Sexual risk factors for cervical cancer among rural Indian women: a case-control study

BACKGROUND

The association between sexual behaviour and cervical cancer is well established. Despite a high incidence of cervical cancer in India, its role has not been widely investigated in Indian women among whom the rate of sexual promiscuity is known to be very low. A hospital-based case-control study was carried out to investigate the role of sexual risk factors in cervical cancer among rural Indian women.

METHODS

A case-control design was used in which a total of 268 subjects, comprising 134 women with invasive cervical cancer as cases and 134 control women were studied. A multiple logistic regression model was used to analyse the data.

RESULTS

The risk factors found to be associated with cervical cancer were early age at first coitus, extramarital sex partners of women and the time interval since first exposure. In a multiple logistic regression model, independent effects were observed for early age at first coitus, showing maximum risk in women who reported their first intercourse at < 12 years of age, compared to that of women at > or = 18 years (odds ratio [OR] = 3.5. 95% confidence interval [CI]: 1.1-10.9). Increased risk was also seen for women who had extramarital sex relationships (OR = 5.5, 95% CI: 1.5-19.5). The significant effect of early age at first coitus persisted after adjustment for latency period which also showed its independent risk association with cervical cancer in the multivariate analysis.

CONCLUSION

These findings confirm the association between early age at first coitus and cervical cancer in women with a low rate of sexual promiscuity and define the role of these risk factors in cervical carcinogenesis among rural Indian women.

Adolescent girls' perceived prevalence of sexually transmitted diseases and condom use

Little is known concerning sexually experienced and inexperienced adolescent girls' perceptions of the prevalence of condom use and sexually transmitted diseases (STDs). Girls (n = 174; 41% sexually experienced) rated the prevalence of condom use among friends and STDs among male and female friends and adolescents in general. Girls perceive the prevalence of STDs similarly across both gender and level of familiarity. For the most part, however, the girls perceived the prevalence among boys and girls more similarly than among friends and adolescents in general. No significant differences were found between sexually experienced and inexperienced girls in perceptions of condom use prevalence, but girls with a history of STD perceived condoms as used less frequently. Girls with an STD history perceived STDs as the most prevalent, followed by sexually inexperienced girls and then sexually experienced girls without a history of an STD. After an adolescent girl initiates sexual intercourse, STD experience could be a key variable in affecting her perceptions. Prevention programs can incorporate an understanding of patients' perceptions of condom use and STDs.

Childhood sexual abuse and women's substance abuse: national survey findings

OBJECTIVE

Clinical studies have found elevated rates of childhood sexual abuse (CSA) in women seeking treatment for alcohol or drug abuse, and elevated rates of alcohol and drug disorders among female psychiatric patients with histories of CSA. The present study examines the relationship of CSA to women's use of alcohol and other drugs in a large, nationally representative sample of U.S. women.

METHOD

As part of a national survey of women's drinking, 1,099 women were asked about sexual experiences occurring before age 18. Women who reported sexual experiences classified as abusive were compared to women without histories of CSA on nine measures of substance use, self-perception of anxiousness, the occurrence of one or more lifetime depressive episodes, five measures of sexual dysfunction, and early onset of masturbation and consensual sexual intercourse.

RESULTS

Results of logit analyses, controlling for age, ethnicity and parental education, indicated that women with histories of CSA were significantly more likely than women without CSA histories to report recent alcohol use, intoxication, drinking-related problems and alcohol dependence symptoms; lifetime use of prescribed psychoactive drugs and illicit drugs; depression and anxiety; pain that prevented intercourse; and consensual sexual intercourse before age 15.

CONCLUSIONS

Findings from this U.S. national sample support those of previous clinical studies and suggest that women's experience of sexual abuse in childhood may be an important risk factor for later substance abuse, psychopathology and sexual dysfunction. Implications of these findings for future research, treatment and prevention are discussed.

Determination of factors associated with condom use among women infected with human immunodeficiency virus

To better understand potential barriers to condom use and the sexual behaviour of women infected with human immunodeficiency virus (HIV), an anonymous self-administered survey was performed on a convenience sample of 83 predominantly single HIV+ women. Most women had only one sexual partner who usually knew of the subject's serostatus. Only a minority of partners (26%) were known to also be HIV infected. Subjects were surprisingly more likely to use condoms with their main partner as opposed to other partners. Factors found to be associated with condom non-use included younger age, low education level, partner HIV+, history of a sexually transmitted disease (STD), and use of drugs or alcohol during sex. Although most subjects indicated the decision was mutual when deciding not to use a condom, 20% stated it a was a partner decision. Future intervention efforts should target these identified high-risk individuals and optimally involve the partners of HIV-infected women.

HIV infection and sexual behaviour among women with infertility in Tanzania: a hospital-based study

BACKGROUND

Infertility is common in Africa, but virtually no data exist on HIV prevalence among infertile women. Mainly anthropological studies in Africa have shown that infertile women have higher risks of marital instability and possibly also have more sexual partners than fertile women.

METHOD

This study was conducted in a hospital in northwest Tanzania during 1994 and 1995. Women presenting themselves with infertility problems to the outpatient clinic were interviewed, examined and blood was drawn. Women who came to deliver in the hospital, excluding primiparae, were taken as a control group. The analysis was limited to women > or = 24 years. In total 154 infertile and 259 fertile women were included in the study.

RESULTS

HIV prevalence was markedly higher among infertile women than among fertile women: 18.2% and 6.6% respectively (adjusted odds ratio [OR] for age, residence and occupation 2.7; 95%-confidence interval [CI]: 1.4-5.3). Data on past sexual behaviour showed that infertile women had more marital breakdowns, more lifetime sexual partners and a higher level of exposure to sexually transmitted diseases (STD).

CONCLUSION

Women with fertility problems appear to have higher HIV prevalence, which justifies more attention for such women in the context of AIDS programmes. In addition, caution is needed when using sentinel surveillance data from antenatal clinics to monitor HIV prevalence.

Sexual behaviour in a fishing community on Lake Victoria, Uganda

This study describes the sexual behaviour of men and women in a fishing village on the shores of Lake Victoria in southwest Uganda. The village is near a well known trading town-truckstop on the main trans-Africa highway with a high recorded prevalence of HIV infection. Data were obtained on the daily travel and sexual activities of 26 women and 54 men with particular attention paid to the rate of partner change and the proportion of sexual contacts with people outside the village. During a total of 587 person weeks the men made 1086 trips, mostly returning home the same day. They had a total of 1226 sexual contacts, most of which occurred either in their own village (83%) or a neighbouring fishing village (11%); 17 per cent of sexual contacts were with new partners. Fifteen of the women described themselves as married; 42 per cent of their sexual contacts were casual, paying partners. Of the eleven women who were single, between 80 and 100 per cent of contacts were with paying partners. Most of the women's partners were resident in the village. These data show a very high rate of sexual mixing within the village. Such communities should be targeted in future STD control programs.

Increasing condom use: evaluation of a theory-based intervention to prevent sexually transmitted diseases in young women

A multicomponent intervention to increase condom use in sexually active young women was designed, implemented, and evaluated in a randomized experiment. Participants were 198 unmarried female college students (mean age = 18.6 years) who received a 1-session condom promotion intervention or a control (stress management) intervention. The condom promotion intervention led to increased self-reported condom use up to 6 months following intervention as well as positive changes in perceived benefits of condom use, affective attitudes toward condom use and condom users, perceived acceptance of sexuality, control over the sexual encounter, perceived self-efficacy for condom use, and intentions to use condoms. Mediational analysis illustrated the mechanisms of the condom promotion intervention effects, linking psychological constructs affected by the intervention (perceived benefits, acceptance of sexuality, control over the sexual encounter, attitudes toward condoms, and self-efficacy for condom use) to condom use intentions.

Underlying factors in female sexual partner instability in Kampala

Divorced or separated persons are more likely to be infected with HIV than those in marital unions: sexual partner instability appears to have significant implications in STD/HIV transmission. While this appears empirically true, most current STD/HIV preventive strategies do not seem to address partner instability as an important underlying factor in STD/HIV transmission and control. This paper describes reasons why young females may be motivated to change sexual partners or have more than one sexual partner. The problems appear to be dissatisfaction due to infidelity of the male partner, fear of getting STD from current partner, drunken or unattractive male partner, economic problems, lack of leisure time together, male partner's children with other women, and male partner's relatives' influence. STD/AIDS Control Programs should note that dissatisfaction with partner may be an underlying factor in HIV transmission.

Increasing condom use: evaluation of a theory-based intervention to prevent sexually transmitted diseases in young women

A multicomponent intervention to increase condom use in sexually active young women was designed, implemented, and evaluated in a randomized experiment. Participants were 198 unmarried female college students (mean age = 18.6 years) who received a 1-session condom promotion intervention or a control (stress management) intervention. The condom promotion intervention led to increased self-reported condom use up to 6 months following intervention as well as positive changes in perceived benefits of condom use, affective attitudes toward condom use and condom users, perceived acceptance of sexuality, control over the sexual encounter, perceived self-efficacy for condom use, and intentions to use condoms. Mediational analysis illustrated the mechanisms of the condom promotion intervention effects, linking psychological constructs affected by the intervention (perceived benefits, acceptance of sexuality, control over the sexual encounter, attitudes toward condoms, and self-efficacy for condom use) to condom use intentions.

HIV sexual risk reduction interventions for women: a review

AIDS has emerged as a serious public health threat for women. Reducing the risk for HIV infection among sexually active women requires the adoption of preventive strategies that effectively inhibit viral transmission. However, there is a paucity of published literature describing interventions targeted toward women and even fewer published reports evaluating their effectiveness. We conducted a search of HIV prevention interventions for women using the MEDLINE, ERIC and PSYCHLIT on-line computer database for the years January 1984-May 1995 to assess the effectiveness of interventions in increasing condom use during sexual intercourse. Interventions efficacious at increasing condom use applied a social psychological model of behavior to guide the development and implementation of the intervention, used randomized controlled designs to evaluate program efficacy, emphasized gender-related influences, were peer-led, and used multiple intervention sessions. While these findings are promising, methodologic limitations preclude any definitive assessment of programmatic efficacy. One challenge for future studies is to corroborate and extend these findings using rigorous methodologic research designs to evaluate programmatic efficacy, in particular, longer follow-up to assess stability of treatment effects over time. Another challenge is to understand the implications of previous research for the development of more gender-relevant interventions. The urgency of the HIV epidemic demands that the development and evaluation of HIV-prevention interventions tailored toward women remain a public health priority. Medical Subject Headings (MeSH): women, HIV/AIDS, interventions, prevention.

Stage of behavior change for condom use: the influence of partner type, relationship and pregnancy factors

A theoretical model was used to examine the influence of relationship factors, pregnancy intentions, contraceptive behavior and other psychosocial characteristics on stages of behavior change in condom use among heterosexual black women of reproductive age. Data from an inner-city street survey compared women who were not contemplating condom use, women who were attempting to use condoms or had used them consistently for short periods of time, and those who had achieved long-term consistent use. Women's relationship with their main partner appears to be an important factor in understanding their use of condoms both with main partners and with other partners. For condom use with the main partner, factors such as emotional closeness and partner support were significant predictors of the likelihood that women would be attempting to use condoms rather than not contemplating use. Cohabitation and the belief that condom use builds trust were significant predictors of long-term consistent condom use. Having a regular or main partner was strongly associated with intentions to use condoms with other partners. Women who wanted to become pregnant were much less likely to intend to use condoms with their main partner, and women using oral contraceptives were less likely to be long-term consistent condom users.

Validation of measures of condom and other contraceptive use among women at high risk for HIV infection and unintended pregnancy

This study assessed the applicability of the transtheoretical model of behavior change (J.O. Prochaska & C.C. DiClemente, 1983, 1984) to the measurement of contraceptive use among 296 women at high risk for HIV infection and transmission. Structural equation modeling suggested that a measure of general contraceptive use could be used to assess use of oral contraceptives and hormonal implants but that measurement of condom use required separate assessments for main and other partners. Self-efficacy (SE) and decisional balance scales were internally consistent for general contraceptive use, for condom use with main partners, and for condom use with other partners. Consistent with research on other health behaviors, SE scores rose significantly across stages, from precontemplation to maintenance, and a shift in decisional balance was observed for 2 of 3 behaviors. This measurement strategy may enhance the ability to evaluate prevention programs for women at risk.

Sexual behavior in pregnancy among Hong Kong Chinese women

Sexual behavior during pregnancy was examined in a retrospective study of 150 Hong Kong Chinese women interviewed in the immediate postpartum period. Sexual activity was found to decline abruptly during the first trimester of pregnancy, and continued to decrease in frequency as the pregnancy advanced. The frequency of intercourse was lower both before and during pregnancy than has been reported in similar studies among Western populations. There was no consistent relationship between age, parity, level of education, or employment status and sexual behavior either before or during pregnancy. These results suggest that a relatively conservative attitude toward sexual activity persists within this population.

Oral contraceptives and sexuality in university women

The relationship between use of oral contraceptives and sexuality in university women who completed the McCoy Female Sexuality Questionnaire was examined. Pill users reported sexual intercourse earlier, were less likely to be virgins, more likely to have a sex partner, more apt to be engaging in petting and intercourse than nonusers, and reported more frequent intercourse than sexually active nonusers. Nonusers reported a greater frequency and enjoyment of anal intercourse than pill users. The prediction that pill users would have less vaginal lubrication than nonusers was supported. Contrary to prediction, pill users reported a higher frequency of sexual thoughts and fantasies, and level of sexual interest than active nonusers. Triphasic Orthonovum 7/7/7 (OR7/7/7) users reported more sexual thoughts and fantasies and had higher Sexual Interest (Factor 1) scores than monophasic Orthonovum 1/35 (OR1/35) users. Triphasic users as a group enjoyed sexual activity more, were more aroused during sexual activity, and had higher Sexual Interest factor scores than monophasic users. Triphasic users reported more sexual thoughts and fantasies, sexual interest and had higher Sexual Interest factor scores than nonusers, while monophasic users did not. Monophasic users reported less vaginal lubrication than nonusers, whereas triphasic users did not. Comparisons of OR7/7/7 and OR1/35 users with nonusers revealed the same findings. Results suggest that women using triphasic pills experience greater sexual interest and response than those using monophasics. Possible reasons for these differences are discussed.

Sexual health and use of condoms among local and international sex workers in Sydney

OBJECTIVES

To compare indicators of sexual health and predictors of condom use for commercial sex among local and international female sex workers first attending an STD clinic.

SETTING

A public STD clinic in Sydney, Australia.

SUBJECTS

All sex workers first attending between June 1991 and May 1993.

METHODS

Cross-sectional analysis of demographic, behavioural and morbidity data from proforma medical records.

RESULTS

91 local sex workers and 123 international sex workers (predominantly from Thailand, Malaysia and China) first presented during the study period. There were significantly higher prevalences of chlamydia (0 v. 15%, p = 0.0002), gonorrhoea (0 v. 14%, p = 0.0006), syphilis (0 v. 10%, p = 0.006) and clinical genital herpes (0 v. 5%, p = 0.04) among international sex workers. The only case of HIV infection was in an international sex worker. Inconsistent condom use for commercial sex was significantly more common among international sex workers (RR = 4.5; 95% CI 3.1-6.5). On multivariate analysis, inconsistent condom use in international sex workers was associated with a recent history of prostitution outside Australia (p = 0.04), while inconsistent condom usage among local sex workers was associated with increasing age (p = 0.003).

CONCLUSIONS

These data illustrate the efficacy of condoms and the success of targeted education programmes in local sex workers in Sydney. By contrast, international sex workers continued to be at high risk of STDs. The international sex industry in Sydney requires enhanced culture-specific interventions. Immigration laws as they affect sex workers should also be reviewed.

Reported condom use is not associated with incidence of sexually transmitted diseases in Malawi

OBJECTIVES

To establish frequency of reported condom use and validate reliability of self-reporting among urban women in Malawi.

DESIGN

Cross-sectional survey in antenatal women in 1989 and 1993. Prospective study in cohort first surveyed in 1989.

METHODS

A total of 6561 women in 1989 and 2460 women in 1993 answered questions about condom use and sexual activity, had a physical examination and were screened for HIV. A subset of women from the 1989 screening were administered a questionnaire and tested for syphilis, Neisseria gonorrhoeae and Trichomonas vaginalis infections every 6 months.

RESULTS

Although between the two cross-sectional studies intermittent condom use increased from 6 to 15% (P < 0.001) with no difference according to HIV infection, consistent use was reported by less than 1%. In the prospective study, women reported a higher condom use at any visit than either group assessed cross-sectionally. Consistent condom use peaked at 62% in the first 6 months, but declined to as low as 8% in the second year of follow-up. Condom use at each visit, either intermittent or consistent, was higher in HIV-seropositive than HIV-seronegative women. Overall, the incidence of gonorrhea, trichomoniasis and syphilis did not decline in women reporting consistent condom use.

CONCLUSIONS

In prospectively followed women reports of consistent condom use was substantially higher than in cross-sectional surveys, but rapidly decreased over time, irrespective of HIV status. The presence of new sexually transmitted diseases suggests that this population of urban women overreports condom use or underreports sexual activity, or both. Intensive and sustained education is needed to achieve consistent condom use. Biologic markers of sexual activity are useful in interpreting reported condom use.

AIDS prevention in high-risk African American women: behavioral, psychological, and gender issues

A three-year longitudinal intervention study was implemented to reduce high-risk drug and sexual behaviors in methadone-dependent African American women. Participants were recruited from four inner-city methadone maintenance programs and randomly assigned either to an eight-week peer counseling and leadership training group or to a control group. The 107 trainees and 97 controls completed pretests and posttests at two, four, and seven months. This paper focuses on final data related to the subjects' sexual beliefs, attitudes, knowledge, and behaviors that put them at risk for HIV/AIDS. Reasons for not using condoms are categorized and discussed. Despite the women's awareness of the seriousness of AIDS, perceived powerlessness to negotiate condom use, negative attitudes about the use of condoms, influence of drugs, and unavailablility of condoms interfered with safer sex practices. The inability of education alone to prevent many high-risk sexual behaviors suggests that more serious consideration be given to expanded distribution of condoms as well as needle exchange programs and legalization of illicit drugs.

[Results of reproduction and health research, the Czech Republic, 1993: Part 2]

This article "aims at the following topics: problems of health of pregnant women, sexual behaviour of young women and attitudes towards health." Data are from a 1993 survey on reproduction and health research in the Czech Republic. (SUMMARY IN ENG)

The effects of steroidal contraceptives on the well-being and sexuality of women: a double-blind, placebo-controlled, two-centre study of combined and progestogen-only methods

A placebo-controlled, double-blind study was carried out to assess the direct hormonal effects of combined and progestogen-only oral contraceptives on well-being and sexuality of women in two contrasting cultures. One-hundred-fifty women, who had been sterilised or whose partners had been vasectomised, were recruited from two centres-Manila, Philippines, and Edinburgh, Scotland. After one month pretreatment assessment, women were randomly assigned to one of three treatments (combined oral contraceptive (COC), progestogen-only pill (POP), or placebo; 50 within each treatment group, 25 per centre) and continued on treatment for four months. Assessment was by daily ratings, questionnaires and interviews. The COC adversely affected sexuality in the Edinburgh women, with 12 of the 25 women in this group also reporting the side effect of reduced sexual interest. There were modest negative effects of the combined pill on mood, more noticeable in the Edinburgh women. The POP was associated with no adverse effects on sexuality and some improvement in well-being in both centres. Possible explanations for the apparent lack of adverse effects in the Manila women are discussed. The negative effects reported may be less evident in women using the COC for contraceptive purposes but may lead to discontinuation in some women and warrant further investigation.

Validation of measures of condom and other contraceptive use among women at high risk for HIV infection and unintended pregnancy

This study assessed the applicability of the transtheoretical model of behavior change (J.O. Prochaska & C.C. DiClemente, 1983, 1984) to the measurement of contraceptive use among 296 women at high risk for HIV infection and transmission. Structural equation modeling suggested that a measure of general contraceptive use could be used to assess use of oral contraceptives and hormonal implants but that measurement of condom use required separate assessments for main and other partners. Self-efficacy (SE) and decisional balance scales were internally consistent for general contraceptive use, for condom use with main partners, and for condom use with other partners. Consistent with research on other health behaviors, SE scores rose significantly across stages, from precontemplation to maintenance, and a shift in decisional balance was observed for 2 of 3 behaviors. This measurement strategy may enhance the ability to evaluate prevention programs for women at risk.

Impact on sexually transmitted disease spread of increased condom use by young females, 1987-1992

BACKGROUND

Sexual behaviour data are crucial for understanding the spread of sexually transmitted diseases (STD). Over a period (1987-1992) in which the HIV epidemic increased public awareness of safe sexual practices, we describe predictors of condom use, changes in condom use over time, and the estimated effects of these changes on the spread of STD.

METHODS

Condom use reported by females aged 18-35 years with non-cohabiting partners was analysed using data from two cross-sectional postal surveys performed 5 years apart (1987 and 1992) on two separate representative samples of 10,000 subjects aged 18-60 years living in Norway. A simple mathematical model was used to assess the effects of selection bias. A more complicated model was used to predict the effects of condom use on the prevalence of STD in a population which includes a core group of highly sexually active subjects.

RESULTS

We found an increase in the prevalence of condom use in the latest intercourse from 14% to 20% with non-foreign partners and from 10% to 38% with foreign partners, from 1987 to 1992. In a logistic regression model, low frequency of intercourse, high education, one lifetime partner, and late sexual debut were predictors for condom use. Controlled for these variables, the odds ratio (OR) for condom use in 1992 versus 1987 was 1.4 (95% confidence interval [CI]: 0.9-2.0) if the partner was non-foreign, and 7.1 (95% CI: 2.5-20.5) if the partner was foreign. Not using other contraceptive methods was a strong predictor for condom use; OR = 17.4 (95% CI: 8.0-38.0). Condom use in the first intercourse with the last partner was a strong predictor for condom use in the last intercourse; OR = 19.2 (95% CI: 8.2-45.3). It appeared unlikely that the increase in condom use could be explained by response bias. The predicted reductions in STD prevalence due to the increase in condom use ranged from zero to 30% depending on consistency of use, and on the agent that is transmitted.

CONCLUSIONS

Condom use among 18-35 year old women has increased over the period, particularly with foreign partners. Condoms are used primarily as contraception. The prevalences of STD with high transmission rates are not reduced by inconsistent condom use, while the prevalences of STD with low transmission rates are reduced by both consistent and inconsistent condom use. Condom use in a core group is more effective for reducing the STD prevalence than condom use in the non-core group for gonorrhoea and HIV. For chlamydial infection, condom use in the non-core group is more effective.

Risky heterosexual practices amongst women over 30: gender, power and long term relationships

Statistics suggest that older and younger people are about equally at risk for HIV infection, yet existing research on heterosexuality and safer sexual practices has tended to focus on people under the age of 25. The present qualitative study investigates risk behaviours and the practice of safer sex in older populations. Group discussions comprising women over the age of 30 (n = 23) targeted two issues: the gendered power dimension of heterosexuality and safer sex in long term relationships. Cohort issues were also discussed. The discussion groups revealed that the imbalance of power between men and women which has been shown by previous research to constrain younger women's choices with regard to safer sex, continues to affect older women's decisions. Many of the group participants still found it difficult to assert themselves in sexual relationships and even those who were able to challenge overt pressures to engage in unsafe sex were still susceptible to internalized social pressures. In addition, it seems that risks for older age groups are increased by difficulties in continuing to use condoms in long term relationships where monogamy cannot be taken for granted. It was also apparent that there are difficulties in changing sexual behaviours which were established before HIV became an issue.

Predictors of AIDS knowledge, condom use and high-risk sexual behaviour among women in Dar-es-Salaam, Tanzania

Reducing the number of sex partners and using condoms are the major means for individuals to protect themselves from STDs and AIDS in sub-Saharan Africa. To identify predictors of having only one sex partner in the last year and to assess knowledge and use of condoms among women of reproductive age in Dar-es-Salaam, Tanzania, we interviewed 2285 women at 3 representative family planning clinics between February 1991 and June 1992. After interview, blood and genital specimens were collected for laboratory diagnosis of HIV and other sexually transmitted diseases (STDs). Although knowledge of sexual transmission of AIDS was very high, less than a half of the respondents (42.8%) mentioned use of condoms as an AIDS preventive measure. Younger and more educated women were more likely to mention use of condoms for AIDS prevention, however only 4.6% of women interviewed were regular users of condoms, while 19.8% were occasional users. The majority of women who had never used a condom (57.5%) reported not using condoms because 'men did not like them'. Condom use was positively associated with increasing level of education and increasing number of sexual partners. 14.8% of women reported having more than one sex partner in the last year; this behaviour was more likely among cohabiting women (increased by 210%); HIV-positives (increased by 120%); and among women with STDs (increased by 50%).(ABSTRACT TRUNCATED AT 250 WORDS)