January 29, 2024

One in four women experience violence from a partner, according to global data on violence against women from the World Health Organization. This burden makes partner violence one of the globe’s more prominent social determinants of health.

But despite evidence that partner violence worsens women’s reproductive and mental health, there are few proven solutions for preventing it. Effective approaches often require multiple sessions led by highly trained staff, which may cost more than governments or donors are willing to pay.

A complementary approach to reducing violence involves digital solutions to reach more users at lower cost.

Dr. Abigail Hatcher

Dr. Abigail Hatcher

Abigail Hatcher, PhD, an associate professor of health behavior at the UNC Gillings School of Global Public Health, tested one such solution. Together with the Behavioral Insights Team and Reach Digital Health, the group designed a chatbot called “ChattyCuz” in South Africa. Using WhatsApp, young women take part in six ChattyCuz sessions to practice skills and safety behaviors. Throughout roughly two hours of gamified content, users were asked to reflect on their beliefs about the power women have in relationships.

Alexandra De Filippo

Alexandra De Filippo

WhatsApp is a great platform, as it’s widely used, private and engaging,” said Alexandra De Filippo, a behavioral insights specialist and ChattyCuz co-designer. “After talking with young women themselves, we were looking for a way to give users feedback about the content in real time. A chatbot with two-way communication was a great fit.”

In a randomized controlled trial, approximately 19,000 young women between 18 and 24 years were randomly assigned to interact with the gamified chatbot, a narrative story (as an alternate intervention) or no intervention (as a “control condition”).

De Filippo, Hatcher and colleagues recently published the results in PLoS Digital Health. Compared to the pure control, women taking part in the gamified chatbot had 11.3% less exposure to partner violence after interacting with the chatbot compared to the control. The team defined this outcome as any physical, sexual or technological act of violence in the past three months, for example hitting or forced sexual intercourse.

Driving the promising effect is the finding that the ChattyCuz gamified chatbot significantly decreased violence facilitated by technology – such as when a partner used social media to control or monitor a young woman’s movements. This is a newer finding that may have applications for recent efforts to prevent violence online.

Women who took part in either the gamified chatbot or the narrative story showed improved attitudes about power in relationships and better skills at identifying harmful behavior.

Importantly, young women who interacted with ChattyCuz did not report more mental distress than those in the control condition, which provides preliminary evidence of safety for this digital option. The trial had a safety mechanism for those in need of personalized help through direct referral to a live mental health practitioner who used WhatsApp for counseling.

Hatcher explains, “One of the tricky parts of testing light-touch interventions is we need to keep users safe from distress or any escalation in violence. We met this need by matching users to a live WhatsApp counselor, and just under 5% did want this service. This trial starts to show that we can fairly rapidly and safely ask young people about real events in their lives.”

Hatcher and De Filippo were invited to combine lessons from designing the chatbot with other innovative approaches in violence prevention. Their United Nations (UN) Women policy brief suggests digital work may be one essential avenue for reaching wider populations at scale.

They also highlight a key challenge that violence prevention remains underfunded. A UN Women report found only 0.2% of development aid is earmarked for the topic and a National Institutes of Health analysis showed 0.4% of federal research funding goes to preventing violence against women.

As a widely adopted human right to live free from bodily harm, the UN lists ending violence and gender equality as sustainable development goals, but these are a long way from being achieved by 2030.

“I imagine the ‘prevention toolbelt’ will always include in-person strategies — but if we’re going to alter partner violence at scale, we’ll also need lower-cost options. Ultimately, if these distinct strategies are paired, perhaps digital solutions become an entry point for further care,” said Hatcher.

ChattyCuz is being adapted for school-age girls in Colombia with support from the University of Los Andes and Aulas en Paz. The team is also exploring how to redesign the content for young men and expand it for sexual and gender minorities.

Since the trial, ChattyCuz has been rebranded #SafeSigns and is available as an open-source offering for teams interested in exploring or implementing the chatbot.

Contact the UNC Gillings School of Global Public Health communications team at sphcomm@unc.edu.

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