7

Practical Applications
of mPreventViolence

Although the use of information and communications technology (ICT) in violence prevention is fairly new, some interventions have already capitalized on this new avenue with promising results. This chapter includes papers from presenters at the workshop who explored this intersection and its potential.

The first paper presents data from an intervention designed to assess the impact of adding a mobile phone component to an existing intervention that teaches parenting skills. The paper describes the intervention design and evaluation and results of the study.

The second paper is a case study in using video and community education to raise awareness and reduce the prevalence of domestic violence, as part of the Bell Bajao! campaign in India. The case study examines the impact of the campaign and explores the potential for expanding the program.

In the third, fourth, and fifth papers, the authors describe the applicability of ICTs to dating violence, elder abuse, and suicide prevention, respectively. These authors, who had previously not collaborated before, worked together before the workshop to frame breakout discussions on day 2 of the workshop. Their papers explore the needs and challenges of each type of violence prevention, the use (or potential use) of ICTs, and any additional gaps or questions that needed to be addressed.



The National Academies | 500 Fifth St. N.W. | Washington, D.C. 20001
Copyright © National Academy of Sciences. All rights reserved.
Terms of Use and Privacy Statement



Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter. Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.

Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.

OCR for page 87
7 Practical Applications of mPreventViolence A lthough the use of information and communications technology (ICT) in violence prevention is fairly new, some interventions have already capitalized on this new avenue with promising results. This chapter includes papers from presenters at the workshop who explored this intersection and its potential. The first paper presents data from an intervention designed to assess the impact of adding a mobile phone component to an existing intervention that teaches parenting skills. The paper describes the intervention design and evaluation and results of the study. The second paper is a case study in using video and community educa- tion to raise awareness and reduce the prevalence of domestic violence, as part of the Bell Bajao! campaign in India. The case study examines the im- pact of the campaign and explores the potential for expanding the program. In the third, fourth, and fifth papers, the authors describe the appli- cability of ICTs to dating violence, elder abuse, and suicide prevention, respectively. These authors, who had previously not collaborated before, worked together before the workshop to frame breakout discussions on day 2 of the workshop. Their papers explore the needs and challenges of each type of violence prevention, the use (or potential use) of ICTs, and any ad- ditional gaps or questions that needed to be addressed. 87

OCR for page 87
88 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION USING MOBILE PHONES TO ENHANCE PARENT ENGAGEMENT IN A HOME VISITING INTERVENTION TO PREVENT CHILD MALTREATMENT Judith J. Carta, Ph.D., Kathryn Bigelow, Ph.D. University of Kansas Jennifer Burke Lefever, Ph.D., John Borkowski, Ph.D. Notre Dame University A recent worldwide study of child maltreatment reported that from 80 to 98 percent of children suffer physical punishment in their homes, with a third or more experiencing severe physical punishment from the use of implements. In the United States, approximately 800,000 cases of child maltreatment are reported each year. Of these cases, child neglect remains the largest single category. A disproportionate number of cases of abuse and neglect occur with mothers who have their own personal histories of maltreatment. As a result, an intergenerational pattern of inappropriate and destructive pattern is continued. As the cycle passes from one generation to the next, society—as well as the families directly involved—bear enor- mous costs, including mounting mental health concerns, increased medical expenses, greater needs for public assistance, and excessive burdens on the criminal justice system. In the United States and other countries, a growing number of home- visiting parenting programs have shown positive results in reducing child maltreatment and enhancing parenting skills in high-risk populations (Olds et al., 2002; Barlow, 2006). However, studies of home-visiting programs have not found uniformly positive outcomes for parents and children. Rather, meta-analyses of these studies have produced mixed results (Layzer et al., 2001; Sweet and Appelbaum, 2004; Astuto and Allen, 2009). One barrier to achieving improved outcomes is parent participation (McCurdy and Daro, 2001). Program retention rates vary widely, and, as the pre- scribed duration of the programs increases, so do the programs’ rates of at- trition for families—especially for the highest-risk families (McCurdy et al., 2003). When families fail to show up for their home visit or drop out of in- terventions early, even the most powerful interventions will have diminished effects. A second determinant of effectiveness is parent engagement—the extent to which parents carry out the behavioral or affective components of the intervention program, such as keeping up with learning activities be- tween visits and seeking more information (Berlin et al., 1998; Korfmacher et al., 2008). Programs that are able to maintain parents’ participation and

OCR for page 87
89 PRACTICAL APPLICATIONS OF mPREVENTVIOLENCE keep them involved and actively engaged are thus more likely to achieve the desired results of improved parenting outcomes (Gomby, 2005). A recently developed innovation for preventing attrition and promot- ing engagement in a variety of health promotion interventions is the use of mobile phones to increase contact with patients, provide reminders of patient behaviors in the health protocol, and send messages that encour- age continued involvement. For example, researchers have recently tested the effectiveness of using mobile phones to increase HIV-positive patients’ adherence to antiretroviral medication therapies (Villanueva, 2007) and to maintain smokers’ involvement in smoking cessation programs (Lazev et al., 2004). The CPAT Program In a recently completed project, we sought to examine whether enhanc- ing an evidence-based parenting intervention, Planned Activities Training (PAT), by using mobile phones for increasing contact between home visits would increase parents’ engagement in the intervention, decrease their attri- tion, and result in greater improvements in their parenting skills compared to parents who received the parenting intervention without mobile phone enhancements. PAT is one component of Project SafeCare, an approach to prevent- ing child maltreatment that has been shown to improve positive parenting practices and parent–child interactions and to reduce challenging child behaviors (Silovsky et al., 2011). The current project employs a three- group experimental design with random assignment of parents to one of three groups: Planned Activities Training as usual (PAT), cellular phone– enhanced PAT (CPAT), or a waitlist control group (WLC). For both PAT and CPAT groups, family coaches teach parents posi- tive ways to interact with their children and to engage in appropriate behavioral expectations for common family activities and routines. Across approximately five sessions that take place in home visits, coaches help parents learn how to use PAT strategies in a play situation and in at least two daily routines that parents self-select as ones that have been difficult or challenging. Within the experimental design, parents assigned to the PAT or CPAT intervention groups were assessed prior to the intervention, as well as at 1-, 6-, and 12-month post-intervention time points. The control group participants completed assessments at time points similar to those of the intervention groups. Several outcomes were examined to measure intervention effects, including child maltreatment risk and occurrences, parent behaviors, and child behaviors.

OCR for page 87
90 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION Results thus far show the following: • Parents in the CPAT group were more likely to complete the inter- vention, with 79 percent of the CPAT and 66 percent of PAT par- ents finishing [c2 (1, n = 255) = 5.42, p = .02, φ = .15]. • Parents in the CPAT group were rated as being more highly en- gaged during the home visits (M = 14.97, SD = 2.21) than parents in the PAT group [M = 14.16, SD = 2.72; F(1, 220) = 5.69; p = .02, d = .32]. • Parents in the CPAT group were just as likely to learn new posi- tive parenting practices as those in the PAT group, with parents in both groups demonstrating more significant improvements in positive parenting practices than those in the control group. These improved parenting skills were still apparent even 6 months after the training ended. • Improved child behavior was apparent for children whose parents had received either PAT or CPAT intervention compared with chil- dren whose parents were in the control group when behaviors such as their responsiveness to their parent or their general affect were measured 6 months following the end of parent training. Conclusions One of the major challenges in preventing child maltreatment is the fact that across available sets of studies, only 30 to 80 percent of families who are at risk for child maltreatment actually complete prevention pro- grams. Our finding that parents were significantly more likely to stay in parenting programs enhanced with cellular phone technology may point to a promising approach to keeping families involved in interventions that help them learn new approaches to interacting with their children, and thus lead to much larger reductions in overall rates of child neglect. Moreover, this approach using mobile phones can be useful for other home visiting programs with high-risk groups, such as those that seek to improve health outcomes of women who are pregnant or mothers of young infants. Even more broadly, mobile phones can be applied to any intervention in which continuous support from a coach or counselor is important, such as suicide prevention, bullying and youth violence prevention, prevention of intimate partner violence, and prevention of elder abuse. We look forward to apply- ing this type of support for these and other issues and to using other more recent technological innovations to enhance the effectiveness of violence prevention efforts.

OCR for page 87
91 PRACTICAL APPLICATIONS OF mPREVENTVIOLENCE BELL BAJAO! AS A CASE STUDY1 Jael Silliman, Ph.D. Breakthrough Overview Bell Bajao! is a cultural, organizing, and media campaign strategy that calls on men and boys to join efforts to end violence against women. As such, it provides an object lesson in the principles, procedures, and pro- cesses that Breakthrough2 uses to achieve its objectives. Breakthrough has been conducting Bell Bajao! in India since 2008, and it announced in late 2010 that the campaign would become global in scope starting in 2011. The campaign’s media component was its most prominent and vis- ible feature—a series of television, radio, and print ads created pro bono by Ogilvy & Mather (O&M), which were disseminated widely through a partnership with the Indian Ministry of Women and Child Development. Bollywood actor Boman Irani was the campaign’s first male ambassador. The powerful television advertisements show a man or a boy who hears a woman being beaten behind the closed door of her home. After a moment of deliberation, the man or boy then rings the doorbell of the woman’s home. When the abuser comes to the door, the man or boy asks to borrow a cup of milk (in one advertisement) or use the phone or to retrieve a lost cricket ball (in others). In watching advertisements it is clear that the bell ringer is making the request as a pretext: He heard violence committed against the woman, and he is putting the abuser on notice that the violence will not be tolerated. The media campaign was accompanied by a strong community mo- bilization initiative in the Indian states of Karnataka and Uttar Pradesh, led by Breakthrough’s Rights Advocates Program (RAP). The mobilization initiative involved extensive leadership training, mass outreach, and face- to-face educational events. In 2010 Breakthrough released a series of three new TV advertisements asking if people had “rung the bell” and taken action against domestic violence. To date the campaign has reached more than 130 million people in India and has won multiple awards, including 1 This paper is an excerpt from the report Breakthrough’s Bell Bajao!: A Campaign to Bring Domestic Violence to a Halt. The full report is available at http://www.breakthrough. tv/images/downloads/147/BellBajao_Insight.pdf. 2 Breakthrough is a global human rights organization that uses the power of media, arts, pop culture, and community-based action to inspire people to take bold action for dignity, equality, and justice. Working out of centers in the United States and India, Breakthrough addresses critical global issues, including violence against women, HIV and sexuality, im- migration, and racial justice.

OCR for page 87
92 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION the prestigious Silver Lion at the 2010 Cannes International Advertising Festival. The Bell Bajao! campaign provides an excellent example of the Break- through methodology: • Bell Bajao! is Breakthrough’s most evolved and sustained campaign to date; it has had the greatest impact, scale, and the most compre- hensive set of partners. • Bell Bajao! integrates mass media with community mobilization tools and leadership development training. • Bell Bajao! incorporates lessons from Breakthrough’s preceding campaigns, What Kind of Man Are You? and Is This Justice?, as well as using new social media tools such as Facebook, Twit- ter, YouTube, and blogging that it learned about from its U.S. programs. • Bell Bajao! has been thoroughly evaluated and monitored using state-of-the-art tools and techniques. • Bell Bajao! has demonstrated its efficacy in furthering knowledge about domestic violence, changing attitudes and perceptions to- ward such violence at the individual and community levels, and bringing about behavior change that challenges violence against women and reduces stigma and discrimination toward women liv- ing with HIV/AIDS. At a time when Bell Bajao! is going global, this paper provides insight into how the campaign was conceived and rolled out as well as its scale and impact. Message Development Conceptualizing and Framing the Message The first task for Bell Bajao! was to create a message, which is a rig- orous and critical process. The goal of the campaign was to advance the current discussion and knowledge about violence against women while re- maining consistent with Breakthrough’s philosophy and mission. The mes- sage also needed to respond to current political realities and opportunities, build on past learning, and draw from what has been learned from research into violence against women in India and globally.

OCR for page 87
93 PRACTICAL APPLICATIONS OF mPREVENTVIOLENCE Employing a Variety of Research Instruments and Findings to Direct Its Message Breakthrough retained the Centre for Media Studies (CMS), a media research organization, to conduct a baseline survey to determine the extent of the public’s knowledge about the Protection of Women Against Domestic Violence Act of 2005. It also asked CMS to research attitudes toward and responses to domestic violence among a cross-section of the public. The center’s findings showed that very few people take any action when they are aware of domestic violence occurring around them. The findings also showed that men and women were equally likely to take some action to stop domestic violence and that men typically take the lead to intervene in such situations. Breakthrough also studied the literature in the fields of domestic vio- lence and violence against women that focused on the attitudes that deter people from acting to stop domestic violence. The research pointed to several prevailing social norms: Domestic violence is viewed as a private matter, people resist intervening because of a fear of retaliation, and people are unwilling to get involved in protracted family issues. The prominent finding that men play a central role in intervening in situations of domestic violence led Breakthrough to undertake secondary research on programs that engaged men and boys in various parts of the world to stop violence. This dataset provided additional background infor- mation that informed the message-development process. After this research process, Breakthrough concluded that a single, direct media message to stop domestic violence was required for its campaign. The message needed to be grounded in women’s rights, guided by research on the topic, and reinforcing of the political moment occasioned by the Indian government’s commitment to end domestic violence. Men and boys were identified as the critical targets for this campaign. Developing Media Components and Messages for Bell Bajao! Once the leadership team agreed upon the message framework, Break- through located an appropriate partner, O&M, to deliver the message using multiple media techniques and instruments. Determining the Media Message O&M’s creative team suggested two campaign directions based on Breakthrough’s feedback: (1) direct action—Bell Bajao! and (2) unpacking masculinity. Breakthrough chose to move forward with the direct action concept. The message that O&M developed was “Ring the Bell: Can I Have

OCR for page 87
94 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION Some Milk?” After considerable discussion, the team decided that implicit in the ads would be the idea that the ringing of the bell was an “excuse” to intervene when domestic violence was occurring. The bell ringer, the domestic violence perpetrator, the woman, and the audience would all be “in the know” about the bell-ringing being a pretext to stop violence. From this concept, a tagline emerged: “Bring domestic violence to a halt. Ring the bell.” Dissemination Strategy The dissemination strategy for Bell Bajao! was determined after exam- ining media viewership as documented by Mindshare, a media-planning agency, and a baseline survey carried out by CMS. Using the opinion- research datasets, Breakthrough determined the platforms and channels for the campaign. Breakthrough determined that Bell Bajao! should be broadcast on news channels, sports channels, and general entertainment channels as well as Doordarshan, the government-owned national televi- sion network. Selection of Media Formats for Campaign In keeping with commercial best practices, Breakthrough used a range of media platforms to disseminate its message. This is based on the widely accepted belief that audiences are heterogeneous and access information from multiple platforms. Repetition through multiple channels reaffirms messages and places them firmly in the minds of viewers. For Bell Bajao! Breakthrough decided to use a mix of traditional and new media tools for dissemination: television spots, radio and print ads, a robust online presence (including a campaign website and social media tools such as Facebook, Twitter, and blogs), and a retail strategy of mobile video vans to ensure face-to-face communication. Television proved to be by far the most effective and far-reaching dis- semination tool for the campaign, reaching more than 130 million viewers through multiple channels during the first and second phases of the cam- paign. Radio and print advertising were most effective in some areas, such as the city of Lucknow in Uttar Pradesh, but they did not achieve the wide reach and recall of television. The Bell Bajao! microsite engaged public audiences through its blog and social media tools.3 3 The Bell Bajao! microsite received praise from media leaders such as IndiaSocial’s Casebook. Breakthrough is now exploring the expansion of the campaign into mobile platforms and user-generated materials. Because there are few precedents for these kinds of programs, Breakthrough is experimenting with an Internet and mobile solution that was piloted in Lucknow, Uttar Pradesh, in November 2010.

OCR for page 87
95 PRACTICAL APPLICATIONS OF mPREVENTVIOLENCE Dissemination via video vans proved to be extremely effective. Vans carrying the campaign message were accompanied by staff and youth ad- vocates who engaged directly with individuals, enabling the public to ask questions about domestic violence and women’s rights. This strategy was especially effective in sustaining community engagement over a 2-year period. Bell Bajao! has been more ambitious than previous Breakthrough cam- paigns in using the blogosphere. To raise awareness and stimulate dis- cussion, Breakthrough developed a domestic violence–themed blog on its website. The blog is an interactive and dynamic virtual space where users leave comments and share their experiences. Bell Bajao! expanded its online presence in key social networking sites such as Facebook and Twitter, where news and views of domestic violence and other women’s issues and causes are regularly posted. These social networking sites operated as discussion forums and as traffic generators for the campaign site and blog. Integrating Media and Community Mobilization to Roll Out Bell Bajao! The two strategic approaches that Breakthrough uses in its work— media and edutainment (entertainment designed to educate) development, and training activities for the community mobilization—occur in tandem and often overlap with one another. In this way partner organizations are trained and ready to conduct community mobilization efforts to deepen the media message. At the same time media products are finalized for rollout. With the partner organizations ready and the media products final- ized, Breakthrough was poised to initiate the next set of activities: At the local level, in four districts in Karnataka and another four districts in Uttar Pradesh, a “360-degree” comprehensive multimedia campaign was initi- ated. At the national level, Breakthrough conducted a media launch. It also deployed video vans in the cities of Mumbai and Delhi. This combination of national and local initiatives is a critical component of the Bell Bajao! campaign. Activities at the District Level: Building a Sense of Ownership Among Partners Prior to the Bell Bajao! campaign launch, partners had to develop a sense of ownership of the campaign. In its campaigns Breakthrough builds campaign ownership by collaborating on launch activities, including pro- viding its partners with a road map of the intervention strategies that they will jointly undertake. Campaign publications designed by Breakthrough— brochures, pamphlets, information booklets, and posters—are shared with partners for review. Partner logos are incorporated in all publication mate- rials, enhancing the partners’ sense of ownership and giving them greater

OCR for page 87
96 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION visibility in the campaign. For example, Breakthrough developed a CD with footage and voice-to-camera interviews with local opinion leaders, heads of collaborating organizations, artists, and local government officials for screening in the larger community during the campaign. This CD provided local specificity as well as partner buy-in. Working with Government at National and District Levels for Campaign Rollout The Indian Ministry of Women and Child Development (MWCD) re- leased the first phase of Bell Bajao! in 2008–2009 at the national level on all prime-time channels, including entertainment, news, and sports channels. Breakthrough optimized the national commitment of MWCD and collabo- rated with its district- and state-level officials to demonstrate local govern- ment support to end violence and empower women. Breakthrough also networked with government officials to involve them in campaign activities. Protection officers lent legitimacy to Breakthrough’s human rights mes- saging by their participation in trainings. Public and government officials spoke at Breakthrough events and in public venues. Government officials that took a public stand on violence against women during the campaign gave legitimacy to the Protection of Women from Domestic Violence Act (PWDVA) of 2005 and signified their willingness to implement it. Gearing Up the Video Van The video van is a mobile unit with audiovisual screenings on violence against women issues that was developed by the Breakthrough media team. Managed by selected rights advocates, the van carries video endorsements featuring local opinion leaders on campaign issues and interactive games and theater on the topic. The rights advocates, who accompany the van and lead most of the interactive sessions with the public, receive a small stipend and certificate for their participation. Handouts and other public- ity materials—items such as t-shirts, caps, and flashlights—are dispensed from the van. Trained youth advocates accompany the video van and perform activi- ties such as street theater, interactive games, and puppet theater in order to amplify campaign messages. Rights advocates conduct games to draw in crowds, serving as a prelude to engagement on issues of violence against women. Once a critical mass gathers, street theater is performed, Bell Bajao! videos are screened,4 and questions are fielded on violence against 4 In Karnataka the video ads were transferred by Bluetooth technology to viewers’ mobile phones so that they could be watched and shared at viewer convenience.

OCR for page 87
97 PRACTICAL APPLICATIONS OF mPREVENTVIOLENCE women. The van is stationed at each site for approximately 1 hour, which includes time for setting up and winding down, allowing at least 35 minutes of substantive engagement on the campaign themes. Audience Reach of Video Van The van travels in each of the eight campaign districts of Uttar Pradesh and Karnataka from 10 a.m. to 5 p.m. for 25 days. It is estimated that in 2009 the video van reached 2.5 million people with the Bell Bajao! mes- sage, with an intended outreach by 2011 of 6 million people. The van will revisit the eight districts of Karnataka and Uttar Pradesh to reinforce Bell Bajao! messages with additional materials and new public service an- nouncements (PSAs). In addition, the van will circulate for 15 days each in the cities of Delhi and Mumbai. National Level Activities for Roll Out of Bell Bajao! Campaign rollout at the national level is focused on getting optimum exposure for the campaign. Media planning—such issues as when to start the campaign and how to mix the media platforms—is done with the help of a professional agency. Breakthrough launched Bell Bajao! with its televi- sion campaign because television has the widest coverage. All other plat- forms—radio, print, advertising, and the video van—followed the television broadcasts in a staggered rollout. Media Rollout for National TV The decisions about the rollout of Bell Bajao! on national television were made by evaluating the efficacy and popularity of different platforms. Mindshare provided Breakthrough with state- and district-level data on the efficacy and popularity of different platforms. In 2008–2009 an investment from MWCD enabled Bell Bajao! PSAs to air during prime-time on all TV channels. Additionally, Breakthrough made direct media buys for print and radio dissemination. In 2010 Breakthrough commissioned Doordarshan, IBN7, Zee News, TV Today, Suvarana News, Zee Kannada, ETV Kannada, and Asia Net to broadcast the Bell Bajao! PSAs. Radio partners for the PSAs included AIR, Big FM, and Red FM. Breakthrough’s print partners for the campaign rollout included Vijay Karnataka, Praja Vani, and Dainik Jagran. As a nongovernmental organization (NGO), Breakthrough was able to leverage good rates for media buys and often had additional value-added features, such as viewing in other television programs.

OCR for page 87
118 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION Summary Elder abuse is a pervasive public health and human rights issue and is associated with premature morbidity and mortality. Despite the fact that an older adult is victimized every 2.7 minutes, there remain major challenges and barriers in raising social awareness on these issues. The three authors of this paper collaborated synergistically outside our traditional comfort zones to tackle the global issue of elder abuse. We believe this process demonstrated that fruitful collaboration is possible and that it is feasible to combine scientific knowledge with input from experts in technology and social media to increase community and societal awareness of elder abuse and to improve the health and aging of an extremely vulnerable population. USING BIG DATA TO UNDERSTAND AND PREVENT SUICIDE Daniel J. Reidenberg, Psy.D. Suicide Awareness Voices of Education John Gordon Fenton There is no greater tragedy or malady in our world than the loss of life by self-harm. While many people today will say the word “suicide,” on a global level, it remains a taboo word in most cultures. Suicide still invokes questions and curiosity, myth and misery, especially for the survivors (those left behind after a suicide). For researchers there are more questions than answers, and the more that is learned, the more that is still unknown comes into view. Often suicide is said to be the most preventable fatality, and al- though this may be true, there is a long way to go before claiming victory over this complicated and devastating form of death. Historically we have approached suicide prevention as a traditional public health campaign and used traditional “gatekeepers” (individuals, family, friends, and survivors after a suicide) as the target audience for these campaigns. Unfortunately, these efforts have proven less than successful, and the rates of suicide have not been reduced despite widespread efforts using this approach. We can summarize the current situation as follows: 1. There are few good data on suicide—what causes it and what truly can prevent it. 2. Up to now programs have focused primarily on education instead of intervention.

OCR for page 87
119 PRACTICAL APPLICATIONS OF mPREVENTVIOLENCE 3. Society is moving to an increasing public lifestyle using social (on- line) media and technology. 4. Current online behavior is generating massive data streams (“big data”) that might be helpful in identifying people at risk of suicide as well as effective intervention approaches. To begin understanding the links between suicide, online behavior, and the goal of saving lives on a global scale, it is important to start with knowledge-sharing in order to form a basis for where to go next. The most interesting thing about this process is that this is not only where we began, but also where we ended in our thinking about suicide prevention and technology. Ultimately, what we know about suicide is almost as limited as what we know about how technology can help prevent suicide. Thankfully, the potential is far greater than what heretofore has been imagined, and, once clarified and implemented, it could offer the first real opportunity to save more lives. Definition of Suicide Suicide is a fatal, self-inflicted destructive act with an explicit or in- ferred intent to die (IOM, 2002). Suicide methods vary across the globe, with ingestion of pesticides being the leading one. However, suicide by fire- arm, hanging, poisoning, and, to a far lesser percentage, jumping, falling, and drowning are also ways in which people take their life. A suicide attempt is a non-fatal, self-inflicted destructive act with ex- plicit or inferred intent to die (IOM, 2002). The methods used in suicide attempts are similar to those used in successful suicides. Suicidal ideation refers to thoughts of harming or killing oneself (IOM, 2002). Estimates of the number of those who have suicidal ideation vary, but they are always in the millions, with the vast majority of those who think about suicide never actually dying by suicide. Yet, the idea that a person would contem- plate taking his or her own life—in particular, when paired with other risk factors, such as mental illness, prior attempt at suicide, family history of suicide, and substance abuse—makes those millions with suicidal ideation of great concern. Global Aspects of the Issue There are 1 million suicides every year in the world—one every 40 seconds. More people have died by suicide than from all the wars in his- tory combined (WHO, 2012). Some countries have better reporting and monitoring systems than others, but it is believed that suicide occurs in all countries, among all ages and all demographic groups. More males die by

OCR for page 87
120 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION suicide than females (by a four-to-one ratio) in all countries except China. On the other hand, females attempt suicide more often (three to four times more often) than do males. The loss of life is tragedy enough, but com- pounding this tragedy is the fact that this topic remains largely unspoken in the media, by governments, and in health care systems. Imagine seeing a news report that there were 1 million deaths by suicide last year. There would likely be public outrage around the world, with people demanding more research, better treatments, and early intervention programs. Yet today suicide is one of the least funded health-related causes of death in our world. People at Risk for Suicide We have learned much about the risk factors for suicide. For example, males are at a higher risk of completed suicide, while females are at greater risk of attempted suicide. A psychiatric disorder increases one’s risk of sui- cide, and 90 percent of those who die by suicide have a psychiatric disorder at the time of their death. Mood disorders and substance abuse disorders in- crease one’s risk of suicide (Moscicki, 2001). By the year 2020 depression is projected to become the second-leading cause of loss of DALYs (death- and disability-adjusted life years) for all ages and both sexes. Today, depression is already the second-leading cause of DALYs among people aged 15 to 44 (WHO, 2012). A prior suicide attempt significantly increases one’s risk, and older adults are disproportionately at risk of suicide (CDC, 2010b). Other risk factors include a history of impulsivity, mental illness, physical illness, violence and trauma (including physical or sexual abuse, exposure to war), substance abuse, suicide in one’s family, lack of access to care, and failed treatment. Persons with access to lethal means and who are socially isolated or lack connectedness are also at greater risk. Just knowing the risk factors does not by itself prevent suicide, but technology to better recognize the written, posted, and communicated risks could hold the key to more effective prevention efforts. Prevention Strategies Shown Effective There are several strategies currently used in suicide prevention. Public awareness campaigns show promise and are effective at getting a message out and reducing stigma; however, there is little research on their long- term effectiveness. There is evidence that safe media reporting reduces the risk of suicide contagion (Gould and Davidson, 1988). Reducing access to lethal means (such as storing firearms, providing for safe pill dispensing, and installing barriers for access to railroad tracks, bridges, dangerous buildings, and pesticides) has been shown to be effective at reducing sui- cide. Selected prevention programs include screening programs, gatekeeper

OCR for page 87
121 PRACTICAL APPLICATIONS OF mPREVENTVIOLENCE training, skills training, and the U.S. Air Force suicide prevention program. Indicated prevention programs address specific populations, such as those in need of a crisis response and youths judged to be at risk because of a previous attempt. Cognitive behavioral therapy, a form of psychotherapy, has been shown to be effective at reducing the rate of repeated suicide attempts by 50 per- cent during a 1-year follow-up (Brown et al., 2005). Some medications, such as Clozapine, has been shown to be effective in preventing suicide among patients with schizophrenia (Meltzer et al., 2003), and lithium has been found to be effective in reducing suicide among patients with bipolar disorder. According to the National Institute of Mental Health, when com- bined, psychotherapy and medications together effectively treat depression 85 to 90 percent of the time. Treating mental illnesses (brain disorders of mood, thought, anxiety, and substance abuse) has been shown to prevent suicide. Strikingly, none of the prevention efforts mentioned above include the use of new technology and all it has to offer. Need to Better Understand How Someone at Risk Communicates: Can Technology Help Save Lives? Research shows that the majority of those who died by suicide commu- nicated their intent prior to their death (Michel et al., 2001). Sometimes this verbal communication was very direct—“I am going to kill myself”—while in other cases it was more indirect, such as, “The team would be better off without me.” Thus if we know how those at risk communicate, know their intent and ideation, and recognize the rapid advancements made in technol- ogy’s ability to help us communicate, we should be able to use technology to help us identify those individuals at risk and when these communications should occur to better prevent a suicide. Although it is not a proven, evidence-based technique, consider the following approach: A person who has several risk factors for suicide uses his or her mobile phone to text, e-mail, post, or send out a message via one of the many current applications available. This hypothetical person might type something like, “Thanks for everything, checking out now,” or “I know you’d be better off without me around. See ya.” Or the language could be more direct: “I’m sorry. I just can’t take this pain any longer. I just want to die.” If we had a better sense of the language that people naturally use to communicate their intents, whether it is logical or not at the time, and if we had a better analysis of the online behaviors and rituals that precede an attempt, technology might be able to catch the pattern and offer interventions immediately. For example, a post as described above is sent out. The platform algorithms compare the words and phrases of the current post to past posts, and then an alert is sent to the sender. “We see

OCR for page 87
122 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION you posted something a few minutes ago. This is a little worrisome to us. Are you ok? Would you like to chat with someone?” The system could then be programmed to offer a chat service, to make a connection to a live phone contact, or to continue the monitoring of the posts. Further analysis will reveal if this is a suitable intervention, but first we need to determine the relevant information that helps us identify the early and late stages of suicide communication. Research Is the First Key to Developing Technology That Can Prevent Suicide Technological advances have brought about remarkable capabilities and a wealth of new measurable data, but to date they have not been ap- plied to suicide prevention efforts. We must begin by acknowledging that data can help us develop better preventive strategies and possibly better intervention strategies. There is a virtually unlimited amount of data that already exists that we can use to begin to understand communication pat- terns. Why start here? Because going back to the previous example, what appears clear is that how people communicate (in this case, communica- tion about suicidal intent) does not appear to be the basis for how current suicide prevention strategies identify or assess the risk of suicide. We did a brief look into written communication messages about sui- cidal intent. We found the following: • There are far more searches performed on the phrases “suicide how to” (7.4 million per month) and “suicide methods” (110,000 per month) than on “suicide help” (40,000 per month) and “suicide hotline” (49,000 per month). • There is a high volume of natural speech searches like “how to kill yourself” (246,000 per month), “I want to die” (368,000 per month), and “how you can kill yourself” (246,000 per month). A Google search for “commit suicide” yielded 12 million hits. A Google search for “kill myself” yielded 17.8 million hits. In addition to the sites displayed by Google, advertisements appeared on the right side and at the top of the page containing the searches. While there have been few studies on advertising and suicide prevention, research by Klimes-Dougan et al. (2009) found that brief exposure to billboard campaigns resulted in increased maladaptive coping by viewers who were at risk of suicide. The billboards studied displayed the message “Prevent Suicide. Treat Depres- sion. See your doctor.” The brief messages portrayed in advertisements in search results might have the same unintended consequences as the short billboard signs and should be examined further.

OCR for page 87
123 PRACTICAL APPLICATIONS OF mPREVENTVIOLENCE More research is needed to better understand the effects of ICT-based suicide prevention efforts. The ways in which people are thinking and us- ing technology may not be the same as current science-based assessment or intervention strategies would lead us to believe, and research is needed to better understand the effects. Existing technology has already provided us some idea of the power of language. If a person carries out a search using any of the terms in our first example, Google displays a red telephone with a National Suicide Prevention Hotline phone number as the first result. Interestingly, when the search terms from our second example are used instead, Google’s red phone and crisis number come up third on the list. Another example of an existing suicide program that uses information and communications technology can be found on Facebook’s social net- working site. When someone is concerned about a person at risk of suicide, that person can immediately report his or her concern through Facebook’s Safety Center, and Facebook will contact the individual reported to be at risk and offer a national crisis line number and the ability to engage in an online chat with a certified mental health professional. Even if we were able to gather all of the search engine data on people who typed in “commit suicide” or “kill myself,” we still might miss a substantial number of people at risk of suicide. On the other hand, if we learned more about how people are actually using technology to commu- nicate, it might allow us to do a better job of identifying people at risk. Taking this further, suppose we could use technology to intervene when someone at risk was identified. And suppose that technology could be used to alert others in the at-risk person’s life of the communication so that they too could reach out and intervene? Technology might also be able to be used to send a message to the at-risk person with information about lo- cal resources, hospitals, and crisis lines and other national resources, or it could provide messages of hope and recovery or immediate interaction with someone who could help through text, chat, or video platforms. In reality, there is no limit to how much could be done to immediately intervene and prevent a suicide, provided that we know who is truly at risk. What Are Some of the Questions We Need to Ask? • Is there a pattern to online social behavior that mirrors offline suicide behavior? • Is there posting or social behavior that is unique to social media? • What words do people use when they decide to commit suicide? • What role does or could anonymity play in outreach and engage- ment with our audiences? • Are there media consumption patterns that precipitate an attempt?

OCR for page 87
124 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION There are some challenges and limitations to ICT-based suicide pre- vention efforts that should be addressed. For example, privacy and confi- dentiality are critically important to users as well as to the platforms and systems that obtain this information. It is important to address when and how communications that are believed to be private are shared with law enforcement, mental health agencies, and even within system staff. Another limitation is the workforce capacity of the systems that run these applica- tions. Most likely do not have mental health professionals on staff to deal with either user issues or work stress from addressing suicide risk. Further, most health care professionals’ lack of technological skills limits their abil- ity to truly respond to and address this type of online content. Recommendations Given the wealth of social media and online data already in exis- tence from user content, we propose working with Facebook, Google, and Twitter to try to better understand the online behaviors of people consider- ing suicide. We propose studying audience, behavior, language, and tone to look for patterns that match verbal communications and online communi- cations of people who have died by suicide or who have attempted suicide. We believe there could be significant benefits to obtaining this information. Those benefits could include • Direct online intervention strategies • Search and Facebook advertising • Search-optimized landing pages • Filters and notifications • Offline education materials for gatekeepers Therefore, we recommend: 1. National suicide prevention (content) experts should continue to develop relationships with social media and new technology busi- nesses, including coding and development experts. 2. One or more major platforms (e.g., Facebook or Google) should conduct an analysis of user-generated content (posts or searches) and look for patterns that might help inform designers of programs about ways that technology can identify those at risk of suicide. This may require looking at content from users who have died by suicide or those who have attempted suicide and who allow access to the content for analysis.

OCR for page 87
125 PRACTICAL APPLICATIONS OF mPREVENTVIOLENCE 3. Development of policies and practices for technology platforms should be considered based on research on the language of users at risk of suicide. 4. Suicide prevention experts and mental health professionals should be trained in the new technology and implications for use with patients. REFERENCES Acierno, R., M. A. Hernandez, A. B. Amstadter, H. S. Resnick, K. Steve, W. Muzzy, and D. G. Kilpatrick. 2010. Prevalence and correlates of emotional, physical, sexual, and financial abuse and potential neglect in the United States: The national elder mistreatment study. American Journal of Public Health 100(2):292–297. Astuto, J., and L. Allen. 2009. Home visitation and young children: An approach worth invest- ing in? SRCD Social Policy Report 23(4):1–22. Barlow, J. 2006. Home visiting for parents of pre-school children in the UK. In Enhancing the well-being of children and families through effective interventions: International evidence for practice, edited by C. McAuley, P. J. Pecora and W. Rose. London: Jessica Kingsley. Beach, S. R., R. Schulz, N. G. Castle, and J. Rosen. 2010. Financial exploitation and psycho- logical mistreatment among older adults: Differences between African Americans and non-African Americans in a population-based survey. Gerontologist 50(6):744–757. Berlin, L. J., C. R. O’Neal, and J. Brooks-Gunn. 1998. What makes early intervention pro- grams work? The program, its participants, or their interaction. Zero to Three 18:4–15. Black, M. C., K. C. Basile, M. J. Breiding, S. G. Smith, M. L. Walters, M. T. Merrick, J. Chen, and M. R. Stevens. 2011. The national intimate partner violence and sexual violence survey: 2010 summary report. Atlanta, GA: National Center for Injury Prevention and Control, Centers for Disease Control and Prevention. Brown, G. K., T. Ten Have, G. R. Henriques, S. X. Xie, J. E. Hollander, and A. T. Beck. 2005. Cognitive therapy for the prevention of suicide attempts. Journal of the American Medi- cal Association 294(5):563–570. CDC (Centers for Disease Control and Prevention). 2010a. Fact sheet: Understanding teen dating violence. www.cdc.gov/ViolencePrevention/pdf/TeenDatingViolence2012-a.pdf. CDC. 2010b. Suicide: Risk and protective factors. www.cdc.gov/ViolencePrevention/suicide/ riskprotectivefactors.html (accessed February 15, 2012). Dong, M., R. Anda, V. Felitti, and W. Giles. 2005. The relationship of childhood abuse, neglect and household dysfunction to premature death of family members: Findings from the Adverse Childhood Experiences Study. American Journal of Epidemiology 161(11):S110. Dong, X. 2011. Prospective study of the elder self-neglect and emergency department use in a community population. Journal of the American Geriatrics Society 59:S190–S191. Dong, X., M. Simon, C. Mendes de Leon, T. Fulmer, T. Beck, L. Hebert, C. Dyer, G. Paveza, and D. Evans. 2009. Elder self-neglect and abuse and mortality risk in a community- dwelling population. Journal of the American Medical Association 302(5):517–526. Dong, X., M. Simon, T. Fulmer, C. F. Mendes de Leon, B. Rajan, and D. A. Evans. 2010. Physi- cal function decline and the risk of elder self-neglect in a community-dwelling population. Gerontologist 50(3):316–326. Dong, X. Q., M. A. Simon, T. T. Beck, C. Farran, J. J. McCann, C. F. M. de Leon, E. Laumann, and D. A. Evans. 2011a. Elder abuse and mortality: The role of psychological and social wellbeing. Gerontology 57(6):549–558.

OCR for page 87
126 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION Dong, X. Q., M. A. Simon, T. Fulmer, C. F. M. de Leon, L. E. Hebert, T. Beck, P. A. Scherr, and D. A. Evans. 2011b. A prospective population-based study of differences in elder self-neglect and mortality between black and white older adults. Journals of Gerontology A: Biological Sciences and Medical Sciences 66(6):695–704. Eaton, D. K., L. Kann, S. Kinchen, S. Shanklin, J. Ross, J. Hawkins, W. A. Harris, R. Lowry, T. McManus, D. Chyen, C. Lim, L. Whittle, N. D. Brener, and H. Wechsler. 2010. Youth risk behavior surveillance—United States, 2009. MMWR Surveillance Summaries 59(SS–5):144. Foshee, V.A., K. E. Bauman, X. B. Arriaga, R. W. Helms, G. G. Koch, and G. F. Linder. 1998. An evaluation of Safe Dates, an adolescent dating violence prevention program. American Journal of Public Health 88(1):45–50. Gomby, D. S. 2005. Home visitation in 2005: Outcomes for children and parents. Invest in kinds working. Working Paper No. 7: Committee for Economic Development. Gould, M. S., and L. Davidson. 1988. Suicide contagion among adolescents. In Advances in adolescent mental health, Vol. III. Depression and Suicide, edited by A. R. Stiffman and R. A. Felman. Greenwich, CT: JAI Press. Heise, L., and C. García-Moreno. 2002. Violence by intimate partners. In World report on violence and health, edited by E. G. Krug. Geneva, Switzerland: World Health Organiza- tion. Pp. 87–121. Heise, L., M. Ellsberg, and M. Gottemoeller. 1999. Ending violence against women. Baltimore, MD: Johns Hopkins University School of Public Health, Center for Communications Programs. IOM (Institute of Medicine). 2002. Reducing suicide: A national imperative. Washington, DC: The National Academies Press. Jewkes, R., M. Nduna, J. Levin, N. Jama, K. Dunkle, A. Puren, and N. Duvvury. 2008. Im- pact of Stepping Stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: Cluster randomised controlled trial. British Medical Journal 337:383–387. Klimes-Dougan, B., C. Y. S. Lee, and A. K. Houri. 2009. Suicide prevention with adolescents considering potential benefits and untoward effects of public service announcements. Crisis: The Journal of Crisis Intervention and Suicide Prevention 30(3):128–135. Korfmacher, J., B. Green, F. Staerkel, C. Peterson, G. Cook, L. Roggman, R. A. Faldowski, and R. Schiffman. 2008. Parent involvement in early childhood home visiting. Child & Youth Care Forum 37(4):171–196. Lachs, M. S., C. S. Williams, S. O’Brien, L. Hurst, A. Kossack, A. Siegal, and M. E. Tinetti. 1997. ED use by older victims of family violence. Annals of Emergency Medicine 30(4):448–454. Lachs, M. S., C. S. Williams, S. O’Brien, K. A. Pillemer, and M. E. Charlson. 1998. The mortal- ity of elder mistreatment. Journal of the American Medical Association 280(5):428–432. Lachs, M. S., C. S. Williams, S. O’Brien, and K. A. Pillemer. 2002. Adult protective service use and nursing home placement. Gerontologist 42(6):734–739. Layzer, J., B. D. Goodson, L. Bernstein, and C. Price. 2001. National Evaluation of Family Support Programs final report. Volume A, the meta-analysis. Report submitted to Ad- ministration for Children, Youth and Families. Abt Associates. Lazev, A. B., D. J. Vidrine, R. C. Arduino, and E. R. Gritz. 2004. Increasing access to smoking cessation treatment in a low-income, HIV-positive population: The feasibility of using cellular telephones. Nicotine & Tobacco Research 6(2):281–286. Lewis, S. F., and W. Fremouw. 2001. Dating violence: A critical review of the literature. Clini- cal Psychology Review 21(1):105–127. McCurdy, K., and D. Daro. 2001. Parent involvement in family support programs: An inte- grated theory. Family Relations 50(2):113–121.

OCR for page 87
127 PRACTICAL APPLICATIONS OF mPREVENTVIOLENCE McCurdy, K., R. A. Gannon, and D. Daro. 2003. Participation patterns in home-based family support programs: Ethnic variations. Family Relations 52(1):3–11. Meltzer, H. Y., L. Alphs, A. I. Green, A. C. Altamura, R. Anand, A. Bertoldi, M. Bourgeois, G. Chouinard, Z. Islam, J. Kane, R. Krishnan, J. P. Lindenmayer, and S. Potkin, for the InterSePT study group. 2003. Clozapine treatment for suicidality in schizophre- nia—International Suicide Prevention Trial (InterSePT). Archives of General Psychiatry 60(1):82–91. Michel, K., P. Dey, and L. Valach. 2001. Suicide as goal-directed action. In Understanding suicidal behaviour: The suicidal process approach to research and treatment, edited by K. V. Heeringen. Chichester, UK: Wiley and Sons. Moscicki, E. K. 2001. Epidemiology of completed and attempted suicide: Toward a framework for prevention. Clinical Neuroscience Research 1(5):310–323. Mosqueda, L., and X. Q. Dong. 2011. Elder abuse and self-neglect: “I don’t care anything about going to the doctor, to be honest . . . .” Journal of the American Medical Associa- tion 306(5):532–540. Nation, M., C. Crusto, A. Wandersman, K. L. Kumpfer, D. Seybolt, E. Morrissey-Kane, and K. Davino. 2003. What works in prevention—Principles of effective prevention programs. American Psychologist 58(6–7):449–456. NRC (National Research Council). 2003. Elder mistreatment: Abuse, neglect, and exploitation in an aging America, edited by R. J. Bonnie and R. B. Wallace. Washington, DC: The National Academies Press. Olds, D. L., J. Robinson, R. O’Brien, D. W. Luckey, L. M. Pettitt, C. R. Henderson, R. K. Ng, K. L. Sheff, J. Korfmacher, S. Hiatt, and A. Talmi. 2002. Home visiting by paraprofes- sionals and by nurses: A randomized, controlled trial. Pediatrics 110(3):486–496. O’Leary, K. D., and A. M. S. Slep. 2011. Prevention of partner abuse by focusing on males and females. Prevention Science (12):1–11. Reza, A., M. J. Breiding, J. Gulaid, J. A. Mercy, C. Blanton, Z. Mthethwa, S. Bamrah, L. L. Dahlberg, and M. Anderson. 2009. Sexual violence and its health consequences for female children in Swaziland: A cluster survey study. Lancet 373(9679):1966–1972. Silovsky, J. F., D. Bard, M. Chaffin, D. Hecht, L. Burris, A. Owora, L. Beasley, D. Doughty, and J. Lutzker. 2011. Prevention of child maltreatment in high-risk rural families: A ran- domized clinical trial with child welfare outcomes. Children and Youth Services Review 33(8):1435–1444. Sweet, M. A., and M. I. Appelbaum. 2004. Is home visiting an effective strategy? A meta- analytic review of home visiting programs for families with young children. Child De- velopment 75(5):1435–1456. Taylor, B., N. D. Stein, D. Woods, and E. Mumford. 2011. Shifting boundaries: Final report on an experientmental evaluation of a youth dating violence prevention program in New York City middle schools. Document 236175. Washington, DC: National Institute of Justice. Teaster, P., T. Dugar, M. Moendiondo, E. Abner, K. Cecil, and J. Otto. 2004. The 2004 Survey of Adult Protective Services: Abuse of adults 60 years of age and older. www.elderabuse center.org/pdf/research/apsreport030703.pdf (accessed April 4, 2007). United Republic of Tanzania. 2011. Violence against children in Tanzania: Finding of a na- tional survey 2009. www.unicef.org/media/files/violence_against_children_in_tanzania_ report.pdf (accessed April 3, 2012). Vagi, K., E. M. Rothman, N. Elkovitch, A. Teten Tharp, M. J. Breiding, and D. M. Hall. In preparation. Beyond correlates: A review of risk and protective factors for teen dating violence perpetration and victimization.

OCR for page 87
128 COMMUNICATIONS AND TECHNOLOGY FOR VIOLENCE PREVENTION Villanueva, A. 2007. Can cell phone message service increase adherence in HIV/AIDS patients on therapy? http://apin.harvard.edu/research/takemi/files/RP216.pdf (accessed November 28, 2007). WHO (World Health Organization). 2012. Suicide prevention (SUPRE). www.who.int/ mental_health/prevention/suicide/suicideprevent/en/. Wolfe, D. A., C. Wekerle, K. Scott, A. L. Straatman, C. Grasley, and D. Reitzel–Jaffe. 2003. Dating violence prevention with at-risk youth: A controlled outcome evaluation. Journal of Consulting and Clinical Psychology 71(2):279–291. Wolfe, D. A., C. Crooks, P. Jaffe, D. Chiodo, R. Hughes, W. Ellis, L. Stitt, and A. Donner. 2009. A school-based program to prevent adolescent dating violence: A cluster random- ized trial. Archives of Paediatrics & Adolescent Medicine 163(8):692–699.