This paper is in the following e-collection/theme issue:

Usability of Apps and User Perceptions of mHealth (993) Human Factors and Usability Case Studies (809) User-centred Design Case Studies (602) Violence including Domestic Violence/Abuse (125) Design and Formative Evaluation of Mobile Apps (706)

Published on in Vol 8, No 8 (2020): August

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/15866, first published .
Designing an Information and Communications Technology Tool With and for Victims of Violence and Their Case Managers in San Francisco: Human-Centered Design Study

Designing an Information and Communications Technology Tool With and for Victims of Violence and Their Case Managers in San Francisco: Human-Centered Design Study

Designing an Information and Communications Technology Tool With and for Victims of Violence and Their Case Managers in San Francisco: Human-Centered Design Study

Authors of this article:

Devika Patel1 Author Orcid Image ;   Siavash Sarlati2 Author Orcid Image ;   Patrick Martin-Tuite3 Author Orcid Image ;   Joshua Feler4 Author Orcid Image ;   Lara Chehab1 Author Orcid Image ;   Michael Texada1 Author Orcid Image ;   Ruben Marquez1 Author Orcid Image ;   F Julia Orellana1 Author Orcid Image ;   Terrell L Henderson1 Author Orcid Image ;   Adaobi Nwabuo1 Author Orcid Image ;   Rebecca Plevin1 Author Orcid Image ;   Rochelle Ami Dicker5 Author Orcid Image ;   Catherine Juillard5 Author Orcid Image ;   Amanda Sammann1 Author Orcid Image
Article Authors Cited by (12) Tweetations (16) Metrics

    Original Paper

    1Department of Surgery, University of California, San Francisco, CA, United States

    2Department of Emergency Medicine, University of California, San Francisco, CA, United States

    3University of California, San Francisco School of Medicine, San Francisco, CA, United States

    4Yale University School of Medicine, New Haven, CT, United States

    5Division of Surgical Critical Care, Department of Surgery, University of California, Los Angeles, CA, United States

    Corresponding Author:

    Devika Patel, MS

    Department of Surgery

    University of California, San Francisco

    1001 Potrero Ave

    San Francisco, CA, 94110

    United States

    Phone: 1 (628) 206 3764

    Email: devika.patel@ucsf.edu


    Background: Violence is a public health problem. Hospital-based violence intervention programs such as the San Francisco Wraparound Project (WAP) have been shown to reduce future violent injury. The WAP model employs culturally competent case managers who recruit and enroll violently injured patients as clients. Client acceptance of the WAP intervention is variable, and program success depends on streamlined, timely communication and access to resources. High rates of smartphone usage in populations who are at risk for violent reinjury create an opportunity to design a tailored information and communications technology (ICT) tool to support hospital-based violence intervention programs.

    Objective: Current evidence shows that ICT tools developed in the health care space may not be successful in engaging vulnerable populations. The goal of this study was to use human-centered design methodology to identify the unique communication needs of the clients and case managers at WAP to design a mobile ICT.

    Methods: We conducted 15 semi-structured interviews with users: clients, their friends and families, case managers, and other stakeholders in violence intervention and prevention. We used a human-centered design and general inductive approach to thematic analysis to identify themes in the qualitative data, which were extrapolated to insight statements and then reframed into design opportunities. Wireframes of potential mobile ICT app screens were developed to depict these opportunities.

    Results: Thematic analysis revealed four main insights that were characterized by the opposing needs of our users. (1) A successful relationship is both professional and personal. Clients need this around the clock, but case managers can only support this while on the clock. (2) Communications need to feel personal, but they do not always need to be personalized. (3) Healing is a journey of skill development and lifestyle changes that must be acknowledged, monitored, and rewarded. (4) Social networks need to provide peer support for healing rather than peer pressure to propagate violence. These insights resulted in the following associated design opportunities: (1) Maximize personal connection while controlling access, (2) allow case managers to personalize automated client interactions, (3) hold clients accountable to progress and reward achievements, and (4) build a connected, yet confidential community.

    Conclusions: Human-centered design enabled us to identify unique insights and design opportunities that may inform the design of a novel and tailored mobile ICT tool for the WAP community.

    JMIR Mhealth Uhealth 2020;8(8):e15866

    doi:10.2196/15866

    Keywords

    human-centered design; violence intervention; information and communications technology 


    Violence is a public health problem that targets vulnerable populations in the United States [1,2]. Homicide is among the leading causes of death for young people aged 10-30 years, and for every fatal assault, members of this age group experience 90 non-fatal assault injuries [3]. Risk factors associated with urban violence are concentrated among vulnerable populations and include low income, unemployment, being of racial or ethnic minority background, low education levels, substance abuse, and neighborhood disorder [4-9]. Violence persists among these communities that experience social inequity, and individuals are caught in a cycle of constant perpetration or reinjury [6,10-14]. Previous exposure to violence is a strong predictor of future violence with data showing that up to 45% of patients injured by assault will be reinjured, and 20% will be killed within 5 years of an index injury [4,5,10,11].

    The health care setting presents an opportunity to leverage a teachable moment to prevent violence by mitigating future risks [15]. Hospital-based violence intervention programs are cost-effective and successfully reduce violent reinjury among high-risk, assault-injured victims [16,17]. These programs employ culturally competent violence intervention specialists (case managers), who are often from the same neighborhoods and ethnic groups as their clients. These case managers help victims of violence (clients) navigate the emotional and logistical challenges following injury. Case managers use shared experiences, common culture and language, and a trauma-informed approach by recognizing the signs and symptoms of trauma and responding in a safe, respectful, and transparent way. As a result, these case managers are best equipped to foster the high level of trust and communication required to guide clients towards protective behaviors and services.

    Information and communications technology (ICT) provides a promising mechanism to address future risks of violence, as mobile apps and web-based communication platforms are effective adjuncts in promoting behavior change and risk-factor modification in the health care setting [18-20]. Studies show high levels of smartphone penetration among marginalized and minority populations who access health care through the emergency department [21,22], and increased dependence on smartphones for internet use [23]. Ethnic minority groups are more likely to use smartphones to seek health information, employment, and educational content than non-smartphone users [24]. Despite these trends, few targeted digital interventions have been developed to address the issues faced by vulnerable and underserved populations, and even fewer have addressed the unique needs of victims of violence [25,26]. Digital health care tools are not culturally tailored and have not been purposefully designed to address the needs of vulnerable populations, leading to technology with poor usability, acceptability, and effectiveness in these groups [25,27,28]. As such, ethnic minority groups, individuals at lower socioeconomic status levels, and other vulnerable groups are less likely to engage successfully with health care providers using available digital tools [27,29,30].

    This study is a partnership with The San Francisco Wraparound Project (WAP), a hospital-based violence intervention program at a public safety-net hospital and level 1 trauma center in San Francisco. We use a human-centered design approach to understand user needs and expectations and develop ICT that is tailored to the vulnerable population served by the WAP in San Francisco. Human-centered design is a well-established methodology used for problem-solving and innovation, employing ethnographic research to develop a deep understanding of users’ unmet needs, and iteratively prototypes solutions to address those needs [31]. The methodology is rooted in empathy to ensure that design solutions address real problems, avoid designer bias, and build trust with the community [31-33]. The purpose of this study is to develop a deep understanding of WAP client and case manager needs and to identify key design opportunities that can inform the development of a smartphone-enabled ICT tool that scales the unique impact of case managers in hospital-based violence intervention programs nationwide.


    Study Design and Setting

    This prospective observational study is a collaboration between the San Francisco Wraparound Project (WAP) and The Better Lab, a mixed-methods research center located at the Zuckerberg San Francisco General (ZSFG) Hospital and Trauma Center that specializes in human-centered design research techniques. Study activities were conducted at the hospital, which is an affiliate of the University of California, San Francisco (UCSF), and the only level one trauma center in the city. The UCSF institutional review board approved this study as an expedited human subjects research protocol, and verbal consent was approved for all activities.

    The San Francisco Wraparound Project

    The San Francisco WAP offers intensive case management addressing the psychosocial needs of victims of violence aged 10-30 years at the ZSFG hospital who are at high risk for reinjury. Over the first 10 years of WAP implementation, ZSFG saw a 42% relative reduction in assault-related trauma reinjuries, and for every 100 clients served, WAP confers a net benefit of 24 quality-adjusted life years over standard practices [16,34]. The WAP case managers use their professional expertise and community connections to develop direct pipelines to resources, which include jobs, educational programs, legal services, mental health services, relocation services, emotional outlets in the arts and community service projects, and camps and retreats. These assets are operationalized through face-to-face interactions, text messages, phone calls, and emails between clients and case managers to support and direct clients towards the tasks necessary for them to “graduate” from WAP. A client graduates once their major needs are met by the program or independent means.

    Human-Centered Design

    Human-centered design is an approach to problem-solving that is rooted in ethnography and iterative prototyping in order to develop solutions that are tailored to the end-user group. This methodology has been used to effectively deliver context-specific experiences, services, and products to manage diseases such as diabetes, post-traumatic stress disorder, and patient falls [35-37], with evidence suggesting that focusing on the end user yields more effective and sustainable results [38-40]. The human-centered design method leverages ethnographic interviews and observations to develop rich insights and prioritizes iterative and collaborative solution development with its users at each stage of the process. We chose this approach to develop ICT that is intentionally designed for victims of violence and maximizes the impact of WAP case managers. This study focuses on the first step of the human-centered design process, the ‘inspiration’ phase, to develop a thorough understanding of users’ experiences through interviews, followed by a synthesis of themes that will inform the design of human-centered ICT (Figure 1). We will refer to all subjects involved in this study, including clients, case managers, and other violence prevention specialists as “users.”

    ‎
    Figure 1. Human-Centered Design Process.
    View this figure

    Qualitative Data Collection

    Qualitative data were obtained through semi-structured user interviews to understand perspectives about WAP and the experience of being a victim of violence in the community. All interviews were anonymous, each lasting approximately 60 minutes at the WAP offices at ZSFG. Interviews were conducted in two phases. Phase one interviews were conducted with “violence intervention specialists” by a three-person team, including two design researchers from The Better Lab and one project manager from WAP. Interview subjects included WAP case managers and members of violence recovery and prevention organizations in the community. These interviews covered topics of daily workflow, communication activities, and barriers or challenges in their work. When appropriate and not violating the confidentiality of the clients, we asked our violence intervention specialists to describe experiences working with clients to illustrate challenges, barriers, and successes.

    Phase two interviews were conducted with clients, ranging from 16 through 30 years old, and their friends and family. These interviews were performed by a four-person team, including two design researchers from The Better Lab, the client’s case manager, and a project manager from WAP. Client interviews covered topics including their personal background, violence history, experience with WAP, goals for the future, and thoughts on using technology to communicate with their case manager. Requests to audio record the interviews were declined due to the sensitive nature of the conversations. As a result, an additional design researcher was included during each interview to capture notes and quotes in real-time.

    Interview Subject Selection and Recruitment

    A total of 15 people participated in the study: 7 clients, 2 family members or friends of clients, 4 case managers, 1 program director from a partner violence prevention program, and 1 licensed clinical social worker specializing in crisis management. All participants were recruited through the WAP using purposeful sampling, a human-centered design approach to recruitment that draws a diverse cohort of subjects in order to represent all aspects of the victim of violence experience [41]. This approach to subject selection yields a heterogeneous sample of demographics and experiences with the WAP and violent injury community that can better inform the design of solutions. Table 1 describes each user. Participation was voluntary, and users from this second phase were compensated with $25 gift cards for their participation.

    Table 1. Descriptions of Users.
    Interviewee pseudonymDescription
    Violence Prevention Specialists

    		1Longest-standing case manager with WAP who has a deep connection in the community.

    		2Younger case manager from the neighborhoods WAP serves, seen as the role model for young men in the program.

    		3Case manager with a background in grassroots community activism.

    		4The only female-identifying case manager specializes in job placement.

    		5Leader of a city initiative that conducts real-time violence mediation and street-level outreach to reduce street violence.

    		6A licensed clinical social worker who works on crisis response by providing immediate emotional, mental, and logistical support following violent trauma.
    Clients

    		AA client who graduated from WAP who is doing well and has not been reinjured.

    		BThe model client—has engaged with WAP to varying degrees for 5+ years without reinjury, proactive in seeking support when needed even after graduating, but also aims to support other clients and serve as a positive example.

    		CA client who is a teenager recently returned to the Bay Area and re-engaging in WAP services—interviewed with a parent.

    		DA client who is currently in WAP early in their work (ie, recently enrolled).

    		EThe parent/guardian of a client.

    		FA client who is further along in WAP, but was reinjured by shooting.

    		GA client who initially refused WAP services, but eventually enrolled.

    		HA peer of a client who has not been a victim of violence.

    		IA younger client (age early 20s), currently in the middle of the program.

    Qualitative Data Analysis

    Development of Insight Statements

    The general inductive approach to thematic analysis was used to analyze interviews and to identify themes [42,43]. This approach was chosen to allow the emergence of themes that are closely related to the interview data [44]. First, all interview notes were read separately by two members of the research team. During this process, they identified specific themes that captured the core messages of the interviewees. Second, the researchers met to identify and describe common categories of themes. In this phase, descriptions of themes were developed and refined, and redundant themes were consolidated. Third, the researchers reviewed the interview notes a second time to extract key text or quotes associated with each thematic category. The data were reviewed a final time to ensure that a name, description, and supporting quotes for each thematic category were defined and consensus achieved.

    Following the human-centered design method to qualitative analysis, researchers then extrapolated ‘insight statements’ from these themes. Insight statement development is an integral step in the human-centered design analysis process that involves re-reviewing the notes to understand themes in the context of the individual interviews and deduce unique human perspectives, motivations, or tensions from the thematic data. Insight statements ascribe meaning to the data and are then used to develop design opportunities [45].

    Development of Design Opportunities

    Design opportunities were developed from insight statements using the human-centered design approach to qualitative analysis. Design opportunities are action statements that provide direction to address tensions or challenges described in the insight. They guide the innovation process and solutions by framing and focusing the design effort [32,46]. Figure 2 depicts this process. The output of this process includes insight statements with supporting data and the associated design opportunity illustrated by a wireframe and list of features. These wireframes and features will be the first prototype to be iteratively tested with users in the next phase of this study.

    ‎
    Figure 2. Process for developing insights and opportunities using human-centered design.
    View this figure

    Our analysis revealed four main insights that represent tensions or ‘opposing needs’ between the clients and case managers. These insights informed each subsequent design opportunity. This section presents the following for each insight: a description of the opposing needs of the case manager and client; an example of this tension from the interviews; the associated design opportunity; and an initial wireframe and list of features. Table 2 includes a summary of each insight with supporting quotations.

    Insight 1: A Successful Relationship is Both Professional and Personal. Clients Need This Around the Clock, but Case Managers can Only Support This While on the Clock

    Case managers are motivated by the steadfast goal of wanting to ensure success for their clients. However, maintaining both a personal and professional relationship can be very disruptive to case managers’ lives because it is challenging to set boundaries for clients who need support during nonbusiness hours. Clients are often in a vulnerable emotional, mental, and physical state and need a trusted confidant. The personal connection between case managers and clients is critical to WAP’s success. Clients often consider the case managers to be a friend or a part of their family.

    Example of Tension

    To establish a trusting relationship, case managers often tell clients to call whenever there is an emergency. However, clients often call after hours with nonemergent issues, which leaves case managers feeling drained as they work around the clock. Clients value the deep bond they feel with their case managers and express a desire for continuous access in order to receive support at all hours across a range of issues.

    Table 2. Supporting insight quotations from semi-structured interviews.
    Insight and case manager quotationsClient quotations
    Insight 1: A successful relationship is both professional and personal. Clients need this around the clock, but case managers can only support this while on the clock.

    		Sometimes they share way too much. As workers, we sometimes need to look at the situation and get them help that they need… A lot of people who call just want someone to talk to. They trust the case managers because they’re part of the community, but oftentimes they need a therapist… We explain that this is just our jobs. We explain that we need to talk to them in a certain way. [Subject 4][My case manager] does stuff he don’t got to do… He is a big bro… I got to give him the same love he gives me. [Subject A]

    		We love you and want to support you, but this is our job. [Subject 4][My case manager] is my lifesaver, my #1 supporter... I’ve been through a lot with him. [Subject F]

    		I got a call at 2 am, which was just an excuse to call me... I’m a trusting ear. [Subject 4]We’re real tight. She’s like family to me. [Subject G]

    		I’ve had clients call me on a Saturday. Some to pray. [Subject 1]—
    Insight 2: Communications need to feel personal, but they don’t always need to be personalized.

    		[The app needs to have] reminders. They will wait until the last hour, the last minute. [Subject 1]Texting is cool, but I’d rather talk face to face. You can’t tell what someone is going through on FB or text. [Subject C]

    		You need something to gather their attention... We need to give them something right now. [Subject 2]Not really an email person, I would rather someone call... I also don’t really check voicemails. [Subject A]

    		You’ve gotta create a plan. Everyone’s looks different. [Subject 4][I] can talk to him like we’re friends and text… he [case manager] also talks to my mom. [Subject I]

    		—I feel good every time I talk to her. I can talk to her about anything... I know I’m safe when I talk to her. I know I don’t have to worry about people knowing my business. [Subject G]

    		—The communication was good, but it was kind of difficult because I took a night class... whenever [I] wanted to talk to [Subject 2], he would be off duty. [Subject I]
    Insight 3: Healing is a journey of skill development and lifestyle changes that must be acknowledged, monitored, and rewarded.

    		[After helping a client with housing], I need a way to hook you…something that can assure that I got you! [Subject 3]The app should show accomplishments, something you can always return to and see… I did, and I can still do more. [Subject B]

    		I tell them, bring me a paycheck after thirty days. They gotta hold a job for thirty days. Then we’ll get lunch. [Subject 4][This] is a complicated process…how can we make a roadmap? [Subject L]

    		We don’t work for [the client], we work with [the client]. [Subject 3][Client referring to visual aspects of the app] “Once it’s out of sight, you forget about it. [Subject D]

    		I will never give up on you. [Mistakes] are just a learning curve. [Subject 3]—
    Insight 4: Social networks need to provide peer support for healing, not peer pressure to propagate violence.

    		Sometimes we’ll monitor people through Facebook, see if they’re posting suggestive videos [of violence]. [Subject 1]The app should give a person a chance to help another person…to hear their stories and give advice. [Subject B]

    		If you have a permanent home, you’re more likely to get hurt because there’s a place to attach you to...social media doesn’t help this. [Subject 3]The app should maybe have a chatroom…start it anonymous with the option of revealing yourself. Some people feel comfortable typing, but don’t feel comfortable sharing their feelings in person. [Subject G]

    		—You’re not the only person who got something… [being able to] chat with other people, that would be cool. [Subject I]

    		—Nothing is safe on social media… [need] ability to make it private. [Subject D]
    Design Opportunity 1: Maximize Personal Connection While Controlling Access

    An ICT tool should be designed to encourage personal interactions while providing systems to differentiate nonemergent issues from emergencies in order to maintain professional boundaries for case managers. Figure 3 illustrates an initial prototype of this opportunity. The essential features include:

    • Facilitate the role of the case manager as a trusted confidant by placing the onus of enforcing boundaries and deferring non-urgent client inquiries onto the system instead of on the individual case manager.
    • Support clients at the greatest risk of reinjury by allowing case managers to negotiate and set client communication permissions on an individual basis.
    • Minimize feelings of rejection by framing communication deferrals in terms that humanize the case managers (eg, “Steve is out of the office right now and will be back on Monday. He is sleeping, is this an emergency?”).
    • Allow clients to escalate communications after hours as emergencies arise to ensure case manager response. As an example, the wireframe in Figure 3 depicts an example of an after-hours communication with a case manager.
    ‎
    Figure 3. Proposed depiction of a mobile application wireframe showing a conversation between a case manager and client. In this particular case, the client messages their case manager after hours. The mobile application allows the user to either escalate the message or wait until business hours.
    View this figure

    Insight 2: Communications Need to Feel Personal, but They do not Always Need to be Personalized

    Case managers need a way to provide administrative and tactical communication to reduce the burden of continuous, individualized messaging. With a caseload of up to 10 clients, case managers need a way to attract and maintain their clients’ attention that does not require them to craft each routine message or reminder manually. Clients want to communicate regularly and unpredictably with their case managers and value personal attention, positive feedback, and acknowledgment of their achievements. They prefer to meet their case managers face to face to discuss personal matters.

    Example of Tension

    Case managers spend significant time sending administrative messages such as appointment reminders and resume-building information. They want to focus on the high-value personal interactions and need a way to streamline the routine administrative tasks. However, clients cherish the personal relationship and fear that automating communications will lead to an impersonal experience by diminishing their close relationship.

    Design Opportunity 2: Allow Case Managers to Personalize Automated Client Interactions

    An ICT tool must help case managers keep clients engaged through multiple communications and automate routine reminders that feel personal and are tailored to clients’ unique needs. Figure 4 illustrates an initial prototype of this opportunity. The essential features include:

    • Break down essential tasks such as building resumes, applying for schools, training, and jobs, searching for housing, and completing inquiries and applications for social services into sequential, achievable tasks. For example, the wireframe in Figure 4 focuses on the multiple and diverse tasks that are required to apply for a new job.
    • Allow case managers and clients to set unique goals and deadlines for each task.
    • Enable users to set automated reminders and suggest next steps after missed deadlines or successful task completion.
    ‎
    Figure 4. Proposed depiction of a mobile application wireframe showing a job application workflow. The client begins with a list of incomplete and complete tasks on the first screen. The screens Step 1 through Step 4 detail the step-by-step process of applying for a job, with options to ask questions, as well as a positive, affirming message to encourage the client to continue working towards their goals on the last screen.
    View this figure

    Insight 3: Healing is a Journey of Skill Development and Lifestyle Changes That Must be Acknowledged, Monitored, and Rewarded

    Recovery after a violent injury extends far beyond physical recovery and includes significant lifestyle changes. Case managers work closely with clients to co-create a new future and support their achievements along the way. Case managers need a way to document, monitor, and share each client’s unique journey in order to redefine expectations and set goals for their clients’ future. They need to provide “tough love” by being stern on goals and expectations while offering compassion and encouragement to their clients. Clients need a clear roadmap for their recovery that includes feedback when they have gone off trajectory and celebration for the milestones they have successfully achieved.

    Example of Tension

    Case managers use their own systems to track a client’s progress and send text messages or make reminder calls about upcoming appointments. When clients miss deadlines, case managers call and text the client to discuss why it was missed and express their disappointment. Clients do not have tools to track their progress or access to their case manager’s system, so they have no choice but to respond reactively to reminders without a clear picture of where they are in their journey.

    Design Opportunity 3: Hold Clients Accountable for Progress and Reward Achievements

    The ICT tool should incorporate a shared roadmap that clients and case managers can use to track progress. Figure 5 illustrates an initial prototype of this opportunity. The essential features include:

    • Define and illustrate milestones throughout a client’s recovery to measure success.
    • Identify struggling clients early by implementing alerts to clients and case managers.
    • Enable transparent and targeted interventions by allowing the case manager to explore each client’s recent activity, historical trajectory, and future goals. As an example, the wireframe in Figure 5 focuses on how a case manager can interact with and congratulate a client for a recent accomplishment.
    ‎
    Figure 5. Proposed depiction of tracking a client’s journey. Clients input their goals. Once a goal is marked as achieved, a photo of the achievement can be attached. These screens help a client visualize their successes and progress towards their goals.
    View this figure

    Insight 4: Social Networks Need to Provide Peer Support for Healing Rather Than Peer Pressure to Propagate Violence

    Clients may be on opposing sides of violence within the community and need to know that there is a safe and confidential space to build community with peers who have experienced similar trauma. Clients want to share stories with others who have had similar experiences being a victim of violence. Case managers need a way to connect clients without compromising emotional, mental, or physical safety and security.

    Example of Tension

    Social media is a source of personal expression for clients, and some use it as their diary to document and articulate their emotions and thoughts. However, online platforms provide the opportunity to escalate interpersonal arguments and publicly pressure or publish threats of violence. Case managers do not have tools that allow them to create private, anonymized communities for their clients to connect, share, and learn from each other.

    Design Opportunity 4: Build a Connected yet Confidential Community

    The ICT should include the capability to create multiple community platforms that are curated by case managers where clients can engage anonymously. Figure 6 illustrates an initial prototype of this opportunity. The essential features include:

    • Enable knowledge-sharing and community support by constructing a client social network. As an example, the wireframe below showcases a forum where clients can share their personal experiences.
    • Mitigate violent communications by anonymizing identities, establishing clear rules for participation, enabling moderation by case managers, and providing training on internet safety.
    • Stimulate useful conversations by structuring forums on topics of community interest so that clients can find the resources that they need.
    • Ensure security with modern data-protection protocols such as HIPAA compliance.
    ‎
    Figure 6. Proposed depiction of a community forum and/or social network for clients to share resources and experiences with peers in an anonymous environment. The last screen depicts a reporting mechanism within the application to ensure safe interactions between clients within the community.
    View this figure

    This study used the human-centered design methodology to identify essential features for a smartphone-enabled ICT tool to support hospital-based violence intervention program clients and violence intervention specialists. The findings of this study identified opportunities and informed the initial wireframes that will be prototyped within the community of victims of violence in the next phase of the study. The human-centered design process was essential to this work because it allowed us to identify important opposing needs facing case managers and clients. Although case managers desired clear boundaries, automation of routine tasks, and caution in using social media, their clients wanted close relationships, personalized communication, and an online community. A unique ICT must be designed to address these opposing needs to support both stakeholder groups.

    Processes and technology tools in health care tend to be designed in a silo and lack coordination with other aspects of care delivery [47]. The human-centered design method provides a structure that avoids the pitfalls common to traditional ICT development, such as lack of a deliberate process for innovation, all-in-one solutions that do not adequately meet users’ needs, or solutions that are developed without user input [48,49]. For example, phase one of our interviews with case managers revealed that an ICT tool needed to focus primarily on efficiency to allow them to reach more clients. However, phase two of our interviews with clients revealed that the personal connection is what makes the violence intervention program successful. This tension between automation and personalization, among others described here, made it clear that the features of an effective ICT tool would require the artful synthesis of opposing needs that have not yet been addressed.

    Thoughtful ICT is important in health care, but essential for the violence community because a poorly designed tool could compromise the safety of our clients and case managers. Our clients are a technologically savvy group with high digital literacy and significant social media activity. Although we identified an opportunity to build a social community for peer support, social networking in this population has the potential to amplify threats of violence in the form of what is known as “internet banging” [50]. Surveys of advocates for and victims of domestic violence and stalking show that technology can be used to threaten and perpetrate psychological and social attacks [51]. We identified these same concerns in our qualitative research, which reinforced the fact that an ICT tool that replicates current social media forums is both inadequate and potentially dangerous. A social networking tool on an ICT application for victims of violence needs features to create secured, anonymous, and moderated conversation forums.

    Limitations

    There are several limitations to our study and the human-centered design methodology. The features of the ICT tool we have described here are specific to our population and environment and represent early prototypes that will be iterated on in the next phase of the design process. The wireframes and their associated features are preliminary ideas developed by the design researchers in order to represent the design opportunity visually. The content of the wireframes is based on quotes and insights from our users. These wireframes have not been tested with users. Design and implementation specifications will be the focus of the next phase of our study. We anticipate that the features identified in this phase may change through our iterative process and may not be generalizable to other organizations. However, the broader insights and opportunities are likely transferable to other organizations interested in developing an ICT tool for victims of violence. Other settings that support vulnerable populations in health care may also find the human-centered design methodology to be an effective way to uncover previously unknown needs and potential tensions in the communities they aim to support through ICT.

    Lastly, we used a purposeful sampling methodology in order to capture a diverse set of experiences in a time-efficient way, which is an essential part of the rapid iteration process at the heart of human-centered design. However, this approach yields a relatively small sample size. For example, this study only included one peer and one parent/guardian representative of WAP clients. While this is not uncommon in human-centered design, we acknowledge that this small number of users may limit the generalizability of those findings to other communities and settings. Additionally, while interviewees were intentionally chosen based on the breadth and diversity of their experience in the community in order to provide information-rich insights and design opportunities, this approach to sampling carries a risk of selection bias. We attempted to mitigate this risk by asking our four experienced case managers to select the most diverse interview subjects.

    Next Steps

    This study identified key insights and design opportunities to develop a mobile ICT tool that meets the personal needs of WAP clients while enabling case managers to support their clients’ goals effectively. The opportunities presented here will serve as core principles when developing, testing, and refining wireframes in the next phase of this work.

    Conclusions

    The success of hospital-based violence intervention programs is predicated on the value of intensive case management, ready access to services, and securing personal and professional development opportunities for the clients [52]. Meeting these goals requires that case managers effectively and efficiently provide life-changing resources. This study has contributed to the understanding of violence intervention program clients and case managers in the design and development of an ICT tool for case management. Importantly, our findings indicate that the use of human-centered design uncovered previously unknown tensions between the needs of clients and case managers. Designers of ICT tools for this population must consider how issues of safety, privacy, automation, personal connection, and efficiency impact their users.

    Acknowledgments

    We thank and acknowledge our interviewees, both clients and their families, along with the WAP team. We would also like to thank Pam Derish for her support in editing the manuscript. AS and CJ conceived of this study; AS, DP, SS, PMT, LZC, MT, TH, JO, and RM conducted interviews. DP, SS, PMT, and AS analyzed and interpreted data. DP, SS, AS, and JF wrote the manuscript drafts. All authors reviewed and edited the paper as needed.

    Conflicts of Interest

    AS, LZC, and DP are human-centered design consultants for The Empathy Studio, LLC. SS recently joined Anthem, Inc, as a Medical Director of Digital Technologies, where he is involved in digital health development that incorporates human-centered design. All other authors declare they have no competing interests.

    1. Office of the Surgeon General. Surgeon General’s Workshop on Violence and Public Health Report. Department of Health and Human Services & Department of Justice. 1986 May.   URL: https://www.nlm.nih.gov/exhibition/confrontingviolence/materials/OB10998.pdf [accessed 2019-08-05] [WebCite Cache]
    2. Dalhberg L, Mercy, JA. The History of Violence as a Public Health Problem. AMA Journal of Ethics 2009;11(2):167-172. [CrossRef]
    3. CDC National Center for Injury Prevention Control. Web-based injury statistics query and reporting system (WISQARS). CDC.   URL: https://www.cdc.gov/injury/wisqars/index.html [accessed 2019-01-10] [WebCite Cache]
    4. Hankin A, Meagley B, Wei SC, Houry D. Prevalence of Exposure to Risk Factors for Violence among Young Adults Seen in an Inner-City Emergency Department. West J Emerg Med 2013 Aug;14(4):303-308 [FREE Full text] [CrossRef] [Medline]
    5. Rivara FP, Shepherd JP, Farrington DP, Richmond PW, Cannon P. Victim as offender in youth violence. Ann Emerg Med 1995 Nov;26(5):609-614. [CrossRef] [Medline]
    6. Green B, Horel T, Papachristos AV. Modeling Contagion Through Social Networks to Explain and Predict Gunshot Violence in Chicago, 2006 to 2014. JAMA Intern Med 2017 Mar 01;177(3):326-333. [CrossRef] [Medline]
    7. Newgard CD, Schmicker RH, Sopko G, Andrusiek D, Bialkowski W, Minei JP, Resuscitation Outcomes Consortium Investigators. Trauma in the neighborhood: a geospatial analysis and assessment of social determinants of major injury in North America. Am J Public Health 2011 Apr;101(4):669-677. [CrossRef] [Medline]
    8. Morenoff JD, Sampson RJ, Raudenbush SW. Neighborhood Inequality, Collective Efficacy, and the Spatial Dynamics of Urban Violence. Criminology 2001 Aug;39(3):517-558. [CrossRef]
    9. Rich JA, Grey CM. Pathways to recurrent trauma among young Black men: traumatic stress, substance use, and the "code of the street". Am J Public Health 2005 May;95(5):816-824. [CrossRef] [Medline]
    10. Goins WA, Thompson J, Simpkins C. Recurrent intentional injury. J Natl Med Assoc 1992 May;84(5):431-435. [Medline]
    11. Sims DW, Bivins BA, Obeid FN, Horst HM, Sorensen VJ, Fath JJ. Urban trauma: a chronic recurrent disease. J Trauma 1989 Jul;29(7):940-947. [Medline]
    12. Cunningham RM, Carter PM, Ranney M, Zimmerman MA, Blow FC, Booth BM, et al. Violent reinjury and mortality among youth seeking emergency department care for assault-related injury: a 2-year prospective cohort study. JAMA Pediatr 2015 Jan;169(1):63-70 [FREE Full text] [CrossRef] [Medline]
    13. Turcotte Benedict F, Amanullah S, Linakis JG, Ranney M. Emergency Department Utilization Among Assault-Injured Youth: Implications for Youth Violence Screening. Pediatr Emerg Care 2017 Sep;33(9):607-612 [FREE Full text] [CrossRef] [Medline]
    14. Bingenheimer JB, Brennan RT, Earls FJ. Firearm violence exposure and serious violent behavior. Science 2005 May 27;308(5726):1323-1326 [FREE Full text] [CrossRef] [Medline]
    15. Johnson SB, Bradshaw CP, Wright JL, Haynie DL, Simons-Morton BG, Cheng TL. Characterizing the teachable moment: is an emergency department visit a teachable moment for intervention among assault-injured youth and their parents? Pediatr Emerg Care 2007 Aug;23(8):553-559. [CrossRef] [Medline]
    16. Juillard C, Smith R, Anaya N, Garcia A, Kahn JG, Dicker RA. Saving lives and saving money: hospital-based violence intervention is cost-effective. J Trauma Acute Care Surg 2015 Feb;78(2):252-257. [CrossRef] [Medline]
    17. Strong BL, Shipper AG, Downton KD, Lane WG. The effects of health care-based violence intervention programs on injury recidivism and costs: A systematic review. J Trauma Acute Care Surg 2016 Nov;81(5):961-970. [CrossRef] [Medline]
    18. Gonzalez VM, Dulin PL. Comparison of a smartphone app for alcohol use disorders with an Internet-based intervention plus bibliotherapy: A pilot study. Journal of Consulting and Clinical Psychology 2015 Apr;83(2):335-345. [CrossRef]
    19. Kirwan M, Vandelanotte C, Fenning A, Duncan MJ. Diabetes Self-Management Smartphone Application for Adults With Type 1 Diabetes: Randomized Controlled Trial. J Med Internet Res 2013 Nov 13;15(11):e235. [CrossRef]
    20. Zhao J, Freeman B, Li M. Can Mobile Phone Apps Influence People's Health Behavior Change? An Evidence Review. J Med Internet Res 2016 Oct 31;18(11):e287 [FREE Full text] [CrossRef] [Medline]
    21. Post LA, Vaca FE, Biroscak BJ, Dziura J, Brandt C, Bernstein SL, et al. The Prevalence and Characteristics of Emergency Medicine Patient Use of New Media. JMIR Mhealth Uhealth 2015 Jul 08;3(3):e72 [FREE Full text] [CrossRef] [Medline]
    22. Ray M, Dayan PS, Pahalyants V, Chernick LS. Mobile Health Technology to Communicate Discharge and Follow-Up Information to Adolescents From the Emergency Department. Pediatr Emerg Care 2016 Dec;32(12):900-905. [CrossRef] [Medline]
    23. Pew Research Center. Internet/Broadband Fact Sheet. Pew Research Center.   URL: http://www.pewinternet.org/fact-sheet/internet-broadband/ [accessed 2019-08-05]
    24. Anderson M. Racial and ethnic differences in how people use mobile technology. Pew Research Center.   URL: http:/​/www.​pewresearch.org/​fact-tank/​2015/​04/​30/​racial-and-ethnic-differences-in-how-people-use-mobile-technology/​ [accessed 2019-08-05]
    25. Stowell E, Lyson MC, Saksono H, Wurth RC, Jimison H, Pavel M, et al. Designing and Evaluating mHealth Interventions for Vulnerable Populations. CHI '18: Proceedings of the 2018 CHI Conference on Human Factors in Computing Systems 2018;1:1-17. [CrossRef]
    26. Hicks ER. Digital Citizenship and Health Promotion Programs: The Power of Knowing. Health Promot Pract 2017 Jan;18(1):8-10. [CrossRef] [Medline]
    27. Vangeepuram N, Mayer V, Fei K, Hanlen-Rosado E, Andrade C, Wright S, et al. Smartphone ownership and perspectives on health apps among a vulnerable population in East Harlem, New York. Mhealth 2018;4(31). [CrossRef] [Medline]
    28. Montague E, Perchonok J. Health and wellness technology use by historically underserved health consumers: systematic review. J Med Internet Res 2012;14(3):e78 [FREE Full text] [CrossRef] [Medline]
    29. Sarkar U, Karter AJ, Liu JY, Adler NE, Nguyen R, López A, et al. Social disparities in internet patient portal use in diabetes: evidence that the digital divide extends beyond access. J Am Med Inform Assoc 2011 May 1;18(3):318-321 [FREE Full text] [CrossRef] [Medline]
    30. Kontos E, Blake KD, Chou WS, Prestin A. Predictors of eHealth usage: insights on the digital divide from the Health Information National Trends Survey 2012. J Med Internet Res 2014;16(7):e172 [FREE Full text] [CrossRef] [Medline]
    31. Brown T. Design Thinking. Harvard Business Review.   URL: https://new-ideo-com.s3.amazonaws.com/assets/files/pdfs/IDEO_HBR_DT_08.pdf [accessed 2020-08-19]
    32. Ideo.org. The Field Guide to Human-Centered Design.   URL: http://www.designkit.org/resources/1 [accessed 2019-08-05]
    33. Ideo. Design Thinking.   URL: https://designthinking.ideo.com/ [accessed 2019-08-05]
    34. Juillard C, Cooperman L, Allen I, Pirracchio R, Henderson T, Marquez R, et al. A decade of hospital-based violence intervention: Benefits and shortcomings. J Trauma Acute Care Surg 2016 Dec;81(6):1156-1161. [CrossRef] [Medline]
    35. LeRouge C, Wickramasinghe N. A review of user-centered design for diabetes-related consumer health informatics technologies. J Diabetes Sci Technol 2013 Jul;7(4):1039-1056 [FREE Full text] [Medline]
    36. Owen JE, Kuhn E, Jaworski BK, McGee-Vincent P, Juhasz K, Hoffman JE, et al. VA mobile apps for PTSD and related problems: public health resources for veterans and those who care for them. Mhealth 2018;4(28) [FREE Full text] [CrossRef] [Medline]
    37. Harte R, Quinlan LR, Glynn L, Rodríguez-Molinero A, Baker PM, Scharf T, et al. Human-Centered Design Study: Enhancing the Usability of a Mobile Phone App in an Integrated Falls Risk Detection System for Use by Older Adult Users. JMIR Mhealth Uhealth 2017 May 30;5(5):e71 [FREE Full text] [CrossRef] [Medline]
    38. Altman M, Huang TTK, Breland JY. Design Thinking in Health Care. Prev Chronic Dis 2018 Sep 27;15:e117 [FREE Full text] [CrossRef] [Medline]
    39. Compton-Phillips A, Mohta N. Care Redesign Survey: How Design Thinking Can Transform Health Care. NEJM Catalyst 2020 Jun 07 . [CrossRef]
    40. Kachirskaia I, Mate K, Neuwirth E. Human-Centered Design and Performance Improvement: Better Together. NEJM Catalyst 2018 Jun 28 [FREE Full text]
    41. Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. Adm Policy Ment Health 2015 Sep;42(5):533-544 [FREE Full text] [CrossRef] [Medline]
    42. Thomas DR. A General Inductive Approach for Analyzing Qualitative Evaluation Data. American Journal of Evaluation 2016 Jun 30;27(2):237-246. [CrossRef]
    43. Frith H, Gleeson K. Clothing and Embodiment: Men Managing Body Image and Appearance. Psychology of Men & Masculinity 2004 Jan;5(1):40-48. [CrossRef]
    44. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006 Jan;3(2):77-101. [CrossRef]
    45. Dalton J. What is an Insight? The 5 Principles of Insight Definition.   URL: https://thrivethinking.com/2016/03/28/what-is-insight-definition/ [accessed 2019-08-04]
    46. Bridge Innovate. Turning Insights into Opportunities.   URL: https://www.bridgeinnovate.com/blog/2017/12/19/turning-insights-into-opportunities [accessed 2020-08-19]
    47. Kelly Y, Goodwin D, Wichmann L, Mendu ML. Breaking Down Health Care Silos. Harvard Business Review. 2019 Jul.   URL: https://www.hbr.org/2019/07/breaking-down-health-care-silos/ [accessed 2019-08-04]
    48. Blevins K, Azagury D, Wall J, Chandra V, Wynne E, Krummel T. How Good Ideas Die: Understanding Common Pitfalls of Medtech Innovation. In: Behrns KE, Gingles B, Sarr MG, editors. Medical Innovation: Concept to Commercialization. London: Academic Press; 2018:117-127.
    49. Liappas N, Teriús-Padrón J, García-Betances R, Cabrera UM, Arredondo M. User-Centered Design in Defining and Developing Health Well-Being ICT Solutions. In: Chen F, García-Betances RI, Chen L, Cabrera Umpiérrez MF, Nugent C, editors. Smart Assisted Living. Computer Communications and Networks. Switzerland: Springer, Cham; 2019.
    50. Patton DU, Eschmann RD, Elsaesser C, Bocanegra E. Sticks, stones and Facebook accounts: What violence outreach workers know about social media and urban-based gang violence in Chicago. Computers in Human Behavior 2016 Dec;65:591-600. [CrossRef]
    51. Woodlock D. The Abuse of Technology in Domestic Violence and Stalking. Violence Against Women 2017 Apr;23(5):584-602. [CrossRef] [Medline]
    52. Smith R, Dobbins S, Evans A, Balhotra K, Dicker RA. Hospital-based violence intervention: risk reduction resources that are essential for success. J Trauma Acute Care Surg 2013 Apr;74(4):976-980. [CrossRef] [Medline]

    ‎
    ICT: information and communication technology
    UCSF: University of California at San Francisco
    WAP: The Wraparound Project
    ZSFG: Zuckerberg San Francisco General

    Edited by G Eysenbach; submitted 16.08.19; peer-reviewed by J Beard, D Freed; comments to author 05.10.19; revised version received 31.01.20; accepted 03.06.20; published 24.08.20

    Copyright

    ©Devika Patel, Siavash Sarlati, Patrick Martin-Tuite, Joshua Feler, Lara Chehab, Michael Texada, Ruben Marquez, F Julia Orellana, Terrell L Henderson, Adaobi Nwabuo, Rebecca Plevin, Rochelle Ami Dicker, Catherine Juillard, Amanda Sammann. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 24.08.2020.

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR mHealth and uHealth, is properly cited. The complete bibliographic information, a link to the original publication on http://mhealth.jmir.org/, as well as this copyright and license information must be included.