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

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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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