Alcohol’s Effect on the Body Sample

Alcohol’s Effect on the Body Sample Essay Alcohol’s Effect on the Body Sample Essay Dental hygienists and therapists are encouraged to take a holistic approach to their patients care.Alcohol’s Effect on the Body Sample Essay Holistic medicine is defined as ‘treatment of the whole person, taking into account mental and social factors, rather than just the symptoms of a disease’ Oxford dictionaries (2015). Dental clinicians therefore require an understanding of all alcohol related issues not just that of the oral cavity. The following section highlights the main complications alcohol can cause for the major organs of the body. Permalink: alcohols-effect-…y-sample-essay / Brain — Alcohol affects the brain by altering the chemical processes. The short term alterations consist of slurred speech, vision changes, lack of coordination, impaired judgment and memory loss. Alcohol is a depressant, so long term excessive alcohol drinking can lead to mental health issues such as depression, anxiety and suicide (Singleton et al, 2001).Alcohol’s Effect on the Body Sample Essay It can also lead to frontal lobe shrinkage causing poor thinking skills ( Mukherjee, S (2013 p 256-262) states that “Alcohol interacts with the brain receptors, interfering with the communication between nerve cells” Heart — Regular alcohol consumption can lead to an increased risk of cardiovascular disease. This can cause hypertension, arrhythmia, strokes or myocardial infarction. (National Institute on Alcohol Abuse and Alcoholism) Digestive System — In the short term alcohol can cause stomach disturbances and lead to vomiting or diarrhoea. Excess alcohol is linked with gastrointestinal ulcers, pancreatitis (inflammation of the pancreas caused by cell damage) and malabsorption of essential nutrients such as B vitamins and folic acid. Cancers of the digestive tract (mouth, oesophagus, stomach and colon) are also a threat (’s Effect on the Body Sample Essay Liver — Our liver’s deal with the breakdown of waste products, this also includes alcohol and drugs. Alcohol causes great harm to the liver due to toxins and the effort the liver must use to deal with alcohol ( Alcohol-related liver disease can be categorised in to three main categories; • Fatty liver (first stage of liver disease but can be reversed if addressed early enough) • Alcoholic hepatitis • Cirrhosis (scarring of the liver) ( Reproductive System — Alcohol affects both male and female sex hormones, causing imbalance and potentially infertility. If a woman has conceived, drinking during gestation puts the unborn child at risk of Foetal Alcohol Spectrum Disorder (FASD). Alcohol passes through to the child via the bloodstream, and exposure to alcohol can lead to a host of problems during a person’s lifetime which come under the umbrella term FASD these can include; deformities, mental health problems, memory difficulties and addiction. Drinking alcohol whilst pregnant can also lead to miscarriage, still birth, pre-term delivery and low birth weights ( Immune System — Drinking regularly can weaken a person’s immune system. A session of binge drinking can make your body vulnerable to infection for up to twenty four hours after (’s Effect on the Body Sample Essay Oral Cavity — As outlined in the introduction to this paper, alcohol has many adverse effects on the oral cavity. These will now be explored in further detail; • Non-carious tooth surface loss — Robb and Smith (1990) showed that in a study of thirty seven alcoholic patients, their teeth had decidedly more erosive wear in comparison to the age and sex matched control subjects. This can be attributed to the acidity of many alcoholic beverages and also the increased incidence of vomiting after excessive alcohol consumption.Alcohol’s Effect on the Body Sample Essay • Dental caries — Dental caries can occur more frequently in patients who regularly expose their mouth to alcohol. This can have multiple root causes; initially we know that the progression of caries begins with the demineralisation of enamel which occurs when the critical pH of 5.4 is breached. This happens during an acid attack, where the microorganisms in the oral cavity feed off a substrate; sugar. We know that alcohol contains large amounts of sugar; an alcopop such as Smirnoff Ice for example contains 7.5 teaspoons of sugar (, 2014). In a drinking session when the alcohol may be sipped over a period of time the oral cavity can never revert back to a neutral pH. If a patient is doing this regularly we can presume demineralisation may result and logically, caries. Often excessive alcohol drinkers will have poorer oral hygiene habits also leading to the possibility of caries developing.Alcohol’s Effect on the Body Sample Essay • Periodontal disease — Tezal (2001) found that alcohol consumption may affect the periodontium in the following ways, aside from poor plaque control exhibited by frequent alcohol drinkers; Impaired immune response leading to a decrease in neutrophil function which is vital in the response to periodontal bacterium, decrease in liver function leading to inflamed or bleeding gingivae, alcohol also affects tissue healing.Alcohol’s Effect on the Body Sample Essay • Xerostomia — Use of alcohol can add to dry mouth (Ongole and Praveen, 2012). Consequently it can be deduced that lack of saliva would decrease the antimicrobial benefits especially in dealing with dental caries and periodontitis. • Oral and facial trauma — Hutchinson et al (1998) performed a study of accident and emergency departments over a weekend period in the United Kingdom, to assess how many admittances were dental/facial injuries, they found that fifty five percent of the total admittances were alcohol related. In conclusion they suggested the implementation of a scheme to make young people more aware of the risks associated with drinking and injury.Alcohol’s Effect on the Body Sample Essay • Oral Cancer — The most life threatening of all the oral implications is oral cancer, Brocklehurst et al (2013) states that it is the sixth most prevalent cancer worldwide and is on the increase. Alcohol is a clear risk factor. Dal Maso et al (2015) found that is some cases patients who both drink alcohol and smoke tobacco the synergistic effect increases the chance of head and neck cancer by 35 times. According to Figuero-Ruiz et al (2004) the active component of alcohol is ethanol, this in itself is not carcinogenic, however the primary metabolite acetaldehyde has been established to be a carcinogen. It goes on to explain that the permeability of the oral mucous membrane, coupled with the cytotoxic effect of acetaldehyde and the lack of salivary buffering can cause cellular mutations and damage to the deoxyribonucleic acid (DNA). Oral cancer lesions tend to be pain free and in sheltered areas of the mouth or oropharynx, sometimes leading to late diagnosis, as the patient may be unaware of changes. A specific screening programme including visual examination may be useful in decreasing mortality rates in oral cancer (Brocklehurst et al, 2013).Alcohol’s Effect on the Body Sample Essay United Kingdom Alcohol Statistics According to the charity Alcohol Concern, alcohol is the third biggest risk factor for preventable illness and death in the UK, and costs the National Health Service £3.5 billion per year, this equates to a cost of £120 for each tax payer. The Organisation for Economic Co-operation and Development (from henceforth referred to as OECD) is an organisation combining and analysing data from its member countries, primarily Western countries, but also monitoring countries outside the OECD. In 2015 they conducted research on the drinking habits from thirty four Western countries. Their research highlighted that hazardous drinking (defined as drinking double the amount of safe units — 14 units per week for women and 21 for men) is most common amongst women who are both highly educated and of a high socioeconomic status. This can possibly be attributed to women placing a greater importance on forging a career, higher earning jobs requiring networking after work and the stress of balancing work, childcare and living costs. These women are also more likely to drink at home. The survey also noted that teenage girls are catching up with teenage boys, stating that 43% of boys had experienced being drunk by age 15, and 41% of girls in 2010 compared with 30%:26% ratio in 2001. Men in the high education bracket are also the more hazardous drinkers.Alcohol’s Effect on the Body Sample Essay In light of the findings above, it would be a natural assumption that during the career of a dental clinician, the importance of screening patients using AUDIT (C) and advising as necessary will become an essential part of patient care. This means that dental clinicians need to be equipped with the skillset to give accurate and pertinent advice to the patient and feel confident in doing so.Alcohol’s Effect on the Body Sample Essay Delivering Better Oral Health Delivering Better Oral Health is a guidance tool, collated by experts using information gathered from multiples resources including systematic reviews, research papers and studies. The evidence included is rated dependent on its strength or weakness. DBOH advocates a preventative approach and urges all dental healthcare professionals to give their patients some form of advice or praise relative to the subheadings in DBOH irrespective of their level of risk or need. A range of topics are covered in DBOH including, fluoride, smoking and oral hygiene.Alcohol’s Effect on the Body Sample Essay The behavioural change DBOH sets out to achieve is via ‘brief intervention’ and ‘motivational interviewing’. Brief intervention involves raising the subject with the patient, gauging their reaction, offering brief advice and either signposting the patient to further assistance or revisiting the issue at the next appointment. DBOH understands that true behaviour change is a lengthy process as it is multifactorial. Alcohol’s Effect on the Body Sample EssayFor example a patient may smoke tobacco and drink alcohol regularly putting them in a high risk category, this would mean the clinician would need to address the reasons behind these choices and encourage changing the behaviour for both issues. Another limiting reason for behaviour change is the patient’s lifestyle and social factors, for example a patient who is grieving due to a recent bereavement would be less motivated to change than a woman who has found out she is expecting her first child after a year of trying to conceive. This ties in to motivational interviewing. Experts now recognise that using health risks as an incentive to change behaviour is not successful with everybody. The clinician needs to talk to the patient to identify what motivates them and use that for encouragement. Some examples of this are; highlighting to a patient how much money they could save if they stopped spending on cigarettes or alcohol or the aesthetic benefits a patient could expect to achieve orally if they stopped smoking and had less staining on their teeth.Alcohol’s Effect on the Body Sample Essay Experts also note that the ideal person to achieve change is a person with good motivation and a good support network. It is therefore important to get to know the patient to assess when you can best assist them.Alcohol’s Effect on the Body Sample Essay The alcohol section of DBOH highlights the effect alcohol misuse has generally in the United Kingdom and also specifically to oral health. It illustrates how much a unit of alcohol is using different types of alcohol. It identifies the role dental professionals can have in supporting alcohol misusers and lists useful resources. It also contains AUDIT(C) which stands for ‘Alcohol use disorder identification test’. Once completed the patient can be placed in to a category depending on their level of risk, if a patient scores over 10 the importance of referral to their GP or local alcohol support service must be stressed. The fundamental message DBOH encourages dental clinicians to employ is ‘Ask, Advise, Act’; this should be actioned to every patient who requires it.Alcohol’s Effect on the Body Sample Essay Questionnaire Design and Methodology The aim of this questionnaire (Appendix – Figure A) was to gather data to attempt to answer the primary research question ‘Are dental clinicians implementing the alcohol toolkit from delivering better oral health?’ As stated initially the questionnaire was created using guidance from the University of Leeds website. To create an appropriate questionnaire the research aims must be clear. For this research project the author required demographic information on the participants and to create questions which would provide an insight in to the relationship between the dental clinician and their patients regarding the conversations which take place surrounding alcohol consumption and advice. As the primary research aim is to identify if DBOH is being used or not, the author had to ensure no bias was shown toward DBOH in the questions. To ensure this the questions asked in the survey included the mention of multiple publications; there was only one question which asked specifically about DBOH. The intended sample participants were dentists, dental hygienists and dual qualified dental hygienists and therapists working in dental practices in the United Kingdom. The aim was to achieve one hundred participants to garner an adequate cross section of the population of dental clinicians in the United Kingdom, to gather enough data to deduce meaningful conclusions to the primary question in the time frame set and with the resources available to the author.Alcohol’s Effect on the Body Sample Essay The format of this questionnaire was self-administered and not conducted through one to one interviews. This was chosen to accommodate the resources and time available to the author. The questionnaire was designed on as mentioned in the introduction.Alcohol’s Effect on the Body Sample Essay The link to the questionnaire was primarily distributed through two mediums to attract the most responses. Firstly the website which is a website for dental professionals containing new articles, blogs, classified advertisements and importantly a forum. The link was distributed in the forum along with a cover note (Appendix Fig B) explaining that the project would be looking at alcohol and the oral cavity with an emphasis on alcohol advice, DBOH was not mentioned as this would infer bias. Secondly the questionnaire was distributed on the Facebook group Dental Hygienist and Therapist Network which is a non-public group and has over three thousand members. The link was posted, along with a cover letter. Alcohol’s Effect on the Body Sample EssayThe link to the questionnaire was also passed on through the authors contacts within the dental industry. The ideal number of participants was one hundred; within forty eight hours of distributing the questionnaire one hundred and five responses had already been submitted. The final amount at the close of the questionnaire was one hundred and twenty respondents. The layout of the questionnaire was determined mainly by, there was a ten question limit due to limited funding available to spend on purchasing more questions. Nine questions were tick box and closed questions with single response answers, unless there was an ‘other’ selection in which case the respondent would need to specify their answer. One question offered the respondent to add anything they wished to write making it an open question. Tick box answers were chosen for simplicity and time management. According to The University of Leeds guidance, the most successful questionnaires are quick, as people tend to be hesitant to commit to completing a questionnaire that they presume will be complex or take a long time.Alcohol’s Effect on the Body Sample Essay There is some conflict amongst questionnaire guides whether easy questions such as gender, occupation and location, should be at the start or the end of a questionnaire. In this questionnaire the simple questions were split and inserted both at the beginning and end. Starting with occupation and ending with gender, age and location. All respondents were reassured of their anonymity by completing the questionnaire on and also assured that the data they provided would only be used in connection with this research project.Alcohol’s Effect on the Body Sample Essay Although it is best practice to run a pilot survey first, due to time restraints this was not possible. However the author did ask for proof reading and feedback from colleagues and family to ensure there were no obvious errors or omissions.Alcohol’s Effect on the Body Sample Essay Data Analysis & Discussion Out of one hundred and twenty respondents, one person did not select their occupation; this meant 44% of respondents were dentists, 21% dental hygienists and 35% dual qualified dental hygienist/therapists.Alcohol’s Effect on the Body Sample Essay Question two asked’How often do you ask your patients about their alcohol intake?’. The answer with the most responses was ‘At every appointment/3+ times per year’ with a total of 38, however ‘Once per year’ was close behind with 36 selections (Appendix – Fig 2). It is interesting to note that when the results were broken down in to occupation the most popular selections were as follows; dentists — Twice per year 71%, dental hygienists — Never 41% and dental hygienists/therapists — At every appointment/3+ times per year 55% (Appendix – Fig 3). The survey indicated that the majority of sole qualified dental hygienists in this survey are not asking their patients about their alcohol intake at all. When the author asked a sole qualified dental hygienist colleague why he thought this might be, the colleague disclosed that he had never been taught anything during his studies to do with alcohol, nor DBOH. This response may go some way to establishing the cause, but it also identifies a need for further research to investigate the reason for this.Alcohol’s Effect on the Body Sample Essay Question three is one of the most important questions in the survey as it concerns where dental clinicians are obtaining their alcohol advice. The most popular answer was ‘NICE guidelines’ with 37% (Appendix — Fig 4). Once it has been disseminated in to occupation the results are as follows; Dentists — NHS Scotland: Alcohol and Oral health 70%, Dental hygienists — NHS Live Well Guide 26% and Dental hygienists/therapists — Delivering Better Oral Health 47%.Alcohol’s Effect on the Body Sample Essay When considering range, the age group which uses DBOH the most are 18-24 years at 60%, 65-74 years do not use DBOH at all and 45-54 years comes in second least with 17% (Appendix – Fig 6). A possible reason for this could be the time at which the participant qualified. Currently many dental hygiene and therapy programmes in the United Kingdom promote and encourage the use of DBOH these results may imply that those in the younger age group qualified recently so continued using DBOH in practice as they were in university. Whereas the older age groups may not be as aware or comfortable using it. However this highlights a need for further research.Alcohol’s Effect on the Body Sample Essay Question four asks the question how does a dental clinician decide what advice is appropriate. Interestingly the most popular answer was ‘I do not normally give alcohol advice’ (40%) and the second most popular answer with only a difference of 0.17% was ‘I check to see if their units of alcohol per week are over or under the national recommendations’ (Appendix — Fig 7). Whilst it may be suitable to assess a patients level of risk by checking their weekly units of alcohol, it does not provide as much in depth information as AUDIT (C), nor does it place a person in an official risk category as outlined by DBOH.Alcohol’s Effect on the Body Sample Essay More concerning is the fact that nearly half of the participants surveyed do not offer any alcohol advice at all. Many patients are unaware of what constitutes a unit, how many units per week are advisable and importantly the risks associated with drinking alcohol. The most popular results per occupation are as follows (Appendix — Fig 8); dentists equally chose ‘I do not normally give alcohol advice’ and ‘I check to see if their units of alcohol are over or under the national recommendations’ with 47% each, dental hygienists — ‘I do not normally give alcohol advice’ and dental hygienists/therapists — ‘I ask the patient to complete AUDIT (C) from DBOH’. As mentioned previously further research is needed to highlight any reasons for the varied choices from the three professions.Alcohol’s Effect on the Body Sample Essay Question five relates to the advice advocated by DBOH, which is the aforementioned ‘Ask, Advise, Act’. If it has become apparent the patient requires professional support it is the responsibility of the clinician to encourage referring them on to their GP or local alcohol support service. Whilst only 93% of clinicians had never referred a patient and 7% had (Appendix — Fig 9). More females have referred than males at a ratio of 9%:3%, however this may not be significant if the research was repeated with a larger sample size as this survey had more female respondents than male with a ratio of 86:34. Question six is also important in answering the question for the primary research goal. This question asks for the participant’s opinion on the alcohol chapter of DBOH. Interestingly 71% of respondents replied ‘I do not use it’ and only 16% like it (Appendix — Fig 11). From the occupation groups the highest non-users were the dental hygienists (Appendix – Fig 12). As there are currently no publications regarding the usage or the opinion of clinicians using DBOH, there are no points of comparison or studies for the author to speculate the reasons why such a large proportion does not use DBOH. This study has highlighted a need for a further field of study in to DBOH and patient care, and to identify the best way for patients to receive best practice, standardised care, whether this is via DBOH or other relevant guidelines.Alcohol’s Effect on the Body Sample Essay From the demographic questions we can see that out of 120 participants 86 were female and 34 were male (Appendix — Fig 13). Of the age groups sampled jointly the 25-34 years and 35-44 years had a total of 36 respondents, the highest amount out of all the age categories (Appendix — Fig 14). This may be indicative of the platforms the questionnaire was distributed, via Facebook and a website. Paper copies or emails sent directly to dental practices might allow for more varied age range responses. The most popular location was the South East of England with 24 respondents (Appendix — Fig 15).Alcohol’s Effect on the Body Sample Essay Statistical Significance To test the validity of this research and to identify whether the hypothesis is correct the statistics must be tested. The data in this research consists of categorical variables; this simply means the options can be placed in to categories, for example occupation, the variables are not numeric. For data with categorical variables a chi square test is performed to identify significance. The categorical variables in this research can also be further broken down in to independent and dependent variables. This research consists of mostly dependent variables. Dependent variables are things that can be changed by other factors, some examples of this are; • A dental hygienist may do further training to become a dental therapist. • A dentist may not currently like DBOH but once the publication has been altered or updated they may change their mind. Independent variables are things that cannot be changed by other factors for example eye colour or gender. Using question six ‘How do you feel about section 8’Alcohol misuse and oral health’ in DBOH?’ An online chi-square calculator was used to analyse the relevant information as depicted in Fig 16; This table sets out the observed values, expected values in round brackets and chi-square values for each cell in square brackets. To interpret your chi-square statistic you must first decide your significance value, this is usually 5% or 0.05. Then it is necessary to identify your degree of freedom, this is a table which allows you visualise how much your statistic is allowed to vary. To work out your degree of freedom a simple equation must be calculated; (Number of rows-1) X (Number of columns-1) =Degree of freedom So for this table we have; (3-1) X (5-1) = 8 degrees of freedom Fig 17 is a chi-square degree of freedom table; The chi square statistic for this research is 21.90, and the degree of freedom as highlighted in blue above is 15.51. This means the statistic is greater than the degree of freedom therefore the null hypothesis (H0) ‘Dental clinicians are implementing DBOH’’ is rejected and the alternative hypothesis (H1) ‘Dental clinicians are not implementing the alcohol toolkit from DBOH’’ is accepted.Alcohol’s Effect on the Body Sample Essay The p-value of this study also confirms the above statement. The significance value was set at 0.05, so a small p-value or a p-value of less than 0.05 confirms rejection of the null hypothesis and acceptance of the alternative hypothesis. The p-value was 0.005. Therefore the primary research identifies that the majority of clinicians are either not using the alcohol toolkit of DBOH at all, or are only using some parts of it, not in its entirety.Alcohol’s Effect on the Body Sample Essay Why is there a reluctance to address alcohol consumption? Question seven on the questionnaire asked the participants ‘Anything you would like to add?’. The answers provided a thorough insight in to some of the reasons why dental clinicians may be reluctant to address alcohol with their patients. Many participants commented that alcohol consumption was answered on the medical history form, this may indicate that they believe as long as they have a written record of the patient’s alcohol consumption that would be enough information or they are covered medico-legally. However if they do not discuss it further with the patient they will not know whether the patient understands what a unit of alcohol is or even if the patient understands the risks associated with drinking regularly. The clinician may also be placing themselves in a risky position regarding negligence. In 2013 a patient took dentist Ian Hughes to the high court for failing to diagnose her oral cancer, he was in this instance cleared of the charges ( However it should be a warning to clinicians who fail to either risk assess the patient or perform a thorough examination.Alcohol’s Effect on the Body Sample Essay Another participant stated ‘already too much to do for my £8.30 (Scottish exam fee) without doing this. Writing the notes alone takes long enough!’ this seems to broach the idea that time and money are a factor in what dental professionals should be or are capable of covering in their appointments with patients. Further participants mentioned the constraint of time. There is a huge demand in the United Kingdom for access to dental care, especially National Health Service practices, therefore there is pressure placed upon clinicians to treat as many patients as possible. There may be an argument to suggest that dental clinicians are not afforded the time to cover all the areas necessary as part of a standard dental visit. Some participants made reference to the fact that they would only discuss alcohol consumption if they found an ‘oral development’ they felt could link to alcohol or evidence of acid erosion. However the opposing argument to this is if they had addressed alcohol earlier in their professional relationship where possible, would the patient be exhibiting those oral manifestations.Alcohol’s Effect on the Body Sample Essay A common reaction is that smoking is a topic that is easier to address, one participant divulged ‘I find patients are more defensive about how much they drink than smoking (sic) and many do not understand its relevance to oral health’. The government has spent a lot of money on resources attempting to encourage people to stop smoking by highlighting the associated risk. Some key events were the ban on smoking in all enclosed work places in 2007 ( and graphic images being printed on to cigarette packets in 2008 ( There has not been such government investment in exploring alcohol related disease and formulating nationwide advertisements or publications to explain the health implications to the general public.Alcohol’s Effect on the Body Sample Essay There seems to be a social acceptance that the risks of smoking and encouragement to quit can be openly discussed with smokers without undue tension. Therefore this ties in with the overwhelming reaction from the participants that there is an awkwardness surrounding discussions about alcohol consumption. One participant stated ‘Patients can be even more coy about alcohol consumption than they are about smoking’, this might suggest that they feel patients would not provide an accurate or truthful answer to begin basing advice on. Some further comments to illustrate participants feeling awkward are ‘Alcohol can be a sensitive issue to approach’; ‘…it is not my responsibility to question their lifestyle choices’, ‘I find it too awkward an area to broach with patients’ and ‘We all have bad habits’. Unlike smoking, historically alcohol tends to still be a socially accepted activity. Fermented drinks can be dated as far back as the Stone Age ( Alcohol is commonly consumed as part of a celebration or social time spent with colleagues, family or friends, as part of religious services and might even be a person’s career e.g. professional wine taster. It is therefore not surprising that dental clinicians find it a tricky subject to deal with because the probability is that they too consume alcohol. Underwood, Fox and Manogue (2010) conducted a survey of tobacco, alcohol and drug use among dental undergraduates at an English university. They compared results from 1998 and 2008. Alcohol’s Effect on the Body Sample EssayThe 2008 results showed that 63% of males and 69.5% of females drank alcohol. There has also been an increase in binge drinking amongst both sexes since 1998. Underwood, Hackshaw and Fox (2007) also conducted a survey of tobacco, alcohol and drug use amongst newly qualified dentists completing a year’s vocational training comparing data from 2000 and 2005. The findings showed that whilst the amount of males and females drinking alcohol had decreased since 2000, it was still at a high proportion with 82% of males and 81% of females in 2005. It can consequently be suggested that as many dental clinicians are consuming alcohol despite being aware of the risks, thus they feel it is hypocritical to evaluate and admonish another person for their decisions. The Role of the Dental Hygienist/Therapist From an ethical and medical point of view alcohol intake must be part of gathering a complete history about your patient. Thorough soft and hard tissue checks should be completed to check for any abnormalities. The patient should be informed of their relative level of risk for oral disease from any of their habits. Advice should be offered where appropriate and done with evidence based backing. The clinician must be able to identify where further specialist referral is required.Alcohol’s Effect on the Body Sample Essay How could this research be furthered? If the author were to continue this research the initial changes to implement would be the sample size. A larger sample size would provide more data to analyse and a greater opportunity for knowledge in this field. The questionnaire would also be provided in different formats such as email, paper copies and other modes of internet based distribution. Interestingly question three asked the participants where the

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