The Fit After Baby randomized controlled trial: An mHealth postpartum lifestyle intervention for women with elevated cardiometabolic risk.

BACKGROUND: Postpartum women with overweight/obesity and a history of adverse pregnancy outcomes are at elevated risk for cardiometabolic disease. Postpartum weight loss and lifestyle changes can decrease these risks, yet traditional face-to-face interventions often fail. We adapted the Diabetes Prevention Program into a theory-based mobile health (mHealth) program called Fit After Baby (FAB) and tested FAB in a randomized controlled trial. METHODS: The FAB program provided 12 weeks of daily evidence-based content, facilitated tracking of weight, diet, and activity, and included weekly coaching and gamification with points and rewards. We randomized women at 6 weeks postpartum 2:1 to FAB or to the publicly available Text4baby (T4B) app (active control). We measured weight and administered behavioral questionnaires at 6 weeks, and 6 and 12 months postpartum, and collected app user data. RESULTS: 81 eligible women participated (77% White, 2% Asian, 15% Black, with 23% Hispanic), mean baseline BMI 32±5 kg/m2 and age 31±5 years. FAB participants logged into the app a median of 51/84 (IQR 25,71) days, wore activity trackers 66/84 (IQR 43,84) days, logged weight 17 times (IQR 11,24), and did coach check-ins 5.5/12 (IQR 4,9) weeks. The COVID-19 pandemic interrupted data collection for the primary 12-month endpoint, and impacted diet, physical activity, and body weight for many participants. At 12 months postpartum women in the FAB group lost 2.8 kg [95% CI -4.2,-1.4] from baseline compared to a loss of 1.8 kg [95% CI -3.8,+0.3] in the T4B group (p = 0.42 for the difference between groups). In 60 women who reached 12 months postpartum before the onset of the COVID-19 pandemic, women randomized to FAB lost 4.3 kg [95% CI -6.0,-2.6] compared to loss in the control group of 1.3 kg [95% CI -3.7,+1.1] (p = 0.0451 for the difference between groups). CONCLUSIONS: There were no significant differences between groups for postpartum weight loss for the entire study population. Among those unaffected by the COVID pandemic, women randomized to the FAB program lost significantly more weight than those randomized to the T4B program. The mHealth FAB program demonstrated a substantial level of engagement. Given the scalability and potential public health impact of the FAB program, the efficacy for decreasing cardiometabolic risk by increasing postpartum weight loss should be tested in a larger trial.

Sexual decision making of Ugandan young adults: findings from national online discussions.

Fifty-one 18-22-year-old Ugandans took part in asynchronous online discussions about sexual decision-making. To increase generalizability and variability of experience, youth were recruited across the country using social media advertising. Participants were stratified into 8 groups by sex and sexual experience (e.g., women who had not had sex). Participants were asked questions such as, "What role do you think [men/women] play in deciding when a couple is going to play sex?" Several themes emerged. Both young men and women articulated social pressures to be abstinent, particularly to avoid STIs and pregnancy moreso than saving oneself for marriage. That said, women noted pressures to be seen as "pure". There also were pressures to have sex: Men were expected to have sex to demonstrate their virility. Women were expected to have sex if they accepted gifts or other commodities from their partners. It seemed that the specter of HIV and other STIs, as well as unwanted pregnancy, served to mitigate these expectations however, resulting in self-efficacy to use condoms among both men and women. Nonetheless, both men and women acknowledged that it could be hard for women to negotiate condoms. Implications for HIV prevention are discussed.

An artificially intelligent, natural language processing chatbot designed to promote COVID-19 vaccination: A proof-of-concept pilot study.

Objective: Our goal is to establish the feasibility of using an artificially intelligent chatbot in diverse healthcare settings to promote COVID-19 vaccination. Methods: We designed an artificially intelligent chatbot deployed via short message services and web-based platforms. Guided by communication theories, we developed persuasive messages to respond to users' COVID-19-related questions and encourage vaccination. We implemented the system in healthcare settings in the U.S. between April 2021 and March 2022 and logged the number of users, topics discussed, and information on system accuracy in matching responses to user intents. We regularly reviewed queries and reclassified responses to better match responses to query intents as COVID-19 events evolved. Results: A total of 2479 users engaged with the system, exchanging 3994 COVID-19 relevant messages. The most popular queries to the system were about boosters and where to get a vaccine. The system's accuracy rate in matching responses to user queries ranged from 54% to 91.1%. Accuracy lagged when new information related to COVID emerged, such as that related to the Delta variant. Accuracy increased when we added new content to the system. Conclusions: It is feasible and potentially valuable to create chatbot systems using AI to facilitate access to current, accurate, complete, and persuasive information on infectious diseases. Such a system can be adapted to use with patients and populations needing detailed information and motivation to act in support of their health.

Development and Modification of a Mobile Health Program to Promote Postpartum Weight Loss in Women at Elevated Risk for Cardiometabolic Disease: Single-Arm Pilot Study.

BACKGROUND: Pregnancy complications in combination with postpartum weight retention lead to significant risks of cardiometabolic disease and obesity. The majority of traditional face-to-face interventions have not been effective in postpartum women. Mobile technology enables the active engagement of postpartum women to promote lifestyle changes to prevent chronic diseases. OBJECTIVE: We sought to employ an interactive, user-centered, and participatory method of development, evaluation, and iteration to design and optimize the mobile health (mHealth) Fit After Baby program. METHODS: For the initial development, a multidisciplinary team integrated evidence-based approaches for health behavior, diet and physical activity, and user-centered design and engagement. We implemented an iterative feedback and design process via 3 month-long beta pilots in which postpartum women with cardiometabolic risk factors participated in the program and provided weekly and ongoing feedback. We also conducted two group interviews using a structured interview guide to gather additional feedback. Qualitative data were recorded, transcribed, and analyzed using established qualitative methods. Modifications based on feedback were integrated into successive versions of the app. RESULTS: We conducted three pilot testing rounds with a total of 26 women. Feedback from each pilot cohort informed changes to the functionality and content of the app, and then a subsequent pilot group participated in the program. We optimized the program in response to feedback through three iterations leading to a final version. CONCLUSIONS: This study demonstrates the feasibility of using an interactive, user-centered, participatory method of rapid, iterative design and evaluation to develop and optimize a mHealth intervention program for postpartum women. TRIAL REGISTRATION: ClinicalTrials.gov NCT02384226; https://www.clinicaltrials.gov/ct2/show/NCT02384226.

Feasibility, Acceptability, and Process Indicators for Guy2Guy, an mHealth HIV Prevention Program for Sexual Minority Adolescent Boys.

PURPOSE: Guy2Guy is one of the first mHealth HIV prevention programs for sexual minority boys aged 14-18 years, evaluated nationally. Here, we examine the program's feasibility and acceptability and explore participants' feedback about program content and components intended to invigorate program engagement. METHODS: Guy2Guy was tested in a randomized controlled trial of 302 youth assigned to either the intervention or an attention-matched control group. At 3-month follow-up, participants completed a survey that included questions about feasibility and acceptability. Focus groups were conducted with a subset of intervention participants (n = 45) to further understand their program experience. RESULTS: The protocol and program appeared to be feasible: 94% completed the 3-month follow-up survey. The intervention also appeared to be acceptable: 93% of intervention participants said they somewhat or strongly agreed that they liked the program. Although ∼20% boys agreed that the program sent too many messages, only 10% said they stopped reading the messages by the end. Focus group participants were largely enthusiastic about program content and generally appreciated receiving information and skills-building messages that talked about HIV risk reduction. Some indicated a desire for more content that addressed condom negotiation. Program engagement components, particularly the weekly "level up" quiz, also were generally well received. CONCLUSIONS: Sexual minority boys are willing to engage in Guy2Guy, an intensive, multiweek sexual health intervention via text messaging, and most would recommend the program to their friends.

Legalized marijuana: Language-associated knowledge of laws and risk perceptions among Latinos.

This study examines the extent to which knowledge of recreational marijuana laws, health effects, and perceptions of risk for marijuana use differ between Spanish- and English-speaking Latino survey respondents from a registry of Colorado adults. Spanish-speaking Latino respondents (n = 47) had less accurate knowledge of laws permitting use of marijuana than English-speaking Latino respondents (n = 154), while reporting greater agreement with negative health effects and higher perception of risk associated with marijuana use. The results suggest that efforts to communicate health and informational messaging to the public about legalized marijuana should consider linguistic variations when tailoring campaigns for Latino audiences.

Pilot RCT Results of an mHealth HIV Prevention Program for Sexual Minority Male Adolescents.

BACKGROUND: Guy2Guy (G2G) is the first comprehensive HIV prevention program developed for sexual minority males as young as 14 years old and is delivered nationally via text messaging. Here, we report the results of the pilot randomized control trial. METHODS: G2G was tested against an attention-matched "healthy lifestyle" control (eg, self-esteem). Both programs lasted 5 weeks and delivered 5 to 10 text messages daily. A 1-week booster was delivered 6 weeks subsequently. Participants were cisgender males ages 14 to 18 years old who were gay, bisexual, and/or queer and had an unlimited text messaging plan. Youth were recruited across the United States via Facebook and enrolled by telephone from October 2014 to April 2015. Ninety-day postintervention outcomes were condomless sex acts (CSA) and abstinence and, secondarily, HIV testing. We also examined these outcomes at intervention end and stratified them by sexual experience. RESULTS: At 90 days postintervention, there were no significant differences in CSAs or abstinence noted. Among participants who were sexually active at baseline, intervention participants were significantly more likely to report getting an HIV test (adjusted odds ratio = 3.42, P = .001). They were also less likely than control youth to be abstinent (adjusted odds ratio = 0.48, P = .05). CSAs were significantly lower for those in the intervention versus control at intervention end (incident rate ratio = 0.39, P = .04), although significance was lost once age was added to the analysis (incident rate ratio = 0.58, P = .26). CONCLUSIONS: G2G appears promising in increasing adolescent HIV testing rates. Sex-positive intervention messages appear to have increased the participants' comfort with having sex (ie, less abstinence) while not increasing their potential for HIV transmission (ie, more CSAs). Additional content or features may be needed to invigorate condom use.

Awareness, Perception of Risk and Behaviors Related to Retail Marijuana Among a Sample of Colorado Youth.

Youth marijuana use is a growing concern with increasingly permissive views towards marijuana use. Little is known about attitudes and beliefs toward marijuana use among youth in the context of legalization. This study describes youth attitudes and beliefs about health risks associated with marijuana use, social norms of peer use, conversations with parents about marijuana use, and knowledge of recreational marijuana laws, using a venue-day-time sampling approach with diverse Colorado youth (n = 241) post-legalization. We considered demographic (gender, racial/ethnic and geographic) differences in knowledge of laws and perceptions of risk using bivariate and multivariate analyses. While many youth are knowledgeable about retail marijuana laws in Colorado, males were 2.12 times more likely to be familiar with laws compared to females. While 40 % of the sample perceived a moderate to high risk from weekly marijuana consumption and 57 % from daily consumption, fewer males perceived these risks. Over ¾ of the sample indicate they discuss marijuana with parents, but many fewer indicate discussing consequences and health effects of use with parents. Results suggest opportunities for parents and clinicians to influence youth attitudes and behaviors towards marijuana use. It may be worthwhile to target educational campaigns to different demographic groups, and to offer training and capacity building for parents to discuss marijuana with their teenaged children.

Reaching Adolescent Gay, Bisexual, and Queer Men Online: Development and Refinement of a National Recruitment Strategy.

BACKGROUND: Using social networking websites to recruit research participants is increasingly documented in the literature, although few studies have leveraged these sites to reach those younger than 18 years. OBJECTIVE: To discuss the development and refinement of a recruitment protocol to reach and engage adolescent gay, bisexual, and other teenaged men who have sex with men (AGBM). Participants were recruited for development and evaluation activities related to Guy2Guy, a text messaging-based human immunodeficiency virus infection prevention program. METHODS: Eligibility criteria included being between 14 to 18 years old; being a cisgender male; self-identifying as gay, bisexual, and/or queer; being literate in English, exclusively owning a cell phone, enrolled in an unlimited text messaging plan, intending to keep their current phone number over the next 6 months, and having used text messaging for at least the past 6 months. Recruitment experiences and subsequent steps to refine the Internet-based recruitment strategy are discussed for 4 research activities: online focus groups, content advisory team, beta test, and randomized controlled trial (RCT). Recruitment relied primarily on Facebook advertising. To a lesser extent, Google AdWords and promotion through partner organizations working with AGBM youth were also utilized. RESULTS: Facebook advertising strategies were regularly adjusted based on preidentified recruitment targets for race, ethnicity, urban-rural residence, and sexual experience. The result was a diverse sample of participants, of whom 30% belonged to a racial minority and 20% were Hispanic. Facebook advertising was the most cost-effective method, and it was also able to reach diverse recruitment goals: recruitment for the first focus group cost an average of US $2.50 per enrolled participant, and it took 9 days to enroll 40 participants; the second focus group cost an average of US $6.96 per enrolled participant, and it took 11 days to enroll 40 participants. Recruitment for the first content advisory team cost an average of US $32.52 per enrolled participant; the second cost US $29.52 per participant. Both recruitment drives required 10 days to enroll 24 participants. For the beta test, recruitment cost an average of US $17.19 per enrolled participant, and it took 16 days to complete enrollment of 20 participants. For the RCT, recruitment cost an average of US $12.54 per enrolled participant, and it took 148 days to enroll 302 participants. Google AdWords campaigns did not result in any enrolled participants of whom the research staff members were aware. CONCLUSIONS: Internet-based strategies can be a cost-efficient means to recruit and retain hard-to-reach populations from across the country. With real-time monitoring of participant demographic characteristics, diverse samples can be achieved. Although Facebook advertising was particularly successful in this study, alternative social media strategies can be explored in future research as these media are ever-changing.

Ethical Considerations in Recruiting Online and Implementing a Text Messaging-Based HIV Prevention Program With Gay, Bisexual, and Queer Adolescent Males.

PURPOSE: There is a dearth of HIV prevention/healthy sexuality programs developed for adolescent gay and bisexual males (AGBM) as young as 14 years old, in part because of the myriad ethical concerns. To address this gap, we present our ethics-related experiences implementing Guy2Guy, a text messaging-based HIV prevention/healthy sexuality program, in a randomized controlled trial of 302 14- to 18-year-old sexual minority males. METHODS: Potential risks and efforts to reduce these risks are discussed within the framework of the Belmont Report: Respect for persons, beneficence (e.g., risks and benefits), and justice (e.g., fair distribution of benefits and burdens). RESULTS: To ensure "respect for persons," online enrollment was coupled with telephone assent, which included assessing decisional capacity to assent. Beneficence was promoted by obtaining a waiver of parental permission and using a self-safety assessment to help youth evaluate their risk in taking part. Justice was supported through efforts to develop and test the program among those who would be most likely to use it if it were publicly available (e.g., youth who own a cell phone and are enrolled in an unlimited text messaging plan), along with the use of recruitment targets to ensure a racially, ethnically, and regionally diverse sample. CONCLUSIONS: It is possible to safely implement a sensitive and HIV prevention/healthy sexuality program with sexual minority youth as young as 14 years old when a rigorous ethical protocol is in place.

More than just tracking time: Complex measures of user engagement with an internet-based health promotion intervention.

BACKGROUND: There has been a rise in internet-based health interventions without a concomitant focus on new methods to measure user engagement and its effect on outcomes. We describe current user tracking methods for internet-based health interventions and offer suggestions for improvement based on the design and pilot testing of healthMpowerment.org (HMP). METHODS: HMP is a multi-component online intervention for young Black men and transgender women who have sex with men (YBMSM/TW) to reduce risky sexual behaviors, promote healthy living and build social support. The intervention is non-directive, incorporates interactive features, and utilizes a point-based reward system. Fifteen YBMSM/TW (age 20-30) participated in a one-month pilot study to test the usability and efficacy of HMP. Engagement with the intervention was tracked using a customized data capture system and validated with Google Analytics. Usage was measured in time spent (total and across sections) and points earned. RESULTS: Average total time spent on HMP was five hours per person (range 0-13). Total time spent was correlated with total points earned and overall site satisfaction. CONCLUSION: Measuring engagement in internet-based interventions is crucial to determining efficacy. Multiple methods of tracking helped derive more comprehensive user profiles. Results highlighted the limitations of measures to capture user activity and the elusiveness of the concept of engagement.

Iteratively Developing an mHealth HIV Prevention Program for Sexual Minority Adolescent Men.

Five activities were implemented between November 2012 and June 2014 to develop an mHealth HIV prevention program for adolescent gay, bisexual, and queer men (AGBM): (1) focus groups to gather acceptability of the program components; (2) ongoing development of content; (3) Content Advisory Teams to confirm the tone, flow, and understandability of program content; (4) an internal team test to alpha test software functionality; and (5) a beta test to test the protocol and intervention messages. Findings suggest that AGBM preferred positive and friendly content that at the same time, did not try to sound like a peer. They deemed the number of daily text messages (i.e., 8-15 per day) to be acceptable. The Text Buddy component was well received but youth needed concrete direction about appropriate discussion topics. AGBM determined the self-safety assessment also was acceptable. Its feasible implementation in the beta test suggests that AGBM can actively self-determine their potential danger when participating in sexual health programs. Partnering with the target population in intervention development is critical to ensure that a salient final product and feasible protocol are created.

The Use of the Internet to Meet Sexual Partners: A Comparison of Non-Heterosexually-Identified Men with Heterosexually-Identified Men and Women.

In 2008, we conducted online interviews with 65 self-identified adult heterosexual men and women and gay/bisexual men to explore perceptions and experiences with meeting people online. Reasons for meeting people online, desired partner characteristics, and the process of connecting for sex paralleled those observed in real-life; but the Internet allowed people to identify more partners and specific partner characteristics. "Background checks" of online partners, even though often believed to be false, increased familiarity and trust leading to reduced perceived need for condom use. Participants said online condom use negotiation was easier, but usually occurred in face-to-face contexts in practice. (99).

Acceptability and feasibility of CyberSenga: an Internet-based HIV-prevention program for adolescents in Mbarara, Uganda.

Capitalizing on emerging data suggesting that HIV-preventive behaviors can be positively affected by Internet-based programs, we developed and tested CyberSenga, an Internet-based, comprehensive sexuality education program for adolescents in Mbarara, Uganda. Three hundred and sixty-six secondary school students were randomly assigned to either the five-lesson program (+ booster) or a treatment-as-usual control. At three-month follow-up, intervention participants provided feedback on the program acceptability. Six focus groups with intervention participants were additionally conducted after the final follow-up at 6 months. Data support a hypothesis of feasibility: despite schedule interruptions, 95% of intervention participants completed all the five modules; only 17% deviated from the once-a-week intended delivery schedule. Internet service was uninterrupted during the field period and, in general, the technology performed to specifications. The intervention also appears to be acceptable: 94% of intervention youth somewhat or strongly agreed that they learned a lot and 93% said they were somewhat or very likely to recommend the program. Although more than two in three youth somewhat or strongly agreed that the program talked too much about sex (70%) and condoms (75%), 89% somewhat or strongly disagreed that "I do not think kids like me should do the CyberSenga program." Feedback from focus group participants further suggested that the content was generally acceptable and did not contradict local norms in most cases. In fact, despite concerns from some local stakeholders to the contrary, information about condoms did not appear to be confusing or contradictory for youth who were abstinent. Nonetheless, some of the sexual topics seemed to be unfamiliar or uncomfortable for some participants - particularly brief references to oral and anal sex. Together, both qualitative and quantitative data suggest that the program is a feasible and acceptable way of delivering HIV preventive information to both sexually experienced and inexperienced adolescents in Mbarara, Uganda.

Adolescent abstinence and unprotected sex in CyberSenga, an Internet-based HIV prevention program: randomized clinical trial of efficacy.

CONTEXT: Cost-effective, scalable programs are urgently needed in countries deeply affected by HIV. METHODS: This parallel-group RCT was conducted in four secondary schools in Mbarara, Uganda. Participants were 12 years and older, reported past-year computer or Internet use, and provided informed caregiver permission and youth assent. The intervention, CyberSenga, was a five-hour online healthy sexuality program. Half of the intervention group was further randomized to receive a booster at four-months post-intervention. The control arm received 'treatment as usual' (i.e., school-delivered sexuality programming). The main outcome measures were: 1) condom use and 2) abstinence in the past three months at six-months' post-intervention. Secondary outcomes were: 1) condom use and 2) abstinence at three-month's post-intervention; and 6-month outcomes by booster exposure. Analyses were intention to treat. RESULTS: All 416 eligible youth were invited to participate, 88% (n = 366) of whom enrolled. Participants were randomized to the intervention (n = 183) or control (n = 183) arm; 91 intervention participants were further randomized to the booster. No statistically significant results were noted among the main outcomes. Among the secondary outcomes: At three-month follow-up, trends suggested that intervention participants (81%) were more likely to be abstinent than control participants (74%; p = 0.08), and this was particularly true among youth who were abstinent at baseline (88% vs. 77%; p = 0.02). At six-month follow-up, those in the booster group (80%) reported higher rates of abstinence than youth in the intervention, no booster (57%) and control (55%) groups (p = 0.15); they also reported lower rates of unprotected sex (5%) compared to youth in the intervention, no booster (24%) and control (21%) groups (p = 0.21) among youth sexually active at baseline. CONCLUSIONS: The CyberSenga program may affect HIV preventive behavior among abstinent youth in the short term and, with the booster, may also promote HIV preventive behavior among sexually active youth in the longer term. TRIAL REGISTRATION: NCT00906178.

Preventing HIV among young people: research priorities for the future.

OBJECTIVE: To review the current state of knowledge on the prevention of sexual transmission of HIV in adolescents and to highlight the existing gaps and priority areas for future research. BACKGROUND: A disproportionate burden of HIV infections falls on adolescents, a developmental stage marked by unique neural, biological, and social transition. Successful interventions are critical to prevent the spread of HIV in this vulnerable population. METHODS: We summarized the current state of research on HIV prevention in adolescents by providing examples of successful interventions and best practices, and highlighting current research gaps. RESULTS: Adolescent interventions fall into 3 main categories: biomedical, behavioral, and structural. The majority of current research has focused on individual behavior change, whereas promising biomedical and structural interventions have been largely understudied in adolescents. Combination prevention interventions may be particularly valuable to this group. CONCLUSIONS: Adolescents have unique needs with respect to HIV prevention, and, thus, interventions should be designed to most effectively reach out to this population with information and services that will be relevant to them.

Putting prevention in their pockets: developing mobile phone-based HIV interventions for black men who have sex with men.

Young black men who have sex with men (MSM) bear a disproportionate burden of HIV. Rapid expansion of mobile technologies, including smartphone applications (apps), provides a unique opportunity for outreach and tailored health messaging. We collected electronic daily journals and conducted surveys and focus groups with 22 black MSM (age 18-30) at three sites in North Carolina to inform the development of a mobile phone-based intervention. Qualitative data was analyzed thematically using NVivo. Half of the sample earned under $11,000 annually. All participants owned smartphones and had unlimited texting and many had unlimited data plans. Phones were integral to participants' lives and were a primary means of Internet access. Communication was primarily through text messaging and Internet (on-line chatting, social networking sites) rather than calls. Apps were used daily for entertainment, information, productivity, and social networking. Half of participants used their phones to find sex partners; over half used phones to find health information. For an HIV-related app, participants requested user-friendly content about test site locators, sexually transmitted diseases, symptom evaluation, drug and alcohol risk, safe sex, sexuality and relationships, gay-friendly health providers, and connection to other gay/HIV-positive men. For young black MSM in this qualitative study, mobile technologies were a widely used, acceptable means for HIV intervention. Future research is needed to measure patterns and preferences of mobile technology use among broader samples.

Sexting, substance use, and sexual risk behavior in young adults.

PURPOSE: Cell phone use has become more widespread over the past decade. Young adults are frequently early adopters of new technologies, including cell phones. Most previous research examining sexting, the act of sending sexually explicit or suggestive images via text message, has focused on the legal or social consequences of this behavior. The current study focused on the public health implications of sexting by examining associations between sexting, substance use, and sexual risk behavior in youth. METHODS: Young adults (N = 763) completed online questionnaires assessing demographics, cell phone use (e.g., texting, sexting), substance use, and sexual risk behaviors. RESULTS: Sexting was reported by a substantial minority of participants (44%). Compared with their nonsexting counterparts, participants who engaged in sexting were more likely to report recent substance use and high-risk sexual behaviors, including unprotected sex and sex with multiple partners. Of those who engaged in sexting, a considerable percentage (31.8%) reported having sex with a new partner for the first time after sexting with that person. In multivariate analyses, sexting was associated with high-risk sexual behavior, after accounting for demographic factors, total texting behaviors, and substance use. CONCLUSIONS: Results suggest that sexting is robustly associated with high-risk sexual behavior. Many individuals exchange explicit or provocative photos with long-term sexual partners, but at least some participants in this study were incurring new sexual risks after sexting. Additional research is needed to understand the contexts in which sexting occurs, motivations for sexting, and relationship of sexting to risk behavior.