Utilization of information and communication technology (ICT) among sexually transmitted disease clinics attendees with ...

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Utilization of information and communication technology (ICT) among sexually transmitted disease clinics attendees with coexisting drinking problems
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Hu, Xingdi
Dodd, Virginia J.
Oliverio, James C.
Cook, Robert L.
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Background: Alcohol misuse remains a major risk factor for contracting sexually transmitted diseases (STDs) not typically addressed in STD clinic settings. Information and communication technology (ICT) can offer new avenues to deliver evidence-based screening and treatment for problematic drinking, however, few data exists regarding the utilization of ICT among STD clinic attendees with coexisting drinking problems. The objectives of this study are to identify STD clinics attendees with hazardous drinking, to examine socio-demographic factors associated with ICT use, and to explore individuals’ interests in engaging in ICT-based health interventions. Methods: Cross-sectional questionnaires examining alcohol consumption and ICT use were administered to 396 persons attending two non-urban STD clinics. Descriptive statistics for ICT use were calculated for both hazardous drinkers and the entire sample. Multivariable logistic regression models among hazardous drinkers identified factors significantly associated with use of each kind of ICT. Results: The mean age of the 396 participants was 25 years, 66% were females and 60% were African-Americans. One third of the sample met the criteria of hazardous drinking. ICT use in hazardous drinkers included 94% reporting having internet access at least monthly, 82% reporting having an email account, 85% reporting currently owning a cell phone, and 91% reporting use of any cell phone application. More than two thirds (73%) of hazardous drinkers were willing to play health-related video games during clinic waiting time, slightly higher than the entire sample (69%). Multivariable analyses indicated that younger age were significantly related to monthly internet use, and multifunction cell phone use, while being males and younger age were significantly associated with monthly video game playing. Conclusions: Our study demonstrates commonality of ICT use among STD clinic attendees with hazardous drinking, indicating the viability of using ICT to assist screening and behavioural intervention for alcohol misuse in STD clinic settings. Future research is needed to demonstrate the effectiveness of ICT-based health behavioural interventions in the STD clinic settings or other venues that serve populations at high risk for substance abuse, HIV or other STDs. Keywords: Information and communication technology (ICT), Hazardous drinking, Substance abuse, Sexually transmitted diseases (STDs), Cell phone, Email, Internet, Video games, Digital divide
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Hu et al. BMC Research Notes 2014, 7:178 http://www.biomedcentral.com/1756-0500/7/178; Pages 1-7
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doi:10.1186/1756-0500-7-178 Cite this article as: Hu et al.: Utilization of information and communication technology (ICT) among sexually transmitted disease clinics attendees with coexisting drinking problems. BMC Research Notes 2014 7:178.

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RESEARCHARTICLEOpenAccessUtilizationofinformationandcommunication technology(ICT)amongsexuallytransmitted diseaseclinicsattendeeswithcoexisting drinkingproblemsXingdiHu1*,VirginiaJDodd2,JamesCOliverio3andRobertLCook1,4AbstractBackground: Alcoholmisuseremainsamajorriskfactorforcontractingsexuallytransmitteddiseases(STDs)not typicallyaddressedinSTDclinicsettings.Informationandcommunicationtechnology(ICT)canoffernewavenues todeliverevidence-basedscreeningandtreatmentforproblematicdrinking,however,fewdataexistsregardingthe utilizationofICTamongSTDclinicattendeeswithcoexistingdrinkingproblems.Theobjectivesofthisstudyareto identifySTDclinicsattendeeswithhazardousdrinking,toexaminesocio-demographicfactorsassociatedwithICT use,andtoexploreindividuals ’ interestsinengaginginICT-basedhealthinterventions. Methods: Cross-sectionalquestionnairesexaminingalcoholconsumptionandICTusewereadministeredto396 personsattendingtwonon-urbanSTDclinics.DescriptivestatisticsforICTusewerecalculatedforbothhazardous drinkersandtheentiresample.Multivariablelogisticregressionmodelsamonghazardousdrinkersidentifiedfactors significantlyassociatedwithuseofeachkindofICT. Results: Themeanageofthe396participantswas25years,66%werefemalesand60%wereAfrican-Americans. Onethirdofthesamplemetthecriteriaofhazardousdrinking.ICTuseinhazardousdrinkersincluded94%reporting havinginternetaccessatleastmonthly,82%reportinghavinganemailaccount,85%reportingcurrentlyowningacell phone,and91%reportinguseofanycellphoneapplication.Morethantwothirds(73%)ofhazardousdrinkerswere willingtoplayhealth-relatedvideogamesduringclinicwaitingtime,slightlyhigherthantheentiresample(69%). Multivariableanalysesindicatedthatyoungerageweresignificantlyrelatedtomonthlyinternetuse,andmultifunction cellphoneuse,whilebeingmalesandyoungerageweresignificantlyassociatedwithmonthlyvideogameplaying. Conclusions: OurstudydemonstratescommonalityofICTuseamongSTDclinicattendeeswithhazardousdrinking, indicatingtheviabilityofusingICTtoassistscreeningandbehaviouralinterventionforalcoholmisuseinSTDclinic settings.FutureresearchisneededtodemonstratetheeffectivenessofICT-basedhealthbehaviouralinterventionsin theSTDclinicsettingsorothervenuesthatservepopulationsathighriskforsubstanceabuse,HIVorotherSTDs. Keywords: Informationandcommunicationtechnology(ICT),Hazardousdrinking,Substanceabuse,Sexually transmitteddiseases(STDs),Cellphone,Email,Internet,Videogames,Digitaldivide *Correspondence: qmshjwhx@phhp.ufl.edu1DepartmentofEpidemiology,UniversityofFlorida,Gainesville,FL,USA Fulllistofauthorinformationisavailableattheendofthearticle 2014Huetal.;licenseeBioMedCentralLtd.ThisisanOpenAccessarticledistributedunderthetermsoftheCreative CommonsAttributionLicense(http://creativecommons.org/licenses/by/2.0),whichpermitsunrestricteduse,distribution,and reproductioninanymedium,providedtheoriginalworkisproperlycredited.TheCreativeCommonsPublicDomain Dedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle, unlessotherwisestated.Hu etal.BMCResearchNotes 2014, 7 :178 http://www.biomedcentral.com/1756-0500/7/178

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BackgroundHazardousalcoholconsumptioncouldimpairjudgement anddecision-making,leadingpeopletoengageinrisky sexualbehaviours,suchashavingmultiplesexualpartners and/orhavingsexwithoutcondoms.Thesebehaviours furtherleadtoincreasedriskofsexuallytransmitteddiseases(STDs)[1-3].Previousstudieshaveunderscoreda highrateofalcoholconsumptionamongpeopleattending STDclinics[4-6].Forinstance,Cooketal.foundahigh rateofbingedrinking(48.0%ofmenand39.6%of women)amongasampleofyoungadultsattendingaSTD clinic,with28.3%meetingthecriteriaforalcoholusedisorder,aprevalencemuchhigherthanthatfoundinthe generalpopulation[7].ProvidingscreeningandbehaviouralinterventionsforhazardousdrinkinginSTDclinics offersauniqueopportunitytoaddressbothhazardous drinkingandriskysexualbehaviours,andtheseinterventionshavethepotentialtoreducetransmissionofSTDs. However,moststaffmembersinSTDclinicstraditionally lacktraininginscreeningandmanagementofproblematic drinking.Asaresult,theydonotoftenidentifycoexisting hazardousdrinkingandprovideadequatecare.Innovative methods,likeinformationandcommunicationtechnology (ICT),couldprovideanewavenuetodeliverevidencebasedscreeningandbriefinterventionsforhazardous drinkersathigh-riskofSTDs.Suchinterventionscould allowforconsistentscreeningforalcoholuse,areinexpensive,potentiallyengaging,andcanminimizestaffburdenrequiredforinterventiondelivery. Forsubstanceabusetreatment,anumberofICT-based applicationshavebeendevelopedandhaveshownpromisingresults[8-10].Forexample,arecentmeta-analysis foundthatcomputer-basedtreatmentswereeffectivein reducingalcoholconsumption[11].However,littleis knownregardingthepatternofICTuseamongproblematicdrinkerswhoseektesting/treatmentforSTDs.Samal etal.examinedinternetandcellularphoneuseamong 200womenattendinganurbanSTDclinicandfound80% reportinginternetuse,and93%havingacellphone[12]. Anotherstudyconductedin2006reportedsimilarlevel ofinternetuse(80%)among251STDclinicattendees [13].Thesestudies,althoughprovidingimportantpreliminaryestimatesofICTuseingeneralSTDhighriskpopulation,didnotestimatetheprevalenceof hazardousdrinking,orcharacterizerateofICTuse amongthehazardousdrinkers,ortriedtodetermine technologytypesotherthancellphonesorinternet. Therefore,weconductedasurveyamongattendeesof twonon-urbanSTDclinicswiththepurposeofidentifyingthosewithhazardousdrinking,examiningtheir accessibilityandutilizationofICT,exploringfactors associatedwiththeirICTuse,andprovidingbaseline estimatesintermsofwillingnesstoadoptICT-based healthinterventions.MethodsFromJanuary13,2009toMarch10,2009,attwopublic countyhealthdepartmentsinFlorida,USA,consecutive personspresentingattheSTDclinicswereaskedto completeananonymous,self-administeredquestionnaire. Toensureprivacy,participantscompletedthequestionnaireinaprivateroomoradesignatedareaoftheclinic. Toensureanonymity,theysealedcompletedquestionnairesinanenvelopeandthenplacedtheenvelopeintoa boxwithaslotontop.ThisstudywasapprovedbytheinstitutionalreviewboardsoftheUniversityofFloridaand theFloridaDepartmentofHealth. Thefirstnineitemsofthesurveyassessedsociodemographiccharacteristics,includinggender,age,race, education,employmentstatus,maritalstatus,andhealth insurancecoverage.Individualalcoholconsumptionwas measuredbytheAlcoholUseDisordersIdentification Test(AUDIT).AUDIThasbeenwidelyusedtoidentify patientswithawidespectrumofalcoholusedisorders [14,15].InadditiontoAUDIT,wealsoaskedparticipants aboutfrequencyofengaginginbingedrinking,defined asatleastfive(male)orfour(female)drinksperoccasion[16].BasedonbothAUDITandthebingedrinking question,personswereclassifiedashazardousdrinkers ifAUDIT 8orbingedrinkingwasreportedatleast oncemonthly.Marijuanaandotherdrugusewerealso assessed,includingcocaineorcrack,stimulants,anxiety medicationorsedatives,prescriptionpainmedications, hallucinogens,inhalants,andopioids. Therestofthesurveyaskedlocally-developedquestionsaboutthetypeandthefrequencyofICTuse. “ Monthlyinternetuse ” wasdefinedasatleastmonthly accesstointernetathome,school,libraries,orwork. “ Dailyemailuse ” wasdefinedashavingandcheckingan emailaccountatleastonceeveryday.Questionsassessingcellphoneuseaskedwhetherparticipantscurrently ownedacellphone,andwhethertheyusedanycommon cellphonefunctions,suchassendingtextmessages, downloadingringtones,downloadinggamesortaking picturesviathephonecamera.Informationtodistinguishsmartphoneusefromothercellphonetypeswas notspecificallyaskedinthissurvey. “ Multifunctioncell phoneuse ” wasdefinedasparticipantsreportingboth owningacellphoneandusinganyofabovecellphone functions. “ Monthlyvideogameplaying ” wasdefinedas videogameplayingatleastonceamonththroughvariousvideogameconsoles(i.e.NintendoWii,XBOX360, Playstation2/3,Gameboy,andPSP). Toexplorepotentialacceptabilityofusingvideogame forhealthpromotion,participantswereaskedwhether theywouldbewillingtoplayanyhealth-relatedvideo gameduringwaitingtimeattheSTDclinic.Wealso assessedindividuals ’ privacyconcernofICTbyasking whethertheyagreedwithstatementsthatcellphoneHu etal.BMCResearchNotes 2014, 7 :178 Page2of7 http://www.biomedcentral.com/1756-0500/7/178

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conversationsandtextmessagingwereprivate.Intheend, amongthosewhoreportedaccesstothesetechnologies, weexploredtheirwillingnesstoreceiveremindersvia emailortextmessagesaboutSTDtestresultsreadiness. WeanalyseddatausingthestatisticalpackageSAS9.2. Descriptivestatisticsforvariablesofinterests,including demographicsandICTuse,werepresentedforboth hazardousdrinkersandtheentiresampleforcomparisonpurpose.Fishers ’ exacttestandtwo-wayPearson chi-squareanalyseswereperformedtoassessassociations ofuseofeachICTmodalitywithsocio-demographiccharacteristics.Agewascategorizedinto14 – 24,25 – 34,and35 orolder.Racewascategorizedintowhite,black,Hispanic, andotherracialgroup,includingAsian,NativeHawaiian/ PacificIslander,andAmericanIndian/AlaskanNative. Thehighestlevelofeducationattainedwasclassifiedinto highschooldegree/GEDorless,somecollegeorvocationaldegree,andcollegedegreeormore.Maritalstatus wascategorizedintothreelevels:beingmarried,memberofunmarriedcouple,andsingle.Wegenerated twodichotomousvariablesforemployment(employed/ unemployed)andinsurancestatus(insured/uninsured). Variablesachievingstatisticalsignificanceinthebivariate analyseswereincludedinthemultivariablelogisticregressionmodelswhichassessedtheiradjustedassociations withICTusewhilecontrollingforothercovariates.Multivariableanalysiswasperformedonlyamongthosemeetingthecriteriaofhazardousdrinking.ResultsSamplecharacteristicsOfthe489personsapproachedbyresearchstaffs,eightyonepercent(n=396)completedthequestionnairesand themeanagewas25yearsold(SD=8.3).Mostoftheparticipantswerefemales(66%,n=258),AfricanAmerican (60%,n=234),unemployed(59%,n=231),hadahigh schooldegreeorless(57%,n=223),andwereuninsured (50%,n=199).Approximatelyonethirdofthetotalsample(n=126)metthecriteriaforhazardousdrinking.Participantsweresignificantly(P<0.05orP<0.01)more likelytoreporthazardousdrinkingiftheyweremales, white,ofolderage(25+years),hadhighereducational status,and/orwerepositiveforself-reporteduseof marijuanaorotherdrugsinthepastyear(Table1).Fortysevenpercentoftheentiresamplereportedmarijuanause inthepast12monthsand13%reportedotherdruguse whileamonghazardousdrinkerstheseproportionsincreasedto69%and27%,respectively.ICTuseDatadescribingICTusewerepresentedinTable2. Among126hazardousdrinkers,94%reportedinternet useatleastmonthly,82%reportedowninganemail account,and58%reporteddailyemailuse.Eighty-five percentofhazardousdrinkerscurrentlyownedacell phone,and91%reporteduseofanycellphoneapplication:textmessages(90%),takingpictures(90%), Table1Socio-demographiccharacteristicsofthestudy population(N=396)HazardousdrinkersbCharacteristicsTotala(n=396) N(%) Yes (n=126) N(%) No (n=264) N(%) Gender Male134(34)66(52)c64(25) Female258(66)60(48)196(75) Age(years) 14-24261(68)74(60)d185(73) 25-3476(20)33(27)41(16) 35+46(12)17(13)27(11) Race White104(27)55(44)c49(19) Black234(60)54(43)175(67) Hispanic32(8)11(9)21(8) Othere21(5)6(5)15(6) Education Highschooldegree/GEDorless223(57)57(45)c161(72) Somecollege/vocationaldegree131(33)44(35)86(33) 4yearcollegegraduateormore38(10)25(20)13(5) Employment Unemployed231(59)81(64)146(56) Employed161(41)45(36)114(44) Maritalstatus Married28(7)7(6)21(8) Memberofunmarriedcouple305(81)98(83)201(80) Single44(12)13(11)31(12) Insurancecoverage No199(50)72(58)124(47) Yes193(50)53(42)138(53) Marijuanauseinthepastyear No208(53)39(31)c168(64) Yes182(47)86(69)93(36) Otherdrugfuseinthepastyear No334(87)90(73)c241(93) Yes52(13)33(27)19(7)aDatadonotalwayssumuptototalsamplesizeduetomissingdatafor specificvariable.bDefinedifAUDITscore>=8orbingedrinkingatleastoncemonthly.cp<0.01.dP<0.05.eIncludeAsian,NativeHawaiian/PacificIslander,andAmerican Indian/AlaskanNative.fIncludecocaineorcrack,stimulants,anxietymedicationorsedatives, prescriptionpainmedications,hallucinogens,inhalants,andopioids.Hu etal.BMCResearchNotes 2014, 7 :178 Page3of7 http://www.biomedcentral.com/1756-0500/7/178

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downloadingringtones(71%),music(58%)andgames (45%).Morethantwothirds(73%)ofthemwerewillingto playhealth-relatedvideogamesduringtheirclinicwaiting time,slightlyhigherthantheentiresample(69%).Generally,therewasnosignificantdifferenceinusingany modalityofICTamonghazardousdrinkersascomparedwithnon-hazardousdrinkersexceptforself-reported playinganyvideogameatleastoncemonthly(71%vs.53%, P<0.01).PrivacyconcernsofICTuseThemajorityofhazardousdrinkersagreedthateither cellphoneconversations(86%)ortextmessages(86%) wereprivate.Amongthosewhoreportedhavingan emailaccountand/orowninganycellphone,41%reportedfeelingcomfortablereceivingemail/textmessage remindersfortheirSTDtestresultsreadiness.Incontrast,mostofthem(77%)mightnotfeelcomfortablereceivingtestresultsviaemail/textmessages.FactorsassociatedwithfourmodalitiesofICTuseTable3showedtheassociationsbetweensocio-demographic characteristicsanduseoffourmodalitiesofICT,including cellphone,internet,emailandvideogames.Themultivariablelogisticregressionmodelfoundsignificantassociationsbetweenmultifunctioncellphoneuseandyounger age(14 – 24vs.35+,AdjustedOddsRatio(AOR)=7.8, 95%CI(ConfidenceInterval):1.8,32.9;25 – 34vs.35+, AOR=6.4,95%CI:1.4,29.9).Similarly,greateroddsof monthlyinternetusewerefoundamongrespondents whowereyounger(14 – 24vs.35+,AOR=11.4,95% CI:1.4,95.5).Higherlevelofeducationwastheonly variableassociatedwithincreasedoddsofdailyemailuse whencontrollingforothersocio-demographiccharacteristics.Themultivariablemodelfoundincreasedoddsof monthlyvideogameplayingamongmalesandthosewith youngerage.DiscussionHazardousalcoholconsumptionwascommoninthis sampleofpersonsattendingtwonon-urbanSTDclinics intheSoutheasternUnitedStates:approximatelyone thirdofparticipantsmethazardousdrinkingcriteria.We foundoverallhighratesofaccessibilityandutilizationof varioustypesofICT,indicatingastrongpotentialfor theintegrationofICT-basedinterventionintohealthcare deliveryinSTDclinicsettings.Forexample,information relevanttoSTD/HIVpreventioncouldbeadministered viaICTapplication(i.e.web-based)toSTDclinicsattendeeswithoutthepresenceofhealthcareproviders. Similarly,theICT-basedprogrammayhelphealthcare providersidentifyindividualswithdrinkingproblems andevenprovidebriefinterventionstothoseatincreasedriskofacquiringorspreadingSTD.Inaddition, mostoftherespondentsindicatedthattheywerewilling totryhealth-relatedvideogamesduringtheirwaiting time.Whileemailsortextmessagingmayworkforthe purposeofnotifyingwhetherSTDtestresultsareready, Table2ICTuseamongpersonsattendingtwonon-urbanSTDclinicsinFlorida,USAICTuse Totala(n=396) N(%) Hazardousdrinkersb(n=126) N(%) Haveinternetaccessatleastmonthly?c363(93)118(94) Haveanemailaccount? 306(80)102(82) Checkemailaccountatleastoncedaily?180(53)67(58) Currentlyownacellphone? 335(87)105(85) Usecellphoneapplications?d366(94)114(91) Enjoyplayingavideogame? 239(69)79(66) Playanyvideogameconsoleatleastoncemonthly?e230(59)89(71) Cellphoneconversationsareprivate?330(84)107(86) Textingmessagesareprivate?325(84)107(86) Duringyourwaitingtimeatclinicvisits,wouldyoubewillingtoplayhealthrelatedvideogames?265(69)90(73) WouldyoubecomfortablewithreceivingareminderthatyouhaveSTDresultsavailablewith emailortextmessages?f156(43)49(41) Wouldyoubecomfortablewithreceivingyouractualtestresultswithemailortextmessages?f71(19)27(23)aDatadonotalwayssumuptototalsamplesizeduetomissingdataforspecificvariable.bDefinedifAUDITscore>=8orbingedrinkingatleastoncemonthly.cIncludeinternetaccessathome,work,school,library,orthefriend ’ shouse.dIncludedownloadingringtones,music,games,sendingtextmessage,ortakingpictures.eIncludeNintendoWii,Playstation2or3,Xbox360,Gameboy,andPS.fProportionwascomputedbasedonrespondentswhoreportedhavinganemailaccountorowninganycellphone.Hu etal.BMCResearchNotes 2014, 7 :178 Page4of7 http://www.biomedcentral.com/1756-0500/7/178

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itwasgenerallynotacceptableintermsofthedelivery ofactualresults.Itisnotsurprisingtoseethatageand levelsofeducationplayamajorroleininfluencingthe utilizationofICT.Thus,researchersshouldcontinuouslyconsiderthesetwofactorsinanydesignanddevelopmentofhealthinterventiononthebasisofICT. TheprevalentinternetusefoundinthisstudyisconsistentwithpriorworkbasedongeneralSTDpatients fromurbanclinicalsettings[12,13].Web-basedscreeningandbriefinterventiontoaddressalcoholmisuse havealreadybeenevaluatedandhaveshownpromising resultsinsomepopulations.Forexample,adoubleblind,randomizedtrialconductedincollegestudents showedthatthe6-weekweb-basedbriefintervention significantlyreducedalcoholconsumptionandfewer personalproblems,whiletheseeffectswerenotpersistentaftertreatmentended[17]. Ahighrateofcellphoneownershipwasreported amonghazardousdrinkers.Thisfindingisconsistent withtheresultsfromarecentstudyassessingcellphone useamong266patientsreceivingsubstanceabusetreatmentsfrom8psychologicaloropioid-replacementtherapyclinics[18].Cellphone-basedhealthinterventions havebeenexaminedforupto12clinicalareas,ranging fromsmokingcessationprograms,pediatricvaccination reminders,tohypertension,diabetesandasthmamanagement,whereassimilarstudiesarelackinginthefield ofalcoholabusepreventionandintervention[19].In addition,severalrealisticconcernshavebeenraised regardingadoptionofcellphone – basedhealth Table3FactorsassociatedwithICTuseamong126hazardousdrinkersaCharacteristicsMultifunctioncellphoneuseMonthlyinternetuseDailyemailuseMonthlyvideogameplaying AOR(95%CI)bAOR(95%CI)AOR(95%CI)AOR(95%CI) Gender Male —c—— 5.2(2.2,12.6) Female Ref Age(years) 14-24 7.8(1.8,32.9)11.4(1.4,95.5) 1.8(0.4,8.4) 29.7(2.9,301.3) 25-34 6.4(1.4,29.9) 13.6(0.99,186.5)1.2(0.2,6.1) 32.6(3.0,358.0) 35+RefRefRefRef Race White —— 0.1(0.0,1.4) — Black 1.3(0.1,36.2) Hispanic 1.0(0.1,13.1) OtherdRef Education Highschooldegree/GEDorlesssomeRefRefRef — College/vocationaldegree2.4(0.8,7.7)4.0(0.4,40.0) 12.9(3.7,45.7) 4Yearcollegegraduateormore9.1(0.9,86.9)2.9(0.2,54.7) 14.2(1.6,123.8) Employment UnemployedRef — Ref — Employed2.1(0.6,7.2)1.6(0.5,5.3) Maritalstatus Married — 0.3(0.0,16.1) — 3.4(0.1,76.2) Memberofunmarriedcouple0.7(0.1,8.9)1.5(0.4,5.9) SingleRefRef Insurance NoRefRef —— Yes2.2(0.7,6.9)7.9(0.7,94.7)aDefinedifAUDITscore>=8orbingedrinkingatleastoncemonthly.bAORindicatesadjustedoddsratio;CI,confidenceinterval.cVariablesnotincludedinmultivariablelogisticregressionmodelssincestatisticallyinsignificanceinbivariateanalysis.dIncludeAsian,NativeHawaiianorPacificIslander,andAmericanIndian/AlaskanNative. Significantassociations(P<0.05)arehighlightedinboldface.Hu etal.BMCResearchNotes 2014, 7 :178 Page5of7 http://www.biomedcentral.com/1756-0500/7/178

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interventions:costsofdevelopmentandimplementation,potentialabuseofshortmessageservices(SMS)for thingsirrelevanttostudy,andlackofreimbursementfor healthprofessionals ’ involvementandextratimecommitment.Nevertheless,ourstudysuggestspervasiveuseof cellphoneamongSTDpatients,especiallyforthosewith hazardousdrinking.Withtheflexibilityofcombining voiceandtextmessagingwithinteractivemultimedia components,cellphonetechnologycouldincreasethe likelihoodofsuccessfullydeliveringhealthbehaviouralinterventionstotraditionallyhard-to-reachpopulation,such asthosewithalcoholmisuse. MultivariableregressionsfoundnosignificantracialdiscrepancyintermsofICTuse.However,a “ digitaldivide ” appearstoexistamongpeoplefromdifferentagegroups andlevelsofeducation.Interestingly,ourregression resultssuggestthatmalesaremuchmorelikelytoplay videogamethanfemales.Health-relatedvideogames playingmayprovideanovelapproachtodeliverbehaviouraleducationandintervention.Avideogame-based healthinterventioncouldbeofferedviagameconsolesor computerslocatedinclinicalfacilitiesorcellphonesto reachbroaderpopulations.However,ourresultsshowthat malesaremorelikelytoplayvideogamethanfemales, whichmayleadtogenderdisparityinaccesstocare.Futureresearchexploringvideogamesasameanstoimplementhealthinterventionsshouldconsiderthisandtryto adjustthedesigntoensureequalresponsesfromboth genders. Ourparticipantsappeartobeinterestedinplayinga health-relatedvideogameduringtheirwaitingtimeat clinicvisits.Meanwhile,theyalsodisclosegreatconcerns ofreceivingSTDtestresultsviaeitheremailsortext messages.Itisnotedthatparticipantsmayonlyperceive textmessagingprivateforordinarycommunication,but notprivateenoughfordeliveringinformationassensitiveasSTDresults.Onepotentialsolutiontosecureconfidentialityoftextmessagesistoaddasecuritycodeto thephoneoreventothemessagebox.Thisfunctionis commonlyavailableinsmartphonesandcouldbeeasily achievedbyusingappsdesignedforthispurpose. Severallimitationsofthisstudyshouldbenoted.First, ourfindingsofICTuserepresentasamplein2009,and maynotnecessarilyreflectthecurrentaccessand utilizationofICTamonggeneralSTDclinicattendees andhazardousdrinkers.Second,theresultsofthisstudy maynotbeeasilygeneralizedtoothergeographicareas sincethisstudyisonlybasedontwonon-urbanclinics locatedintheSoutheasternUS.However,wespecifically evaluatedtheICTusebysubgroupstoallowothersto compareourfindingstosimilarsettings.Finally,our studyiscross-sectional,andthuswecanonlystatethat differentcharacteristicsareassociatedwithuseofcertain typesofICTbutnotpredictive.ConclusionsOnethirdofpersonsattendingtwonon-urbanSTD clinicswerecurrenthazardousdrinkers,andevenmore usedmarijuanaorotherdrugs.Thesefindingsreinforce thepressingneedforinterventiontoaddressalcoholor substanceabuseinSTDclinicsettings.OurstudydemonstratescommonalityofICTuseamongSTDpatients withhazardousdrinking,whichindicatestheviabilityof usingICTtoassistscreeningandbehaviouralinterventionforalcoholmisuse.VariationspresentedinICTuse andaccessacrossagegroups,gendersandeducation levelsreflectthecontinuedpresenceofa “ digitaldivide ” CliniciansandICTprogramdevelopersinterestedin creatingICT-basedhealthinterventionsforalcoholand substanceabuseinterventionshouldbeawareofandtry toaddressitbyincludingmultipleICTalternativesto avoidlessrepresentationofsomesub-population,likefemalesforvideogamesplaying.Moreresearchisneeded todemonstratetheacceptabilityandeffectivenessofdifferenttypesofICT-basedinterventionsintheSTDclinic settingsorothervenuesthatservepopulationsathigh riskforsubstanceabuse,HIVorotherSTDs.Abbreviations ICT: Informationandcommunicationtechnology;STD:Sexuallytransmitted disease;AUDIT:Alcoholusedisordersidentificationtest;AOR:Adjustedodds ratio;CI:Confidenceinterval;GED:Generaleducationaldevelopment. Competinginterests Theauthorsdeclarethattherearenocompetinginterestsinthisstudy. Authors ’ contributions XHperformedthedataanalysisandwrotethemanuscript.VJD,JOCandRLC participatedinthedesignofthestudy,collectedthedataandhelpedto draftthemanuscript.Allauthorsreadandapprovedthefinalmanuscript. Acknowledgements ThisstudywaspartlyfoundedbytheUniversityofFloridaOpportunityFund AwardandNIHgrant(U24-022002). TheauthorswishtothankJillSonkeforherassistancewithearlydesignof thestudyandOkaforChukwuemekafortherevisionofthemanuscript. Authordetails1DepartmentofEpidemiology,UniversityofFlorida,Gainesville,FL,USA.2DepartmentofCommunityDentistryandBehavioralScience,Universityof Florida,Gainesville,FL,USA.3DigitalWorldsInstitute,UniversityofFlorida, Gainesville,FL,USA.4CollegeofMedicine,UniversityofFlorida,Gainesville, FL,USA. Received:31March2013Accepted:20March2014 Published:26March2014 References1.HuttonHE,McCaulME,ChanderG,JenckesMW,NollenC,SharpVL, ErbeldingEJ: AlcoholUse,analSex,andotherriskysexualbehaviors amongHIV-infectedwomenandMen. AIDSBehav 2013, 17 (5):1694 – 1704. 2.CookRL,ClarkDB: Isthereanassociationbetweenalcoholconsumption andsexuallytransmitteddiseases?Asystematicreview. SexTransmDis 2005, 32: 156 – 164. 3.CooperML: Alcoholuseandriskysexualbehavioramongcollege studentsandyouth:evaluatingtheevidence. JStudAlcoholSuppl 2002, 14: 101. 4.CelumCL,BolanG,KroneM,CodeK,LeoneP,SpauldingC,HenryK,ClarkeP, SmithM,HookEW3rd: PatientsattendingSTDclinicsinanevolvinghealthHu etal.BMCResearchNotes 2014, 7 :178 Page6of7 http://www.biomedcentral.com/1756-0500/7/178

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