation and mediation analyses provide valuable insights into the relationships between KAP. The direct impact of knowledge on both attitude and practice underscores the central role of awareness in shaping individuals’ perceptions and behaviours related to prostate cancer. The lack of a discernible indirect effect between attitude and practice suggests that, in this context, attitudes may not significantly mediate the knowledge-to-practice pathway. Possible explanations for this include the influence of unconsidered factors directly affecting behaviour, the limited predictive power of attitudes, potential cognitive or emotional gaps, and context-specific influences (20-22). This finding challenges the traditional KAP framework, which posits a linear progression from knowledge to attitude and finally to practice. In the specific context of prostate cancer screening among middle-aged and elderly men, it is possible that practical knowledge and direct advice from physicians exert a more immediate influence on screening behaviors than subjective emotional attitudes such as fear or embarrassment. According to health belief models and theories of planned behavior, perceived benefits and cues to action (e.g., recommendations from healthcare providers) can have a stronger impact on preventive practices than attitudes alone. This suggests that targeted knowledge-based interventions and physician-led counseling might be more effective strategies for promoting proactive screening behaviors in this demographic, rather than relying solely on attitude change.

The findings offer important insights into the KAP of individuals regarding prostate cancer and its early screening. Participants demonstrated varying degrees of awareness, with a substantial proportion familiar with general concepts but exhibiting notable gaps in specific areas, such as dietary influences and diagnostic procedures. To address these knowledge gaps, targeted educational interventions should focus on clarifying misconceptions related to dietary habits and specific diagnostic procedures (23-26). Successful strategies in similar contexts, such as interactive workshops, informative pamphlets, and community awareness campaigns, can provide useful models for effective intervention (27,28).

In terms of attitudes, a range of sentiments was observed, from concerns and anxiety to misconceptions about the necessity of screening for different age groups. The emotional barriers and misconceptions identified in this study align with existing literature, which highlights the role of psychological factors in shaping attitudes towards cancer screening (29,30). The concerns about embarrassment and misconceptions related to screening for younger individuals underscore the need to address emotional barriers and provide accurate information. Efforts should focus on tackling these emotional barriers and misconceptions by implementing tailored interventions such as counselling services and community forums to facilitate open discussions and address concerns effectively (31-33).

Regarding practices, the survey revealed variations in proactive engagement in preventive behaviours related to prostate cancer. Significant gaps were identified in dietary adjustments and regular health check-ups, suggesting potential areas for targeted intervention. Practical guidance and tailored strategies are essential to address these gaps effectively. To translate positive attitudes into concrete practices, interventions should extend beyond mere knowledge dissemination, incorporating practical guidance on implementing preventive behaviours. Targeted strategies may include lifestyle coaching, community-based exercise programmes, and the integration of preventive practices into routine healthcare check-ups (12,34).

While the findings offer valuable insights, there are limitations in this study, including its single-centre focus, which may restrict the generalisability of the results to a broader population. Additionally, the cross-sectional design limits the ability to establish causal relationships. Furthermore, the use of convenience sampling might introduce selection bias, as participants who visit the urologic surgery clinic and agree to participate may have higher health awareness or different health-seeking behaviours compared to the general middle-aged and elderly male population. This potential bias may limit the representativeness of the sample and affect the generalizability of the findings. Moreover, despite efforts to standardize administration, the survey was conducted in a clinic setting, which carries a risk of the Hawthorne effect (social desirability bias), potentially leading to an overestimation of actual KAP levels. In addition, participants were recruited from the urologic surgery clinic rather than primary care settings. This decision was made to ensure recruitment feasibility, as patients attending the urology clinic were more concentrated, more likely to meet inclusion criteria, and could receive standardized explanations from trained investigators. However, we acknowledge that this approach may limit generalizability, as patients in primary care could provide a broader representation of the general male population. Another potential consideration is that some participants were prostate cancer patients. Another potential consideration is that some participants were prostate cancer patients. Their prior diagnosis and treatment experiences might have shaped their KAP, which could have influenced the overall findings. Future research may benefit from conducting stratified analyses or focusing on cancer-free populations to further validate these observations. Nonetheless, the study’s strengths—such as a substantial sample size, comprehensive questionnaire assessment, and rigorous statistical analyses, including correlation and mediation analysis—contribute valuable information to the existing literature. Despite these limitations, the study underscores the importance of targeted educational interventions to enhance awareness and understanding of prostate cancer among men.

Conclusions

In conclusion, the findings of this research reveal a significant gap in awareness and understanding of prostate cancer among middle-aged and elderly men, a demographic particularly susceptible to this disease. Despite generally positive attitudes and proactive engagement in early screening, there remains a notable deficit in knowledge. To address this gap, it is essential for healthcare professionals to prioritise and implement educational initiatives specifically designed for this age group. These interventions should focus on providing comprehensive information about prostate cancer, targeting specific misconceptions and addressing critical knowledge gaps unique to this demographic. A targeted and proactive educational approach is anticipated to substantially improve preventive practices and encourage early detection among middle-aged and elderly men. This, in turn, could lead to more favourable prostate health outcomes, highlighting the clinical importance of targeted awareness and education in managing and mitigating the impact of prostate cancer in this vulnerable population.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SURGE reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-503/rc

Data Sharing Statement: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-503/dss

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-503/prf

Funding: This study was supported by the Young Talent Development Plan of Changzhou Health Commission (No. 2020-045).

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-503/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Ethics Committee of the First People’s Hospital of Changzhou (No. 2023-166), and written informed consent was obtained from all participants.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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