Disorders - Alcohol Use
Mitchell, Jennifer M., Teague, Candice H., Kayser, Andrew S., Bartlett, Selena E., Fields, Howard L.
Rationale: Emerging evidence suggests that the α4β2 form of the nicotinic acetylcholine receptor (nAChR) modulates the rewarding effects of alcohol. The nAChR α4β2 subunit partial agonist varenicline (Chantix™), which is approved by the Food and Drug Administration for smoking cessation, also decreases ethanol consumption in rodents (Steensland et al., Proc Natl Acad Sci U S A 104:12518-12523, 2007) and in human laboratory and open-label studies (Fucito et al., Psychopharmacology (Berl) 215:655-663, 2011; McKee et al., Biol Psychiatry 66:185-190 2009).; Objectives: We present a randomized, double-blind, 16-week study in heavy-drinking smokers (n = 64 randomized to treatment) who were seeking treatment for their smoking. The study was designed to determine the effects of varenicline on alcohol craving and consumption. Outcome measures included number of alcoholic drinks per week, cigarettes per week, amount of alcohol craving per week, cumulative cigarettes and alcoholic drinks consumed during the treatment period, number of abstinent days, and weekly percentage of positive ethyl glucuronide and cotinine screens.; Results: Varenicline significantly decreases alcohol consumption (χ (2) = 35.32, p < 0.0001) in smokers. Although varenicline has previously been associated with suicidality and depression, side effects were low in this study and declined over time in the varenicline treatment group.; Conclusions: Varenicline can produce a sustained decrease in alcohol consumption in individuals who also smoke. Further studies are warranted to assess varenicline efficacy in treatment-seeking alcohol abusers who do not smoke and to ascertain the relationship between varenicline effects on smoking and drinking.;
Psychopharmacology, 223(3) : 299-306
- Year: 2012
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Biological Interventions (any)
, Medications used to treat substance abuse, Other biological interventions
Miranda, R., Ray, L., Reynolds, E., Monti, P., Justus, A., Tidey, J., Gwaltney, C., et-al
Alcohol dependence (AD) is a major reason for substance abuse treatment admissions among teenagers. Despite clinical demand for effective interventions for youth, less than one-third of treated youth experience sustained benefit from existing treatments. While medication development research has advanced treatment for adults, double-blind pharmacotherapy research with adolescents is virtually nonexistent. Our major objective was to test the effects of naltrexone (NTX) - one of the most efficacious medications for treating adults with AD - on drinking, craving, and subjective responses to alcohol intoxication among adolescents. To this end we captured the real-time occurrence of adolescents' subjective responses to alcohol in their natural environments using ecological momentary assessment (EMA) methods. Nontreatment seeking adolescent drinkers (n = 29; ages 15-19 years) were enrolled in a doubleblind, placebo-controlled, crossover study (55% female, 69% Caucasian, and 83% non- Hispanic; 72% met criteria for an alcohol use disorder). Participants completed two 10-day medication periods in which they received NTX (50 mg/day) or matched placebo in randomized and counterbalanced order; the two arms of the study were separated by at least a 4-day washout period. During each condition, youth completed momentary assessments of mood and craving immediately before and after the first three drinks of a drinking episode using a handheld electronic diary. Medication and EMA compliance was high across the trial. Generalized estimating equations (GEE) showed that teens consumed fewer drinks per day and were less likely to drink heavily while taking NTX compared to placebo (p < .05). In addition, youth reported less craving and tension and more sedation after drinking while taking NTX as compared to placebo (p values < .05). Notably, decreases in craving were associated with reductions in subsequent drinking that day. Findings of this initial study show that NTX decreased drinking and altered subjective responses to alcohol among teens and support the need for larger-scale clinical trials with longer-term follow-ups. The clinical utility of NTX in this population may be especially high given that adolescents and young adults are more likely to engage in controlled drinking, as opposed to adhering to an abstinence-only model of treatment.
Alcoholism: Clinical & Experimental Research, 36 : 89A
- Year: 2012
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: Disorder established (diagnosed disorder)
-
Treatment and intervention: Biological Interventions (any)
, Medications used to treat substance abuse
Moreira, Maria T., Oskrochi, Reza, Foxcroft, David R.
Background: Young people tend to over-estimate peer group drinking levels. Personalised normative feedback (PNF) aims to correct this misperception by providing information about personal drinking levels and patterns compared with norms in similar aged peer groups. PNF is intended to raise motivation for behaviour change and has been highlighted for alcohol misuse prevention by the British Government Behavioural Insight Team. The objective of the trial was to assess the effectiveness of PNF with college students for the prevention of alcohol misuse. Methodology: Solomon three-group randomised controlled trial. 1751 students, from 22 British Universities, allocated to a PNF group, a normal control group, or a delayed measurement control group to allow assessment of any measurement effects. PNF was provided by email. Participants completed online questionnaires at baseline, 6- and 12-months (only 12- months for the delayed measurement controls). Drinking behaviour measures were (i) alcohol disorders; (ii) frequency; (iii) typical quantity, (iv) weekly consumption; (v) alcohol-related problems; (vi) perceived drinking norms; and (vii) positive alcohol expectancies. Analyses focused on high-risk drinkers, as well as all students, because of research evidence for the prevention paradox in student drinkers. Principal Findings: Follow-up rates were low, with only 50% and 40% responding at 6- and 12-months, respectively, though comparable to similar European studies. We found no evidence for any systematic attrition bias. Overall, statistical analyses with the high risk sub-sample, and for all students, showed no significant effects of the intervention, at either time-point, in a completed case analysis and a multiple imputation analysis. Conclusions: We found no evidence for the effectiveness of PNF for the prevention of alcohol misuse and alcohol-related problems in a UK student population. (PsycINFO Database Record (c) 2012 APA, all rights reserved) (journal abstract)
PLoS ONE, 7(9) :
- Year: 2012
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Service Delivery & Improvement, Psychological Interventions (any)
, Personalised feedback, normative feedback
, Technology, interventions delivered using technology (e.g. online, SMS)
Murphy, James G., Dennhardt, Ashley A., Skidmore, Jessica R., Borsari, Brian, Barnett, Nancy P., Colby, Suzanne M., Martens, Matthew P.
Objective: Behavioral economic theory suggests that a reduction in substance use is most likely when there is an increase in rewarding substance-free activities. The goal of this randomized controlled clinical trial was to evaluate the incremental efficacy of a novel behavioral economic supplement (Substance-Free Activity Session [SFAS]) to a standard alcohol brief motivational interviewing (BMI) session for heavy-drinking college students. Method: Participants were 82 first-year college students (50% female; 81.7% White/European American; M age = 18.5 years, SD = 0.71) who reported 2 or more past-month heavy drinking episodes. After completing a baseline assessment and an individual alcohol-focused BMI, participants were randomized to either the SFAS or to a Relaxation Training (RT) control session. The SFAS was delivered in an MI style and attempted to increase the salience of delayed academic and career rewards and the patterns of behavior leading to those rewards. Results: The combination of an alcohol BMI plus the SFAS was associated with significantly greater reductions in alcohol problems compared with an alcohol BMI plus RT at the 1-month and 6-month follow-up assessments (p = .015, η[sub] p[/sub]p² = .07), an effect that was partially mediated by increases in protective behavioral strategies. BMI + SFAS was also associated with greater reductions in heavy drinking among participants who at baseline reported low levels of substance-free reinforcement or symptoms of depression. Conclusion: These results are consistent with behavioral economic theory and suggest that a single session focused on increasing engagement in alternatives to drinking can enhance the effects of brief alcohol interventions. (PsycINFO Database Record (c) 2012 APA, all rights reserved) (journal abstract)
Journal of Consulting & Clinical Psychology, 80(5) : 876-886
- Year: 2012
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Complementary & Alternative Interventions (CAM)
, Psychological Interventions (any)
, Motivational interviewing, includes Motivational Enhancing Therapy, Other Psychological Interventions, Relaxation
Neighbors, Clayton, Lee, Christine M., Atkins, David C., Lewis, Melissa A., Kaysen, Debra, Mittmann, Angela, Fossos, Nicole, et-al
Objective: While research has documented heavy drinking practices and associated negative consequences of college students turning 21, few studies have examined prevention efforts aimed at reducing high-risk drinking during 21st birthday celebrations. The present study evaluated the comparative efficacy of a general prevention effort (i.e., Brief Alcohol Screening and Intervention for College Students, or BASICS) and event-specific prevention in reducing 21st birthday drinking and related negative consequences. Furthermore, this study evaluated inclusion of peers in interventions and mode of intervention delivery (i.e., in-person vs. via the Web). Method: Participants included 599 college students (46% male): men who intended to consume at least 5 drinks and women who intended to consume at least 4 drinks on their 21st birthday. After completing a screening/baseline assessment approximately 1 week before turning 21, participants were randomly assigned to 1 of 6 conditions: 21st birthday in-person BASICS, 21st birthday web BASICS, 21st birthday in-person BASICS plus friend intervention, 21st birthday web BASICS plus friend intervention, BASICS, or an attention control. A follow-up assessment was completed approximately 1 week after students' birthdays. Results: Results indicated a significant intervention effect for BASICS in reducing blood alcohol content reached and number of negative consequences experienced. All 3 in-person interventions reduced negative consequences experienced. Results for the web-based interventions varied by drinking outcome and whether a friend was included. Conclusions: Overall, results provide support for both general intervention and ESP approaches across modalities for reducing extreme drinking and negative consequences associated with turning 21. These results suggest there are several promising options for campuses seeking to reduce both use and negative consequences associated with 21st birthday celebrations. (PsycINFO Database Record (c) 2012 APA, all rights reserved) (journal abstract)
Journal of Consulting & Clinical Psychology, 80(5) : 850-862
- Year: 2012
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Service Delivery & Improvement, Psychological Interventions (any)
, Motivational interviewing, includes Motivational Enhancing Therapy, Other Psychological Interventions, Personalised feedback, normative feedback
, Technology, comparing delivery mode (e.g. online vs. face-to-face)
Suffoletto, Brian, Callaway, Clifton, Kristan, Jeff, Kraemer, Kevin, Clark, Duncan B.
Background: Brief interventions have the potential to reduce heavy drinking in young adults who present to the emergency department (ED), but require time and resources rarely available. Text-messaging (TM) may provide an effective way to collect drinking data from young adults after ED discharge as well as to provide immediate feedback and ongoing support for behavior change. The feasibility of screening young adults in the ED, recruiting them for a TM-based interventional trial, collecting weekly drinking data through TM, and the variance in drinking outcomes remains unknown. Methods: Young adults in 3 urban EDs (n = 45; aged 18 to 24 years, 54% women) identified as hazardous drinkers by the Alcohol Use Disorders Identification Test-Consumption score were randomly assigned to weekly TM-based feedback with goal setting (Intervention), weekly TM-based drinking assessments without feedback (Assessment), or control. Participants in the Intervention group who reported ≥5 (for men) and ≥4 (for women) maximum drinks during any one 24-hour period were asked whether they would set a goal to reduce their drinking the following week. We describe the interaction with TM and goal setting. We also describe the heavy drinking days (HDDs), drinks per drinking day (DPDD) using timeline follow-back procedure at baseline and 3 months. Results: We screened 109 young adults over 157 hours across 24 unique days and 52 (48%; 95% CI 38 to 50) screened positive for hazardous drinking. Of these, 45 (87%; 95% CI 74 to 94) met inclusion criteria, were enrolled and randomized, and 6 (13%; 95% CI 5 to 27) did not complete 3-month web-based follow-up; 88% (95% CI 84 to 91) of weekly TM-based drinking assessments were answered, with 77% (95% CI 58 to 90) of participants responding to all 12 weeks. Agreeing to set a goal was associated with a repeat HDD 36% (95% CI 17 to 55) of the time compared with 63% (95% CI 44 to 81) when not willing to set a goal. At 3 months, participants that were exposed to the TM-based intervention had 3.4 (SD 5.4) fewer HDDs in the last month and 2.1 (SD 1.5) fewer DPDD when compared to baseline. Conclusions: TM can be used to assess drinking in young adults and can deliver brief interventions to young adults discharged from the ED. TM-based interventions have the potential to reduce heavy drinking among young adults but larger studies are needed to establish efficacy. (PsycINFO Database Record (c) 2012 APA, all rights reserved) (journal abstract)
Alcoholism: Clinical & Experimental Research, 36(3) : 552-560
- Year: 2012
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Service Delivery & Improvement, Psychological Interventions (any)
, Personalised feedback, normative feedback
, Technology, interventions delivered using technology (e.g. online, SMS)
Stewart, S. H., Comeau, N. M., Collins, P., Van-Wilgenburg, H. A.
Targeting alcohol prevention at the level of personality risk (i.e., sensation seeking, hopelessness, and anxiety sensitivity) impacts alcohol use and problems in majority culture teens. A prior pilot study showed that a culturally-adapted matched intervention led to a reduction in drinking, binge drinking, and alcohol problems at 4 months post-intervention, in high personality risk youth in 2 Mi'kmaq communities. The present project investigated the feasibility of using culturally-adapted versions of these matched early interventions in several Canadian Aboriginal communities. 10 schools in 3 provinces participated. In each community, a cultural adaptation of the intervention took place which involved close community collaboration including: input from a community advisory group (e.g., elders) regarding cultural relevance; qualitative interviews with high personality risk youth regarding the contexts and circumstances surrounding drinking in each community; translation of the material from the interviews into 'scenarios' used in adapting the existing manuals; and youth artists in each community providing artwork that was used in the manuals. We tested these interventions with 99 youth who reported elevations on 1 of 3 factors on the Substance Use Risk Profile Scale and drinking in the 4 months prior to intervention. Students were randomized to either the matched intervention (n = 51) or to a control (n = 48) condition. Interventions were 2 sessions long, delivered by trained guidance counsellors, and conducted in groups. Participating schools also received culturally-relevant universal interventions developed by the communities. 59 of the original sample provided data at 4 months post-intervention; stringent intent-to-treat analyses were conducted. In a 2 x 2 (group x time) ANOVA, significant time effects emerged for all outcomes. At post-intervention, youth reported lower drinking quantity, frequency, binge drinking, and alcohol problems compared to pre-treatment. No significant group x time interactions emerged. Reasons for the failure to observe additional benefits of the matched treatment include: insufficient facilitator training; simultaneous universal programs; insufficient power; or possible 'herd effects' where treated high risk youth impacted the drinking of untreated high risk youth in these small communities. Results suggest no harms and possible benefits of this intervention and demonstrate feasibility for conducting a larger RCT.
Alcoholism: Clinical & Experimental Research, 36 : 350A
- Year: 2012
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Psychological Interventions (any)
, Other Psychological Interventions
Suffoletto, B. P., Callaway, C. W., Kraemer, K. L., Clark, D. B.
Aims: To examine whether an outpatient text-message-based intervention is feasible among young adults with at-risk drinking who presented to the emergency department (ED). Design: Randomized controlled trial. Participants: Forty-five adults aged 18-24 years identified as at-risk drinkers by the Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) during an ED visit between August and September 2010 were assigned randomly to three groups. Controls received the NIAAA Rethinking Drinking booklet. The assessment group received weekly text-message-based assessments about drinking behavior. The intervention group received weekly text-messagebased dialogue incorporating personalized normative and motivational feedback for 12 weeks (intervention group). Measurements: The primary outcomes were the proportion of eligible patients, willingness of participants to be randomized, response rates to text messages, rates of follow-up and variance in alcohol consumption measured using 1-month timeline follow-back (TLFB) procedure, including change in total binge drinking episodes (four or more drinks for women and five or more drinks for men) and the change in drinks per drinking day from baseline to 3 months. Findings: Among 109 subjects, AUDIT-C indicated 52 (49%) were at-risk drinkers, and 45 (87%) agreed to randomization. Of those in the assessment arm, 11 (73%) completed all 12 weeks of text-message queries and 12 (80%) completed the end-instruments. Of those in the intervention arm, 12 (80%) completed all 12 weeks of text-message-based queries and 14 (93%) completed the end-instruments. The mean change in binge episodes in the intervention group was )3.4 (standard deviation [SD] 5.4) compared with )1.2 (SD 4.1) in the control group (p = 0.7) and 1.1 (SD 5.2) in the assessment group (p = 0.03). The mean change in drinks per drinking day in the intervention group was )2.1 (SD 1.5) compared with )0.6 (SD 1.5) in the control group (p = 0.09) and 1.1 (SD 2.1) in the assessment group (p = 0.001). Conclusions: A text-message-based intervention delivered to young adults with at-risk drinking who present to the ED is feasible and reduces binge drinking and alcohol consumption at 3 months compared to text-message assessments alone.
Alcoholism: Clinical & Experimental Research, 35 : 146A
- Year: 2011
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Service Delivery & Improvement, Psychological Interventions (any)
, Psychoeducation, Personalised feedback, normative feedback
, Technology, interventions delivered using technology (e.g. online, SMS)
Terlecki, Meredith A., Buckner, Julia D., Larimer, Mary E., Copeland, Amy L.
The Brief Alcohol Screening and Intervention for College Students (BASICS) reduces alcohol use and alcohol-related problems among undergraduates, yet variability in outcomes exists. Identifying individual difference variables related to outcomes could inform efforts to improve treatment protocols. The current study evaluated the role of social anxiety during BASICS. High socially anxious (HSA; n = 26) and low socially anxious (LSA; n = 44) heavy-drinking undergraduates were randomly assigned to BASICS (n = 38) or an assessment-only control (n = 32). HSA patients reported higher baseline alcohol consumption (typical drinks, weekly quantity, and frequency). BASICS significantly decreased weekly alcohol consumption and alcohol-related problems relative to the control group. Social anxiety moderated outcomes such that in the BASICS condition; HSA patients reported heavier typical drinks at posttest, even after controlling for referral status, baseline typical drinks, and trait anxiety. This was not the case in the control group. HSA patients may benefit from social anxiety-specific interventions during BASICS. (PsycINFO Database Record (c) 2011 APA, all rights reserved) (journal abstract)
Journal of Cognitive Psychotherapy, 25(1) : 7-21
- Year: 2011
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Service Delivery & Improvement, Psychological Interventions (any)
, Motivational interviewing, includes Motivational Enhancing Therapy, Personalised feedback, normative feedback
Todd, J., Mullan, B.
The current study investigated whether binge drinking in female undergraduates could be reduced by the mere measurement effect (MME), and by altering binge drinker prototypes from the prototype willingness model (PWM). Whether willingness added to the theory of planned behaviour (TPB) was also explored. Female undergraduates aged 17-25 (N. = 122) were randomly allocated to a prototype manipulation, mere measurement, or control group, and completed two online questionnaires separated by 14-21. days. Controlling for past behaviour, MME group consumed less alcohol than the control group, and this effect was more extreme for those who previously consumed more alcohol. However, the prototype manipulation had no effect. The TPB variables were predictive of intentions and behaviour, but willingness was not. Despite limitations, the MME could be utilised to reduce binge drinking in female undergraduates. The TPB appears to model binge drinking in female undergraduates better than the PWM, implying that binge drinking can be a reasoned behaviour. (copyright) 2011 Elsevier Ltd.
Addictive Behaviors, 36(10) : 980-986
- Year: 2011
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: Universal prevention
-
Treatment and intervention: Psychological Interventions (any)
, Other Psychological Interventions
Thompson, R. G.
Background: Although a history of living in foster care has been identified as an increased risk for later alcohol use and sexual risk behaviors, minimal attention has given to reducing alcohol use and HIV sexual risk among young adults who become homeless after exiting foster care. This pilot study evaluates the feasibility and effectiveness of One Plus One (OPO) brief intervention. OPO is a two-session, individual-level, motivation-based intervention designed to reduce alcohol use and HIV sexual risk behaviors among young adults. Methods: This pilot study is a randomized clinical trial, comparing 30 OPO with time-matched 30 control subjects. The subjects in the experimental group received individualized OPO sessions while control subjects received alcohol and HIV information-only sessions. The study was conducted at an inner-city crisis shelter for homeless on young adults who exited foster care. Past month alcohol and sexual risk behaviors were assessed at baseline and one-month postintervention. To date 36 OPO subjects have been enrolled and completed the baseline assessment; 29 have completed the OPO intervention. The study will complete the intervention and follow-up assessments within the next month. Results: Preliminary analyses of data from 15 subjects who have completed OPO with complete baseline and post assessments has found a significant decrease in alcohol use (days drank, amount drank, times drunk) and sexual risk behaviors (number of partners, times sex without condom, drank before sexual activity). Findings from participant evaluations, collected at postassessment, revealed that participants were satisfied with the overall quality, approach, and content of OPO and found it to raise personal awareness of risk, increase motivation to change behaviors, and decrease their alcohol and HIV risk behaviors. Conclusions: Preliminary findings suggest OPO is feasible and effective in reducing alcohol use and sexual risk behaviors. OPO requires minimal resources and transfers readily to other settings. We have encountered less attrition than longer, multisession interventions reported in the literature. While long-term behavior change cannot be examined in this pilot study, OPO's ease of dissemination could increase treatment coverage, particularly among high risk individuals who are difficult to locate and retain. The intervention could eventually result in a larger overall public health effect.
Alcoholism: Clinical & Experimental Research, 35 : 293A
- Year: 2011
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Psychological Interventions (any)
, Motivational interviewing, includes Motivational Enhancing Therapy
Neighbors, C., Lee, C. M.
Prior research has shown that a majority of young people drink alcohol as part of their twentyfirst birthday celebrations, many of whom drink large quantities and experience negative consequences. The present research evaluated factors associated with twenty-first birthday drinking consequences in the context of event specific prevention (ESP) interventions targeting twenty-first birthday drinking. Participants included 642 students (54.0% female) who reported intending to consume 5/4+ (men/women) drinks while celebrating their twenty-first birthday. Participants were randomly assigned to one of six conditions including an individually delivered brief in-person ESP intervention (21 BASICS) with or without a friend intervention, a Web-based personalized feedback intervention (21 WEB BASICS) with or without a friend intervention, a nonspecific empirically supported brief intervention (BASICS), or an assessment only control condition. Interventions were expected to reduce drinking and alcohol related consequences during the twenty-first birthday week by changing normative misperceptions of twenty-first birthday drinking and by increasing the use of protective behaviors during the twenty-first birthday week. Generalized linear models provided some support for intervention effects in reducing drinking, reducing negative consequences (controlling for drinking), reducing perceived norms, and increasing use of protective behaviors during the twenty-first birthday week. The number of drinks consumed during the twenty-first birthday week accounted for approximately 25% of the variance in alcohol-related negative consequences experienced during this week. Follow-up analyses indicated that perceived norms for twenty-first birthday drinking were associated with negative consequences but only through their association with drinking. In contrast, at least for some consequences (blacking out, hangover, drinking, and skipping and evening meal because of drinking), protective behaviors were associated with reducing consequences after controlling for their association with drinking. Overall, findings support consideration of alcohol-related negative consequences as an independent outcome for intervention studies. Reducing the consequences of twentyfirst birthday drinking is at least as important as reducing the quantity of alcohol consumed.
Alcoholism: Clinical & Experimental Research, 35 : 284A
- Year: 2011
- Problem: Alcohol Use
- Type: Randomised controlled trials
-
Stage: At risk (indicated or selected prevention)
-
Treatment and intervention: Service Delivery & Improvement, Psychological Interventions (any)
, Motivational interviewing, includes Motivational Enhancing Therapy, Other Psychological Interventions, Personalised feedback, normative feedback
, Technology, comparing delivery mode (e.g. online vs. face-to-face)