Worldwide rates of Internet access are high, with more than 3.5 billion people currently connected [1]. This reach is ever increased by mobile networks, which cover more than 90% of the globe, a reach forecasted to penetrate 71% of the global population by 2019 [2]. In Australia, 86% of households have Internet access, a rate which continues to increase with the development of the National Broadband Network [3,4]. Further, 3G and 4G networks increase this reach through mobile phone and tablet devices [5,6], making Internet-based programs more available. Using the Internet and technology for health, otherwise known as eHealth, is becoming more popular, with online programs used to deliver mental health care [7], change health behaviors [8], and deliver postsurgery rehabilitation programs [9]. eHealth programs are also attractive means of delivering interventions because they have a low cost per user [4,10], have the potential to reach people who may not have otherwise sought support [11], reduce stigma [4], and provide timely support when it is most needed [4]. Additionally, utilizing eHealth has been found to be acceptable to health care providers and patients [12,13].

Reviews on the effectiveness of eHealth interventions for health behavior change have found a mixed effect, stating that more research is needed in this area [14-17]. Potential factors contributing to this finding may include low uptake, adherence, or retention to online programs, with the format of online interventions regarded as an important factor in intervention effectiveness [18]. Therefore, consumer-based research to help understand patient-related factors likely to improve eHealth intervention use is important.

Within the hospital setting, previous research with people receiving treatment for orthopedic trauma has found that the receipt of health behavior change advice is low, despite patients’ interest in receiving such care [19,20]. Reasons for low levels of behavior change support include lack of time or appropriate knowledge [21-28]. eHealth interventions may be one way to address this lack of care by providing behavior change support with minimal staff involvement. Previous eHealth programs developed to promote postsurgery rehabilitation have been acceptable to patients [9]. Another potential benefit is that eHealth-delivered care can be continued postdischarge from hospital, a component of hospital interventions that has been found to improve effectiveness [29].

Rates of engagement in risky behaviors such as heavy alcohol use, cannabis use, and tobacco smoking have been found to be higher in the orthopedic trauma population than the general population [19,30,31]. Continued tobacco use can have devastating effects on recovery from surgery, such as increased risk of postoperative infection [32-34], wound and flap necrosis [35], and a decrease in the tensile strength of wounds [36]. The benefits of abstinence after surgery are clear, with a review of 20 studies finding significantly fewer complications in former smokers when compared to current smokers postoperation [32]. The benefits of abstinence from postoperative smoking may include better wound healing, shorter length of hospital admission, decreased risk of mortality [37], as well as reduced interaction with prescribed medications [38]. Similar to tobacco use, alcohol and cannabis use can have a negative impact on recovery from surgery such as vasoconstriction resulting in decreased blood flow and delays in healing as well as lung disorders, if smoked (cannabis) [39]; and increased risk of infection and impaired wound healing (alcohol) [40]. Therefore, understanding the rates of usage of substances following orthopedic trauma may be a potential health risk behavior that needs addressing.

Characterization of orthopedic trauma patients has previously found they are more often younger males who come from a lower socioeconomic status, partake in more risky behavior, and have a lower level of educational attainment [31]. Younger males [3,41-43], who are of a higher socioeconomic status [41,43] and have attained a higher level of education [6,41,44], are more likely to use the Internet for health; however, younger males are also less likely to seek health care [45-48]. Therefore, online programs may provide an option to increase the care they receive during admission and postdischarge.

Previous research suggests that 75% to 92% of orthopedic trauma patients use the Internet [49-51]. Between 45% and 58% reported using the Internet for health information [49,50] and the majority used the Internet at home [51]. Further, using the Internet for postsurgery follow-up has been found acceptable by patients in this population [52,53]. This suggests that online health behavior change interventions may be well received by patients.

Although rates of access to the Internet are high, there is limited information about interest in using the Internet for health and no knowledge regarding the characteristics of patients more likely to use the Internet for health. Such information helps develop eHealth interventions that reach and engage the highest number of the target population. Because previous rates of current tobacco smoking, alcohol, and cannabis use are high among orthopedic trauma patients, an online program may be a potential option to address these risky health behaviors. Therefore, this study of hospitalized orthopedic trauma patients has a number of aims:

A total of 1708 orthopedic trauma admissions occurred during the study period, of which 1128 were approached and 819 subsequently agreed to participate in the survey (72 refused, 103 were too ill to participate, and 134 were not eligible; response rate: 72.61%). Some respondents dropped out during survey completion due to fatigue. A total of 803 individuals completed the survey (completion rate: 98.0%). Of these individuals, 175 (21.8%) identified as current tobacco users and form the subpopulation analyzed in this paper. A total of 173 current smokers completed the survey (completion rate: 98.9%). Due to the format and branching of survey questions, not all smokers answered the same questions (eg, individuals who did not own a computer at home were not asked if they would use a smoking cessation program on their computer at home).

A minimum of at least weekly Internet usage was slightly lower in this sample of orthopedic trauma patients than the national average (72.5% vs 86%) [6]. As expected, age and education were both found to be associated with at least weekly Internet access. Country of birth, educational attainment, smoking status, and alcohol consumption were also found to be significant predictors of Internet access. These are important patient characteristics to note because rates of substance use and factors around their use and treatment often differ between cultures [63], a point which may need considering in the development of any eHealth interventions for substance use within this population. Further, when examining Internet use by current smoking status, the percentage of at least weekly access dropped to 63.6%. This may indicate that an online smoking cessation program may only benefit those individuals who are younger and who have a greater level of educational attainment. This is important because the development of an online program may segregate a portion of the population who are unable to access the Internet postdischarge (if hospitals provide devices and Internet access to use during admission). Further, this may reflect the lower socioeconomic status of trauma patients [31] and current tobacco users [64], with younger age and a higher level of education attainment related to higher rates of Internet usage [3,41,44]. Differences in access to the Internet may deepen the digital divide in receipt of care, with age and education [44] found to be associated with access to eHealth interventions. However, previous research suggests the digital divide to be a myth in the orthopedic trauma population [51], although results from this study may suggest otherwise. Therefore, the possibility of a digital divide should be acknowledged during intervention development and implementation, with alternate care designed for those who may not have access.

Just over half the respondents indicated that they would be interested in using the Internet for health, with interest in using the Internet for health found to be associated with younger age, higher education, and higher household income. Other research has found greater use of the Internet for health by users with higher socioeconomic status [65] and this too may contribute to the potential for a digital divide in this population. Alternatively, patients may simply be unaware of what eHealth programs are and what they could deliver. In a large mental health survey, attitudinal resistance toward Internet-based interventions was cited as a possible explanation for lack of interest in using the Internet for heath [66]. Patient education of eHealth programs may counter this effect [67].

Tobacco smoking in particular is a serious threat to the recovery and health of orthopedic trauma patients. When respondents who were current tobacco users were asked what types of quit-smoking programs they would prefer to use while in hospital, an Internet program was supported, second only to face-to-face counseling. Given there are a multitude of barriers to the delivery of face-to-face smoking cessation counseling, these results suggest online programs may be well received by patients who smoke. Continuing to address smoking in the orthopedic trauma population has the added benefit of reducing the overall health-related costs, both to the individual and the health care system.