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6 Foundations of mPreventViolence: Integrating Violence Prevention and Information and Communications Technologies I n considering the potential usefulness of information and communica- tions technology (ICT) to violence prevention, speakers at the workshop explored the existing structures and processes within their respective fields and assessed any potential overlap between the two. These papers provide the beginnings of a foundation upon which this new integration can be built. In the first paper, Cathryn Meurn presents a scan of existing ICT ap- plications to violence prevention. Ms. Meurn explores the design and plan- ning of interventions for various types of violence, the gaps that still exist in designing ICT-enhanced violence prevention interventions, and potential needs for monitoring and evaluation. The second paper, by Mark L. Rosenberg and colleagues, examines the current status of violence prevention, including a discussion of the idea that violence prevention can be addressed from a public health perspective. This paper also addresses current obstacles and needs in violence prevention, and potential avenues for the inclusion of ICT. In the third paper, Jody Ranck explores the current state of ICT and how ICT might meet the needs of public health and violence prevention now and in the future. He also discusses how ICT affects the means of data collection, program design, and community-based interventions, a situa- tion that could pose both solutions and challenges for violence prevention practitioners. In the final paper, William T. Riley describes current and potential evaluation methodologies for determining the success of ICT-enhanced in- terventions. After examining the gap between the time required to perform 43

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44 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION traditional evaluations and the speed at which technology changes, Dr. Riley also suggests several adapted methodologies that might be better suited for rapidly changing environments. THE ROLE OF INFORMATION AND COMMUNICATIONS TECHNOLOGIES IN VIOLENCE PREVENTION Cathryn Meurn Introduction Violence is a global problem that crosses cultural and socioeconomic boundaries. From collective to interpersonal to self-inflicted violence, its impact on health is substantial. Violence is one of the leading causes of death worldwide for people between 15 and 44 years of age (WHO, 2002). However, the actual cost and extent to which violence occurs is difficult to measure. Countless violent acts happen out of public view in offices, homes, or even public institutions. Violence can be prevented, and this assertion has been proven true within the field of public health. Action to prevent violence has been undertaken at various levels, from the local and community level to the international system. Methods have ranged from primary prevention, aim- ing to prevent a violent act before it occurs, to the tertiary level, which encompasses approaches that focus on long-term care. The goal of this background paper is to provide a brief introduction to the current and potential role that ICTs can play in the reduction and prevention of violence. This paper by no means offers an extensive study on the intersection of ICTs and violence prevention. There are many ongoing projects, and a deeper landscape analysis is recommended. Furthermore, the use of ICTs in the field of public health is in its early stages. Much of the research cited in this paper can be classified as pilot projects, and, to date, there have been no in-depth measurements of their impacts. Therefore, this paper is intended to introduce the potential of the area and to encourage collective action going forward. The Technology and the Debate Technologies such as the smartphone, crowdsourcing tools, remote diagnostics, and other technological innovations have proliferated over the past decade, and many of them have shifted over to mainstream use. With this technological expansion, debate has also arisen concerning the positive and negative impacts that these innovations have within communities and worldwide.

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45 FOUNDATIONS OF mPREVENTVIOLENCE ICT can be defined as a set of technological tools and resources used to communicate, create, disseminate, store, and manage information. These can include video, radio, television, Internet programs, social media plat- forms, and mobile phones. Distinctions are emerging between “old” and “new” forms of media and technology—that is, between the use of televi- sion, radio, and other forms of traditional media that have been employed for decades and newer forms of media, including social media and the mobile phone. Particularly in the case of the developing world, the adoption of the mobile phone has created a new avenue for combating longstanding prob- lems. With more than 5 billion mobile subscriptions worldwide, phone ownership has exploded. Two-thirds of these subscriptions are in develop- ing countries, and it is predicted that soon 90 percent of the world’s popu- lation will be within the coverage of wireless networks. Furthermore, the number of unique users active on social networks is up nearly 30 percent globally, having risen from 244.2 million in 2009 to 314.5 million in 2010 as reported by the Nielsen Company (Grove, 2010). There are more than 800 million users on Facebook; Twitter is estimated to have more than 200 million users; and more video content is uploaded to YouTube in a 60-day period than three major U.S. television networks created in 60 years (Elliott, 2010). Teens are texting at record rates, and areas such as eLearn- ing, remote diagnostics, and mServices are growing steadily. Despite the hype, these various technologies are simply tools that can be used either for social good or for harm. The same was true for the inven- tion of paper, the printing press, and the telephone, all of which changed the way in which we interact with each other. These innovations all had a positive impact on society, but these tools were also conduits for such negative things as yellow journalism and mass media campaigns against ethnic groups and certain minorities. It is also important to keep in mind that technology is only a small part of any solution. Today, these new forms of communication and new technologies have led to some fantastic outcomes, as discussed in the next section. On the other hand, they have also elicited unintended adverse consequences in the pursuit of preventing and reducing violence. Trends in cyberbullying, losses in privacy and security, and stories of perpetrators targeting victims through social media sites—all of these must be kept in mind when we speak of us- ing these tools for social good.

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46 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION Program and Intervention Designs Collective Violence Collective violence is perhaps the most visible type of violence and of- ten receives a high level of public and political attention. Whether arising from violent intrastate conflicts that account for the majority of conflicts today, from the flow of displaced persons, from acts of terrorism, or from genocide, the effects of such violence can be immense. Violent conflicts have profound health effects on civilian society via increased mortality, morbidity, and disability. The World Health Organization (WHO) defines collective violence as the instrumental use of violence by people who identify themselves as a member of a group—whether this group is transitory or has a more per- manent identity—against another group or set of individuals, in order to achieve political, economic or social objectives. (WHO, 2002) With the rise of new media, and advances in and increased access to technology, opportunities exist to prevent some of this violence. One of the most popular types of programs using mobile phones is based on short message service (SMS) messaging, better known as text messages. The most frequent use of SMS has been the use of one-way messaging for educational awareness, such as in Amnesty International’s SMS urgent-action appeals campaign in the Netherlands. This campaign raised the awareness of tor- ture victims through text campaigns and in turn enabled the agency to collect “signatures” when immediate action from supporters was necessary (New Tactics in Human Rights, n.d.). One of the most cited cases of the use of SMS, which exemplified its potential beyond simple awareness campaigns, occurred during the 2007 Kenyan election. Although initial results indicated the opposition candidate Raila Odinga was in the lead, incumbent President Mwai Kibaki was an- nounced as the official victor. Six weeks of violence ensued during which the influential role of mobiles became apparent. Through the Ushahidi platform, those with mobile phones were able to send texts to a specific number to report on human rights abuses and incidents, which were then mapped geographically on a website. This use of both texts and online tools not only enabled the reporting of events in real time but also aided the mobilization of groups to prevent further violent outbreaks (Harvard Humanitarian Initiative, 2011). Other examples of the use of the Ushahidi platform have been during the earthquake in Haiti and, more recently, in the protests in Egypt and the crisis in Libya (Ushahidi, 2011). Nevertheless, it is important to note that this mode of communication can also make it

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47 FOUNDATIONS OF mPREVENTVIOLENCE cheap and easy for others to spread hateful messages to incite additional violence, as happened in Kenya. Traditional types of ICT, such as phone networks, radio, and television, can also play important roles. Radio and television have been used in many forms since their invention. One project of note that used phone networks was devised by Interaction Belfast, which created a mobile phone network to prevent outbreaks of violence between warring neighborhoods in Belfast. Volunteers in both Protestant and Catholic communities were given mobile phones to enable communication with their counterparts when potentially violent crowds gathered or when rumors of violence started to spread, with the goal of resolving the issue peacefully. Technologies provide not only increased communication but also in- creased accountability and transparency. The organization Witness works to use the power of video advocacy by documenting and sharing human rights abuses via cameras. By working with constituents to use video to shed light on certain atrocities, the organization has helped to shed light on the repression of ethnic minorities in Burma and has helped to prosecute recruiters of child soldiers in the Democratic Republic of the Congo.1 The organization’s training includes information on how to use video safely, which is important given the complexities to which this type of interven- tion can give rise. An opportunity that deserves highlighting, particularly in the develop- ing world, is the increasing role of the health worker. As task shifting con- tinues to progress in these countries, community health workers can help to draw attention to indications of violence. With multiple programs now using these health workers for community outreach, data collection, and reporting via the use of ICTs and mobile phones, opportunities for leverag- ing technology for violence prevention exist. Interpersonal Violence Opportunities for leveraging technology exist with respect to inter- personal violence as well. This category includes sexual violence, intimate partner violence, elder abuse, youth violence, and child abuse. Sexual violence Sexual violence is defined as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or acts to traffic, or otherwise directed, against a person’s sexuality using coercion” (WHO, 2002). Research suggests that at least one in four women in the United States has experienced sexual violence (National Center on Domes- tic and Sexual Violence, n.d.). Sexual violence is a universal problem, and it 1 For more information, see www.witness.org/about-us/witness-background.

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48 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION can have deep impacts on both physical and mental health, including injury, stigma, and even death. One regularly noted aspect of this type of violence is the lack of information surrounding the magnitude of the problem. Data tend to be limited because many women do not report the violent act or seek medical services immediately afterward. Further complicating matters, data come from varying sectors, such as clinical settings, nongovernmental organizations, and the police. SMS and geocoding can be applied to the prevention of interpersonal violence in much the same way that it has been applied to collective vio- lence, as in the example of the aftermath of the election in Kenya. In Egypt, Medic:Mobile, a text messaging–based system, was used in combination with the Ushahidi platform in a project called Harassmap. In Egypt 83 percent of women are exposed to sexual harassment (Heatwole, 2010). The basic idea behind the program is that if a woman is sexually harassed she can send an SMS to the Harassmap number with corresponding details of the incident. This information will then be mapped on the website, allowing “hot-spots” of harassment to be identified. The project also provides help and information for victims (Heatwole, 2010). This program aims to help break through the silence that surrounds this issue. Another program aiming to break through cultural barriers is the Mo- bile Cinema Foundation. This program travels to various soldiers’ camps in the Democratic Republic of the Congo and uses short films to expose soldiers to the consequences of rape. The goal is to educate the soldiers of the Congolese National Army through victim’s testimonies and discussions that are held after the viewing of the film. This form of digital storytelling can be a powerful tool both for empowering the victims and for educating offenders on the effects their actions can elicit. Other programs are based on confidential hotlines, such as the National Sexual Assault Hotline in the United States, which victims can call for help. In a related use, in 2007 the International Organization for Migration part- nered with Ukrainian mobile phone service providers to allow victims to dial a certain number to receive information and advice on migration and trafficking issues (Verclas, 2007). Often it is an intimate partner that commits sexual violence, making sexual violence dovetail closely with intimate partner violence. Thus many interventions can help with both areas, including programs that promote gender equality, additional awareness campaigns, and microfinance pro- grams and support networks for women. Intimate partner violence Intimate partner violence is one of the most common forms of violence against women. This category refers to any “behavior within an intimate relationship that causes physical, psychologi- cal or sexual harm to those in the relationship” (WHO, 2002). Intimate

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49 FOUNDATIONS OF mPREVENTVIOLENCE partner violence occurs throughout the world and crosses social, economic, and religious divisions. Women who are uneducated, low income, and lack support are most likely to fall victim to this behavior (WHO, 2002). Conventional forms of technology and media have been used to pre- vent intimate partner violence. Examples include hotlines and awareness campaigns through both traditional and new media. Bell Bajao!, or Ring the Bell!, is an Indian program that provides a series of public service an- nouncements urging men and boys to stand against domestic violence. The idea is that if one is hearing violence in progress, one should ring the bell and ask a simple question, such as “Can I borrow a cup of sugar?” It is likely the perpetrator recognizes that the person has heard the violence, which will interrupt the action. The organization also hosts a blog for vic- tims to voice their experiences and access information and guidance (Bell Bajao!, n.d.). In the United States the company Liz Claiborne initiated a Love Is Not Abuse program, which provides information and tools for men, women, and children (including teens) to learn more about the issue of domestic violence. In August 2011 it launched the Love Is Not Abuse iPhone applica- tion, which helps teach parents about teen dating abuse and demonstrates how technology, such as text messages, e-mails, and phone calls, can be conduits for committing abuse. Parents receive real-time communication that mimics the abusive and controlling behaviors teens might face in their relationships.2 This program illuminates the negative role technology can play. On the other hand, texting can be a cheap and effective way to prevent intimate partner violence, as demonstrated by a case in Ohio in which a texting service allowed victims to report incidents silently via a simple SMS message and to make contact with a crisis intervention worker or the police without making an actual phone call. The total cost to set up the program, which used the Medic:Mobile platform, was about $380. FamilyFirst, as it was termed, processed between 6,000 to 8,000 texts per month during its first year and helped convict 18 abusers whose victims were able to report confidentially (Papillon, n.d.). Technology can also play a role in helping to transform some of the underlying causes of intimate partner violence. Helping women gain ac- cess to both economic and societal support, such as is done through the Village Phone project by Grameen Phone Foundation, can lead to positive outcomes. The idea behind the Village Phone model is to provide a small loan and a “business in a box” to enable an aspiring entrepreneur to pro- vide customers with access to a mobile phone and to sell mobile airtime. In March 2011, the program reports, 85 percent of the 6,876 entrepreneurs 2 See http://loveisnotabuse.com/web/guest/iphone.

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50 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION who had been recruited into the network were women (Grameen Founda- tion, n.d.). This idea of women having access to a mobile device can also be found in the report Women & Mobile: A Global Opportunity, published in 2010. This report states that 9 out of every 10 women surveyed who had a mobile phone felt safer, and 85 percent felt more independent (Vital Wave Consulting, n.d.). With the rise of mobile payments and mobile money, or mFinance, and with increasing access to mobile devices, women are beginning to gain more economic independence in areas where they have traditionally been limited. Finally, social support is important for women who have found them- selves in domestic violence situations. In the developed world, such support may be derived from in-person working groups or community groups as well as from social media platforms and the Internet, which allow women to connect and share their experiences. In the developing world, however, mobile phones can play a unique role in garnering this type of support. In Senegal, the organizations Tostan and UNICEF launched the Jokko Initia- tive. Using SMS technology, the program allows community members to send out messages on various topics, including information on vital events, service announcements, and income-generating activities (Vital Wave Con- sulting, n.d.). This allows women the opportunity to promote their goods and to provide information about events they organize. Not only does this provide a chance for women to connect with each other and provide support, but also the program is also tied into Tostan’s literacy and math program. Elder Abuse Elder abuse has received the least public attention among the various forms of violence, having historically been defined as a “private matter.” Today it is seen as an important problem that is likely to grow because of the rise in aging populations in many countries (see Figure 6-1). Elder abuse can be “either an act of commission or of omission,” and it may be either intentional or unintentional (WHO, 2002). The elderly can experience vio- lence physically, sexually, or psychologically, and they are also susceptible to economic abuse. Again, the use of hotlines and the sharing of information via the Inter- net are integral to dealing with this type of violence. The National Center on Elder Abuse has state resources such as helplines and hotlines listed directly on its website in addition to listing where to report nursing home abuses and providing information about Adult Protective Services. There are also National Elder Abuse Awareness public service announcements that call attention to the issue.

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51 FOUNDATIONS OF mPREVENTVIOLENCE Percentage of Population Aged 60 or Over World and Development Regions, 1950-2050 World More-Developed Regions 35 32.6 Less-Developed Regions 30 27.4 Percentage 25 21.9 21.4 20.2 20 15.5 14.9 15 12.5 11.7 10.8 8.5 8.5 10 8.1 6.4 6.1 5 0 1950 1975 2009 2025 2050 FIGURE 6-1 Percentage of population aged 60 or over. SOURCE: United Nations, 2009. Figure 6-1 Some sources state that a key prevention tactic could be the further use R02165 of intervention programs in hospital settings, which are currently lacking editable vectors because of an absence of training in this area (WHO, 2002). Recently there has been an increase in the use of electronic checklists within the hospital setting concerning surgical procedures. Certain elements, such as signs and symptoms of abuse, could be integrated into these checklists. As tablets and electronic records become more common, a unique opportunity will appear to progress to a more holistic approach in health care. Furthermore, with the ability to train remotely, technology can be used to keep those in the health care industry abreast of the proper diagnosis of elder abuse and what to do about it. The role of social media should also be mentioned. Social media plat- forms such as Facebook and Twitter, along with communications tools such as Skype, allow those traditionally cut off from the outside world to connect with both family and the wider community. According to a 2009 study by AARP, about one-third of people 75 or older live alone (Clifford, 2009). MyWay Village, a social network installed in nursing homes, allows residents to connect with new people and share their memories and expe- riences. Training sessions make it easy to pick up, and residents can send messages, play games, and, most important, not feel that they are isolated (Clifford, 2009).

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52 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION Youth Violence Youth violence is closely linked with other forms of violence, because youths who are exposed to other types of violence have an increased pro- pensity toward committing violent acts themselves. Adolescents and young adults are often both victims and perpetrators of youth violence. The WHO says that violence involving youth greatly adds to the costs of welfare and health services, decreases productivity, and “undermines the fabric of soci- ety” (WHO, 2002). Technology, particularly social media, is frequently thought to have a negative effect on youth. From online bullying to violent YouTube vid- eos and video games, the various technologies are often cited as leading to increased violence among youth. The type of harassment that occurs through e-mail, instant messaging, and websites or via the mobile phone has even been given a name: “electronic aggression” (Hertz and David- Ferdon, 2008). Regardless of the potential harm, youth are increasingly using social media, and there are ways in which it can be used positively. The increase in use of mobile phones by teens makes it possible to reach each one on an individual basis. A program in South Africa called loveLife launched a Web-based mobile program called MYMsta. This mobile social network allows the youth population to access information about HIV, employment opportunities, scholarships, and tips to improve their lives (Ngcobo, 2010). It also allows them to talk about concerns relating to sexual health and get responses from trained counselors. loveLife employs other services to reach youth, such as its call-back service, which offers users free mobile connectivity to counselors. A user sends a message to the service saying, “Please call me,” and the automated system calls back and links the caller to a trained counselor.3 A similar program exists in the United States. The National Dating Abuse Helpline recently made its services available via text message by providing teens who text “loveis” to 77054 with help from trained peer advocates.4 In another effort to reach out to teens, particularly in cases of intimate partner violence or dating violence, Futures Without Violence developed the online campaign That’s Not Cool. The campaign encourages teenagers to decide for themselves what is okay and what is not okay in their relation- ships through the use of videos, interactive games, and an online forum for teens to share their stories and receive advice. That’s Not Cool recently launched an avatar application that lets teens create their own personalized mobile phone characters in response to animated videos addressing digital 3 See www.lovelife.org.za/what/call_me.php. 4 See www.loveisrespect.org.

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53 FOUNDATIONS OF mPREVENTVIOLENCE dating abuse. Using text-to-speech technology, the character speaks the teen’s response, and the result is a speaking avatar video that can be posted and shared with peers on Facebook and Twitter.5 To deal with youth gangs, an innovative partnership involving the Chicago-based organization CeaseFire had been developed that combines science and street outreach to track where violence is heating up and to in- terrupt in order to calm the situation down. With Ushahidi, Medic:Mobile, and PopTech, the project PeaceTXT will look at how mobile tools, such as those used by other crisis-mapping organizations, and mobile messag- ing can accelerate CeaseFire’s existing success in decreasing deaths (Meier, 2010). Child Abuse Child abuse includes infanticide, mutilation, abandonment, and other forms of physical and sexual violence (WHO, 2002). It is a universal prob- lem and often increases the likelihood of adverse health outcomes in adult- hood. There is also a cultural aspect to child abuse because the standards and expectations of proper parenting can vary in different countries and societies. More often than not, the term “technology” combined with the idea of child abuse conjures up images of child pornography on the Internet and other negative ways in which recent innovations have harmed children. But technology also offers unique ways to prevent this type of abuse. One underlying risk factor for a parent committing child abuse is a lack of education concerning a child’s development (WHO, 2002). There has been a recent rise in health text messaging programs geared toward reaching traditionally underserved groups with important health informa- tion. For instance, in the United States the Text4Baby program piloted by the Department of Health and Human Services (HHS) is a public–private partnership that provides pregnant women and new mothers with free health text messages. The messages range from tips on how to care for a baby to information on what to expect during pregnancy. Evaluations of the program are scheduled to be made available in 2013, and the model is already being taken abroad with interactive voice response technology, which relies on voice instead of text. Another text program that HHS is ex- pected to roll out next year is Text4KidsHealth. The Health Resources and Services Administration (HRSA) will develop text messages on nutrition and physical activity to be used for future programs targeting the parents of children from 1 to 5 years of age (HHS, n.d.). The mobile phone can act as a reporting tool for cases of child abuse. As seen with regard to collective violence, there is power is capturing 5 See www.loveisrespect.org.

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76 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION its theoretical and empirical underpinnings, the core of the software de- velopment process is iterative and incremental development (Larman and Basili, 2003), which utilizes qualitative methodologies to obtain user input throughout the development process. A range of qualitative methods, both from health informatics (Borycki et al., 2011) and from violence research (e.g., Testa et al., 2011), can be used to elicit end-user perspectives on the usability and functionality of various design features during the develop- ment process. Prototype Evaluations As prototypes or components of the mHealth intervention are devel- oped and tested (e.g., debugged), a number of research methodologies are available to evaluate efficacy prior to any full-scale RCT. These prelimi- nary evaluations are particularly important for newly developed mHealth interventions in order to insure that the interventions have been optimized before subjecting them to an RCT. Although a single-arm pre-post pilot trial with a small sample is commonly used to determine if the mHealth intervention produces a significant change and to test the procedures for a subsequent RCT, this design may not provide the flexibility needed to test and further optimize the intervention before subjecting it to an RCT. N-of-1 designs Instead of testing a group of participants pre- and post- trial, detailed testing of individuals longitudinally throughout the interven- tion period (AB) provides the development team with important information on how the intervention is used by each user and the effect on the target problem during the intervention. By staggering these N-of-1 trials, mHealth developers can detect potential improvements after a few users have been evaluated, modify the program, and then test the new version on the next N-of-1 users. (See Lillie et al., 2011, for a review of N-of-1 trials in person- alized medicine and utilizing wireless and mobile devices for N-of-1 trials.) To increase the internal validity of these N-of-1 studies, reversal and interrupted time series designs can be considered. When the effects of the intervention are expected to quickly dissipate once the intervention is with- drawn, a reversal design (ABA) can be considered. Although the improve- ment in the target behavior from baseline (A) to intervention (B) can be the result of a number of confounders, many of these confounders can be eliminated from consideration if the individual returns to baseline levels of the target behavior after the intervention has been withdrawn (A). If the intervention is expected to have an enduring effect after the inter- vention is withdrawn (or if the intervention continues for as long as the user wants to use it), then an interrupted time series design can be considered (Biglan et al., 2000). This design is essentially an AB design, but the baseline

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77 FOUNDATIONS OF mPREVENTVIOLENCE values are used to predict future values of the outcome variable. If after the intervention is introduced, the values for the target problem exceed what would have been predicted from baseline, then it is reasonable to conclude that the intervention produced this effect. Of course, extraneous variable outside of the researcher’s control (e.g., a significant life event) could also have produced this effect, but such confounders can be minimized by stag- gering the initiation of the intervention across multiple users. If the im- provement is seen for each user following interventions that are initiated at different times for different individuals, then the causal inference is stronger. N-of-1 designs were commonly used in early behavioral intervention research and are still used regularly in many applied behavior analysis set- tings (e.g., developmental disabilities). The challenge with these designs is the frequent outcome assessments required to establish a stable baseline and to determine if the intervention affects the subsequent assessments. Mobile health interventions, however, are uniquely suited to generate the frequent longitudinal assessments needed to conduct these various N-of-1 designs. For example, an mHealth intervention is likely to have some specified baseline period (e.g., 7 days) and can be designed to continue the baseline period until a stable baseline has been achieved. The mHealth intervention can then introduce the intervention and continue frequent assessments and fully automate these N-of-1 designs so that every user of the mHealth in- tervention also contributes efficacy data. Intervention optimization designs Even with a solid empirical basis, the development of mobile health interventions still involves guesswork. Which components should get a higher or lower dose in the mHealth intervention? Which modality would be best for delivering a specific intervention com- ponent? Should all of the intervention components be delivered simultane- ously or in some pre-specified order? To address these questions, there are a number of intervention optimization design issues to consider. For N-of-1 designs, systems modeling, such as control systems engineering modeling, can be used to test the model (Rivera et al., 2007). For example, if the inter- vention model indicates that an intervention to identify potential violence or victimization will result in the avoidance of these situations and thereby reduce violence, the process of this change can be assessed and modeled. The intervention can then be revised based on how well the model fits. Group-level randomized optimization designs include factorial, frac- tional factorial, and sequential multiple assignment randomized trials (SMARTs) (Collins et al., 2007). Fractional factorial designs mix and match the various intervention components and modes of delivery that need to be evaluated and determine which components in which combination pro- duce the largest effect. SMART designs are similar in analysis but isolate the sequence of the components according to various considerations. For

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78 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION example, if a user responds well to the first phase of the intervention, what should be the next phase? If the user responds poorly, should the first phase be repeated or should the user move on to a different phase of treatment, and, if so, which one? These optimization designs take time and resources to conduct, but they are important to consider before subjecting an inter- vention to a standard two-arm RCT, especially if considerable questions about how best to deliver the various components of the intervention remain. Evaluating While Disseminating Although an RCT to establish the efficacy of an mHealth intervention in a controlled study is an important step to take before disseminating and implementing the intervention, it is not always feasible to conduct an RCT. There may, for example, be inadequate resources to conduct an RCT, or the mHealth intervention may have been developed for a pressing public health need and the intervention needs to be deployed immediately. The organiza- tion employing the mHealth intervention may not want a random selection of those it serves to not receive the intervention. In these cases, the mHealth intervention should, at the very least, have been developed empirically and evaluated on some small scale (e.g., pilot or N-of-1) before implementation. There are, however, a number of designs that can be employed to evaluate the intervention while it is being disseminated and implemented. Many of these designs have been used in community-based interventions in which it is impractical to randomize communities to an intervention. The same interrupted time series design described above for single subject users can be used for groups. The community or setting in which the intervention is being implemented is evaluated recurrently to obtain a stable baseline. This stable baseline can come from routinely collected pub- lic health data, but it can also be generated via the mHealth intervention itself by incorporating a baseline assessment prior to intervention initiation. Once the baseline is established, the intervention can be implemented with continued assessment to determine if the intervention is associated with a significant change in the outcome variable. For example, if a community-based youth violence prevention program (e.g., Vivolo et al., 2011) incorporated a mobile or wireless intervention component, then the addition of this component could be evaluated in a single community by monitoring the relevant outcomes over time before and after the addition of the mobile or wireless component. An illustra- tion of an interrupted time series design applied to a technological solu- tion (radio-frequency identification, or RFID) for improving workflow and reducing hospital service wait times is shown in Figure 6-5. By tracking wait times for weeks before and after the implementation of the RFID

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79 FOUNDATIONS OF mPREVENTVIOLENCE Mean Waiting Time (minutes) Weeks FIGURE 6-5 Interrupted time series example. SOURCE: Kim et al., 2010. system, Kim and colleagues (2010) were able to show that wait times were significantly reduced. Greater confidence in the causal inference from this Figure 6-5 design can obtained by using a matched control (e.g., a health service that R02165 did not receive the intervention, as shown in Figure 6-5), by staggering the uneditable bitmapped image intervention across communities, or by applying propensity-score weight- ings (Linden and Adams, axis labels retypedRCT is often not feasible 2011). Given that an for community, hospital, or school-based interventions, the interrupted time series design provides a quasi-experimental alternative that requires only one (or slightly more than one) community for evaluation. The stepped-wedge design rolls out the intervention in a staggered or sequential manner to individuals or clusters of individuals over a number of assessment periods (see Figure 6-6, adapted from Brown and Lilford, 2006, for a graphical representation of this design). This design is particularly ap- propriate if there are well defined cohorts (i.e., communities), all of whom should receive the intervention for ethical reasons, and especially if there are insufficient resources to introduce the intervention to all of the groups at once. The groups are defined a priori and randomized as to when they will

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80 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION 5 Participants/Clusters 4 3 2 1 1 2 3 4 5 6 Time periods Shaded cells represent intervention periods Blank cells represent control periods Each cell represents a data collection point FIGURE 6-6 Stepped-wedge design. SOURCE: Brown and Lilford, 2006. Figure 6-6 receive the intervention. Compared to interrupted time series, the stepped- wedge design typically requires less frequent assessments (i.e., one for each R02165 new rollout) but more cohortsgrabbed from original source (e.g., communities, schools, or hospitals). editable vectors To see how the stepped-wedge design might be applied to mobile ap- plications to prevent violence, consider a mobile intervention developed to reduce youth violence in schools. The schools receiving the intervention collect monthly data on violent behavior throughout the school year. The schools are randomly assigned to the order of intervention initiation. After a baseline month, the first randomly selected school receives the interven- tion and continues to use it throughout the school year. In each subsequent month the intervention is rolled out in the next randomly selected school until all of the schools have received the intervention, and violent behavior within and between schools can then be compared. In contrast to an RCT, every school eventually receives the intervention. The stepped-wedge design also makes better use of staff to roll out the intervention because the initial orientation, training, and deployment are performed at a different school each month instead of simultaneously. Newer technologies that have not been fully field-tested are often rolled out sequentially to detect problems before fully deploying, which fits a stepped-wedge model well. (See Handley et al., 2011, for a more detailed description of the stepped-wedge design.)

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81 FOUNDATIONS OF mPREVENTVIOLENCE The regression discontinuity design assigns participants to an interven- tion based on a cutoff variable and then analyzes the change in slope or intercept at the cutoff between those receiving and those not receiving the intervention. The design is often used when only those deemed more in need or at risk are provided the intervention. For example, if only those at risk for dating violence are referred to receive a mobile application to change dating violence attitudes, the intervention can be evaluated by comparing dating violence attitudes of those referred with the attitudes of those not referred by analyzing differences in the prediction of dating violence at- titudes from the risk variable used as the cutoff for referral. It is critical in the regression discontinuity design, however, that the cutoff criteria remain unchanged. Any variation in referral cutoff based on the risk score will introduce bias. Performed rigorously, the regression discontinuity design produces results similar to those of an RCT (Linden and Adams, 2011; Shadish et al., 2011). Regression discontinuity is preferable to an RCT when the referring agency wants all of those referred, not just those ran- domly assigned to the treatment group, to receive the intervention. These examples of evaluating interventions during dissemination clearly show that dissemination should not represent the end of the research evalu- ation process. These methodologies do allow for evaluation during dis- semination, and often these designs are more externally valid than RCTs because the intervention is being evaluated in actual users and, if well de- signed, the internal validity of these designs is comparable to RCTs (Shadish et al., 2011). The frequent longitudinal assessments often integrated into mHealth interventions can be leveraged to perform automated evaluations of the intervention while it is being disseminated and implemented using these designs. Conclusion Interventions delivered via mobile technologies (mHealth) have many potential advantages over traditional interventions. The mobile and wireless infrastructure already exists, so the costs of intervention delivery are greatly reduced. mHealth and other computerized interventions are completely standardized (i.e., they never deviate from the intervention protocol). They can be tailored and adapted over time to the user’s needs. mHealth interven- tions can be more engaging, especially for younger users, because of their graphics and gaming modalities. There are no time or space constraints: mHealth interventions can be delivered at any time or any place. mHealth interventions are fully scalable, which greatly improves their reach when compared with traditional intervention delivery. The ability for frequent and real-time monitoring provides both a base for research and program

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82 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION evaluation as well as for interventions that can adapt to ongoing changes in the users’ responses. All of these advantages, however, are more promise than proven. Public health has a long history of assuming that new technologies will improve public health. The Health Belief Model was developed in response to the failure of a new technology, mobile tuberculosis screenings in the 1950s, to substantially increase these screenings (Rosenstock, 1974). The mobile delivery of violence prevention interventions—and, indeed, of all public health interventions—requires rigorous evaluation. Although RCTs are the standard by which most of these interventions are judged, numerous other research designs can be used throughout the development and dissemina- tion of mHealth interventions. REFERENCES Barry, A. 2001. Political machines: Governing a technological society. New York: Athlone Press. Biglan, A., D. Ary, and A. C. Wagenaar. 2000. The value of interrupted time-series experiments for community intervention research. Prevention Science 1(1):31–49. Bogost, I. 2010. Persuasive games. The expressive power of videogames. Cambridge, MA: MIT Press. Borycki, E. M., M. Househ, A. W. Kushniruk, and C. Kuziemsky. 2011. Use of qualitative methods across the software development lifecycle in health informatics. Studies in Health Technology Information 164:293–297. Bell Bajao! n.d. Breakthrough. My cause. www.bellbajao.org/my-cause/ (accessed October 1, 2012). Brown, C. A., and R. J. Lilford. 2006. The stepped wedge trial design: A systematic review. BMC Medical Research Methodology 6:54. Buber, M. 1923. I and thou, translated by Walter Kaufman in 1996. New York: Touchstone. CDC (Centers for Disease Control and Prevention). 2008. The public health approach to violence prevention. http://www.cdc.gov/ViolencePrevention/overview/publichealth approach.html (accessed March 7, 2012). Chunara, R., J. R. Andrews, and J. S. Brownstein. 2012. Social and news media enable estima- tion of epidemiological patterns early in the 2010 Haitian cholera outbreak. American Journal of Tropical Medicine and Hygiene 86(1):39–45. Clifford, S. 2009. Online, “a reason to keep on going.” New York Times, June 2. www. nytimes.com/2009/06/02/health/02face.html (accessed October 1, 2011). Collins, L. M., S. A. Murphy, and V. Strecher. 2007. The Multiphase Optimization Strategy (MOST) and the Sequential Multiple Assignment Randomized Trial (SMART): New methods for more potent eHealth interventions. American Journal of Preventive Medicine 32(Suppl 5):S112–S118. Elliott, A. 2010. YouTube facts: 10 things you may not have known. Mashable Business, February 19. www.mashable.com/2011/02/19/youtube-facts/ (accessed October 1, 2011). Evans, L. 2011. Mapping murder throughout the world. The Guardian. October 10, 2011. Foege, W. H. 2010. House on fire: The fight to eradicate smallpox. Berkeley: University of California Press. Fogg. 2002. Persuasive technology: Using computers to change what we think and do. Elsevier. http://public.eblib.com/EBLPublic/PublicView.do?ptiID=294303 (accessed April 2, 2012).

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