JMIR FORMATIVE RESEARCH

Rulison et al

Original Paper

Using the Preparation Phase of the Multiphase Optimization
Strategy to Design an Antiextremism Program in Bahrain:
Formative and Pilot Research
Kelly Rulison1*, PhD; GracieLee Weaver1*, MPH, PhD; Jeffrey Milroy1,2,3*, DrPH; Emily Beamon2*, PhD; Samantha
Kelly3*, MPH; Ali Ameeni4*, MSc; Amina Juma4*, BA; Fadhel Abualgasim4*, MBA; Jaafar Husain4*; David Wyrick1,2,3*,
PhD
1Prevention Strategies, Greensboro, NC, United States

2

Department of Public Health Education, University of North Carolina Greensboro, Greensboro, NC, United States

3

Center for Athlete Well-being, University of North Carolina Greensboro, Greensboro, NC, United States

4

D.A.R.E. Bahrain, Southern Province, Bahrain*

all authors contributed equally

Corresponding Author:
Kelly Rulison, PhD
Prevention Strategies
9 Provence Ct
Greensboro, NC, 27410
United States
Phone: 1 3366885770
Email: kelly@preventionstrategies.com

Abstract
Background: Extremism continues to raise concerns about conflict and violent attacks that can lead to deaths, injuries, trauma,and stress. Adolescents are especially vulnerable to radicalization by extremists. Given its location in a region that often experiences
extremism, Bahrain developed 4 peaceful coexistence lessons and 4 antiextremism lessons to be implemented as part of their
Drug Abuse Resistance Education (D.A.R.E.) program.
Objective: The aim of this study is to report the results of the preparation phase of the multiphase optimization strategy (MOST)
to develop a peaceful coexistence program and an antiextremism program implemented by D.A.R.E. officers in Bahrain.
Methods: We developed conceptual models for the peaceful coexistence and antiextremism programs, indicating which mediators
each lesson should target, the proximal outcomes that should be shaped by these mediators, and the distal and ultimate outcomesthat the intervention should change. We recruited 20 middle schools to pilot test our research protocol, survey measures, and theexisting intervention lessons. A total of 854 seventh and ninth grade students completed a pretest survey, 4 peaceful coexistenceintervention lessons, and an immediate posttest survey; and a total of 495 ninth grade students completed the pretest survey, 4antiextremism lessons, and an immediate posttest survey. A series of 3-level models, nesting students within classrooms within
schools, tested mean differences from pretest to posttest.
Results: Pilot test results indicated that most measures had adequate reliability and provided promising evidence that the existing
lessons could change some of the targeted mediators and proximal outcomes. Specifically, students who completed the peacefulcoexistence lessons reported significant changes in 5 targeted mediating variables (eg, injunctive norms about intolerance, P<.001)
and 3 proximal outcomes [eg, social skills empathy (P=.008); tolerance beliefs (P=.041)]. Students who completed the antiextremism
lessons reported significant changes in 3 targeted mediators [eg, self-efficacy to use resistance skills themselves (P<.001)], and1 proximal outcome (ie, social skills empathy, P<.001).
Conclusions: An effective antiextremism program has the potential to protect youth from radicalization and increase peacefulcoexistence. We used the preparation phase of MOST to (1) develop a conceptual model, (2) identify the 4 lessons in each programas the components we will evaluate in the optimization phase of MOST, (3) pilot test the existing lessons, our newly developed
measures, and research protocol, and (4) determine that our optimization objective will be all effective components. We will use
these results to revise the existing lessons and conduct optimization trials to evaluate the efficacy of the individual lessons.

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Rulison et al(JMIR Form Res 2024;8:e58322) doi: 10.2196/58322
KEYWORDS
Antiextremism; peaceful coexistence; intervention; evaluation; international; multiphase optimization strategy; preparation phase;extremism; extremist; peace; peaceful; resistance; violent; violence; radical; radicalism; Bahrain; education; educational; school;
schools; student; students; drug; drugs; abuse; substanceIntroduction
From 2010 to 2020, almost 115,000 terrorist attacks occurred
around the world, accounting for over 266,000 deaths [1].
Although terrorist attacks have decreased since a peak in 2014,
they remain 1.75 times higher than they were in 2010 and deaths
associated with terrorist attacks were almost 3 times higher in2020 than they were in 2010 [1]. Yet terrorist attacks are justone form of violent extremism, albeit one with fatal
consequences that garner a lot of attention on the problems ofextremism. Along with the fatal outcome of death, extremism
and terrorism increase risks to physical and psychological safety
through injuries, abuses, trauma, and stress [2-4].
Extremism is defined by the International Center for
Cooperation and Conflict Resolution as beliefs, attitudes,
feelings, actions, or strategies of someone far removed from theordinary [2] and by the Counter Extremism Project as holding
extreme political or religious beliefs [3]. Although extremist
views can highlight concerns of marginalized communities thatmight otherwise go unnoticed, they can also lead to violent actsthat harm the health, safety, and well-being of others [2,3].
Critical policy and governmental strategies are often used toaddress extremism, yet countering extremism requires amultifaceted approach, intervening across multiple levels of thesocial ecological model to prevent and resolve conflicts before
violence occurs [4]. Some strategies require intensive, early
efforts to promote peace-building opportunities and improve
conflict resolution skills [2,5], suggesting a strong need forcommunity-based, individual-level interventions to promote
the value of peaceful coexistence and prevent extreme or violent
behaviors.
The Kingdom of Bahrain is in the Middle East and North Africa(MENA) region, which experienced over 35% of all terrorist
attacks from 2010 to 2020 [1]. At the political level, Bahrain
has used legislation, law enforcement, and international andregional cooperation to counter and prevent extremism (eg,addressing financing of terrorism and violent extremism). Yet
the government also wanted to focus on early prevention ofviolent extremism, creating an intervention for adolescents, who
are particularly vulnerable to radicalization and recruitment into
extremist groups due to their developmental exploration ofidentity and belonging [6,7]. In response, the Bahraini
government developed a school-based intervention to prevent
middle and high school students from being recruited into
extremist groups and to prevent intolerance within its
communities. By implementing the intervention within schools,
the Bahraini government could reach a broad audience of youth
and ensure all students were exposed to the same content [8].

with the Drug Abuse Resistance Education (D.A.R.E.)
organization. D.A.R.E. implements comprehensive K-12
prevention programs in dozens of countries around the world[9]. As implied by its name, the goal of the core D.A.R.E.
curriculum is to prevent drug use. However, D.A.R.E. also
works closely with its international partners to developintervention lessons that can address the specific needs of thehost country, such as violence, bullying, internet safety, and in
the case here, political extremism and intolerance. In Bahrain,
the D.A.R.E. program is known as ‘Ma’an,’ and, as in the UnitedStates, the lessons are taught by law enforcement officers whoare specially trained in prevention and education.
Typically, once researchers develop these intervention lessons,they assemble them into a multicomponent intervention“package” and evaluate this full intervention. One drawback ofthis approach is that researchers cannot evaluate the effect ofeach individual lesson, or “component.” While the fullintervention package may prove effective, some components
may be weak, ineffective, or even harmful. In contrast, themultiphase optimization strategy (MOST) framework [10,11]
uses 3 phases to design, optimize, and evaluate interventions.
As part of the first phase (i.e., preparation phase) of MOST,
researchers (1) develop a conceptual model to guide the selectionof components and measures for the optimization trials, (2)conduct pilot testing to ensure that the intervention is feasible,and (3) identify an optimization objective that they will pursue
in the optimization phase. During the optimization phase,researchers conduct one or more optimization trials to evaluate
individual intervention components using fully powered,randomized experiments. They use the results from these trials
to determine which set of components meet their optimization
objective identified during the preparation phase and assemble
these components into an optimized intervention package.
Finally, researchers can complete the evaluation phase to test
whether this optimized intervention package is effective, using
standard methods such as randomized control trials.
In the current study, we first describe the development of theconceptual model that we used to guide the optimization trials.
We then report the results of a pilot study to test our proceduresand protocols that we will use to conduct optimization trials of
the peaceful coexistence and antiextremism D.A.R.E. lessons.
As part of the pilot study, we also conducted a pretest-posttest
evaluation of the existing intervention lessons on the targeted
mediating variables and proximal outcomes. This pilot study isthe first in a series of trials intended to optimize the peacefulcoexistence and antiextremism lessons that can be implemented
as part of Ma’an. The results we present here were then used to
inform adaptations to the conceptual model and the protocol
for the optimization phase of MOST.

To develop school-based interventions focused on peacefulcoexistence and antiextremism, Bahrain worked collaboratively
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Methods
Preparation Phase Part 1: Developing a ConceptualModel
The first goal of the preparation phase was to develop a
conceptual model to identify predictors of the ultimate outcomes(here, valuing peaceful coexistence and antiextremism
behaviors). Frequently, researchers create a conceptual model
before an intervention is developed. In our case, however, theintervention content (4 lessons for each intervention) had alreadybeen created before we formed a partnership with Bahraini
leaders. Therefore, to develop our conceptual model, we
reviewed the current content of the lessons, conducted a rigorous

Rulison et al
review of the literature, and interviewed local stakeholders,
D.A.R.E. leaders, and content experts. Based on current content,
research, and stakeholder input, a preliminary conceptual model
was developed and presented back to the key stakeholders andexperts to obtain feedback and guidance for revisions. Following
multiple rounds of revisions and input, we reached consensus
on 2 conceptual models: one for the peaceful coexistenceintervention lessons intended for middle school students (right
3 columns of Figure 1) and one for the antiextremism
intervention lessons intended for high school students (right 3
columns of Figure 2). We then used these conceptual models
to guide measurement choices and to guide future content
revisions to better align with the proposed conceptual model
after pilot testing.

Figure 1. Conceptual model for anticipated effects of the peaceful coexistence lessons.

Figure 2. Conceptual model for anticipated effects of the antiextremism lessons.

Value of peaceful coexistence was a key distal outcome for bothage groups. This focus on peaceful coexistence is particularly
central to antiextremism efforts. Peaceful coexistence wasrecognized as an important part of international law since 1962and stands for an agreement to do no harm without just cause,even in the face of conflict [12]. Achieving peaceful coexistence,just like antiextremism, requires multifaceted approaches,
including community and individual intervention. For thisreason, along with discussions and insights from the D.A.R.E.
Board of Directors, leaders of Ma’an, and community officersof Bahrain, we decided to include the value of peacefulcoexistence as a critical distal outcome in the conceptual model.
We also extended the high school conceptual model to reflect
the goal of changing behavior in addition to increasing students’
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citizenship behaviors and reducing extremist or violent
behaviors.
To instill a value of peaceful coexistence and antiextremism,
there should be awareness of differences, acknowledging
interconnectedness, embracing diversity, and practicing empathy[8,12,13]. These are reflected as proximal outcomes in bothconceptual models with constructs of empathy, tolerance, andopen-mindedness. Another part of peaceful coexistence isunderstanding and learning how to communicate in response
to conflict [2,12,14], which we added as an additional proximal
outcome for the high school conceptual model.

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Normative beliefs is a key concept mentioned alongside peacefulcoexistence education [8,12] and the one included in the core
D.A.R.E drug use prevention curriculum [15,16]; thus, we
included norms about intolerance as targeted mediators in bothmodels. The core D.A.R.E curriculum has also historically
aimed to change expectancies regarding consequences [15,16]
and the current lessons incorporate content that aims to influence
beliefs about the consequences of discrimination, included asa targeted mediator in both models. Finally, the current lessons
targeted efficacy for decision-making and resistance skills,
which are also targeted by the core D.A.R.E. curriculum [15,16],
as they are particularly important for conflict resolution. Eachof these targeted mediators has been important constructs incommon behavior change theories such as the Theory of Planned
Behavior [17,18] and the Social Cognitive Theory [19,20].

Preparation Phase Part 2: Pilot Study of Existing
Curriculum
Participants
The Bahrain Research Team recruited 20 middle schools and
20 D.A.R.E. officers (13 male; 7 female officers; 12 were highschool graduates) to participate in the study. A total of 175
classrooms initially participated in the study, with a total of
N=3769 seventh, eighth, and ninth grade students completing
Survey 1. Officers at 4 schools (n=32 classrooms) did notadminister Survey 2, 4 additional classrooms at another school
were unable to complete Survey 2, and 1 classroom completed
Survey 2 but had errors in the ID numbers that prevented us
from matching students’ surveys to their Survey 1 data.
Therefore, our final baseline sample consisted of 3090 students
in 138 classrooms across 16 middle schools. Of these students,
2779 also completed Survey 2 (89.9% retention rate). A totalof 1349 students in 68 classrooms received the treatment lessons
and are the focus of our current analyses (see analytic plan for
more details).

Procedures
Survey Development
The US Research Team developed the survey in English incollaboration with D.A.R.E.’s Director of Curriculum andTraining. Then, the Bahrain Research Team reviewed the survey
to adjust for unclear wording and made cultural adaptations.
After the English version of the survey was finalized, theBahrain Research Team translated the survey into Arabic anda bilingual US Research Team member reviewed the final
translated survey.
Survey Administration
In mid-October 2021, students completed a paper or pencil
version of the survey in Arabic before participating in theirassigned D.A.R.E. lessons. Students took 30-45 minutes tocomplete Survey 1. D.A.R.E. officers then entered the data into
Excel and conducted random checks for errors in data entry,
sent the file to the Bahrain Research Team, who shared the filewith the US Research Team. D.A.R.E. officers taught theintervention or enhancement lessons (see next section) in
November and December 2021, and then approximately 1 week

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Rulison et al
after the fourth lesson was taught, officers used the same process
to administer Survey 2.
Intervention Administration
Students in seventh and eighth grade were randomly assigned
to either the 4-lesson peaceful coexistence curriculum or a seriesof 4 enhancement lessons focusing on other topics (eg, sexual
harassment and drugs). Students in ninth grade were randomly
assigned to either the 4-lesson antiextremism curriculum or thesame series of 4 enhancement lessons. Although theantiextremism curriculum was designed for high school students,
officers implemented the program in ninth grade (middle school
in Bahrain) for the pilot study because it was more difficult for
D.A.R.E. to partner with new high schools and D.A.R.E. was
not being implemented in enough high schools at the start ofthe study. The US research team created a randomization
schedule, assigning individual classrooms to condition within
officer. The Bahrain Research Team communicated theimplementation schedule with each participating officer andthe officers implemented 1 assigned lesson to each classroom
each week.

Ethical Considerations
The protocol for the current study was reviewed and approvedby the IRBs at Prevention Strategies (Institutional Review Board#11690) and at the University of North Carolina at Greensboro.
The Bahrain Research Team worked with schools to distributea newsletter to parents at each middle school, which described
the study and provided information about how parents could
opt their child out of the study if they wanted. The first page ofthe student survey included a student assent form describing
the study and telling students that they could skip any question
they did not wish to answer. Prior to distributing the surveys tostudents, D.A.R.E. officers created identification numbers forstudents in each class and wrote these numbers on the second
page of each survey. We used these ID numbers to match
students’ responses over time. Students did not include any
identifying information on their surveys, and they were notcompensated for completing the surveys.

Measures
Targeted Mediators
Descriptive Norms About Intolerance
Following standard measures of descriptive norms about otherbehaviors [21], this internally developed 7-item measure asked
students “In your opinion, how many kids your age do thefollowing?” (eg, spread hateful ideas about people who are
different; insult another person’s religion; see Multimedia
Appendix 1 for full list of items). Higher scores indicatedstudents believed more children their age were acting in
intolerant ways (1 = none or almost none; 5 = all or almost
all).
Injunctive Norms About Intolerance
Following standard measures of injunctive norms about otherbehaviors [22,23], this internally developed measure asked
students “In your opinion, how do most kids your age feel aboutother kids doing the following?” and listed the same 7 items as
above. Higher scores indicated students believed more children
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their age approved of acting in intolerant ways the mean of the
7 items (1 = It is completely wrong; 4 = It is completely okay).
Beliefs About Consequences
This internally developed 6-item measure asked students “Howlikely or unlikely is it that NOT listening to different opinions
will lead to each of the following?” (eg, people losing theirrights; people feeling hostile toward others). Higher scoresindicated students believed that ignoring different opinions wasmore likely to lead to negative outcomes (1 = Very Unlikely, 4= Very Likely).
Resistance Skills Self Efficacy
We created a measure of resistance skills self-efficacy basedon skills students learn in the keepin’ it REAL D.A.R.E.
curriculum [24] as well as the current antiextremism andpeaceful coexistence lessons: Refuse, Explain, Avoid, Leave(ie, REAL). Specifically, we asked students “If someone tried
to persuade you to participate in religious, political, or sociallyextreme activities that you were uncomfortable with, howconfident are you that you could resist (eg, say no, explain why
you don’t want to participate).” Higher scores indicated greater
self-efficacy to resist pressure to engage in extremist activities(1 = Not at all confident, 4 = Completely confident). Students
also reported their ability to encourage their friends to use thesesame resistance skills, using the same 4-point scale. Specifically,
we asked students: “If you saw one of your friends being
persuaded to participate in religious, political, or sociallyextreme activities they were uncomfortable with, how confident
are you that YOU could...” (eg, Help your friends say no; Help
your friend explain why they do not want to participate).
Decision-Making
We adapted a measure of resistance skills from a previous
evaluation of the keepin’ it REAL substance use prevention
program for elementary and middle school students [25]. In thecurrent study, students rated the extent to which they engaged
in different behaviors when they do something (eg, thinkcarefully about their choices). We recoded items so that higherscores indicated more thoughtful or less impulsive
decision-making (1 = Strongly Disagree, 4 = Strongly Agree).
Students also reported their ability to encourage their friends
to use these same decision-making strategies, using the same
4-point scale.

Rulison et al
Tolerance
Our team created 10 items to assess students’ beliefs about how
kids their age should act (eg, “Kids my age should have respect
for other religions”). We recoded items so that higher scoresindicated greater tolerance beliefs (1 = Strongly Disagree, 4 =Strongly Agree).
Open Mindedness Toward Political and Religious Views
We asked students about their political and religious
open-mindedness using 6 items adapted from Price et al [28].
Their original measures asked about politics and religion
separately, but for brevity, we combined them into a single
scale. Specifically, we asked students, “In your opinion, howmuch do YOU agree or disagree with the following statements?”(eg, “When it comes to politics and religion, I try to reserve
judgment until I have a chance to hear arguments from bothsides of an issue;” “I am open to considering other political or
religious viewpoints”). The scale consisted of 3 positively
worded (open-minded) and 3 negatively worded (ie,close-minded) items; we recoded items such that higher averagescores indicated greater open-mindedness (1 = Strongly
Disagree, 4 = Strongly Agree).
Open Mindedness Toward Diversity
We adapted 4 items adapted from Francis and McKenna’s [29]attitudes toward religious plurality scale (eg, All religious groups
in Bahrain should have equal rights) and 2 items from theirliving with cultural diversity scale (ie, “People who havedifferent religious beliefs make my school an interesting place”
and “People who come from different countries make my school
an interesting place”). We recoded items such that higher scoresindicated greater open mindedness toward plurality or diversity(1 = Strongly Disagree, 4 = Strongly Agree).
Nonviolent Conflict Resolution
We created 6 items to capture students’ attitudes toward
nonviolent conflict resolution. Specifically, students indicated
how they felt about engaging in different behaviors (eg, “Hitting
other people,” “Getting into fights with other people”), from 1= This is completely wrong to 4 = This is completely okay. We
recoded all items such that higher scores indicated more support
for nonviolent conflict resolution strategies. In alignment withthe conceptual models, we only used this measure to evaluate
the antiextremism lessons.

Distal Outcomes

Analytic Plan

Empathy
We adapted 14 of the 15 items from the Empathy Quotientquestionnaire [26] that assessed 3 factors [27]: cognitive
empathy (eg, “I can quickly figure out how someone else feels),social skills (eg, “I find it hard to know what to do in a social
situation”), and emotional reactivity (eg, “Seeing people crydoesn’t really upset me”). We dropped 1 item about feelingdetached when watching a film and we made small
modifications in wording to make the scale moredevelopmentally appropriate. We recoded items so that eachscale indicated higher empathy (1 = Strongly Disagree, 4 =Strongly Agree).

Originally, we had planned to compare students who received
the treatment lessons with those who completed theenhancement lessons; however, after the pilot trial was complete,
we noted that both the treatment and enhancement lessons
targeted similar mediating variables (eg, resistance skills anddecision-making skills) that are at the core of D.A.R.E.’s
curricular approach. Given that our pilot analyses used the
mediating variables as outcomes, we could not compare theeffects between those who received the treatment lessons andthose who received the enhancement lessons (ie, students inboth conditions received content targeting the key mediating
variables). Therefore, for these pilot test analyses, our analytic
sample only includes students who received the treatment
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students (pretest vs posttest) rather than between students in thetreatment and comparison conditions.
Before beginning the main analyses, we first conducted aprincipal component analysis with varimax rotation for eachmeasure, separately for seventh or eighth grade students (whoreceived the peaceful coexistence lessons) and for ninth gradestudents (who received the antiextremism lessons). Afterremoving items that did not fit within a unidimensional
construct, we computed alphas separately for seventh or eighth
grade and ninth grade students at pretest and posttest.
To test whether the treatment lessons changed the targeted
mediators and distal outcomes, we estimated a series of 3-level
models, to account for the nesting of students (level 1) withinclassroom (level 2) within schools (level 3); there was 1

D.A.R.E. officer per school, so schools and officer were
perfectly confounded. We estimated separate models for each
mediator and distal outcome and separate models for seventh
eighth grade students and ninth grade students.

Results
Pilot Sample Characteristics
Table 1 provides the demographic characteristics of the 1349
students who had both pretest and posttest data and who received
the treatment lessons (ie, the analytic sample). About two-thirdof the sample were boys (note: all schools were single sex).
Most of the sample were Bahraini (>96% per grade level) andmost of the sample (>94% per grade level) lived with bothparents.

Table 1. Demographics for analytic sample.
Peaceful coexistence lessons

Antiextremism lessons

Grade 7 (n=598), n (%)

Grade 8 (n=256), n (%)

Grade 9 (n=495), n (%)

Boy

370 (61.9)

197 (77.0)

298 (60.2)

Girl

228 (38.1)

59 (23.0)

197 (39.8)

2006 and earlier

5 (0.8)2 (0.8)5 (1.0)2007

4 (0.7)2 (0.8)447 (90.3)

2008

15 (2.5)

238 (93.0)

39 (7.9)

2009533 (89.1)

14 (5.4)

15 (0.0)2010

38 (6.4)

0 (0.0)1 (0.2)

Missing

3 (0.5)0 (0.0)3 (0.6)Bahraini

580 (97.0)

246 (96.1)

474 (95.8)

GCCa

1 (0.2)4 (1.6)2 (0.4)

Arabic13(2.2)5 (1.9)16 (3.2)

Other or missing

4 (0.6)

1 (0.4)3 (0.6)

Two parents

564 (94.3)

91.8 (235)471 (95.2)

Mother only

18 (3.0)

16 (6.3)

17 (3.4)

Father only

5 (0.8)3 (1.1)6 (1.2)Other or missing

11 (1.9)

2 (0.8)1 (0.2)Sex

Year of birth

Nationality

Who do you live with most of the time?

a

GCC: Gulf Cooperation Council.

Psychometric Analysis
Each of the targeted mediating variables was a unidimensional
construct (ie, all items loaded on a single component). The
results from our principal component analyses for the proximal
outcomes were less definitive. For empathy, we found that 3-4
components had eigenvalues above 1 (depending on time point
or grade) and the items for emotional reactivity loaded acrossmultiple components. When we dropped these 4 items, theremaining items loaded as expected on either cognitive empathy
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these 2 subscales in our final analyses. For tolerance, we foundthat 2 components had eigenvalues above 1, with multiple items
cross loading on both components. After examining thecomponent loadings and interitem correlations, we kept 4 items(see Multimedia Appendix 1 for details). For open mindedness
toward political and religious views, we found that 2
components had eigenvalues above 1: one component had 3
items that captured open mindedness whereas the other
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Rulison et alcomponent had 3 items that captured apathy toward political or
religious viewpoints; we dropped the latter 3 items from thefinal scale. For open mindedness toward diversity, we foundthat 2 components had eigenvalues above 1. The 2 negatively
worded items (eg, Religion brings more conflict than peace)loaded on the second component; we dropped these 2 items
from the final scale. Finally, the items for attitudes toward
nonviolent conflict resolution all loaded on a single construct.

Table 2 provides the Cronbach’s alpha for each of the targeted
mediating variables and the proximal outcomes, separately foryounger (seventh or eighth grade) and older (ninth grade)
students and separately for the pretest and posttest surveys. In
general, we found that reliability was higher among older
students and higher at posttest.

Table 2. Reliability for each scale.
Variablea

Items, nCronbach α
Seventh (pretest)

Ninth (pretest)

Seventh (posttest) Ninth (posttest)

Descriptive norms about intolerance

7

0.772

0.776

0.821

0.832

Injunctive norms about intolerance

7

0.714

0.774

0.777

0.851

Beliefs about consequences

6

0.855

0.910

0.917

0.932

Resistance skills (self)

4

0.644

0.712

0.745

0.786

Resistance skills (friends)

4

0.688

0.755

0.755

0.822

Decision-making skills (self)

3

0.516

0.553

0.519

0.520

Decision-making skills (friends)

3

0.497

0.583

0.500

0.568

Social skills empathy

5

0.587

0.611

0.671

0.674

Cognitive empathy

5

0.729

0.695

0.789

0.810

Tolerance

4

0.792

0.803

0.855

0.877

Open mindedness toward political and religious views

3

0.637

0.600

0.685

0.657

Open mindedness toward diversity

4

0.713

0.739

0.781

0.801

Attitudes toward nonviolent conflict resolution

6

—a

0.867

—

0.870

Not applicable.

Testing Differences From Pretest to Posttest
Table 3 provides the results for students who received thepeaceful coexistence lessons. Compared to pretest, there was asignificant decrease in injunctive norms about intolerance, as

well as significant increases in beliefs about the consequencesof not listening to others, resistance skills self-efficacy (for self
and friends), decision-making skills for self, social skills
empathy, tolerance beliefs, and open mindedness toward
diversity.

Table 3. Testing pretest versus posttest differences for seventh and eighth grade students.
Variable

Pretest, mean (95% CI)

Posttest, mean (95% CI)

P value

Total, n

Descriptive norms about intolerance

1.91 (1.83-1.99)

1.92 (1.84-2.00)

.80

854

Injunctive norms about intolerance

1.39 (1.34-1.44)

1.31 (1.26-1.35)

<.001

853

Beliefs about consequences

1.87 (1.75-1.98)

1.98 (1.86-2.10)

<.001

850

Resistance skills (self)

2.76 (2.68-2.83)

2.97 (2.89-3.05)

<.001

850

Resistance skills (friends)

2.82 (2.74-2.91)

2.97 (2.88-3.05)

<.001

846

Decision-making skills (self)

3.32 (3.25-3.38)

3.38 (3.31-3.45)

.005

841

Decision-making skills (friends)

3.28 (3.20-3.36)

3.32 (3.24-3.40)

.09

840

Social skills empathy

2.66 (2.61-2.71)

2.73 (2.68-2.78)

.008

830

Cognitive empathy

2.69 (2.62-2.76)

2.74 (2.67-2.81)

.10

827

Tolerance

3.45 (3.36-3.55)

3.50 (3.41-3.60)

.04

828

Open mindedness toward political and religious views

2.87 (2.79-2.96)

2.87 (2.79-2.96)

.95

815

Open mindedness toward diversity

3.27 (3.16-3.38)

3.32 (3.21-3.43)

.02

851

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Table 4 provides the results for students who received theanti-extremism lessons. Compared to pretest, there was asignificant decrease in injunctive norms about intolerance. There

was also a significant increase in beliefs about the consequencesof not listening to others, resistance skills self-efficacy for self
(but not friends), and social skills empathy.

Table 4. Testing pretest versus posttest differences for ninth grade students.
Variable

Pretest, mean (95% CI)

Posttest, mean (95% CI)

P value

Total, n

Descriptive norms about intolerance

2.01 (1.93-2.09)

2.04 (1.96-2.12)

.26

495

Injunctive norms about intolerance

1.36 (1.30-1.42)

1.31 (1.25-1.37)

.01

495

Beliefs about consequences

2.20 (2.07-2.34)

2.38 (2.24-2.52)

<.001

494

Resistance skills (self)

2.99 (2.91-3.07)

3.23 (3.15-3.32)

<.001

494

Resistance skills (friends)

3.08 (3.00-3.16)

3.07 (2.99-3.15)

.87

495

Decision-making skills (self)

3.32 (3.24-3.40)

3.37 (3.29-3.45)

.09

495

Decision-making skills (friends)

3.36 (3.28-3.43)

3.38 (3.30-3.46)

.46

495

Social skills empathy

2.61 (2.54-2.67)

2.72 (2.65-2.78)

<.001

490

Cognitive empathy

2.81 (2.72-2.89)

2.84 (2.75-2.93)

.23

490

Tolerance

3.54 (3.45-3.63)

3.50 (3.41-3.59)

.15

490

Open mindedness toward political and religious views

2.89 (2.82-2.97)

2.90 (2.82-2.98)

.86

486

Open mindedness toward diversity

3.36 (3.24-3.48)

3.32 (3.20-3.44)

.12

495

Attitudes toward nonviolent conflict resolution

1.31 (1.26-1.36)

1.32 (1.27-1.37)

.68

485

Discussion
Principle Findings
In this manuscript, we reported the results of the preparation
phase of the MOST to optimize and evaluate the peacefulcoexistence and antiextremism lessons implemented as part of
D.A.R.E. (ie, Ma’an) in Bahrain to counter the potential forpolitical and religious extremism and radicalization, which arecommon in the MENA region. These lessons, intended to be
implemented for Middle and High School students in Bahrain,
are an important part of the multilevel community approach to
reducing extremism, conflict, and associated violence.
Countering extremism is an important public health issue, as it
helps to increase physical and psychological safety forcommunities [2-4]. Intervening with adolescents not only
attempts to protect a particularly vulnerable population but also
aims to prevent radicalization and growth of extremist groups[6,7].
We started by drawing on the existing lessons that Bahrain
D.A.R.E. officers had created, prior literature, feedback from
US D.A.R.E experts, and local insights from Bahrain D.A.R.E.
officers, to develop 2 conceptual models. These models guided
our measurement efforts in the current pilot test and will
facilitate intervention optimization and program revisions going
forward. We then pilot tested our research protocol by evaluating
the existing intervention “packages.” The results of this pilot
test were encouraging.
First, most of our measures showed evidence of aunidimensional construct and good internal reliability, eventhough our team had to develop or adapt most of the measures
for this study as well as translate them into Arabic. We thenused our results to revise the measures further before moving
into the optimization phase of MOST. For example, we decided
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to add and adapt items for measures with lower reliability andto revise or remove most negatively worded items, as these
seemed to be particularly problematic for this population.
Second, we found that most of the D.A.R.E. officers were able
to follow the randomization protocol (even though we ended
up not being able to compare the students in the intervention
and attention control classrooms), suggesting that they could
successfully implement the more complicated protocol for thefactorial design that would be used in the optimization phaseof our study. Finally, we found initial evidence—described in
more detail below—that the existing intervention lessons couldchange some of the targeted mediating variables and proximal
outcomes, giving us a foundation to build on when using theconceptual model to revise the lessons prior to starting the
optimization phase of MOST.
In terms of the belief or attitude focused targeted mediators, wefound that both students who completed the peaceful coexistence
lessons and those who completed the antiextremism lessons
reported significantly lower perceived approval of intolerance(ie, injunctive norms about intolerance) at the immediate
posttest. By contrast, we found no changes in students’ beliefs
about the frequency of peers engaging in intolerant behaviors,such as spreading hateful ideas about people who are different
and insulting another persons’ religion (ie, descriptive norms).
Some studies suggest that among adults, injunctive norms may
be more meaningful than descriptive norms in situations that
require recommending whether peers should engage in risky
behaviors [30,31]. Still, these studies emphasize the importanceof descriptive norms for individual behavioral choices,
underscoring the importance of continuing to explore how thelessons could better target descriptive norms. We also foundthat students who completed either set of lessons reported asignificantly higher likelihood that not listening to others would
have negative outcomes (ie, beliefs about consequences) at the
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JMIR FORMATIVE RESEARCH
immediate posttest. With an emphasis on communication,
understanding, and empathy [2,12,14], listening is an integral
part of peaceful coexistence and an important hypothesized
predictor of the proximal outcomes.
In terms of the skill-based targeted mediators, students whocompleted either set of lessons reported increased efficacy toimplement resistance skills at the immediate posttest. In contrast,
only the students who received the peaceful coexistence lessons
reported significantly higher confidence that they could also
encourage their friends to use resistance stills and significantly
higher confidence that they could engage in more thoughtful orless impulsive decision-making. Although it is promising thatthe peaceful coexistence lessons successfully changed
self-efficacy toward personal resistance skills and personal
decision-making skills, it highlights that something may be
missing from the antiextremism curriculum. Given theimportance of resistance and decision-making for conflict
resolution, a proximal outcome of the antiextremism curriculumin our conceptual model, we plan to explore whether curriculum
revisions are needed to improve the antiextremism lessons.
Notably, the reliability of the decision-making measures wasquite low, suggesting that we also should add or revise items
for these measures going forward to better capture any truechange in self-efficacy toward decision-making skills over time.
As shown in our conceptual models, we expected that changing
the targeted mediators would lead to changes in 3 proximal
outcomes in the peaceful coexistence intervention (empathy,
tolerance, and open-mindedness) and 4 proximal outcomes in
the antiextremism program (empathy, tolerance, andopen-mindedness, along with nonviolent conflict resolution
skills). The results of our pilot test indicated mixed results:
Students who completed the peaceful coexistence lessons
reported significantly higher social skills empathy, tolerance
beliefs, and open-mindedness toward diversity, but showed nochanges in cognitive empathy or open-mindedness about
political and religious views. Students who completed theantiextremism lessons reported significant increases in social
skills empathy at the immediate posttest but no changes in anyof the other proximal outcomes. There are several potential
explanations for our mixed results. First, some targeted
mediators did not change in response to intervention
participation; therefore, the lessons may need to be revised sothat they have stronger changes in the targeted mediators before
we can expect to see changes in the proximal outcomes. Second,
the antiextremism curriculum was originally developed for highschool students, but for practical reasons, we had to pilot test
the lessons with ninth graders, who are middle school students
in Bahrain. Developmental differences may have impacted how
the lessons were received. Still, the more limited effects on theproximal outcomes for the antiextremism intervention suggeststhat we should examine these lessons more during the
optimization phase of MOST, with an eye toward revising theselessons going forward.
The results of the preparation phase of MOST led to several
conclusions. First, we determined that we would treat each of
the lessons as components when we “break apart” theintervention during the optimization phase: In other words, there
would be 4 components in the peaceful coexistence program
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Rulison et al
and 4 components in the antiextremism program. Second, werecommended that D.A.R.E. work with the Bahraini team toreconfigure the content of the lessons so that each lesson
targeted a single mediator (see the first column in Figures 1 and
2). For example, in the peaceful coexistence program, the lesson
about intolerance and video games could be reconfigured totarget resistance skills. In contrast, in the existing intervention,
the lessons frequently targeted multiple mediators.
Reconfiguring the lessons would make it easier to evaluate theindividual lessons (components) during the optimization phaseof MOST, by allowing us to test whether students who received
a particular lesson (eg, the video games lesson) improved moreon the targeted mediating variable (eg, resistance skills)
compared to students who did not receive that lesson. Third,
based on our conversations with stakeholders, it became clearthat the most important factor for developing an optimized
intervention was identifying the most effective set of lessons
possible; there were no time or money constraints that indicateda need to implement a shorter intervention. Therefore, we
recommended that the optimization objective for the upcoming
optimization trials should be “all effective lessons.” Finally,
given the lack of evidence-based interventions targeting peacefulcoexistence or antiextremism among adolescents and the desire
to build an intervention with clinically meaningful effects, werecommended that the Bahraini team be open to conducting
more than 1 optimization trial going forward. Specifically, wesuggested that we evaluate the reconfigured lessons in 1
optimization trial, then use the results from that trial to further
revise and strengthen lessons with weaker effects, and then test
the revised lessons in another optimization trial before creatinga “final” intervention package.

Limitations
Despite the encouraging results from our pilot test, our study
had several limitations. First, we selected multiple enhancement
lessons for officers to deliver as an “attention control” group.
Unfortunately, we realized after the study began that, although
the content of the lessons differed, these control lessons targeted
many of the same mediators, minimizing our ability to detect
differences between the treatment and control groups. Therefore,
we only analyzed pretest to posttest differences within thetreatment group. As with any pretest versus posttest design, any
difference could reflect developmental changes over time orchanges in response to the survey, rather than changes in
attitudes due to the treatment curriculum. Second, as with any
design that analyzes an entire “treatment package,” we cannot
evaluate the individual lessons. Our results suggest that the
curriculums as a whole have statistically significant effects on
many of the targeted mediators, but we cannot determine
whether each lesson had its intended effect, whether any lessons
had negative effects that undermine the effects of other lessons.
Third, our study did not include any long-term follow-up, whichmeant we could only focus on changes in attitudes and beliefs,
rather than changes in behaviors. Finally, to our knowledge,
none of the measures that we used had been used in Bahrain orother Arabic-speaking countries before. Therefore, as with any
study using new measures, it is unclear if the lack of effects onsome variables was due to a lack of effect from the curriculum
or whether it reflected a measurement issue.
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Conclusions
The eventual goal of our project is to develop and optimize
peaceful coexistence and antiextremism programs that caneventually be used across the Kingdom of Bahrain and translated
for use in other countries to combat the spread of extremism
and intolerance. The aim is for these programs to be
implemented alongside existing community and policy
interventions, allowing for a multilevel and systems approach
which is often noted as an essential strategy to countering
extremism [4]. This is an important topic for research andintervention in order to protect the health and safety ofcommunities worldwide. Our current study begins to address
this critical need by conducting the preparation phase of MOST.

Rulison et alSpecifically, in this study we (1) developed a conceptual model
identifying factors linked to valuing peaceful coexistence andantiextremism behaviors, (2) identified the 4 lessons in eachprogram as the components that we will evaluate in the
optimization phase of MOST, (3) pilot tested the existing
lessons, our newly developed measures, and research protocol,and (4) determined that our optimization objective going forward
will be “all effective components.” Our next step is to conduct
the optimization phase of MOST to evaluate, and revise, theindividual lessons, so as to be able to eventually create the firstever optimized peaceful coexistence and antiextremism
intervention lessons that can be used in other Arabic-speaking
countries as well as other countries that implement D.A.R.E.

Acknowledgments
We would like to acknowledge Francisco Pegueros, Richard Clayton, and Ashely Frazier from D.A.R.E. for their partnershipand support with Bahrain officials to develop the Ma’an curriculum.

Data Availability
The data sets generated during this study are not publicly available due to the sensitivity of the topic and vulnerable population
but are available from the corresponding author on reasonable request.

Conflicts of Interest
None declared.

Multimedia Appendix 1
List of survey items for each scale.
[DOCX File , 26 KB-Multimedia Appendix 1]

References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

12.
13.

National consortium for the study of terrorism and responses to terrorism. Global Terrorism Database. URL: https://www.
start.umd.edu/gtd/ [accessed 2024-02-28]
Coleman PT, Bartolia A. Addressing Extremism. 2015. URL: https://www.fpamed.com/wp-content/uploads/2015/12/
WhitePaper-on-Extremism.pdf [accessed 2024-06-19]
Extremism. Counter Extremism Project. URL: https://www.counterextremism.com/content/extremism [accessed 2024-06-19]
Nasser-Eddine M, Garnham B, Agostino K, Caluya G. Countering Violent Extremism (CVE) Literature Review. Edinburgh.
Counter Terrorism and Security Technology Centre; 2011.
Stepanova E. Anti-terrorism and peace-building during and after conflict. Stockholm International Peace Research Institute
URL: https://www.files.ethz.ch/isn/10475/doc_10505_290_en.pdf [accessed 2024-06-19]
Özerdem A, Podder S. Disarming youth combatants: mitigating youth radicalization and violent extremism. JSS.
2011;4(4):63-80. [FREE Full text] [doi: 10.5038/1944-0472.4.4.3]
Lowe P. Youth and Violent Extremism. In: Counterterrorism Yearbook 2020. Canberra, Australia. Australian Strategic
Policy Institute; 2021.
Bar‐Tal D. Nature, rationale, and effectiveness of education for coexistence. J Soc Issues. 2004;60(2):253-271. [doi:10.1111/j.0022-4537.2004.00110.x]
D.A.R.E. Hometowns – U.S.A. & International. URL: https://dare.org/where-is-d-a-r-e/ [accessed 2024-06-19]
Collins L. Optimization of behavioral, biobehavioral, and biomedical interventions: The Multiphase Optimization Strategy(MOST). New York, NY. Springer International Publishing; 2018.
Landoll RR, Vargas SE, Samardzic KB, Clark MF, Guastaferro K. The preparation phase in the multiphase optimization
strategy (MOST): a systematic review and introduction of a reporting checklist. Transl Behav Med. 2022;12(2):291-303.
[doi: 10.1093/tbm/ibab146] [Medline: 34850214]
Sulaiman KU. An Islamic perspective on peaceful coexistence. EJ-THEOLOGY. 2021;1(5):29-43. [doi:10.24018/theology.2021.1.5.50]
Duderija A. Creating peaceful societies by countering the phenomenon of reactive co-radicalization. In: Hermansen M,
Aslan E, Erşan Akkılıç E, editors. Peace Education and Religion: Perspectives, Pedagogy, Policies. Wiesbaden. Springer
Fachmedien; 2022:161-183.

https://formative.jmir.org/2024/1/e58322

XSL• FO
RenderX

JMIR Form Res 2024 | vol. 8 | e58322 | p. 10(page number not for citation purposes)

JMIR FORMATIVE RESEARCH
14.

15.

16.
17.
18.
19.
20.
21.

22.

23.

24.

25.
26.
27.
28.
29.

30.
31.

Rulison et al

Galvanek J, Planta K. Peaceful coexistence? 'Traditional' and 'non-traditional' conflict resolution mechanisms. Berlin.
Berghof Foundation Operations; 2017. URL: https://berghof-foundation.org/files/publications/20170228_DSF_Report.pdf[accessed 2024-06-26]
Hecht ML, Marsiglia FF, Elek E, Wagstaff DA, Kulis S, Dustman P, et al. Culturally grounded substance use prevention:
an evaluation of the keepin' it R.E.A.L. curriculum. Prev Sci. 2003;4(4):233-248. [doi: 10.1023/a:1026016131401] [Medline:
14598996]
Hansen WB, Beamon ER, Saldana S, Kelly S, Wyrick DL. D.A.R.E./keepin' it REAL elementary curriculum: substanceuse outcomes. PLoS One. 2023;18(4):e0284457. [FREE Full text] [doi: 10.1371/journal.pone.0284457] [Medline: 37115774]
Ajzen I. The theory of planned behavior. Organizational Behavior and Human Decision Processes. 1991;50(2):179-211.
[doi: 10.1016/0749-5978(91)90020-T]
Ajzen I. The theory of planned behaviour: reactions and reflections. Psychol Health. 2011;26(9):1113-1127. [doi:10.1080/08870446.2011.613995] [Medline: 21929476]
Bandura A. Social cognitive theory: an agentic perspective. Annu Rev Psychol. 2001;52:1-26. [doi:10.1146/annurev.psych.52.1.1] [Medline: 11148297]
Bandura A. Human agency in social cognitive theory. Am Psychol. 1989;44(9):1175-1184. [doi:10.1037/0003-066x.44.9.1175] [Medline: 2782727]
Wood MD, Read JP, Mitchell RE, Brand NH. Do parents still matter? Parent and peer influences on alcohol involvement
among recent high school graduates. Psychol Addict Behav. 2004;18(1):19-30. [doi: 10.1037/0893-164X.18.1.19] [Medline:
15008682]
Neighbors C, Lee CM, Lewis MA, Fossos N, Larimer ME. Are social norms the best predictor of outcomes among
heavy-drinking college students? J Stud Alcohol Drugs. 2007;68(4):556-565. [FREE Full text] [doi:10.15288/jsad.2007.68.556] [Medline: 17568961]
Schulenberg J, Patrick M, Johnston L, OMalley P, Bachman J, Miech R. Monitoring the Future National Survey Results
on Drug Use, 1975-2020. Volume II, College Students & Adults Ages 19-60. Ann Arbor. Institute for Social Research,
The University of Michigan; 2021. URL: http://monitoringthefuture.org/pubs.html#monographs [accessed 2024-06-26]
Day LE, Miller-Day M, Hecht ML, Fehmie D. Coming to the new D.A.R.E.: a preliminary test of the officer-taught
elementary keepin' it REAL curriculum. Addict Behav. 2017;74:67-73. [FREE Full text] [doi: 10.1016/j.addbeh.2017.05.025][Medline: 28595059]
Beamon ER, Henson RA, Kelly SE, Hansen WB, Wyrick DL. Fidelity of D.A.R.E. officers’ delivery of “keepin’ it REAL”
in elementary & middle school. Prev Sci. 2023;24(5):985-998. [FREE Full text] [doi: 10.1007/s11121-023-01548-8]
Baron-Cohen S, Wheelwright S. The empathy quotient: an investigation of adults with Asperger syndrome or high functioning
autism, and normal sex differences. J Autism Dev Disord. 2004;34(2):163-175. [doi: 10.1023/b:jadd.0000022607.19833.00]
Muncer SJ, Ling J. Psychometric analysis of the empathy quotient (EQ) scale. Pers Ind Diff. 2006;40(6):1111-1119. [doi:10.1016/j.paid.2005.09.020]
Price E, Ottati V, Wilson C, Kim S. Open-minded cognition. Pers Soc Psychol Bull. 2015;41(11):1488-1504. [doi:10.1177/0146167215600528] [Medline: 26315581]
Francis LJ, McKenna U. The religious and social correlates of muslim identity: an empirical enquiry into religification
among male adolescents in the UK. Oxford Review of Education. 2017;43(5):550-565. [doi:10.1080/03054985.2017.1352351]
Zou X, Savani K. Descriptive norms for me, injunctive norms for you: using norms to explain the risk gap. Judgment and
Decision Making. 2019;14(6):644-648. [doi: 10.1017/s1930297500005362]
Kredentser MS, Fabrigar LR, Smith SM, Fulton K. Following what people think we should do versus what people actually
do: elaboration as a moderator of the impact of descriptive and injunctive norms. Social Psychological and Personality
Science. 2012;3(3):341-347. [doi: 10.1177/1948550611420481]

Abbreviations
D.A.R.E.: Drug Abuse Resistance Education
MOST: multiphase optimization strategy

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Edited by A Mavragani; submitted 12.03.24; peer-reviewed by A Hassan, S Vargas; comments to author 02.04.24; revised version
received 23.04.24; accepted 05.06.24; published 17.07.24
Please cite as:
Rulison K, Weaver G, Milroy J, Beamon E, Kelly S, Ameeni A, Juma A, Abualgasim F, Husain J, Wyrick D
Using the Preparation Phase of the Multiphase Optimization Strategy to Design an Antiextremism Program in Bahrain: Formativeand Pilot Research
JMIR Form Res 2024;8:e58322
URL: https://formative.jmir.org/2024/1/e58322
doi: 10.2196/58322
PMID: 39018090©Kelly Rulison, GracieLee Weaver, Jeffrey Milroy, Emily Beamon, Samantha Kelly, Ali Ameeni, Amina Juma, Fadhel Abualgasim,
Jaafar Husain, David Wyrick. Originally published in JMIR Formative Research (https://formative.jmir.org), 17.07.2024. Thisis 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 Formative Research, is properly cited. The complete bibliographic information,a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

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