Issues in Prevention
Americans have not done well in confronting issues associated with sexual behavior in general and with STDs in particular. Partially as a result of our failure to deal with these public health problems in a straightforward and effective manner, the prevalence of STDs is high, and the economic and health impact of STDs is enormous. Contrary to the misperceptions of some, use of available information and interventions could have a rapid and dramatic impact on the incidence and prevalence of STDs in the United States. Many effective and efficient behavioral and biomedical interventions are available. While there have not been rigorous assessments of the impact of many interventions on health outcomes, there is reason to believe that they could have a substantial impact on the risk of acquiring and spreading STDs if there were the resources and national will to implement some of these programs more widely (Hillis, Black, et al., 1995).
A Mathematical Model for Prevention
The rate of spread of communicable diseases in a population is determined by three factors: (1) the rate of exposure of susceptible persons to infected individuals; (2) the probability that an exposed, susceptible person will acquire the infection (i.e., the "efficiency of transmission"); and (3) the length of time that newly infected persons remain infected and are able to spread the infection to others. A simple transmission cycle for STDs is illustrated in Figure 4-1.
The transmission of STDs in a population can also be represented by the
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--> 4 Prevention of STDs Highlights Americans seriously underestimate their risk for STDs; 77 percent of women and 72 percent of men at high risk for STDs surveyed were not concerned about acquiring an STD. There are many individual- and community-based interventions and tools that are effective and can be used immediately to prevent STDs. Issues in Prevention Americans have not done well in confronting issues associated with sexual behavior in general and with STDs in particular. Partially as a result of our failure to deal with these public health problems in a straightforward and effective manner, the prevalence of STDs is high, and the economic and health impact of STDs is enormous. Contrary to the misperceptions of some, use of available information and interventions could have a rapid and dramatic impact on the incidence and prevalence of STDs in the United States. Many effective and efficient behavioral and biomedical interventions are available. While there have not been rigorous assessments of the impact of many interventions on health outcomes, there is reason to believe that they could have a substantial impact on the risk of acquiring and spreading STDs if there were the resources and national will to implement some of these programs more widely (Hillis, Black, et al., 1995). A Mathematical Model for Prevention The rate of spread of communicable diseases in a population is determined by three factors: (1) the rate of exposure of susceptible persons to infected individuals; (2) the probability that an exposed, susceptible person will acquire the infection (i.e., the "efficiency of transmission"); and (3) the length of time that newly infected persons remain infected and are able to spread the infection to others. A simple transmission cycle for STDs is illustrated in Figure 4-1. The transmission of STDs in a population can also be represented by the
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--> Figure 4-1 Basic transmission cycle for STDs. mathematical model, R0 = cD (May and Anderson, 1987; Anderson, 1991). In this model, R0, the reproductive rate of infection, represents the average number of secondary cases of STDs that arise from a new case; c is the mean rate of sexual partner change within the population; is the mean probability of transmission per exposure; and D is the mean duration of infectiousness of newly infected persons. Thus, interventions can prevent the spread of an STD within a population by reducing the rate of exposure to an STD; lowering the rate of partner change; reducing the efficiency of transmission; or shortening the duration of infectiousness for that STD. An extremely important conclusion from this model is that, for communicable diseases such as STDs, if R0 remains less than 1, the infection eventually disappears from the population. A sustained prevention program can drive the infection to extinction in the entire population, even when these interventions are provided only to individuals and social networks with the highest rates of transmission (Anderson, 1991). Anderson and May (1991) have highlighted differences in the epidemiology of communicable and noncommunicable diseases that have important implications for prevention of STDs. First, rates of partner change within the population and patterns of partner mixing greatly influence the spread of STDs. In essence, individuals with the highest rates of partner change, referred to as "core" groups or transmitters, disproportionately increase the rate of spread. Furthermore, mathematical models show that patterns of sex partner mixing and the characteristics of sexual networks are important determinants of the rate of spread of STDs. For example, if individuals with many partners tend to have sex with others who have
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--> many partners ("assortative mixing"), infection spreads rapidly at first; and it spreads fastest within "dense" sexual networks with many sexual links over a short period of time (Morris, 1993). Thus, interventions should have the greatest impact if they reach, and are effective among, individuals who have many partners and in "dense" networks with "assortative mixing." Primary Versus Secondary Prevention For many infectious diseases, vaccines are a major method of prevention. It is important to recognize that early detection and curative treatment of individuals with communicable diseases provide not only secondary prevention at the individual level, but also primary prevention at the population level by preventing further transmission. Reduction in the duration of infectivity, particularly among those most likely to transmit the infection to others, lowers the reproductive rate of infection (R0). Thus, public health efforts to prevent the spread of communicable diseases need to include not only immunization programs but also early detection and curative treatment of communicable diseases, especially those for which vaccines are not available. For these diseases, behavioral interventions are also important. Behavioral Versus Biomedical Approaches Historically, STD programs have been based on a biomedical model that focused on the treatment of infected individuals and the development of biological and biomechanical interventions such as drugs, diagnostic tests, and barrier methods. Services have centered on the medical screening and treatment of individuals, coupled in some cases with partner notification. The system for delivering services typically has been composed of health professionals practicing in fixed clinical settings. Traditionally, STD prevention activities have involved episodic therapy driven by symptoms of disease and have provided limited clinical counseling or education to promote behavior change. In recent years, the approach to STD prevention has begun to change as a result of critiques by both affected communities and social and behavioral scientists (Fee and Krieger, 1993). Both biomedical and behavioral health disciplines have made important contributions to the knowledge base for STD prevention (Sparling and Aral, 1991). Because both behavioral and biomedical approaches to STD prevention are necessary, distinguishing between them is unimportant. Federal agencies recently have recognized the need to incorporate both behavioral and biomedical approaches in a more holistic approach. Wasserheit (1994) examined six changes in patterns of STDs and described how physical and social environmental changes drive these disease patterns. She called for the development of STD prevention programs based on "an appreciation of the role of risk behaviors and macroenvironmental forces" using companion
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--> clinic-based and community-based services. In another holistic approach to prevention, Stryker and colleagues (1994) identified several fundamental precedents that need to exist before effective HIV prevention is possible. These factors are: (a) sound policies that promote HIV risk reduction; (b) access to health and social services, including condoms, needles, syringes, and information; (c) interventions shown to motivate behavior change; (d) community-based organizations capable of reaching persons at risk; and (e) development and diffusion of technologies to interrupt HIV transmission. Similar conditions are probably necessary for the prevention of other STDs. In terms of the mathematical model previously described, current technology can reduce , the mean probability of transmission per exposure, and D, the mean duration of infectiousness, to zero. This means that we have the technology and resources to interrupt transmission and greatly reduce many STDs in the United States. In this chapter, the committee describes the complex behavioral problems involved in reducing and c ("the effective mean rate of partner change") and in ensuring that individuals have access to, and make use of, the technologies that can reduce the efficiency of transmission and duration of infectiousness. The committee also evaluates the ability to effectively and efficiently screen for and treat STDs and describes available effective methods for preventing STDs. It should be noted that most of the behavioral interventions discussed in this chapter focus more on reducing efficiency of transmission than on reducing the rate of partner change. This is because many studies of behavioral interventions use consistent condom use as the primary behavioral outcome. In actuality, many behavioral interventions have multiple objectives that include reducing the rate of partner change. Examples of this are school-based interventions that seek to delay the onset of sexual intercourse and also promote condom use. Nevertheless, research on behavioral interventions to reduce the rate of partner change have been underemphasized. It should be noted that reducing the rate of partner change or the patterns of partner selection may affect the dynamics of how groups at differing risk for STDs subsequently interact in populations (Morris, 1996). The question implicit in the subsequent sections is a perplexing and disturbing one: Why has the United States been unsuccessful in significantly reducing or eliminating a group of diseases that costs thousands of lives and billions of dollars annually in health care costs, despite the fact that effective tools are available? Figure 4-2 depicts the levels of potential breakdown in steps required to prevent STDs. In regard to the third level (from the top of Figure 4-2), there is currently no way to influence the development of symptoms of STDs. All the other levels, however, represent a point for preventive interventions. Individual and population-level interventions are needed to (a) reduce individual risk behaviors and high population prevalence of STDs, both of which increase exposure to STDs; (b) promote safe practices and protective methods, such as condom use, necessary to reduce acquisition of an STD by those exposed; (c) educate the
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--> Figure 4-2 Schematic representation of the levels of potential breakdown in the steps required for preventing STDs. Each level, except for the third from the top, represents an important point for public health or clinical intervention. ADAPTED FROM: Waller HT, Piot MA. The use of an epidemiological model for estimating the effectiveness of tuberculosis control measures. Bull World Health Organ 1969;41:75-93. Waller HT, Piot MA. Use of an epidemiological model for estimating the effectiveness of tuberculosis control measures. Bull World Health Organ 1970;43:1-16. The model was also described in "Resource allocation model for public health planning-a case study of tuberculosis control," supplement to Vol. 84 of the Bull World Health Organ, 1973.
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--> public, especially adolescents and young adults, to be aware of and recognize symptoms of STDs; (d) motivate prompt health-care-seeking behaviors for symptoms of STDs; (e) ensure access to health care for STDs; (f) train clinicians in risk assessment and diagnosis of STDs; (g) provide access to, and laboratory capabilities for, STD testing; (h) train clinicians how to treat STDs, including use of syndromic treatment when laboratory tests are unavailable or results are pending; (i) make single-dose therapies available for clinicians to dispense directly to patients to ensure compliance; and (j) ensure treatment of sex partners exposed to STDs. The following discussion describes interventions at each of the steps designed to reduce exposure to STDs, reduce transmission to those exposed, and reduce duration of infection. Reducing Exposure and Transmission STDs result from exposure to infectious organisms through sexual contact with an infected individual. Risk factors for exposure include the frequency and type of one's sexual behaviors, use or nonuse of contraceptive methods that provide protection against transmission of STDs, and the likelihood that one's partner is infected. The same behavior (e.g., unprotected intercourse with a new partner) will carry very different levels of risk of transmission, depending on the likelihood of STDs in the social network from which one's partner is chosen. For example, individuals may engage in apparently high-risk behaviors but avoid an STD if their sex partners are not infected. An important strategy for reducing the rate of spread of STDs is to identify and treat infected individuals and their partners. However, it is necessary to supplement this approach with an understanding of how individual behaviors contribute to both exposure and transmission. This is especially important in the case of STDs for several reasons. First, medical treatment will not prevent transmission of some asymptomatic and incurable STDs, such as HIV infection and other viral STDs. For these diseases, initial exposure must be avoided to prevent infection. Second, reduction of STDs will be facilitated not only by secondary prevention through treatment of infected individuals but also by preventing initial infections. Therefore, prevention of most STDs requires modification of the behaviors that place individuals at risk. In this section, the committee summarizes how individual factors influence exposure to and transmission of STDs. The committee then illustrates how individual factors affect condom use and summarizes behavioral and clinical methods for preventing exposure and reducing transmission of STDs. Individual Factors Many factors influence an individual's sexual behavior and risk for STDs. These factors include sexual and other behaviors, perception of risk, and personal
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--> skills. There are also costs and obstacles associated with adopting behaviors that reduce individual risk of STDs. In this section, immediate factors that influence individual risk of STDs are summarized. It is important to note that these factors are influenced by the social, contextual factors described in Chapter 3, such as poverty and substance use. Sexual and Other Behaviors Aral (1994) recently reviewed the sexual and other behaviors that place individuals at greater risk of exposure to STDs. These behaviors are: Initiation of sexual intercourse at an early age. Persons who initiate intercourse at an early age may be at greater risk of STDs because of the longer time they are sexually active and the greater likelihood of risk factors for STDs such as nonvoluntary intercourse, greater number of partners, and less consistent use of condoms. In addition, adolescents are biologically more susceptible to STDs than adults. Greater number of partners. The greater the number of partners an individual has, the greater is the risk of exposure. This association may be due to the increased risk of exposure to an infected partner with increasing number of partners and the fact that having multiple partners may be associated with other risk factors such as high-risk partners and less consistent use of condoms. High-risk partners. Having sex with a partner who is likely to have had many partners increases the risk of an STD. Increased frequency of intercourse and certain sexual practices . The greater is the frequency of intercourse with an infected partner, the greater are the chances of transmission. Risk of HIV infection, hepatitis B virus infection, and other STDs is greater with anal intercourse than with vaginal or oral intercourse. Lack of circumcision of male partner. As discussed in Chapter 3, men who are not circumcised appear to have a greater risk of acquiring and transmitting certain STDs, such as HIV infection and chancroid, compared to men who are circumcised. Women with male partners who are circumcised are at reduced risk of exposure compared to those with uncircumcised partners. Use of vaginal douching. Women who douche are at higher risk for later complications of STDs, such as pelvic inflammatory disease, as discussed in Chapter 3. Lack of barrier contraceptive use. Consistent use of condoms and barrier contraceptives reduces the risk of STDs. As mentioned in Chapter 3 and Table 4-1, hormonal contraceptives may also affect risk of STDs. Perception of Risk Americans commonly underestimate their risk for STDs. In a 1993 survey
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--> mentioned previously (EDK Associates, 1994), 84 percent of women surveyed were not concerned about acquiring an STD, including 72 percent of women from 18 through 24 years of age, and 78 percent of women reported having had ''many" sexual partners during their lifetime. Mays and Cochran (1988) reported on a study of African American college students who believed that African Americans were less likely to get AIDS than European Americans, even though the reverse is true. Of the sexually active women in the sample, almost a third had taken no actions to avoid STDs. Another nationwide survey of 1,000 persons in 1994 found that Americans underestimated their risk of STDs and were therefore not taking appropriate protective measures (EDK Associates, 1995). This survey found that 62 percent of men and 50 percent of women were at moderate to high risk for STDs (see Figure 4-3 for definitions of risk). Single and divorced men and women were most likely to be at high or moderate risk for STDs compared to married persons (Figure 4-3). Among those at high risk for STDs, 77 percent of women and 72 percent of men stated that they were not worried about getting an STD. Perceived susceptibility has played a central role in most theories of health behavior (e.g., Wallston and Wallston, 1984; Weinstein, 1988). Perceiving one's personal susceptibility as low may arise from the experience of remaining STD- or HIV-free in the face of behavior that is known to be associated with a high risk of acquiring infection, such as engaging in anonymous unprotected sex with multiple partners over a prolonged period of time. Such perceptions may be reinforced by periodic negative testing. With consistent reinforcement of negative results in light of high-risk behavior, beliefs congruent with "genetic immunity" or "super invulnerability" may develop, leading to reduced motivation to adopt protective behaviors. Knowledge is necessary but not sufficient to motivate action. Without knowledge, individuals may be unaware of risk or not know what actions to take to protect themselves against STDs. However, among those who do have sufficient knowledge, other factors will affect whether they take action. Thus, among populations with sufficient knowledge, knowledge itself is not related to the behavior (Morrison et al., 1994). Morrison and others (1994) studied adolescents who were incarcerated in the juvenile justice system. These adolescents, who reported engaging in high-risk sexual behaviors, had a good deal of knowledge regarding STDs and condoms, but this knowledge was not related to more positive attitudes toward use of condoms. Similarly, Wulfert and Wan (1993) found that college students with better knowledge about the HIV virus and how it is transmitted were no more likely to use condoms compared to those with less knowledge. In virtually all behavioral theories regarding the reasons individuals either adopt or fail to adopt risk-avoidance strategies, reducing risk is viewed as a principal motivation of behavior (Cleary et al., 1986). Perceived risk is a critical component in the Health Belief Model (Becker and Maiman, 1975) and the Theory of Reasoned Action (Ajzen and Fishbein, 1980) and is reflected in outcome
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--> TABLE 4-1 Effects of Contraceptives on STDs and Pregnancy STDs Contraceptive Method Bacterial Viral (including HIV/AIDS) Pregnancy Condoms Protective (if used for STD/HIV prophylaxis) Protective (if used for STD/HIV prophylaxis) Protective Sterilization Not protective (except against salpingitis) Not protective Highly protective Spermicides with nonoxynol-9 Protective against cervical gonorrhea and chlamydial infection; associated with increased risk of urinary tract infections and altered vaginal floraa No proven protection in vivo Protective Diaphragms Protective against cervical infection; associated with increased risk of altered vaginal florab Insufficient data Protective Oral contraceptives Associated with increased cervical chlamydial infection; protective against symptomatic pelvic inflammatory disease Not protective; some studies suggest increased risk for acquisition of HIV;c others show no effectd Highly protective Implantable/injectable contraceptives Not protective Not protective; some studies suggest increase risk for acquisition of HIV infectiond,e Highly protective IUDs Associated with pelvic inflammatory disease in first month after insertion Not protective Protective Rhythm method Not protective Not protective Protective
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--> a Hooten TM, Fennell CL, Clark AM, Stamm WE. Nonoxonol-9: differential antibacterial activity and enhancement of bacterial adherence to vaginal epithelial cells. J Infect Dis 1991;164:1216-9. b Hooten TM, Roberts PL, Stamm WE. Effects of recent sexual activity and use of a diaphragm on the vaginal microflora. Clin Infect Dis 1994;19:274-8. c Plummer FA, Simonsen JN, Cameron DW, Ndinya-Achola JO, Kreiss JK, Gakinya MN, et al. Co-factors in male-female transmission of human immunodeficiency virus type 1. J Infect Dis 1991;163:233-9. Nyange P, Martin H, Mandaliya K, Jackson D, Ndinya-Achola JO, Ngugi E, et al. Cofactors for heterosexual transmission of HIV to prostitutes in Mombasa Kenya. Proceedings of the 9th International Conference on AIDS and STD in Africa. 1994 December 10-14; Kampala, Uganda. Mostad S, Welch M, Chohan B, Reilly M, Overbaugh J, Mandalya K, et al. Cervical and vaginal HIV-1 DNA shedding in female STD clinic attenders. Eleventh International Conference on AIDS, July 7-12, 1996, Vancouver [abstract no. WeC 333]. Cates W Jr. Contraception, contraceptive technology and STD. In: Holmes KK, Sparling PF, Mårdh PA, Lemon SM, Stamm WE, Piot P, Wasserheit JN, eds. Sexually transmitted diseases. 3rd ed. New York: McGraw-Hill, Inc., in press. d Cates W Jr., et al., in press. (see above) e Marx PA, Spira AI, Gettie A, Dailey PJ, Veazey RS, Lackner AA, et al. Progesterone implants enhance SIV vaginal transmission and early virus load. Nature Med 1996;2:1084-9. Mostad et al., 1996. (see above) Spira AI, Marx PA, Patterson BK, Mahoney J, Koup RA, Wolinsky SM, et al. Cellular targets of infection and route of viral dissemination following intravaginal inoculation of SIV into rhesus macaques. J Exp Med 1996;183:215-25. OTHER SOURCES: CDC. Update: barrier protection against HIV infection and other sexually transmitted diseases. MMWR 1993;42:589-97; Cates W Jr., Stone. Family planning, sexually transmitted diseases, and contraceptive choice: a literature update. Fam Plann Perspect 1992;24:75-84; Ehrhardt AA, Wasserheit JN. Age, gender, and sexual risk behaviors for sexually transmitted diseases in the United States. In: Research issues in human behavior and sexually transmitted disease in the AIDS era. Wasserheit JN, Aral SO, Holmes KK, Hitchcock PJ, eds. Washington, DC: American Society for Microbiology, 1991; Hatcher RA, Trussell J, Stewart F, et al. Contraceptive technology, 16th revised ed. New York, NY: Irvington Publishers, Inc.; 1994: Table 4-2.; IOM. Contraceptive research and development: looking to the future. Harrison PF, Rosenfield A, editors. Washington, D.C.: National Academy Press, 1996.
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--> Figure 4-3 Proportion of persons at high risk for STDs by marital status and gender, 1994. High risk was defined as having at least two of the following: (a) six or more sex partners in lifetime, (b) partners who have had sex with six or more people or have no knowledge of their partners' sexual history, or (c) more than one sex partner in the past year. Moderate risk was defined as having one of these characteristics. SOURCE: EDK Associates, Inc. The ABCs of STDs. New York: EDK Associates, 1995. expectancies in social learning theory (Bandura, 1977). All of these models predict that behavior change will be greater when individuals perceive that they are at risk of infection and that the behavior being recommended will reduce that risk. In addition to the reasons mentioned previously for why individuals fail to adopt protective behaviors, there are other explanations for why the association between perceived risk and protective behaviors is weak. Link Between Perceived Risk and Protective Behaviors Given the centrality of perceived risk to the theoretical models as well as to many intervention programs, it is surprising that the empirical evidence linking
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--> need to be reevaluated and redesigned in light of the changing epidemiology and social context of STDs. The duration of sexually transmitted infections and thus the period during which infected individuals are infectious to others can be reduced primarily by ensuring early diagnosis and treatment of infected persons through screening programs and by improving the clinical skills of health care providers. Appropriate use and interpretation of diagnostic tests and access to laboratory services are essential in ensuring accurate diagnosis and treatment. Barriers to early detection and treatment, such as inadequate access to health care and lack of health-care-seeking behavior, need to be addressed. References AAFP (American Academy of Family Physicians). Age charts for periodic health examination. Kansas City, MO: American Academy of Family Physicians, 1994 (reprint no. 510). AAP (American Academy of Pediatrics), Committee on Adolescence. Sexually transmitted diseases. Pediatr 1994;94 (Pt. 1):568-72. AAP, Committee on Adolescence. Condom availability for youth. Pediatr 1995;95:281-5. ACOG (American College of Obstetricians and Gynecologists). Human immunodeficiency virus infection. Washington, D.C.: American College of Obstetricians and Gynecologists, 1992. [Technical Bulletin No. 169.] Addiss DG, Vaughn ML, Hillis SD, Ludka D, Amsterdam L, Davis JP. History and features of the Wisconsin Chlamydia trachomatis control program. Fam Plann Perspect 1994;26:83-9. Adler NE, Tschann, JM. Conscious and preconscious motivation of pregnancy among female adolescents. In: Lawson A, Rhode D, eds. The politics of pregnancy: adolescent sexuality and public policy. New Haven, CT: Yale University Press, 1993:144-58. Advocates for Youth. Condom availability in schools: an integral component to comprehensive school health programs. Washington, D.C., 1995. Ajzen I, Fishbein M. Understanding attitudes and predicting social behavior. Englewood, NJ: Prentice-Hall, 1980. Alary M, Joly JR, Poulin C. Gonorrhea and chlamydial infection: comparison of contact tracing performed by physicians or by a specialized service. Can J Public Health 1991:82;132-4. Allen S, Tice J, Van de Perre P, Serufilira A, Hudes E, Nsengumuremyi F, et al. Effect of serotesting with counselling on condom use and seroconversion among HIV discordant couples in Africa. British Med J 1992;304:1605-9. AMA (American Medical Association). HIV blood test counseling. Physician guidelines. 2nd ed. Chicago: American Medical Association, 1993. AMA. Policy compendium on reproductive health issues affecting adolescents. Gans Epner JE, ed. Chicago: American Medical Association, 1996. ASHA (American Social Health Association). Teenagers know more than adults about STDs, but knowledge among both groups is low. STD News. A quarterly newsletter of the American Social Health Association. Winter 1996;3:1, 5. Anderson JE, Brackhill R, Mosher WD. Condom use for disease prevention among unmarried U.S. women. Fam Plann Perspect 1996;28:25-8, 39. Anderson RM. The transmission dynamics of sexually transmitted diseases: the behavioral component. In: Wasserheit JN, Aral SO, Holmes KK, Hitchcock PJ, eds. Research issues in human behavior and sexually transmitted diseases in the AIDS era. Washington, D.C.: American Society for Microbiology, 1991:38-60.
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Representative terms from entire chapter: