Development, Acceptance, and Use Patterns of a Computer-Based ...

Pergamon

Computers in Human Behavior,Vol. 11, No. 2, pp. 289-311, 1995 Copyright © 1995 Elsevier Science Ltd Printed in the USA. All rights reserved 0747-5632/95 $9.50 + .00 0747-5632(94)00037-9

Development, Acceptance, and Use Patterns of a Computer-Based Education and Social Support System for People Living With AIDS/HIV Infection Eric W. Boberg, David H. Gustafson, Robert P. Hawkins, Chien-Lung Chan, Earl Bricker, Suzanne Pingree, and Haile Berhe Center for Health System Research and Analysis, University of Wisconsin-Madison

Anthony Peressini Marquette University

Abstract - - A computer-based support system has been developed to provide information, referrals, decision support, and social support to people living with AIDS/HIV infection. CHESS (the Comprehensive Health Enhancement Support System) uses personal computers placed in users' homes and linked together via modem through a central "'host" computer. Color, graphics, and simple user prompts make the system easy to use. HIV-positive subjects (96 male, 20female) were given CHESS computers to use in their homes for 3 to 6 months. Subjects used CHESS services a total of 15,966 times for over 4,600 hr of use, an average of about one use per subject per day throughout the study. Each subject used CHESS an average of over 39 hr. The system was heavily used by all segments of Requests for reprints should be addressed to: Eric W. Boberg, Center for Health Systems Research and Analysis, University of Wisconsin-Madison, 610 Walnut Street, R o o m 1122 WARF Building, Madison, W I 53705-2397. E-mail: [email protected]

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Boberg et al. the study population. Women and minorities used the system at least as frequently as their male and Caucasian counterparts. In fact, Caucasian and minority women used some parts of the system significantly more than other subjects. Subjects rated CHESS very positively in terms of usefulness and ease of use. Thus, CHESS appears to be a heavily used and highly accepted means of providing information and support to HIV-infected individuals.

For people diagnosed with life-threatening illnesses, information and support play a key role in coping with the crisis (Aguilera, 1990; Caplan, 1964; Moos & Schaeffer, 1984). Unfortunately, barriers to obtaining the necessary information and support can be difficult to overcome. These barriers include geography, education, finances, physical mobility, ability to act under stress, and the belief that action must be taken immediately (Slovic, Fischoff, & Lichtenstein, 1977). The emergence of computer technology offers the opportunity to overcome or reduce many of these barriers by providing information and support that is convenient, comprehensible, timely, nonthreatening, anonymous, and controlled by the user (Gustafson, Bosworth, Hawkins, Boberg, & Bricker, 1992). People diagnosed with HIV infection have complex needs, not only for easilyaccessible information, but also for strong psycho-social support (DiPasquale, 1990; Sadovsky, 1991; Volberding, 1988). These needs include: (1) extensive information on the medical, legal, financial, and social aspects of HIV infection; (2) support in making difficult decisions about disclosure and behavior change; (3) knowledge of available services and how to use them; and, (4) social support from other HIVinfected individuals. By combining databases, expert systems, and communications technology, computers can provide all of these services in one package. Most computer-based support systems developed to date have been of limited scope, focusing on a single type of support or a specialized population. In the area of AIDS/HIV infection, for example, numerous systems have been developed to provide information. Some utilize the technology of electronic bulletin boards (Makulowich, 1992), others use on-line or microcomputer-based databases (Veenstra & Gluck, 1991). These systems are intended for medical professionals, however, and rely on extensive medical expertise as well as expensive hardware or significant experience with computers. Other systems have been developed for AIDS education and prevention programs (Li & Xu, 1991; Wolitski & Rhodes, 1990), and for health care worker training (Wood, 1992). None of these programs have been designed to accommodate the needs of people living with AIDS/HIV infection. Two exceptions are systems called ComputerLink, developed at Case Western Reserve University (Brennan, 1993; Brennan, Ripich, & Moore, 1991) and CHESS (the Comprehensive Health Enhancement Support System), which we describe here. ComputerLink has been used by people living with AIDS, and integrates information, decision support and communication systems, utilizing an alreadyexisting, open-access computer system (Hekelman, Kelly, & Grundner, 1990). Users are given terminals in their homes, and are linked together via the public access community computer system. This system has the advantages of using an already-existing network and low-cost terminals in users' homes, but it is unable to provide a user-friendly interface through color or graphic enhancements. CHESS, in contrast, uses personal computers, placed in users' homes, which contain the databases and expert systems. The users' computers are linked together via modems to a central computer (also a PC) to mediate the communications.

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CHESS has been developed by a team of decision, information, education, medical, and communication scientists (Bosworth & Gustafson, 1991; Gustafson et al., 1992). This system not only integrates information, referral, decision support and social support systems, but also uses color, graphics, and simple user prompts to make CHESS appealing and easy to use, even by people with little or no computer experience. We expect that HIV-infected people will use CHESS because it is convenient, it has the information, help, and support they need, and it is easy and interesting to use. A 3-year study to develop and evaluate an AIDS/HIV module of CHESS has recently been completed. This article will describe the level of use, acceptance, and patterns of use observed with 116 HIV-infected male and female subjects from this study who used CHESS for a 3- to 6-month period in their homes. We will also briefly describe the AIDS/HIV module of CHESS and its development.

METHODS

Development of CHESS CHESS was conceived following our experience with the BARN (Body Awareness Resource Network) system (Bosworth, Gustafson, & Hawkins, 1993; Hawkins, Gustafson, Chewning, Bosworth, & Day, 1987), currently used in over 8000 schools nationwide. BARN is a widely-used, computer-based health promotion/ behavior change system for use by adolescents. BARN provides 6th- to 12th-grade students with information and skill-building activities on AIDS, alcohol and other drugs, body management, human sexuality, smoking, and stress management. Compared with BARN, CHESS provides more in-depth information, additional decision- and behavior-support services, and a communications link to other users. CHESS design has been further shaped by various aspects of crisis (Aguilera, 1990; Caplan, 1964; Moos & Schaeffer, 1984) and change (Bandura, 1977; Fishbein & Aizen, 1980; Strecher, McEvoy-DeVellis, Becker, & Rosenstock, 1986) theories. CHESS is a PC-based system providing a single point of access to multiple services, including information, referral, skills training, decision support and social support. Each PC in the CHESS system is linked with others by modem through a central "host" computer, which mediates the communications. By providing an extensive set of integrated services, CHESS provides users with many different types of tools to help them gain control of their lives. Users can: anonymously talk with peers, ask questions of experts, learn where to get help and how to use it, read relevant articles, monitor their health status, analyze tough decisions and how to implement them, and assess their lifestyle risks. CHESS has been designed with a modular structure that will accommodate content on various topics. CHESS modules have already been developed for AIDS/HIV infection, breast cancer, stress management, sexual assault, adult children of alcoholics, and academic crisis. Development of modules on additional topics is planned. Development of content on all modules of CHESS is based on the principle of determining the potential user needs, and providing them in an accessible and interesting format. For the AIDS/HIV module, this involved (1) an extensive needs assessment using literature review, focus groups, and survey research; (2) development of draft content; (3) review of the draft material by a panel of expert

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AIDS/HIV health care providers and patients; (4) revision of the draft material; (5) pilot testing of the revised system with HIV-positive patients; and, (6) additional revisions based on the pilot test results. Updating and refinement is an ongoing process as new information and new technology becomes available.

Description of CHESS CHESS is designed to be user-friendly, even to complete computer novices. A graphic interface provides easy-to-understand prompts; color and graphics highlight key information. CHESS operates on IBM-compatible PCs. The minimum individual work station requirements are a 286 microprocessor, 640KB RAM, 40 MB hard disk drive, color VGA monitor and a 2400-baud modem; simple dot-matrix printers can also be provided. The AIDS/HIV module of CHESS has 11 interlinked services:

Questions and Answers is a compilation of answers to over 400 common questions about AIDS/HIV infection. Answers are brief 1- to 5-screen overviews, with references to where more detailed information can be found, both in other CHESS services and outside CHESS. Users can also create and print a list of questions to take to their next doctor's appointment. Instant Library is a database of over 250 articles, brochures, and pamphlets. Articles cover a broad range of topics and levels of complexity, and are drawn from scientific journals, pamphlets, newsletters, the popular press, and even past CHESS discussion groups. Getting Help/Support helps users understand what health and social services are available (over 150 are included), how they work, how to find a good provider, and how to be an effective and active consumer. Personal Stories are real-life accounts of living and coping with AIDS/HIV infection. Over 20 stories have been collected and transcribed by trained journalists. Users can read 300-500 word overviews, and more detailed "expansions" on specific topics. Ask an Expert allows users to ask AIDS/HIV experts anonymous questions and receive confidential responses within 24 hr. Discussion Group allows anonymous, nonthreatening communication among people infected with HIV. Message senders are identified only by a code name. Users share information, experiences, hopes and fears, give and receive support, and offer different perspectives on common issues. A trained facilitator monitors groups to keep discussion flowing smoothly. Assessment allows users to assess risk of exposure to or transmission of HIV. Users answer a series of detailed questions on behaviors that transmit HIV. A Bayesian model (Gustafson, 1987; Von Winterfeldt & Edwards, 1986) then predicts the risk based on the reported behaviors. Users are offered detailed feedback on their risk factors and how to reduce them. Decision Aid helps people think through difficult decisions. Users consider their various options and the considerations that affect which option they choose. Two different types of decision aids are available. Tailored programs help users with specific decisions such as who to tell about being HIV positive. A more general model can be used for any decision. Both programs use multiattribute utility models (Sainfort, Gustafson, Bosworth, & Hawkins, 1990) for the analyses. CHESS does not tell users what they should do. Instead, users can choose to see how the computer used their input to predict what they might do.

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Action Plan helps users implement a new decision, and is based on change theories (Bandura, 1977; Fishbein & Aizen, 1980). The program asks users how they propose to implement a decision, helps them analyze their strengths and weaknesses, supports and barriers, predicts the likelihood of success, and suggests ways they can strengthen their prospects. Health Charts automatically collects quality-of-life measures, symptoms, medications, and weight data from subjects once a week. This data can be printed and taken to visits with health care providers. Dictionary provides easy-to-understand definitions of over 850 health and AIDS-related terms. The vast amount of material available in CHESS is made easier to access by linking all material about a single subject. Thus, a user concerned about risk of HIV transmission may start in Questions and Answers. After reading an answer, the user is shown a menu of other material CHESS has on the same specific subject, and can move directly to one or more of the following services: (1) a Risk Assessment for behaviors which lead to transmission; (2) an Instant Library article on safer sex; (3) a personal story about HIV transmission; and/or, (4) a description of safer sex programs offered by AIDS Service Organizations.

Study Design The data reported in this article was obtained during a controlled evaluation of the use and impact of CHESS on people living with AIDS/HIV infection. This study was designed to evaluate the effects of CHESS on: (1) health status; (2) health-related behaviors; and, (3) health service utilization. This article will focus on use and acceptance of the system; data on the impact of CHESS in the three areas listed above will be reported in a separate article. A total of three cohorts (60-70 people each) were studied (Table 1). In each cohort, HIV-infected people at all stages of infection were randomly assigned to receive either CHESS Table 1. Demographic Characteristics of Subjects Using CHESS Variables Gender AI DS Stage Age Employment Income Relationship Education Race Living Status Religious Insurance

Classes

% or Average

Male Female Symptomatic Nonsymptomatic Average No Yes Average No Yes Average White Non-White Alone Not alone No Yes No Yes

82.8% 17.2% 65.5% 34.5% 34.9 years 47.8% 52.2% $15,010 49.5% 50.5% 13.9 years 78.1% 21.9% 24.8% 75.2% 29.2% 70.8% 21.6% 78.4%

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(experimental) or no intervention (control). Experimental subjects in the first cohort (from Madison) were given CHESS in their homes for 6 months. In order to maximize the number of subjects studied, two cohorts in Milwaukee were recruited, and experimental subjects were given CHESS in their homes for 3 months. Subject retention was very high. Only 9 of 116 experimental subjects (< 8%) dropped out of the study between installation and removal of the computers. Of those not completing the study, three died, two were jailed, two moved out of state, one lost phone service and chose to withdraw, and one dropped out for unknown reasons. All subjects were surveyed at pretest, and with 2- and 5-month posttests (the Madison cohort also received a 9-month posttest). Subjects were paid to complete the surveys, which assessed reactions to CHESS, health status, health behaviors, and health service utilization. Data on time, number, and patterns of CHESS use was automatically collected by each computer. Although only men were included in the original study design, women were added to the study on a pilot basis after statistics indicated growing numbers of women were being infected. Due to the small number of HIV-infected women in Madison, and to provide maximum feedback on CHESS, all nine women recruited for the first cohort were given CHESS computers. In both Milwaukee cohorts, with a larger population to draw from, women were randomly assigned to experimental and control groups. The demographics of the experimental study subjects (those receiving CHESS) are shown in Table 1. They mirror fairly closely the demographics of all persons with AIDS in the state of Wisconsin (Wisconsin AIDS/HIV Update, 1994).

RESULTS Use of CHESS

To minimize the effects of "browsing" and mistaken entries by users into an unintended component, all uses reported here are of at least 1-min duration. Uses of Health Charts are not included in the totals since these uses were automatic at logon once each week, and thus were not voluntary. Uses of Dictionary were not recorded due to a limitation in the data collection program. CHESS was used very extensively by the study subjects. The 116 subjects who had CHESS computers installed in their homes (96 males, 20 females) used CHESS services a total of 15,966 times, for over 4600 hr. As detailed in Table 2, subjects used CHESS an average of 138 times. Based on the total length of time each subject had access to CHESS, this represents more than one use per subject per day for every day of access to CHESS. Each subject used CHESS on average more than 39 hr during the study. Table 2 also describes the distribution of uses for each CHESS component. The social support services of CHESS (Discussion Group, Personal Stories) were the most heavily used, accounting for 79% of all uses. Information services (Instant Library, Questions and Answers, Ask an Expert, and Getting Help/Support) accounted for 17% of all uses. The analysis services (Decision Aid, Action Plan, Risk Assessment) were the least used, accounting for 4% of all uses. Post-test surveys and focus groups indicated that while social support services (Discussion Group and Personal Stories) were the most frequently used, all s e r -

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Table 2. Use of CHESS Services

% of Subjects Total # of Using Service Uses

Total "Iqme of Use (mins)

Average Time of Each Use (mins)

Average # of Uses Per Subject

Social support services Discussion Group Personal Stories

100 96

12,077 599

249,047 4,592

20.6 7.7

104 5.2

Information services Instant Library Questions and Answers Ask an Expert Getting Help/Support

96 98 87 80

863 654 947 241

8,700 3,108 6,437 1,216

10.1 4.8 6.8 5.0

7.4 5.6 8.2 2.1

Analysis services Decision Analysis Action Plan Risk Assessment

78 67 53

250 174 161

2,017 1,443 814

8.1 8.3 5.0

2.2 1.5 1.4

15,966

277,374

17.4

Total uses

138

vices were considered extremely valuable. The preponderant use of the social support services appears to be due to the ongoing nature of social support, as well as the ever-changing content of the Discussion Group messages. Thus, while an information or analysis service might be used only once (reading a Library article, doing a Risk Assessment), continuing social support needs and the constant flow of new messages encourages repeated, ongoing use of the Discussion Group. Thus, CHESS was used as much more than a vehicle for information; it was also relied on for communication, social support, and problem-solving. Use of CHESS services was not evenly distributed over time (Figure 1). Uses can be broken down into three phases. During weeks 1-4, there was a period of heavy use and exploration of CHESS services. A gradual decline in service use continued from weeks 5-11, followed by a "steady-state" level of use seen between weeks 12 and 26. Although this steady-state use level appears low relative to the first weeks of use, it represents an average of three uses per subject per week, for nearly an hour of use per week. The number of uses per subject ranged widely. Since use varied over time, the total number of uses for each user during the first 13 weeks (the period all three cohorts had access to CHESS) of each cohort is compared in Figure 2. During the first 13 weeks, the number of uses ranged from a high of 685 to a low of 7, with an mean of 122 (124 SD). The median number of uses was considerably lower (88), because the distribution is skewed by a tail of heavy users. Even so, the main body of the distribution still represents heavy use, with a median of one use per day for 13 weeks. Subjects used CHESS at all hours of the day and night (Figure 3). Heaviest usage was from 5:00-11:00 PM, and lightest usage from 4:00-6:00 AM. Over a third (34.2%) of all uses occurred between 9:00 PM and 7:00 AM, a time when few (if any) other sources of information and support are available. Effects of race and gender on CHESS service use are shown in Table 3. This data again summarizes only the first 13 weeks of use, the length of time all three cohorts had access to CHESS. Female subjects used CHESS slightly, though not significantly, more than male subjects (136 vs. 119). The 25 African-American and Hispanic subjects (no other minorities were represented) used CHESS only slightly,

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"~

30

20

3

5

7

9

11

13

15

17

19

21

23

25

Week of Study Figure 1. Use of CHESS services over time.

but not significantly, less than Caucasian subjects (109 vs. 126). The distribution of uses of the various CHESS services by different populations is also shown in Table 3. Each group was compared to the mean of the other three groups. Total system use and use of three services (Discussion Group, Instant Library, and Ask an Expert) was greatest by Caucasian women. This difference was significant 30

20

O

15

Number of Uses Figure 2. Distribution of CHESS uses.

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1,000

800 0

600

o

400

200

0

= flfli=fifllEEEEEEEEEEEE

Time of Day Figure 3. Time of day of use of CHESS services.

(p < 0.02 and p < 0.00l, respectively) for Instant Library and Ask an Expert. Minority women had the highest average use of five services (Questions and Answers, Personal Stories, Getting Help/Support, Decision Analysis, and Action Plan). This difference was significant (p < 0.02 and p < 0.05, respectively) for Table 3. Use of CHESS Services by Different Populations Average Number of Service Uses* By Service

Social support services Discussion Group Personal Stories Information services Instant Library Questions and Answers Ask an Expert Getting Help/Support Analysis services Decision Analysis Action Plan Risk Assessment Total of all services

Caucasian Men (n = 78) 95 4.31"

Caucasion Women (n = 13) 108 5.8

Minority Men (n = 18)

Minority Women (n = 7)

77 5.3

59 9.0

5.8t t 4.6 5.6t 1.7t

10.5tt 6.8 17.4§ 2.5

8.6 6.4 6.8 2.5

8.5 8.0 5.1 3.0

1.8 1.2t 1.1

1.9 1.3 1.5

2.9 2.0 1.7

3.3tt 2.7t 0.6

121

155

113

*Service use totals for the first 13 weeks of access to CHESS. tSignificantly different from the average for all other groups, p < 0.05 (Mann-Whitney test). ttSignificantly different from the average for all other groups, p < 0.02 (Mann-Whitney test). §Significantly different from the average for all other groups, p < 0.001 (Mann-Whitney test),

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Decision Analysis and Action Plan. Caucasian men had a significantly (p < 0.05) lower average use of five services (Personal Stories, Instant Library, Ask an Expert, Getting Help/Support, and Action Plan) than all other groups. Other differences (especially total use and Discussion Group use) were not significant due to the large variance in use. In an effort to further understand the causes for the wide variation in use, the demographic characteristics of the 25% of subjects who used CHESS the least were compared to those of all other subjects. In this analysis, of the 11 demographic characteristics listed in Table 1, only two appeared to influence level of use. The 25% of subjects who used CHESS the least were more likely to have symptomatic HIV disease (p < 0.002) and were more likely to have indicated a religious preference (p < 0.05). Separate, detailed regression analyses of the demographic predictors of CHESS use also showed that younger subjects and subjects living alone used CHESS more, but that level of education did not predict CHESS use (Pingree et al., 1993). Perceived Usefulness and Ease of Use

A total of 107 of the 116 subjects who were given CHESS returned a survey 2 months after installation, which assessed health status, health behavior, and health service utilization, as well as reactions to CHESS. Subjects returning posttests were asked to rate the usefulness and ease of use of CHESS and its individual services using a 7-point Lickert scale. The results are shown in Tables 4 and 5. All services were perceived as easy to use. Discussion Group, Instant Library, and Ask an Expert were perceived to be the easiest to use (with ratings of 5.95, 5.92, and 5.89, respectively). Even Action Plan, which received the lowest average (5.30), was rated as easy to use. All services were perceived to be useful. Instant Library and Ask an Expert received the highest ratings (5.82 and 5.80, respectively) and Action Plan received the lowest rating (4.84, still well above average). Table 4. Perceived Ease of Use of CHESS Services By Different Populations Average Ease of Use* Scores of

Service

Caucasian Men (n = 74)

Caucasion Women (n = 11)

Minority Men (n = 16)

Minority Women (n = 6)

All Subjects (n = 107)

Social support services Discussion Group Personal Stories

5.68 5.51

6.50t 6.40t

5.36 4.86

6.67 6.33

5.95 5.79

5.64 5.60 5.55 5.19

6.90tt 6.80tt 6.70tt 6.00

5.00tt 4.871 5.43 5.00

6.00 6.00 6.50 6.00

5.92 5.82 5.89 5.55

Decision Analysis Action Plan Risk Assessment

5.05tt 4.88t 5.01

6.27tt 5.851 6.001

5.24 5.07 4.93

5.83 5.67 5.60

5.53 5.30 5.40

Average of all services

5.16tt

6.31 t t

5.15

5.97

5.68

Information services Instant Library Questions and Answers Ask an Expert Getting Help/Support

Analysis services

*Ease of use rated by responses to the question, "Is this service easy to use?" Responses ranged from 1 (Disagree completely) to 7 (Agree completely). tSignificantly different from the average for all other groups, p < 0.05 (Mann-Whitney test). ttSignificantly different from the average for all other groups, p < 0.02 (Mann-Whitney test).

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Table 5. Perceived Usefulness of CHESS Services By Different Populations Average Usefulness* Scores of

Service Social support services Discussion Group Personal Stories Information services Instant Library Questions and Answers Ask an Expert Getting Help/Support Analysis services Decision Analysis Action Plan Risk Assessment Average of all services

Caucasian Men (n = 74)

Caucasion Women (n = 11)

Minority Men (n = 16)

Minority Women (n = 6)

All Subjects (n = 107)

5.24 4.89tt

6.40it 6.001

5.20 4.8711.

6.33 6.33tt

5.54 5.26

5.56 5.081 5.4411 4.751"I"

6.70tt 6.10tt 6.9011. 5,88

5.13t 5.00 5.67 5.07

6.00 6.00 6.501" 6.00t

5.82 5.44 5.80 5.22

4.54tt 4.42tt 4.66

5,97tt 5,60tt 5,37

5.13 4.83 4.77

5.83 5.09 5.33

5.09 4.84 5.13

4.8211

6.0711

5.05

5.81

5.35

*Usefulness rated by responses to the question, "Is this service useful?" Responses ranged from 1 (Disagree completely) to 7 (Agree completely). tSignificantly different from the average for all other groups, p < 0.05 (Mann-Whitney test). ttSignificantly different from the average for all other groups, p < 0.02 (Mann-Whitney test).

The ease of use and usefulness scores reported by various populations are also shown in Tables 4 and 5. These scores correlate closely with the levels of use of CHESS reported in Table 3. Thus, Caucasian women, who used Instant Library and Ask an Expert significantly more than did other subjects, gave these services significantly higher scores for usefulness and ease of use than did other subjects. Similarly, Caucasian men, who used Personal Stories significantly less often than did other subjects, gave that service a significantly lower score for usefulness than did other subjects. Overall, women (Caucasian and minority) gave CHESS services significantly higher scores for usefulness (5.97 vs. 4.86) and ease of use (6.10 vs. 5.03) than did men (p < 0.005). However, there was no significant difference in these scores between Caucasian (4.97 usefulness and 5.16 ease of use) and minority (5.27 usefulness and 5.33 ease of use) subjects. Table 6 compares the ease of use and usefulness ratings of CHESS services reported by the heaviest 25% of users of each service, the middle 50%, and the 25% who used each service the least. It is interesting to note that while for some services (Discussion Group and Decision Analysis, for example) there is a strong correlation between usefulness/ease of use scores and heavier use, this correlation is absent for other services (Instant Library, Getting Help/Support).

DISCUSSION This study demonstrates that computers, which are often characterized as sterile, information-only, and intimidating, can be used very successfully to provide information, analysis, and support to people facing a health crisis such as HIV infection. Overall, use of CHESS services by the 116 HIV-positive men and women in this study was enormous. The total of 15,966 uses over an average of 17.4 weeks represented

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Service

Social support services Discussion Group Personal Stories Information services Instant Library Questions and Answers Ask an Expert Getting Help/Support Analysis services Decision Analysis Action Plan Risk Assessment Average of all services

Average Usefulnesst By

Low 25% of Users

Middle 50% of Users

High 25% of Users

Low 25% of Users

Middle 50% High 25% of Users of Users

4.701-1§ 5.47

6.28 5.57

5.96 5.81

4.831"1§ 4.76

5.65 5.06

5.74 5.42

5.79 5.24tt 5.19 t t 5.20

5.80 5.93 5.63§ 5.42

5.64 5.50 6.16 4.87

5.57 5.38 5.00§ 5.12

5.75 5.20 5.56§ 4.87

5.68 5.09 6.36 5.14

4.98 § 5.00§ 4.76tt§

5.21§ 4.96§ 5.42

5.75 5.47 5.87

4.52§ 4.48§ 4.67

4.79§ 4.55§ 4.77

5.56 5.11 5.27

5.07

5.51

5.23

4.77

5.23

4.90

*Rated by responses to the question, "Is this service easy to use?" Responses from 1 (Disagree completely) to 7 (Agree completely). tRated by responses to the question, "is this service useful?" Responses from 1 (Disagree completely) to 7 (Agree completely). ttSignificantly different from the average for the middle 50% of users, p < 0.05 (Mann-Whitney test). §Significantly different from the average for the heaviest 25% of users, p < 0.05 (Mann-Whitney test).

over 7.9 uses (for 138 min of use) by each subject for each week of access to CHESS. Even after the initial period of heavy use and exploration of CHESS, subjects who had the system between 12 and 26 weeks still used CHESS services an average of three times (for 52 min) every week. While all CHESS services were used, Discussion Group accounted for about 75% of all uses. The heavy overall Discussion Group use, compared to the use of other services, can be partly attributed to the nature of the service, where significant benefit only comes with repeated use. However, given that the number of Discussion Group uses was so large, and also that so many of these uses occurred between 9:00 PM and 7:00 AM (when access to other support systems is almost impossible), it is clear that Discussion Group served as an important support service to these subjects. Discussion Group was used much like an in-person support group. A sample set of Discussion Group interactions is included as Appendix 1 to this article. Users asked questions, got answers, and gave and received support. Users reported several advantages to this type of computer-based support. They were able to write messages 24-hr a day, 7 days a week, not just when the group meets. They could remain as anonymous as they wanted to be. Those who were healthy did not have to be faced with the sight of people in terminal stages of the disease. They could relate to other people based solely on what they wrote, not being influenced by automatic prejudices based on race, dress, sex, or other factors. Reported disadvantages to this format included: (1) the time-lag in getting responses to messages (from a few minutes to a few days); (2) the difficulty in conveying certain emotions through written comments (especially sarcasm); and, (3) having to read many messages the user wasn't interested in. Computer-mediated support cannot, of course, replace in-person support. However, for rural people, shut-ins, those with issues about confidentiality and anonymity, and others, CHESS offers a powerful adjunct opportunity for obtaining information and support.

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The sample studied included subjects from both a large urban area and a smaller city. To some extent, the sample is biased away from the most impoverished and under-educated segments of the HIV-infected population. However, the sample included most of both distributions, and the regression analyses that have been performed on CHESS use showed no consistent effect of level of income or education on the amount of CHESS use (Pingree et al., 1993). Furthermore, women (17% of subjects) and minorities (22% of subjects) had levels of use similar to those of their male and Caucasian counterparts. Thus, CHESS appears to be used and accepted by most, if not all, segments of the HIV-infected population. With the rapid spread of HIV infection in women and minorities, acceptance of CHESS by these populations is particularly important. Women used CHESS on average slightly more than did men (136 vs. 119 times during the first 13 weeks, respectively), and reported significantly higher scores than men for the usefulness and ease of use of several CHESS services. Caucasian women used Instant Library and Ask an Expert significantly more than all other groups. Minority women used Decision Analysis and Action Plan significantly more than all other groups. Recent studies that have shown that HIV-infected women are more isolated, want more information, and have less access to services (Pizzi, 1992) offer some explanation for these results and suggest that CHESS may be particularly useful to women. The significantly lower average use of several services, particularly information services, by Caucasian men is most likely attributable to the higher level of information and services available to and utilized by this population outside of CHESS. In other words, CHESS is useful to everyone, but is especially useful to underserved groups (women, minorities) with HIV. One reason for the high use by many different types of subjects may be the user interface. Significant effort was put into using color and graphics to make the interface as attractive and easy to use as possible. Users rated the ease of use of all CHESS services between 5.3 and 6.0, on a 7-point scale, The significant correlation of higher ease of use scores of many services with heavier use underscores the importance of making a system like CHESS easy to use. Related to ease of use issues, the reading level of CHESS content has been an area of great attention. Any program attempting to provide detailed and accurate information on the medical, legal, financial and social aspects of HIV infection will neccessarily have a fairly high reading level due to the large number of medical and technical terms inherent in discussing HIV disease. CHESS currently has an estimated reading level of grade 8, with the dictionary explaining most of the medical and health-related terms. The success of our efforts in making CHESS user-friendly is demonstrated by the fact that education level and minority status were not significantly different in subjects who used CHESS the least, compared to all other subjects, nor do these demographic characteristics predict CHESS use. Efforts to make CHESS even more accessible in future versions are being carried out by lowering the reading level wherever possible, adding graphics, and possibly including sound and voice recognition, full-motion video, and touch screens. Brennan and her colleagues have also developed a computer-based support system called ComputerLink that has been tested on people living with AIDS (Brennan, 1993). In an 11-month study of 26 subjects, they report levels and pattems of use similar to those seen with CHESS in the current study. Thus, on a per person per week basis, overall use levels of the two systems are similar, with communication services accounting for the vast majority of system uses. Given the significantly different system interfaces and types of services offered, this similarity is striking. Ultimately,

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however, it is the effectiveness of such systems, not just the use, which will make a difference for patients, and further study of both systems is clearly wan'anted. The cost of providing a service such as CHESS is significantly lower than might be expected. The relatively low-cost, reusable hardware (about $1000 per unit) results in a total cost, including equipment, personnel, telephone lines, etc., of providing CHESS for 3 months (assuming all-new equipment) of about $200 per person (Gustafson et al., 1993). Varying the length of access to CHESS and/or use of used or more expensive equipment would change these estimates somewhat, but when compared with the lifetime costs of treating a person with HIV infection [$119,000 by the most recent estimate (Hellinger, 1993)] the cost of the information and social support provided by CHESS is minuscule. Ultimately, the personal computer as the delivery system for CHESS programs may be only a short-term mechanism. The information superhighways that will be implemented in the next decade will make it possible to deliver CHESS over even more accessible systems, such as interactive cable TV. CHESS software, with a proven record of use, acceptance, and impact, will be well-positioned for widespread dissemination through such channels. A final indication of the potential for CHESS comes from the feelings of users like the 33-year-old, asymptomatic HIV-positive user who posted this message in the Discussion Group: I ' m proud to say I've gotten as far as I have in the past couple of months because of this CHESS program. I feel as if I've grown by giant leaps and bounds, as if a whole new person has came out from inside me, it was always there but never came out, something like a spring flower. Thanks for all your great support and advice. Coming out so honest to this machine is what 1 feel has broke the barrier I had set up for myself, then this machine came alive and became real, and now suddenly these real people really know me, WOW! I've finally started going to groups and meeting lots of new people, and getting my life going again. I guess when I found out I had this disease, I decided I was dying so I figured I'd beat death at its own game, by dying before I was dead. Well now that I ' m back with the living, I've got some things to catch up on.

Acknowledgments - - This project has been funded by the Agency for Health Care Policy and Research and the W. K. Kellogg Foundation. This manuscript is dedicated to the memory of William Caucutt, whose input was invaluable, and whose courage and humor inspired us all. The authors also wish to acknowledge the assistance of computer programmers Pin Luarn, Haikun Dong, and Leehter Yao; program developers Kris Bosworth, Meg Wise, Tim Tillotson, and Paul G r o s s b e r g ; research assistants Virginia M a y o - B l a c k , Heather Boyd, Lisa Bruce, Sandie Makowski, and Shawna Peressini; and administrative assistants, Karen Graney, Laura Cohen, and Kris Engbring.

REFERENCES Aguilera, D. (1990). Crisis intervention: Theory and methodology. St. Louis: C-V Mosby Company. Bandura, A. (1977). Self-efficacy: Toward a unifying theory of behavioral change. Psychological Review, 84, 191-215. Bosworth, K., Gustafson, D., & Hawkins, R. (1993). The BARN system: Use and impact of adolescent health education via computer. Computers in Human Behavior, 10(4), 467-482. Bosworth, K., & Gustafson, D. H. (1991) CHESS: Providing decision support for reducing health risk behavior and improving access to health services. Interfaces, 21, 93-104. Brennan, P. E (1993). Differential use of computer network services. Proceedings of the 17th Annual Symposium on Computer Applications in Medical Care, 17, 156-160.

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Brennan, P. F., Ripich, S., & Moore, S. M. (1991). The use of home-based computers to support persons living with AIDS/ARC. Journal of Community Health Nursing, 8, 3-14. Caplan, G. (1964) Principles of preventive psychiatry. New York: Basic Books. DiPasquale, J. A. (1990). The psychological effects of support groups on individuals infected by the AIDS virus. Cancer Nursing, 13, 278-285. Fishbein, M., & Aizen, I. (1980). Understanding attitudes and predicting social behavior. Englewood Cliffs, NJ: Prentice Hall. Gustafson, D. H., Wise, M., McTavish, F., Taylor, J. O., Wolberg, W., Stewart, J., Smalley, R. V., & Bosworth, K. (1993). Development and pilot evaluation of a computer based support system for women with breast cancer. Journal ofPsychosocial Oncology, 11(4), 69-93. Gustafson, D. H., Bosworth, K., Hawkins, R. P., Boberg, E. W., & Bricker, E. (1992). CHESS: A computer-based support system for providing information, referrals, decision support and social support to people facing medical and other health-related crises. Proceedings of the 16th Annual Symposium on Computer Applications in Medical Care, 16, 161-165. Gustafson, D. H. (1987). Health risk appraisal, its roles in health services research. Health Service Research, 22(4), 453-465. Hawkins, R. P., Gustafson, D. H., Chewning, B., Bosworth, K., & Day, P. (1987). Interactive computer programs as public information campaigns for hard-to-reach populations: The BARN project example. Journal of Communication, 37(2), 8-28. Hekelman, F. P., Kelly, R., & Grundner, T. M. (1990). Computerized health information networks: House calls of the future? Family Medicine, 22, 392-395. Hellinger, F. J. (1993). The lifetime cost of treating a person with HIV. Journal of the American Medical Association, 270(4), 474-478. Li, X., & Xu, L. D. (1991). An integrated information system for the intervention and prevention of AIDS. International Journal of Bio-Medical Computing, 29, 191-206. Makulowich, J. S. (1992). AIDS and electronic communications, part one: Electronic bulletin board systems. AIDS Patient Care, 6, 160-163. Moos, R. H., & Schaeffer, J. (1984). The crisis of physical illness: An overview and conceptual approach. In R. H. Moos (Ed.), Coping with physical illness H: New perspectives. New York: Plenum Medical Book Company, pp. 3-25. Pingree, S., Hawkins, R. P., Gustafson, D. H., Boberg, E. W., Bricker, E., Wise, M., & Tillotson, T. (1993). Will HIV-positive people use an interactive computer system for information and support? A study of CHESS in two communities. Proceedings of the Seventeenth Annual Symposium on Computer Applications in Medical Care, 17, 22-26. Pizzi, M. (1992). Women, HIV infection and AIDS: Tapestries of life, death and empowerment. The American Journal of Occupational Therapy, 46, 1021-1027. Sadovsky, R. (1991). Psycho social Issues in symptomatic HIV infection. American Family Physician, 44, 2065-2072. Sainfort, F. C., Gustafson, D. H., Bosworth, K., & Hawkins, R. P. (1990). Decision support systems effectiveness: Conceptual framework and empirical evaluation. Organizational Behavior and Human Decision Processes, 45, 232-252. Slovic, P., Fischoff, B., & Lichtenstein, S. (1977). Behavioral decision theory. Annual Review of Psychology, 28(1), 1-39. Strecher, V. J., McEvoy-DeVellis, B., Becker, M. H., & Rosenstock, I. M. (1986). The role of selfefficacy in achieving health behavior change. Health Education Quarterly, 13, 73-91. Veenstra, R. J., & Gluck, J. C. (1991). Access to information about AIDS. Annals of Internal Medicine, 114, 320-324. Volberding, P. (1988). Caring for the patient with AIDS. Infectious Disease Clinics of North America, 2, 543-550. Von Winterfeldt, D, & Edwards, W. (1986). Decision analysis and behavioral research. Cambridge, MA: Cambridge University Press. Wisconsin AIDS/HIV Update (1994, January). AIDS surveillance summary: Wisconsin and US. Madison, WI: Wisconsin AIDS/HIV Program, Department of Health and Social Services-Division of Health. Wolitski, R. J., & Rhodes, F. (1990). AIDS info on-line: A computer-based information system for college campuses. Journal of American College Health, 39, 90-94. Wood, C. L. (1992). A computer-based AIDS education program for nursing students. Computers in Nursing, 10, 25-34.

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APPENDIX. EXAMPLE OF DISCUSSION GROUP INTERACTIONS

#16504 25-OCT-92 17:17

From:Titan

Re:problems ....

Hi all... I need some help. This could get kinda complicated so bear with me. Also, try to put yourselves in my shoes....I will try to make this simple .... Guy meets Girl. Guy likes Girl (Sort of). Girl likes Guy (Definately). Girl wants Guy to ask her out... With me so far....???? Guy has N U M E R O U S health problems...Not just AIDS... Girl doesn't even have any idea of any of his health problems...NONE, ZERO, ZIP!I! Guy doesn't want to tell girl of health problems and make headlines of Wisconsin State Journal...Guy doesn't know girl quite well enuff [sic] to know if she has a big mouth... Guy would N E V E R think of not telling a Girlfriend of health problems, thus causing her to get sick .... HELP!!!!!!!!!!!!! If you need more info to decide, just ask and I will post .... Thanks....Titan ************************ END OF MESSAGE ************************

#16508 26-OCT-92 00:02

From:Brooks

Re:titan

all kinds of suggestions and each should be taken with a block of salt. the first part is do you ask her out or not. thats a decision that you need to make. you have to "sorta" say yes or "sorta" say no to that one. but either way youve gotten past it. lets say you say yes (because if you say no, then its over) and you have a date. cool. now you would be in a better place to decide if you think this person could become a sexual partner. (more than one date may be necessary to reach this place) it may also give you a better idea of how she will respond to the news, right, heres where it could get tricky, if you think she will respond unfavorably, you don't have to disclose anything, we are all in a new time and although i would not suggest that that gives anyone a license to hurt others, it does mean that we need to treat all people everywhere alike, we are all hiv+. you sound like you would not be at all the type to hurt another so you would take the necessary precautions to protect her from you and you from her. if shes the type to respond favoribly [sic], you still dont [sic] have to tell her unless Y O U want to. most things i have learned are a complete extension of our decisions, you have a few too [sic] make but the [sic] will only come one at a time if you let them happen that way. hope it helps, brooks ************************ END OF M E S S A G E ************************

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#16511 26-OCT-92 00:41

From:Weasel

305 Re:PROBLEMS

....

My suggestion would be for Guy to ask Girl out on a date and get to know her better. Take in a show or a game with no implication of sex to follow. Guy can even hint (since he doesn't know Girl well enough to discuss this directly) that he has to get up early next AM and will see Girl home by midnight or whatever. On a more general level, this problem is one we all encounter frequently in life---liking somebody and wondering whether we can be close friends. Have you ever known anybody you liked who wasn't completely honest, in a way that bothered you and kept the relationship from becoming closer? Ever recall finding someone's faults too much of a burden for your friendship to bear? And yet, most of us decide to have some close friends who are less than completely honest, some close buddies who are much less than perfect. How do we decide? Who do we let in to our lives? Who do we keep out? and Why? The decision to tell or not often symbolizes deeper decisions. The Decision analysis program in another section of CHESS lets you enter the variables for any decision. I have found using this tool for working through complex decisions to be very rewarding. Giving names to the factors influencing choice helps understanding. Weasel-************************ END OF MESSAGE ************************

#16519 26-OCT-92 16:09

From:Gomez

Re:Fritened Titan

Hi Ti, You are goiing thru what's known in the trades(I don't mean trade's),whats known as coming out. It is not an easy process. It is helpful to get the general feel of how she feels about things like disease, drugs etc. AIDS afterall is a topic that almost anyone can discuss without being accused of having it. If she seems receptive, maybe a little info about your past, being careful not to give out more that you want. Take your time. Remember the ball is in your court when it comes to disclosure. But be prepared to answer any questions. I personally don't see the need to hide something about yourself that is very important. You might be hurt though. There is no knowing how other people will react. You might be rejected, or she might tell everyone you know. Maybe not, maybe a sense of trust will develop. My problem is that I have had trouble with giving away info I didn't know was private before hand. Or once I confided in someone that I thought was impartial. Good Luck, Gomez c.p.a. (Chess program analysist) ************************ END OF MESSAGE ************************

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#16520 26-OCT-92 21:39 All...

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From:Titan

R e : F R I T E N E D TITAN

Keep the suggestions coming...Thanks to those of you who have given me your suggestions thus far... It's kinda too bad that nobody (except maybe my parents) know all of the problems I have... I would hate to hurt anyone...and therefore wouldn't... But I wasn't even thinking as far as sex... One problem I have that many of you don't is Active Hepatitis...which unlike HIV, is spread through dumb things...like kissing... I guess my problem is really this one... Where do I find a girl who would get past the physical side of a relationship...And, how do I test the waters to decide if I found that person (If such a person exists...) I don't expect any miracle answers...but any words would be helpful!! Titan \SMILE/ ************************ END OF MESSAGE ************************

#16524 26-OCT-92 23:55

From:Brooks

Re:titan

i guess i don't know alot about active hep but does it exclude touching? somehow it seems like only stuff from someones insides needs to infect the insides of others and if thats the case, isn't just touching cool? my new beau and i are touch freaks, i can't seem to keep m y hands of him and he of me. it gives us both a great deal of pleasure to do this with one another and also provides a wonderful arena for intimate discussion, then maybe some of the harder things can be worked through plus you both get to feel really good! another thought for your head. brooks ************************ END OF MESSAGE ************************

#16526 27-OCT-92 00:43

From:Margo

R e : F R I T E N E D TITAN

Titan, Yes, there still are a few of us out there whom are more interested in a person's personality rather than his body. Of course, both is always nice...(sorry, dreaming is as far as I get) Actually, though I do know women that care for more than just the physical side of a relationship I really don't know where to suggest meeting them. I think the best bet would be if a friend knows someone and plans an activity - like a party - where you could be introduced without the pressure of having to be "together" the whole time as in a blind date setting. That way if the person seemed like someone that you would be interested in getting to know better there

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is the option of further contact. Some churches also have activities for single people to do things together, or even activities for any adults to do in a group setting - such as volleyball teams - which would give the option of meeting women. Perhaps if interested in someone, and they seem to also enjoy your company at the function, then suggesting going out for coffee or a drink after the function. Good Luck...Margo ************************ END OF MESSAGE ************************

#16533 27-OCT-92 09:57

From:Eric

Re:more titanic ideas

Titan: Here's some more thoughts to add to the good stuff you've already gotten. You could start by talking to her about some of your health problems without going into the scarier ones. Talk to her about the hemophilia or the Burkitt's Lymphoma first. If her response is encouraging (warm or compassionate or understanding), it will give you some idea of how she might respond to the HIV or hepatitis issues, as well as the beginnings of openness and trust - - good bases for ANY relationship. Another possibility is to try and think of this as a "friend" thing, rather than a "boy meets girl" thing. Sometimes it's easier to make a new friend than it is to make a new relationship. It sort of puts the whole physical aspect on hold for a while. If it works at the friend level, then you can think more about adding the "relationship" aspect to it later. These aren't necessarily easy things to do, but maybe one will work for you. Openness, vulnerability and trust are beautiful gifts, and are the basis for love in all its shapes and colors. Good Luck. ************************ END OF MESSAGE ************************

#16535 27-OCT-92 10:03

From:Eric

Re:Titan PS

That was "titanic" in the sense of "for Titan" or even "huge" but definitely not as in "hit an iceberg and sink on your maiden voyage." So much for trying to be witty! Eric ************************ END OF MESSAGE ************************

#16549 27-OCT-92 22:29

From:Titan

Re:MORE TITANIC IDEAS

Brooks, Eric, Margo...The rest of you, THANKS FOR THE SUGGESTIONS AND THOUGHTS, Yes Brooks...that is an option...But first, I have to clear the huge barrier of telling

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her of my MANY problems... Good suggestion though.. Margo...I sure hope there are people like that in the world...I'm sure I will find one someday... The idea of singles gatherings scares me though... Hopefully, I will not need to resort to that... Eric...You really did open my eyes a bit...I like the idea of being a friend first...I have and am trying to pursue that option with this girl, but I don't want everything to go too fast .... Also, I would kind of hesitant to tell someone about hemophilia, etc.., but startin small is a good idea... Maybe it's just my cynicalness (sp?), but I really do wonder if people like Margo described exist... Also, I will definately have a problem figuring out if the person I met is that kind of a person or not... I guess I should be lucky though... The biggest problem in my life is friendship .... BIG problem...NOTI!I Thanks, Titan SMILE ~ / ************************ END OF MESSAGE ************************

#16557 28-OCT-92 18:58

From:Boris

Re:problems?

Titan- most of us have had similar problems. At your age I definitely recommend a slow cautious approach. First, you are of age. Is she? If not there are parent problems to consider, probably even if she is of age. Second- It seems like a problem of finding out about her before she find out anything about you. Believe it or not this is a classic military intelligence problem. I ' m almost inclined to refer you to a Tom Clancy book The Cardinal of the Kremlin, but lets not get overly tactical, even though you said the problem was complicated. Do you know her friends? Do your friends or family know her friends or family. Does she know enough of your friends to make an adverse reception a problem? I almost defer on this one. I'm way beyond that age to give advice in the age of AIDS. This is a problem where you have to weigh the risks and benefits against what you have to reveal to her in order to learn anything in return. Sorry I can't offer anything more positive. At my age and orientation there are plenty of people in a similar situation, of course lovers don't come with warranties these days either. Boris ************************ END OF MESSAGE ************************

#16560 28-OCT-92 21:58

From:Titan

Re:PROBLEMS?

Boris, Those two questions you posed were definately things I thought about. Right now...I have decided to try to get to know her better. I just worry too much about what is down the road. I have only once before been in the position of having to

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tell someone, and I even blew that. Instead, I ruined the relationship because I couldn't get over the fear I had of telling her. My behavior drove her away... I have always put close relationships like this on a back burner and tried concentrating on other aspects of life....Unfortunately, I just happened to be interested in this girl... Oh well... Thanks for the info...I'll keep you upto date... Titan ************************ END OF MESSAGE ************************

#16634 06-NOV-92 21:22

From:Ganesh

Re:Titan

Hi Titan - I've really enjoyed reading all of these messages ..... now I ' m curious!!! Whats been going on??? I've had a couple of experiences with "telling" and I've ended up with some warm friendships because of it. Be sure to give us an update! \ Ganesh ************************ END OF MESSAGE ************************

#16654 08-NOV-92 16:35

From:Roscoe

R e : F R I T E N E D TITAN

Titan, I have told quite a few people about my status. Some of the people that I have told were ones that I had a romantic interest in. Sometimes it worked, sometimes it din't [sic]. I beleive [sic] that it's better to findout their reaction in the beginning. The situation (telling someone) always seemed bigger to me before I brought it out in the open. Like Ganesh, some of the people that I have told about my status have become very dear friends. Being positive, to me, has become an intergral part of my personality; if someone choses [sic] disregard me for my status, I feel that it ranks right up there with not going out with someone because they're poor! There is a lot more to a person than their bank balance, and their hiv status. Let me know how you're progressing. Michael (roscoe) ************************ END OF MESSAGE ************************

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#16657 08-NOV-92 20:02

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From:Titan

R e : F R I T E N E D TITAN

Everybody ! ! ! ! A n u p d a t e on m y p r o b l e m . First, sorry I h a v e n ' t b e e n a r o u n d . . . S C H O O L Work...aaaaggg ! ! GOOD NEWS!!!!!!!!!! I decided to tell this girl .... It was an interesting experience to say the least. My criteria for having enough trust in someone is EXTREMELY high because I don't want to regret my decision... This girl won my trust over amazingly...I couldn't even believe I told her. But the good news is, is that she is a very caring person as I found out who will keep my secret. She is even gone so far as to still want to go out with me (kinda surprised me...). I believe that she will become a very close and dear friend no matter what happens between us romantically... She was very surprised when I told her... After talking about it, she suggested that in the future that I begin by feeling out the person on the subject of AIDS in casual conversation... To help me know how they would take it... Anyhow, I am EXTREMELY happy and hopefully I will have a lifelong friendship with this girl... Thanks to all for your suggestions... Titan... REMEMBER TO SMILE ! ! ! ! ! ! ! ! ************************ END OF MESSAGE ************************

#16662 09-NOV-92 21:01

From:Luisa

R e : F R I T E N E D TITAN

Titan, I can't begin to tell you how happy I am for you and your new friend. I had a feeling things would work out. I wish there were more open minded people in this world... I wish you and your new friend as much happiness in your lives(whether you get romantic or remain platonic) as Jerry and I have found I wish y'all the very best.

keep me posted luisa ************************ END OF MESSAGE ************************ #16674 ll-NOV-92 19:15

From:Titan

Re:ETC.

Luisa, ...I am determined to make my new relationship last... I have always gotten impatient and screwed up previous ones... This time, I fnally found someone who looks past my physical problems and sees me for who I am... She means more to me than anything. I HOPE it is something more than just a friendship, but if it isn't I am more than happy to accept that... She means too much just to throw it all away..

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Remember to tell me to have patience if I ever post on here about how difficult relationships are... Thanks for the support and I hope you have a great day ! ! ! Titan smile ************************ END OF M E S S A G E ************************