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.
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 enormous 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 prescribed duration of the programs increases, so do the programs’ rates of attrition 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 interventions 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 between visits and seeking more information (Berlin et al., 1998; Korfmacher et al., 2008). Programs that are able to maintain parents’ participation and
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 promoting 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 encourage 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 enhancing 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 attrition, 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 preventing 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 positive 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.
Results thus far show the following:
• Parents in the CPAT group were more likely to complete the intervention, with 79 percent of the CPAT and 66 percent of PAT parents finishing [χ2 (1, n = 255) = 5.42, p = .02, = .15].
• Parents in the CPAT group were rated as being more highly engaged 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 positive 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 children 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.
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 programs. 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 applying 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.
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 processes 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 visible 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 mobilization 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, immigration, and racial justice.
the prestigious Silver Lion at the 2010 Cannes International Advertising Festival.
The Bell Bajao! campaign provides an excellent example of the Breakthrough methodology:
• Bell Bajao! is Breakthrough’s most evolved and sustained campaign to date; it has had the greatest impact, scale, and the most comprehensive 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, Twitter, 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 toward 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 living 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.
Conceptualizing and Framing the Message
The first task for Bell Bajao! was to create a message, which is a rigorous and critical process. The goal of the campaign was to advance the current discussion and knowledge about violence against women while remaining consistent with Breakthrough’s philosophy and mission. The message 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.
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 violence 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 information 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, Breakthrough 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
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.”
The dissemination strategy for Bell Bajao! was determined after examining 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 television 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 dissemination tool for the campaign, reaching more than 130 million viewers through multiple channels during the first and second phases of the campaign. 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.
Dissemination via video vans proved to be extremely effective. Vans carrying the campaign message were accompanied by staff and youth advocates 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 campaigns in using the blogosphere. To raise awareness and stimulate discussion, 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 finalized, 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 initiated. 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 providing 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 materials, enhancing the partners’ sense of ownership and giving them greater
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) released 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 collaborated with its district- and state-level officials to demonstrate local government 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 messaging 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 publicity materials—items such as t-shirts, caps, and flashlights—are dispensed from the van.
Trained youth advocates accompany the video van and perform activities 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.
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! message, 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 announcements (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 television campaign because television has the widest coverage. All other platforms—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.
Using Publicity and Public Relations to Enhance Campaign Visibility
Breakthrough has consciously added earned media as a key strategy to generate greater exposure and impact for Bell Bajao!, actively soliciting media outlets to cover campaign-related events and to write editorials about violence against women and about Bell Bajao!. Breakthrough has found it prudent to outsource this task to a public relations agency because of staff capacity and the specialized nature of public relations work.5
Engaging Media Figures and “Influentials”
To generate publicity for Bell Bajao!, Breakthrough strategically engaged high-profile artists, such as actor Boman Irani, lyricist Javed Akhtar, and various fashion industry leaders, including designers Akki Narula, Laconet Hemant, and Narendra Kumar.
Connecting Users to Services
Breakthrough launched an interactive Google map feature on the Bell Bajao! website (www.bellbajao.org), which provides users with information about national, regional, and local service providers in the states in India where Breakthrough has a presence. Breakthrough is currently developing an interactive mobile-messaging platform to connect rights advocates.
Monitoring and Evaluation of Bell Bajao!
The evaluation of Bell Bajao! captures how a multimedia campaign, supported by in-depth community mobilization activities, can increase knowledge, change perceptions and attitudes, and mobilize action to reduce domestic violence.
A range of monitoring and evaluation techniques have been used to assess the extent to which the Bell Bajao! campaign has met its goals of actualizing changes in individual “hearts and minds,” reaching wide audiences with the Bell Bajao! message to initiate public conversations on issues of domestic violence, and changing the ways in which the issue is framed in the broader culture.
The extensive monitoring and evaluation techniques that were used for Bell Bajao! are instructive for organizational learning. The feedback from monitoring and evaluation activities has enabled Breakthrough to refine
5 Breakthrough’s experience in working with individuals, small and medium public relations firms, and large national companies has led the organization to the conclusion that it is more productive and effective to work with smaller firms that may have only city-level presence. Breakthrough has developed a list of firms and individuals across Breakthrough coverage areas to do public relations for the campaign.
and revise Bell Bajao! to be more effective—and to give it greater potency as the campaign takes on a global scope.
Breakthrough drew on both in-house and external evaluators to monitor and evaluate the Bell Bajao! program. In this section we discuss the various methodologies that Breakthrough used to measure the effectiveness of Bell Bajao! as well as the findings regarding the efficacy of the campaign. This section also discusses the human and financial investment required to implement a thorough evaluation and monitoring process, along with some of its challenges.
Primary data collected Breakthrough undertook primary research in order to obtain detailed, state-specific information related to domestic violence and HIV/AIDS. This research provided more information on the forms of domestic violence, the level of knowledge concerning PWDVA 2005, and the actions that are taken in cases of violence. Such granular information is generally not available in larger studies.
Breakthrough hired CMS to conduct this primary research. CMS conducted a baseline study in the intervention areas, performed “rapid assessment” surveys in the mid-period of the campaign, and did an end-line survey to see what changes occurred as a result of Breakthrough intervention.
Secondary data sources Secondary datasets were used to establish the prevalence of domestic violence and violence toward women with HIV/ AIDS. These included data culled from the National Family Health Survey (NFHS) in India and from the World Health Organization (WHO).6 The data provided a global understanding of violence and its intersection with HIV. It was apparent that physical and sexual violence are not adequately addressed in India. Breakthrough used state-level NFHS data from Uttar Pradesh and Karnataka regarding the level of violence against women in the domestic sphere. This enabled Breakthrough to establish state-level benchmarks and parameters on violence against women.
Qualitative tools applied Breakthrough used state-of-the-art evaluation techniques for assessing the Bell Bajao! program. CMS recommended the use of the Most Significant Change Technique (MSCT), a method of collecting stories that indicate behavior change that occurs because of a particular intervention. MSCT is used to ascertain changes in practice, and it obtains more nuanced outcomes of community education and leadership
6 NFHS, 2005–2006; WHO Multi-Country Study on Women’s Health and Domestic Violence Against Women, 2005.
development programs. MSCT allows beneficiaries and stakeholders to participate in a dynamic and integrated way in defining what constitutes success.
CMS and Breakthrough provided MSCT training to 15 people from different organizations who had received Breakthrough training on issues of domestic violence and HIV/AIDS so that they could monitor and evaluate their work in the community. Story collectors gathered stories originating from their fields, and story selectors validated and selected the best stories that showed significant change. To date, more than 100 stories have been collected. These stories track changes experienced by those who have received RAP training and as well as changes reported by community members who were affected by Breakthrough interventions.
MSCT also serves as an in-house monitoring tool. Every 6 months, stories are selected and used by Breakthrough staff and trainers to gauge if the people they are training are continuing to progress in terms of their knowledge and attitudes toward domestic violence.
In-depth interviews CMS has conducted in depth interviews with different Breakthrough partners—organizational heads, cultural groups, people who travel with the video van—to ascertain the extent to which Breakthrough partners have taken ownership of the campaign and the issue of domestic violence. The key findings of this study were:
• There has been an increase in knowledge and a shift in attitudes and behavior among Breakthrough partners concerning domestic violence and HIV/AIDS issues.
• Partners have started disseminating information about domestic violence and HIV/AIDS in their own spheres of work through one-on-one interactions, group meetings, theater, folk art, and so forth.
• Many of the partner organizations have incorporated Breakthrough’s campaign issues as part of their work mandate. For instance, CARDTS adapted issues of HIV/AIDS and violence against women—in particular, domestic violence—as a priority in its policy and planning.
Longitudinal panel study A longitudinal panel study is currently being conducted by the International Center for Research on Women (ICRW) to track long-term attitude changes that have occurred among the 60 advocates who received a comprehensive RAP training. The participants have been selected to represent the different target audiences of Breakthrough: youth from college, youth from marginalized communities, members of NGOs, and people living with HIV/AIDS. Representatives from each of these groups will participate in an in-depth, 2-hour interview to ascertain whether the training they received led to shifts in attitudes and behavior.
Two follow-up interviews, 6 months apart, will examine whether changes that resulted from the training have been sustained.
ICRW will produce a report that is expected to provide insights on how the Breakthrough training has affected trainees and if it has led to changes in their interactions with peers. Insights from this study will be used to improve training modules.
Quantitative tools applied CMS designed and conducted baseline, midline, and end-line studies in the states of Maharashtra, Uttar Pradesh, and Karnataka to statistically record how the Bell Bajao! campaign changed knowledge, attitudes, and behavior as they relate to domestic violence, PWDVA 2005, and HIV/AIDS. The baseline survey explored attitudes and practices toward issues of gender, condom use and negotiation, inter-spousal communication, HIV/AIDS, and domestic violence. The mid- and end-line surveys made it possible to compare shifts that occurred at both timeframes as a way to capture campaign impact. The survey also sought to capture where people obtained information on these issues.
In order to assess the differential impact of Breakthrough’s education and media interventions, a control group technique was employed. Two districts were selected for research under the assumption that when both media messaging as well as educational and training outreach activities were undertaken, the effect of the campaign would be greater. One district that used education and media components and one district that used only mass media were chosen for study—and comparison—so Breakthrough could see if there were differences in impact.
Key Findings of the End Line Surveys
The key findings from the end-line survey indicated significant changes in knowledge, attitudes, and behavior at both the individual and community levels with regard to domestic violence, HIV/AIDS, and safe sex. Important outcomes include
• Increased knowledge and awareness of what constitutes domestic violence. The end-line survey showed that as a result of the Bell Bajao! campaign there was greater knowledge and community awareness about the various forms of domestic violence. For example, a significantly higher proportion of respondents expanded the definition of domestic violence beyond physical abuse to include emotional abuse, threats, economic deprivation, and sexual abuse.
• Increased knowledge and understanding regarding PWDVA 2005. Respondents had a better grasp of PWDVA 2005 and the protections it offers victims of domestic violence. There was a significant increase in the proportion of respondents who knew that a woman
had the right to stay in her house even after filing a complaint against her husband. There was significantly more knowledge among the public regarding the other benefits to which survivors of violence are entitled, including monetary compensation, right to residence, and custody rights.
• Changes in attitudes toward domestic violence. Public attitudes showed less acceptance and justification for domestic violence as a result of the campaign. For example, fewer people justified wife beating, even when a husband suspected infidelity. The majority of respondents listed many justifiable reasons for a woman refusing to have sex with her spouse: 93 percent of respondents thought it was justifiable to refuse sex when a husband had a sexually transmitted disease, 90 percent thought it was justifiable to refuse sex when a woman was not in the mood for sex, 87 percent felt a woman feeling tired was a justifiable reason, and 86 percent thought that the man having sex with other women was a justifiable reason. Fewer respondents felt that it was justifiable for a man to have sex with other women, to have sex forcefully, or to stop providing financial support if a wife refused sex.
• More women took action against perpetrators of violence. Women are increasingly taking proactive stands against domestic violence as a result of Breakthrough’s campaign. A majority of respondents favored taking legal action (90 percent) in cases of domestic violence. There was a significant decrease in the number of respondents who felt that taking legal action would bring shame to the family.
• Rising concern and greater intervention by community members in cases of domestic violence. There was a significant increase in the proportion of respondents reporting that community intervention had taken place in cases of domestic violence. Only 9 percent of respondents thought that domestic violence is a private matter in which nobody should intervene. Nearly 61 percent of respondents (as compared to 53 percent at baseline) of those who came across incidents of domestic violence reported that the community had taken action to stop it.
The end-line study indicated that community support for legal action against domestic violence is of utmost importance. There was a significant increase in the proportion of respondents reporting that both men and women were taking action against domestic violence but that men continued to be the majority.
• A decline in ignorance and reduced stigmatization of people with HIV/AIDS. There was significant decrease in ignorance and attitudes of shame and blame toward people with HIV/AIDS among
respondents. For example, the percentage of respondents who felt that a woman should be ashamed of her HIV status dropped from 25 percent to 8 percent. The end line study indicated less fear associated with the spread of HIV/AIDS. A significantly lower number of respondents said that an HIV-positive woman should be kept away from her children and that her belongings should be segregated. Stigma and discrimination against women living with HIV/AIDS also showed a significant decrease: Some 86 percent of respondents at end-line said that an HIV-positive woman should not be ostracized from society. The reduction in stigma was also apparent in the significant decrease in respondents wanting to keep family members’ HIV status secret. The percentage dropped from 45.3 percent at baseline to 6.3 percent at end line.
• Increased knowledge and responsibility regarding the practice of safe sex. In the end-line report there was a significant increase in knowledge about safe sex among respondents. Roughly 81 percent promptly referred to “condom use,” while nearly 31 percent could correctly identify safe sex as “consistency in the use of condoms for safe sex.” More than two-thirds of respondents reported that being monogamous is a safe sex practice. Both base- and end-line data revealed that men are comparatively more aware than women about safe-sex issues.
• Increased joint decision making between spouses. Breakthrough’s campaign led to greater respect for women’s role in decision making within the family. A majority of the respondents indicated that decisions relating to children’s education, children’s marriage, the purchase of major household items, and visits to a wife’s relatives were being made by both the husband and wife. A significantly higher proportion of respondents reported joint decision making on family planning matters, including whether to have sex.
• Continued unwillingness among unmarried men to discuss sexual partners. The end-line data underscored the continuing unwillingness of men and women to disclose sexual relationships outside of marriage. Only 6 percent of unmarried, widower, and separated men reported having a sexual partner, and none of their partners asked them to use condoms. None of the unmarried women reported having a sexual partner.
The end-line study also revealed a greater openness to express one’s sexual inclinations and disinclinations. Both male and female respondents indicated a greater willingness to say whether or not they wished to engage in sexual activity with their spouse.
Key Results Regarding Numbers Reached by Bell Bajao!
Audience-reach measurement tools show the extent and scale of the Bell Bajao! campaign and identify the numbers and demographic information of people reached. Television, radio, print, and online audience measurement tools provide estimates of:
• When and how often Bell Bajao! ads, music, or music videos are played on television, radio, or print outlets—data provided by Television Audience Measurement (TAM), the National Readership Survey, Nielsen ratings, and similar industry standards.
• Website viewership and participation through the use of Google AdWords, Google Analytics, and online commentary on the Breakthrough website as well as online platforms such as Facebook, YouTube, The Hub, and MySpace that feature Bell Bajao!
• Audience reach through Bell Bajao! press coverage, including blogs and online coverage.
• Videographic, photographic, and written documentation of Bell Bajao! presentations at workshops, trainings, conferences, forums, and film festivals.
• Use of Bell Bajao! materials by other groups, including civil society actors, educational institutions, the United Nations, and government agencies.
• Number of Bell Bajao! media products and curriculum materials disseminated online, downloaded, or provided in hard or soft copy.
These various measurements indicate that the Bell Bajao! campaign has had extraordinary reach and impact. According to TAM, in 2008-2009 Bell Bajao! reached 130 million people (via television, radio, and print), and the video van reached 2.5 million people. In 2010 Bell Bajao! reached 115 million people through television ads, and the video van reached 2.4 million people. In addition, since 2008 Breakthrough has built capacities of more than 75,000 people through RAP to take the Bell Bajao! message forward. The website (www.bellbajao.org) has reached millions more people.
It is important that Bell Bajao! reach scale because Breakthrough seeks to change public conversations and to change the dialogue around issues of domestic violence, which can be achieved only when significant numbers of people are reached by the campaign and the issues of women’s rights and ending domestic violence enter the public imagination and lexicon. Bell Bajao! continues to resonate in varied mainstream popular culture spaces. For example, Breakthrough’s reach expanded exponentially when Bell Bajao! was featured on the popular television soap opera series Is Desh
Na Aana Laddo and as a question and correct response on Kuan Banega Crorepati (Who Wants to Be a Millionaire?).
Challenges in Evaluation
Monitoring and evaluating social change is not an exact science but is instead a challenging and constantly evolving field of social science. There are always new methodologies and new techniques that can be used to capture the complex change process. To conduct comprehensive evaluation and monitoring requires a great deal of capacity building so that the Bell Bajao! staff them may represent the data they are receiving from analysts in an accurate and meaningful way as well as to use it internally to improve performance and outcomes.
Furthermore, social scientists who design and carry out the research face the issue of communicating with nonprofit organizations that must translate the research findings to make them accessible to non-specialists. Too often the social scientists’ reports are technical and hard to adapt for reporting purposes, making the results difficult to communicate to a larger public.
Despite these difficulties, the evaluation of Bell Bajao! captures how a multimedia campaign, supported by in-depth community mobilization activities, can increase knowledge, change perceptions and attitudes, and mobilize action to reduce domestic violence.
Definition and Prevalence
Dating violence is a type of intimate partner violence that occurs between two young people in a close relationship. The nature of dating
7 Author note: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
violence can be physical, emotional, or sexual, or it can involve stalking behaviors (CDC, 2010a). Dating violence can occur in person or electronically, such as through text messages or on social networking sites. Across studies, the prevalence of dating violence varies by the age and location of the sample as well as by the type of violence that is measured. For example, in the United States it is estimated that 1 in 10 high school students has experienced physical violence from a dating partner in the past 12 months (Eaton et al., 2010) and that about 1 in 5 women and nearly 1 in 7 men who have ever experienced rape, physical violence, or stalking by an intimate partner first experienced some form of partner violence between 11 and 17 years of age (Black et al., 2011). The rates of teen dating violence (TDV) in middle school vary across settings, ranging from 5 percent in rural Canada to 21 percent in rural North Carolina and 45 percent in urban Philadelphia (O’Leary and Slep, 2011). Studies across 48 countries indicate that 10 percent to 69 percent of women report having experienced physical violence from an intimate partner during their lifetimes (Heise et al., 1999; Heise and García-Moreno, 2002). Emerging data from national surveys of violence against children suggest that many individuals experience sexual violence in a dating relationship. For example, in Tanzania 25 percent of women and 50 percent of men who experienced sexual violence before age 18 reported that a dating partner perpetrated the violence (United Republic of Tanzania, 2011), and in Swaziland 26 percent of sexual violence experienced by girls prior to age 18 was perpetrated by a boyfriend (Reza et al., 2009).
Risk Factors for Victimization and Perpetration
Risk factors for experiencing dating violence include having dysfunctional coping strategies, destructive or dysfunctional problem-solving skills, and poor communication skills and experiencing stress (Lewis and Fremouw, 2001). Risk factors associated with perpetrating dating violence include experiencing anger, perpetrating aggression toward peers, holding traditional gender views or beliefs that are accepting of violence in dating relationships, using drugs or alcohol, having multiple sexual partners, experiencing or witnessing violence in the home, and having friends who experience or perpetrate dating violence (Vagi et al., in preparation). Research examining the effects of societal norms and customs on dating violence is scant, but communities in which cultural or social norms accept, promote, or excuse violence against a dating partner may create a context in which dating violence is viewed as acceptable and permissible and in which policies that sanction such violence do not exist or are not enforced. Moreover, norms, practices, and policies that reflect or support harmful traditional gender roles may also foster and reinforce violence in dating relationships.
A shift in primary prevention approaches has taken place over the past several years. Although early work focused only on preventing and responding to violence, current approaches to prevention focus on promoting respectful, nonviolent, and healthy relationships.8 Healthy relationships are relationships in which each partner feels empowered (as opposed to feeling in power), respected, safe, and supported. Such relationships are characterized by trust and shared decision making. Currently, four primary prevention programs have demonstrated effectiveness in preventing physical or sexual dating violence: Safe Dates (Foshee et al., 1998), Fourth R (Wolfe et al., 2009), Youth Relationships Project (Wolfe et al., 2003), and the Shifting Boundaries school-level intervention (Taylor et al., 2011). However, these programs have been developed and evaluated only among middle or high school students in the United States and Canada. Their efficacy in contexts with different cultural or social norms is unknown, and their uptake in other countries has been minimal and has not been evaluated. Globally there have been HIV behavioral prevention programs targeting youth that address harmful gender norms and dating violence as a part of broader agendas. For example, Stepping Stones (Jewkes et al., 2008) has been evaluated and shown to be effective in reducing HIV risk-taking behaviors but has not specifically been evaluated in terms of changing harmful gender norms or the incidence of dating violence. The use of information and communications technologies (ICTs) in these programs is limited to the inclusion of electronic aggression in vignettes and the option to use technology in some of the activities. Although numerous organizations have developed ICT-based approaches to raise awareness of dating violence9 and facilitate help seeking, these approaches have not yet been evaluated.10
Next Steps for Global Dating Violence Prevention
In light of the limited evidence base concerning what works to prevent dating violence among young people, universal primary prevention efforts implemented globally may initially focus on increasing awareness about the frequency and risk factors for dating violence and countering cultural and social norms that support harmful gender norms and the social acceptability of violence in relationships. Increasing awareness may be targeted
8 E.g., Start Strong: Building Healthy Teen Relationships: www.startstrongteens.org/; Dating Matters: Strategies to Promote Healthy Teen Relationships: www.cdc.gov/violenceprevention/DatingMatters/; and CDC Strategic Direction for Intimate Partner Violence Prevention: www.cdc.gov/ViolencePrevention/pdf/IPV_Strategic_Direction_Full-Doc-a.pdf.
10 E.g., the National Dating Abuse Helpline can be called or texted: www.loveisrespect.org/about-national-dating-abuse-helpline.
at policy and decision makers to build political will for dating violence prevention. Efforts to counter harmful cultural and social norms may focus on individuals who are dating or about to initiate dating and on their influencers (e.g., parents, educators, and religious leaders) and may address such issues as negative portrayals of women in the media, media representations that support harmful gender roles, norms that perpetuate intergenerational relationships or child marriage, and norms that promote entitlement rather than respect in relationships.
ICTs provide a vehicle for reaching a specific audience with targeted prevention messages, strategies, and resources in an efficient and cost-effective manner. Popular among health agencies, such as the U.S. Department of Health and Human Services, SMS/text messaging campaigns often link subscribers to resources, such as clinics, treatment facilities, and other resources, based on geographic location. For example, the National Institutes of Health has implemented a SmokefreeTXT campaign that tailors smoking cessation SMS/text messaging to the user’s projected quit date and includes a mobile application to enhance the user’s interaction with tools, tips, and resources provided by the agency. Because mobile technology is so widely accessible, it is an ideal mechanism for disseminating information about healthy relationships as well as dating violence prevention messages. Furthermore, in the global context, dating violence prevention should be incorporated into HIV prevention and broader development agendas. Dating violence increases sexual risk-taking behavior and the risk of HIV infection and, at a broader level, can affect and impede social and economic development in developing countries.
Considerations for ICTs and Global Dating Violence Prevention
Besides identifying the focus of prevention efforts globally, our work integrating ICTs with dating violence prevention suggests a number of considerations are warranted as the field moves forward.
Collaborate on Development of Dating Violence Prevention ICTs
It is critical that the development of ICTs for primary prevention of dating violence reflects and extends the state of the field and the current evidence base on what works to prevent dating violence, including known risk and protective factors for dating violence and best practices in prevention (e.g., Nation et al., 2003). This would entail, for example, targeting prevention strategies to age groups and communities at risk, countering the specific norms and practices that sustain violence in different communities, and building healthy relationship skills. ICTs also should take into account the range of audiences who may be key agents in prevention. For example,
traditional approaches build skills among parents, educators, and youth, and prevention delivered through ICTs may engage these groups. Unfortunately, technology applications for prevention are often developed without taking the best-available science into account and, as a result, do not have the maximum potential to affect violence. Similarly, prevention scientists are often reluctant to entertain alternative modes of delivering prevention (vs. school-based curricula) and, as a result, do not take full advantage of the reach and relevance that ICTs offer. Ideally, the development of global dating violence prevention will be informed by the best available science and will use ICTs to make prevention accessible and engaging to young people and their influencers. Given the length of time that is traditionally involved in developing effective prevention, crowdsourcing techniques such as app challenges (e.g., Apps Against Abuse) may be used to stimulate the rapid development of innovative prevention strategies. When crowdsourcing is used, prevention scientists and technologists may be encouraged to work together to ensure that the strategy reflects the current state of the field as well as being feasible and sought after by the intended users.
Evaluate New Approaches
Similarly, new technologies that are developed and used in prevention must be evaluated for effectiveness. To minimize the dissemination of ineffective or harmful approaches and to maximize the use of limited resources, new evaluation techniques must be integrated into the development and refinement of preventative ICTs. Digital and personal technology, including SMS, mobile applications and social platforms, should encourage a “test and learn” approach to evaluation. Gathering real-time, human-experience feedback while programs are being developed allows programs to be launched with insights embedded in the final product. Moreover, new technology and digital media programs encourage an iterative approach to programming in which a project can be launched with groups in phases so that researchers can evaluate the impact, success, and shortcomings while the program is running. A special consideration with ICTs is the potential use of technologies for violence perpetration rather than prevention. For example, many violence prevention applications currently integrate global positioning system (GPS) to enable friends, families, and law enforcement to know where an individual is in case he or she needs help. However, GPS could also be used to control one’s partner by tracking his or her activities and location. Therefore, it will be critical to carry out evaluations to detect misuse and iatrogenic effects. Although ICTs may necessitate novel evaluation approaches and evaluation timelines may need to be abbreviated to account for the rapid evolution of technologies, nonetheless evaluation should be a cornerstone of the global prevention of dating violence. The
pace of technology innovation and adoption is rapid. Programs should be built to adapt and evolve with technology.
Combine Technology with Traditional Approaches
In order to develop prevention that is both comprehensive and has a sufficient dose (Nation et al., 2003), a first step may be to combine traditional classroom-based approaches with ICTs. For example, the CDC’s Dating Matters youth communication campaign will utilize both social media (e.g., Facebook) and mobile media (e.g., SMS/text messaging) to engage the youth audience with primary prevention messages. The messages will complement the content delivered in the classroom model, but social and mobile media channels present an opportunity for youth to interact with the messages on their terms, in environments where they are comfortable, as well as an opportunity to use the influence of the youths’ own social networks. In addition, ICTs can expand the reach of traditional models in a more cost-effective manner. For example, a teen could opt in to the text message program to receive tips about healthy relationships as well as information about local campaign events. This would be supplemented by a Facebook page on which teens can interact with their peers and talk about the kinds of relationships they see in their communities. While classroom instruction might reach 30 students at a time, mobile and social media have the capacity to reach thousands of teens in that same community. Moreover, a need exists to combine primary and secondary prevention approaches when ICTs are used, so that individuals who are utilizing ICTs and are already experiencing violence may access resources and referrals for dating violence services as well as dating violence prevention.
Be Aware of Regulations Related to Engaging Youth Through Technology
Although the use of ICTs to communicate with multiple audiences, particularly youth, has increased dramatically in recent years, access to youth through technology is often governed by stricter laws and regulations than the laws that regulate similar communications with adults. For example, the Children’s Online Privacy Protection Act of 1998 (COPPA) prohibits the collection of personal information from youth under the age of 13 by all “commercial websites and online services” unless verifiable consent is obtained from a parent or guardian.11 Proposed changes to COPPA made as recently as 2011 would further delineate a data retention and deletion requirement when such information is collected from youth under 13, mandating that information collected should be stored only for the length of time necessary to achieve the purpose for which it was
obtained. Other countries have passed or are considering similar legislation to protect youths under the age of 13. In addition to national laws, consideration should be given to state, territorial, and local regulations further limiting access to youth because some jurisdictions may provide for even less access to youth under a certain age. Because primary prevention must be implemented before dating violence begins, restrictions on interacting with middle-school-aged youth complicate the task of implementing prevention during this key phase in development.
Dating violence is a preventable but all-too-frequent form of violence among young people around the world. ICTs offer the potential to increase the reach and relevance of prevention; however, to maximize the opportunity to stop dating violence before it begins, several considerations must be taken into account as the field moves forward. Collaboration, evaluation, and prevention-informed regulation will ensure that ICTs are applied in a way that promotes healthy relationships globally.
Elder abuse is a substantial global public health and human rights problem. Elder abuse includes physical abuse, sexual abuse, emotional abuse, neglect (both caregiver and self-neglect), and financial abuse. Available prevalence data suggest that at least 10 percent of the elderly population in the United States experiences abuse each year, and many of them experience it in multiple forms (Acierno et al., 2010; Beach et al., 2010). Furthermore, data from U.S. adult protective services agencies depict an increasing trend in the reporting of elder abuse (Teaster et al., 2004). This trend is particularly alarming because the literature suggests that elder abuse is associated with increased risk of morbidity and mortality (Lachs et al., 1997, 1998, 2002; Dong et al., 2005, 2009, 2011a, 2011b; Dong, 2011).
Despite the accessibility of adult protective services and the existence of nursing home regulations in all 50 states as well as mandatory reporting laws for elder abuse in most states, an overwhelming number of abused elderly pass through the health care system undetected and untreated. It is estimated that only 1 in 14 cases of elder abuse comes to the attention of social services (NRC, 2003). In this paper we review the epidemiology of elder abuse and describe how social media and technology could synergistically advance societal awareness of elder abuse at the broad level.
Available evidence suggests that those over 75 years old, African Americans, and those of lower socioeconomic status are at particularly high risk for elder abuse (Mosqueda and Dong, 2011). A number of cross-sectional studies have found that cognitive impairment and physical disability are associated with increased risk for elder abuse. Recent studies suggest that older adults with higher levels of psychological distress and lower levels of social relations are also more likely to be reported to adult protective services (Mosqueda and Dong, 2011). There are few longitudinal studies examining the factors associated with elder abuse. A study of 5,519 older adults from the Chicago Health and Aging Project (CHAP) found that both the presence and severity of self-neglect were related to a decline in physical performance tests as well as a decline in self-reported physical function. The study also found that a decline in cognitive function, particularly executive function, was associated with increased risk of encounters with adult protective services (Dong et al., 2009, 2010).
Morbidity and Mortality
Despite major gaps in our knowledge about the ramifications of elder abuse, available evidence suggests that it is associated with significant adverse health outcomes. Prior studies of 2,812 older adults in the EPESE (Established Populations for Epidemiologic Studies of the Elderly) cohort suggest that elder abuse is associated with an increased risk for nursing home placement and with higher all-cause mortality. Recent data from Dong et al. (2009), who examined the relationship between elder abuse and mortality (all-cause and cause-specific) for 9,813 participants within the CHAP study, found that elder abuse was associated not only with increased all-cause mortality but also with increased cardiovascular-related mortality over the 15 years of follow-up. In addition, mortality associated with elder abuse was most prominent among those with the lowest levels of cognitive function and physical function and the highest levels of psychological distress and social isolation (Dong et al., 2009, 2011a). Dong and colleagues
also found that black older adult victims had significant higher mortality risk than white older adults in the same CHAP cohort (Dong et al., 2011b).
Raising the Awareness of Elder Abuse
We examined the types, prevalence, risk factors, and consequences of elder abuse and discussed reasons why the majority of the abuse goes unreported and unnoticed. For the workshop we were asked to examine prevention strategies globally; therefore, issues of cultural and social norms needed to be considered. Our hypothesis: If we raised awareness of elder abuse at the community level, it would have a positive impact on families and help build the groundswell required to raise awareness and action with policy makers.
Approach We researched successful taglines used in national awareness campaigns on other important societal issues, in order to determine what might be applicable to elder abuse.
We identified common elements found in all of the campaigns: a memorable tagline that empowered the reader or viewer and, in most cases, a call to action. The campaigns made it clear that the reader could do something to make a difference. The taglines were frequently combined with startling imagery.
We generated a list of tagline ideas to help facilitate the brainstorming session:
• Get LOUD about elder abuse.
• This is the unexpected face of abuse.
• Unfortunately, you’re never too old to need protection.
• Treat your elders how you want to be treated. Your children are watching.
• Cherish a life. Report elder abuse.
• Don’t abuse your parents. And your children won’t abuse you.
• Don’t be mean to your elders. Remember, you will be an elder someday, too.
• Stop elder abuse. It is a national shame.
A few of the taglines (Figure 7-1) were paired with images found in the public domain to conceptualize what an actual elder abuse awareness campaign might look like.
Of the three concepts, Concept C came closest to capturing most of the elements of the brand awareness campaigns that we examined. It empowered the viewer with the call to action “Get LOUD,” indicating that it was okay to talk about a topic that may have been traditionally considered
FIGURE 7-1 Concepts for elder abuse awareness campaign.
taboo. This tagline and message were used to mock up awareness campaigns using social media and existing technology.
Social Media We compiled a list of websites, technology tools, and social media campaigns (Table 7-1) with which members of our group had experience, and we imagined what these would look like when translated to the vocabulary and demographic of elder abuse.
Current understanding of the types of elder abuse that exist has been formed by what is reported in mainstream media, which misses much of the breadth of abuse being perpetrated, such as the abuse an elder may experience at the hands of family. In the face of the overwhelming yet underexposed issues and statistics, a general awareness campaign that could address any of the issues—and, more importantly, raise the overall awareness of the need to act—would be a monumental task yet a great starting
TABLE 7-1 Examples of Successful Social Media
User-Generated Content Tools
Allows users to upload videos of human rights violations that have been captured on cameras or phones or by whatever means are available. Elder abuse is a human rights violation issue, so it was easy to imagine a dedicated version of the Witness model focused on elder abuse. (See #1 in the mock-up website: Figure 7-2.)
This project started with the aim of collecting and displaying user-generated videos of LGBT adults telling their stories of abuse and how they have since found happiness. A similar model could be employed for collecting and distributing personal narratives of elder abuse to help elders being abused feel less alone in their situation and envision a future without abuse. (See #2 in the mock-up website: Figure 7-2.)
Web Utility Tools
Allows users to conduct a search based on specific locations to find registered sex offenders within a certain radius. This simple interface and concept could be used to create a search tool for convicted predators of the elderly or to map reported cases of abuse down to specific care facilities. (See #3 in the mock-up website: Figure 7-2.)
The American Foundation for Suicide Prevention has a very simple search function for finding suicide bereavement support groups. It would be very easy to create this type of search function for elder abuse support networks, something that we were unable to find in a simple Google search. (See #4 on mock-up website: Figure 7-2.)
An online tool for creating, distributing, and broadcasting petitions online. Petitions can easily be spread through social networks, requiring a minimal level of effort to engage. We have envisioned a similar tool for galvanizing people around pledging to end elder abuse. (See #5 on mock-up website: Figure 7-2.)
Broadcasting and Network Tools
This program has implemented a mobile phone text notification system that broadcasts children to be on the lookout for, which increased the speed and breadth of the organization’s alert network. This same approach has been applied to mentally disabled and elders through nationalsilveralert.org. We envisioned this same system being used for such things as alerts for financial scams currently targeting the elderly. (See #6 on mock-up website: Figure 7-2.)
It is easy to imagine the moment when a friend asks you to sign a pledge to combat elder abuse for which the commitment is small and the social pressure to do so high. While following the link from Facebook to the pledge on the Loud.org site, users discover all of the other valuable tools and content available to them, leading them to subscribe to the feeds themselves. These feeds, such as the Silver Alert, are then published to that user’s news feed, both broadening awareness and providing a service to the elder community. (See #7 on mock-up website: Figure 7-2.)
place. And for an awareness campaign, the most important place to start is with the brand and the messaging.
Brand awareness We created a mock-up of how different re-purposed Web and social media tools would look if implemented with the taglines and messaging expressed in the awareness and messaging section of this paper and under the faux organizational name Loud.org (Figure 7-2). In exploring why elders do not report abuse—usually because of fear of being removed from the home or from a facility, the fear of change, and the fear of the unknown—the value becomes clear of some of the ideas represented in the list of social media examples, such as providing a place to “tell your story” for others to benefit, generating a pledge that people could take to help end elder abuse in their communities, or using technology to identify violence hot zones.
Scoping and understanding what actions or inactions constitute elder abuse across different cultures, situations, and demographics leads to looking at tools that allow definitions and descriptions to be flexible enough to evolve and incorporate new research and perspectives. For example, Wikipedia uses user-generated content to create an encyclopedia of knowledge to define words, concepts, and events. Using this concept, we thought about crowdsourcing the definition and spectrum of elder abuse by allowing users to complete the phrase “Elder abuse is ________.” Over time this could be refined and edited in different ways to create a growing and ever-changing taxonomy of elder abuse. This concept was informed by the messaging concept formulated in Donna Levin’s brainstorm of “Elder abuse = ” and could carry the experience from the messaging to the actionable items in the campaign (not included in the mock-up).
FIGURE 7-2 Mock-up website for elder abuse.
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.
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 although 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.
3. Society is moving to an increasing public lifestyle using social (online) 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 inferred 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 explicit 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 contemplate 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 history 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
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 compounding 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 suicide, 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 increase 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 suicide. Selected prevention programs include screening programs, gatekeeper
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 percent 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 combined, 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 communicated 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 technology’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
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 applied 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 patterns. Why start here? Because going back to the previous example, what appears clear is that how people communicate (in this case, communication 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 suicidal 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 Depression. 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.
More research is needed to better understand the effects of ICT-based suicide prevention efforts. The ways in which people are thinking and using 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 networking 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 communicate, 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 local 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 engagement with our audiences?
• Are there media consumption patterns that precipitate an attempt?
There are some challenges and limitations to ICT-based suicide prevention efforts that should be addressed. For example, privacy and confidentiality 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 applications. 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 ability to truly respond to and address this type of online content.
Given the wealth of social media and online data already in existence from user content, we propose working with Facebook, Google, and Twitter to try to better understand the online behaviors of people considering suicide. We propose studying audience, behavior, language, and tone to look for patterns that match verbal communications and online communications 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 businesses, 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.
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.
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 investing 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 psychological 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 programs 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 Medical 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. Physical 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.
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 Organization. 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. Impact 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 mortality 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 Administration 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. Clinical Psychology Review 21(1):105–127.
McCurdy, K., and D. Daro. 2001. Parent involvement in family support programs: An integrated theory. Family Relations 50(2):113–121.
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 schizophrenia—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 Association 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 paraprofessionals 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 randomized 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 Development 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.elderabusecenter.org/pdf/research/apsreport030703.pdf (accessed April 4, 2007).
United Republic of Tanzania. 2011. Violence against children in Tanzania: Finding of a national survey 2009. www.unicef.org/media/fles/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.
Villanueva, A. 2007. Can cell phone message service increase adherence in HIV/AIDS patients on therapy? http://apin.harvard.edu/research/takemi/fles/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 randomized trial. Archives of Paediatrics & Adolescent Medicine 163(8): 692–699.