{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T22:26:52Z","timestamp":1791325612181,"version":"4.3.1"},"reference-count":44,"publisher":"Public Library of Science (PLoS)","issue":"10","license":[{"start":{"date-parts":[[2023,10,16]],"date-time":"2023-10-16T00:00:00Z","timestamp":1697414400000},"content-version":"vor","delay-in-days":0,"URL":"http:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"Wellspring Philanthropic Fund","award":["xxxx"],"award-info":[{"award-number":["xxxx"]}]}],"content-domain":{"domain":["www.plosdigitalhealth.org"],"crossmark-restriction":false},"short-container-title":["PLOS Digit Health"],"abstract":"<jats:sec id=\"sec001\">\n<jats:title>Background<\/jats:title>\n<jats:p>South Africa has among the highest rates of intimate partner violence (IPV) globally, with young women at heightened risk due to inequitable gender roles, limited relationship skills, and inadequate social support. Despite an urgent need for violence prevention in low- and middle-income settings, most efficacious approaches are time-intensive and costly to deliver. Digital, interactive chatbots may help young women navigate safer relationships and develop healthier gender beliefs and skills<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec002\">\n<jats:title>Methods<\/jats:title>\n<jats:p>Young women (18\u201324 years old) across South Africa were recruited via <jats:italic>Facebook<\/jats:italic> for participation in an individually randomised controlled trial (<jats:italic>n<\/jats:italic> = 19,643) during the period of June 2021-September 2021. Users were randomly allocated, using a pipeline algorithm, to one of four trial arms: <jats:italic>Pure Control (PC)<\/jats:italic> had no user engagement outside of study measures; <jats:italic>Attention Treatment (T0)<\/jats:italic> provided didactic information about sexual health through a text-based chatbot<jats:italic>; Gamified Treatment (T1<\/jats:italic><jats:bold><jats:italic>)<\/jats:italic><\/jats:bold> was a behaviourally-informed gamified text-based chatbot; <jats:italic>Narrative Treatment (T2)<\/jats:italic> was a behaviourally-informed drama delivered through pre-recorded voice notes. All chatbots were delivered in <jats:italic>WhatsApp<\/jats:italic>, through which users were invited to complete brief \u201cquizzes\u201d comprising adapted versions of validated scales. Primary outcomes were short-form adaptations of scales for gender attitudes (<jats:italic>Gender Relations Scale<\/jats:italic>) and past-month IPV (<jats:italic>WHO Multi-country Study Instrument)<\/jats:italic>. Secondary outcomes were identification of unhealthy relationship behaviours (<jats:italic>Intimate Partner Violence Attitudes Scale<\/jats:italic>) and brief screener for depressive symptoms (<jats:italic>Patient Health Questionnaire)<\/jats:italic>. A direct chat link to a trained counsellor was a safety measure (accessed by 4.5% of the sample). We estimated treatment effects using ordinary least squares and heteroskedasticity robust standard errors<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"sec003\">\n<jats:title>Findings<\/jats:title>\n<jats:p>The trial retained 11,630 (59.2%) to the primary endpoint of gender attitudes. Compared to control, all treatments led to moderate and significant changes in attitudes towards greater gender equity (Cohen\u2019s D = 0.10, 0.29, 0.20 for T0, T1, and T2, respectively). The gamified chatbot (T1) had modest but significant effects on IPV: 56% of young women reported past-month IPV, compared to 62% among those without treatment (marginal effects = -0.07, 95%CI = -0.09to-0.05). The narrative treatment (T2) had no effect on IPV exposure. T1 increased identification of unhealthy relationship behaviours at a moderate and significant level (Cohen\u2019s D = 0.25). Neither T1 nor T2 had a measurable effect on depressive symptoms as measured by the brief screener. <jats:bold>Interpretation:<\/jats:bold> A behaviourally-informed, gamified chatbot increased gender equitable attitudes and was protective for IPV exposure among young women in South Africa. These effects, while modest in magnitude, could represent a meaningful impact given potential to scale the low-cost intervention.<\/jats:p>\n<\/jats:sec>","DOI":"10.1371\/journal.pdig.0000358","type":"journal-article","created":{"date-parts":[[2023,10,16]],"date-time":"2023-10-16T17:30:57Z","timestamp":1697477457000},"page":"e0000358","update-policy":"https:\/\/doi.org\/10.1371\/journal.pdig.corrections_policy","source":"Crossref","is-referenced-by-count":25,"title":["Effects of digital chatbot on gender attitudes and exposure to intimate partner violence among young women in South Africa"],"prefix":"10.1371","volume":"2","author":[{"given":"Alexandra","family":"De Filippo","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Paloma","family":"Bellatin","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Neville","family":"Tietz","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eli","family":"Grant","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Alexander","family":"Whitefield","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Puseletso","family":"Nkopane","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Camilla","family":"Devereux","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kaitlyn","family":"Crawford","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Benjamin","family":"Vermeulen","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4150-1405","authenticated-orcid":true,"given":"Abigail M.","family":"Hatcher","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"340","published-online":{"date-parts":[[2023,10,16]]},"reference":[{"key":"pdig.0000358.ref001","volume-title":"South Africa Demographic and Health Survey 2016: Key Indicator Report","author":"S. SA","year":"2018"},{"issue":"4","key":"pdig.0000358.ref002","doi-asserted-by":"crossref","first-page":"e1001412","DOI":"10.1371\/journal.pmed.1001412","article-title":"Intimate partner femicide in South Africa in 1999 and 2009.","volume":"10","author":"N Abrahams","year":"2013","journal-title":"PLoS Med."},{"key":"pdig.0000358.ref003","article-title":"Describing Relationship Characteristics and Postpartum HIV Risk Among Adolescent, Young Adult, and Adult Women in South Africa","author":"AK Groves","year":"2020","journal-title":"Journal of Adolescent Health"},{"issue":"1","key":"pdig.0000358.ref004","first-page":"18","article-title":"Prevalence and risk factors for intimate partner violence among Grade 8 learners in urban South Africa: baseline analysis from the Skhokho Supporting Success cluster randomised controlled trial.","volume":"8","author":"S Shamu","year":"2016","journal-title":"Int Health."},{"issue":"1","key":"pdig.0000358.ref005","doi-asserted-by":"crossref","first-page":"31","DOI":"10.1080\/13691058.2019.1568578","article-title":"Gender role conflict and sexual health and relationship practices amongst young men living in urban informal settlements in South Africa.","volume":"22","author":"K Closson","year":"2020","journal-title":"Culture, Health & Sexuality."},{"key":"pdig.0000358.ref006","doi-asserted-by":"crossref","first-page":"112637","DOI":"10.1016\/j.socscimed.2019.112637","article-title":"Gendered syndemic of intimate partner violence, alcohol misuse, and HIV risk among peri-urban, heterosexual men in South Africa.","volume":"295","author":"AM Hatcher","year":"2022","journal-title":"Soc Sci Med."},{"issue":"14","key":"pdig.0000358.ref007","doi-asserted-by":"crossref","first-page":"2975","DOI":"10.1177\/0886260516664316","article-title":"Intimate Partner Violence and Its Association With Self-Determination Needs and Gender-Power Constructs Among Rural South African Women.","volume":"34","author":"F Mpondo","year":"2019","journal-title":"J Interpers Violence."},{"key":"pdig.0000358.ref008","doi-asserted-by":"crossref","first-page":"751","DOI":"10.1186\/1471-2458-14-751","article-title":"Intimate partner violence among adolescents and young women: prevalence and associated factors in nine countries: a cross-sectional study.","volume":"14","author":"H Stockl","year":"2014","journal-title":"BMC Public Health"},{"issue":"3","key":"pdig.0000358.ref009","doi-asserted-by":"crossref","first-page":"283","DOI":"10.1007\/s11121-013-0405-7","article-title":"Intimate partner violence among adolescents in Cape Town, South Africa.","volume":"15","author":"M Russell","year":"2014","journal-title":"Prev Sci"},{"issue":"1\u20132","key":"pdig.0000358.ref010","doi-asserted-by":"crossref","first-page":"7","DOI":"10.1177\/0886260517726413","article-title":"Awareness and rejection accounts of intimate partner violence by young women in Soweto, Johannesburg, South Africa.","volume":"36","author":"M Makongoza","year":"2021","journal-title":"Journal of interpersonal violence"},{"issue":"11","key":"pdig.0000358.ref011","doi-asserted-by":"crossref","first-page":"e0139430","DOI":"10.1371\/journal.pone.0139430","article-title":"Intimate Partner Violence, Relationship Power Inequity and the Role of Sexual and Social Risk Factors in the Production of Violence among Young Women Who Have Multiple Sexual Partners in a Peri-Urban Setting in South Africa.","volume":"10","author":"YZ Zembe","year":"2015","journal-title":"PLoS One."},{"issue":"11","key":"pdig.0000358.ref012","doi-asserted-by":"crossref","first-page":"1225","DOI":"10.1080\/13691058.2018.1554189","article-title":"Exploring young women\u2019s constructions of love and strategies to navigate violent relationships in South African informal settlements.","volume":"21","author":"S Willan","year":"2019","journal-title":"Cult Health Sex"},{"issue":"1","key":"pdig.0000358.ref013","doi-asserted-by":"crossref","first-page":"122","DOI":"10.1186\/s12916-014-0122-5","article-title":"Findings from the SASA! Study: a cluster randomized controlled trial to assess the impact of a community mobilization intervention to prevent violence against women and reduce HIV risk in Kampala, Uganda.","volume":"12","author":"T Abramsky","year":"2014","journal-title":"BMC medicine."},{"issue":"10","key":"pdig.0000358.ref014","doi-asserted-by":"crossref","first-page":"e1423","DOI":"10.1016\/S2214-109X(19)30316-X","article-title":"A social empowerment intervention to prevent intimate partner violence against women in a microfinance scheme in Tanzania: findings from the MAISHA cluster randomised controlled trial","volume":"7","author":"S Kapiga","year":"2019","journal-title":"Lancet Glob Health"},{"issue":"9551","key":"pdig.0000358.ref015","doi-asserted-by":"crossref","first-page":"1973","DOI":"10.1016\/S0140-6736(06)69744-4","article-title":"Effect of a structural intervention for the prevention of intimate-partner violence and HIV in rural South Africa: a cluster randomised trial","volume":"368","author":"PM Pronyk","year":"2006","journal-title":"Lancet"},{"key":"pdig.0000358.ref016","first-page":"15248380211068136","article-title":"A Systematic Review of Interventions to Reduce Gender-Based Violence Among Women and Girls in Sub-Saharan Africa.","author":"T Keith","year":"2022","journal-title":"Trauma Violence Abuse."},{"key":"pdig.0000358.ref017","doi-asserted-by":"crossref","first-page":"a506","DOI":"10.1136\/bmj.a506","article-title":"Impact of stepping stones on incidence of HIV and HSV-2 and sexual behaviour in rural South Africa: cluster randomised controlled trial","volume":"337","author":"R Jewkes","year":"2008","journal-title":"BMJ"},{"key":"pdig.0000358.ref018","article-title":"Stepping Stones and Creating Futures Intervention to Prevent Intimate Partner Violence Among Young People: Cluster Randomized Controlled Trial.","author":"A Gibbs","year":"2019","journal-title":"J Adolesc Health."},{"key":"pdig.0000358.ref019","doi-asserted-by":"crossref","first-page":"339","DOI":"10.1186\/1471-2458-14-339","article-title":"Working with men to prevent intimate partner violence in a conflict-affected setting: a pilot cluster randomized controlled trial in rural Cote d\u2019Ivoire.","volume":"14","author":"M Hossain","year":"2014","journal-title":"BMC public health."},{"issue":"7","key":"pdig.0000358.ref020","doi-asserted-by":"crossref","first-page":"e25134","DOI":"10.1002\/jia2.25134","article-title":"Community mobilization to modify harmful gender norms and reduce HIV risk: results from a community cluster randomized trial in South Africa.","volume":"21","author":"A Pettifor","year":"2018","journal-title":"J Int AIDS Soc"},{"key":"pdig.0000358.ref021","doi-asserted-by":"crossref","first-page":"393","DOI":"10.1146\/annurev-publhealth-031914-122855","article-title":"Mobile text messaging for health: a systematic review of reviews.","volume":"36","author":"AK Hall","year":"2015","journal-title":"Annu Rev Public Health"},{"key":"pdig.0000358.ref022","volume-title":"Social norms marketing aimed at gender based violence: A literature review and critical assessment","author":"EL Paluck","year":"2010"},{"issue":"2","key":"pdig.0000358.ref023","doi-asserted-by":"crossref","first-page":"121","DOI":"10.1071\/HE04121","article-title":"Evaluating health communication\u2013a holistic overview of the impact of Soul City IV","volume":"15","author":"E Scheepers","year":"2004","journal-title":"Health Promotion Journal of Australia"},{"issue":"7","key":"pdig.0000358.ref024","doi-asserted-by":"crossref","DOI":"10.1136\/bmjgh-2019-002091","article-title":"Safety decision-making and planning mobile app for intimate partner violence prevention and response: randomised controlled trial in Kenya","volume":"5","author":"MR Decker","year":"2020","journal-title":"BMJ Glob Health"},{"issue":"14","key":"pdig.0000358.ref025","doi-asserted-by":"crossref","first-page":"2283","DOI":"10.1177\/0010414020912275","article-title":"Countering violence against women by encouraging disclosure: A mass media experiment in rural Uganda.","volume":"53","author":"DP Green","year":"2020","journal-title":"Comparative Political Studies"},{"key":"pdig.0000358.ref026","article-title":"Can media campaigns empower women facing gender-based violence amid COVID-19?","author":"C Fotini","year":"2022","journal-title":"Toulouse School of Economics"},{"issue":"6","key":"pdig.0000358.ref027","doi-asserted-by":"crossref","first-page":"618","DOI":"10.1080\/17441692.2012.672581","article-title":"Constructs of power and equity and their association with contraceptive use among men and women in rural Ethiopia and Kenya.","volume":"7","author":"R Stephenson","year":"2012","journal-title":"Global public health."},{"issue":"9619","key":"pdig.0000358.ref028","doi-asserted-by":"crossref","first-page":"1165","DOI":"10.1016\/S0140-6736(08)60522-X","article-title":"Intimate partner violence and women\u2019s physical and mental health in the WHO multi-country study on women\u2019s health and domestic violence: an observational study.","volume":"371","author":"M Ellsberg","year":"2008","journal-title":"Lancet"},{"issue":"4","key":"pdig.0000358.ref029","doi-asserted-by":"crossref","first-page":"442","DOI":"10.1177\/0739986305281233","article-title":"Development of the intimate partner violence attitude scales (IPVAS) with a predominantly Mexican American college sample.","volume":"27","author":"BA Smith","year":"2005","journal-title":"Hispanic Journal of Behavioral Sciences."},{"key":"pdig.0000358.ref030","author":"UNICEF","year":"2019","journal-title":"Case Study: RapidPro"},{"issue":"6","key":"pdig.0000358.ref031","doi-asserted-by":"crossref","first-page":"584","DOI":"10.1016\/j.whi.2014.08.001","article-title":"Intimate partner violence and safety strategy use: Frequency of use and perceived effectiveness.","volume":"24","author":"EM Parker","year":"2014","journal-title":"Women\u2019s health issues."},{"issue":"31","key":"pdig.0000358.ref032","doi-asserted-by":"crossref","first-page":"e2200262119","DOI":"10.1073\/pnas.2200262119","article-title":"Religious leaders can motivate men to cede power and reduce intimate partner violence: Experimental evidence from Uganda","volume":"119","author":"C Boyer","year":"2022","journal-title":"Proceedings of the National Academy of Sciences"},{"key":"pdig.0000358.ref033","doi-asserted-by":"crossref","DOI":"10.2139\/ssrn.4158065","article-title":"Using Social Media to Change Gender Norms: An Experimental Evaluation Within Facebook Messenger in India.","author":"D Donati","year":"2022"},{"key":"pdig.0000358.ref034","doi-asserted-by":"crossref","first-page":"106573","DOI":"10.1016\/j.childyouth.2022.106573","article-title":"Technology \u201cFeels Less Threatening\u201d: The processes by which digital technologies facilitate youths\u2019 access to services at intimate partner violence organizations.","volume":"139","author":"HL Storer","year":"2022","journal-title":"Children and youth services review."},{"issue":"2","key":"pdig.0000358.ref035","doi-asserted-by":"crossref","first-page":"195","DOI":"10.1177\/1524838016650189","article-title":"Technology-facilitated sexual violence: A literature review of empirical research.","volume":"19","author":"N Henry","year":"2018","journal-title":"Trauma, violence, & abuse."},{"issue":"10","key":"pdig.0000358.ref036","doi-asserted-by":"crossref","first-page":"e0221049","DOI":"10.1371\/journal.pone.0221049","article-title":"Prevalence, associated factors and health impact of intimate partner violence against women in different life stages.","volume":"14","author":"B Sanz-Barbero","year":"2019","journal-title":"PLoS one"},{"issue":"5","key":"pdig.0000358.ref037","doi-asserted-by":"crossref","first-page":"e0154478","DOI":"10.1371\/journal.pone.0154478","article-title":"Mental health inequalities in adolescents growing up in post-apartheid South Africa: cross-sectional survey, SHaW study.","volume":"11","author":"J Das-Munshi","year":"2016","journal-title":"PloS one"},{"key":"pdig.0000358.ref038","volume-title":"Experiences of violence and safety.","author":"AM Hatcher","year":"2021"},{"key":"pdig.0000358.ref039","doi-asserted-by":"crossref","unstructured":"Hamari J, Koivisto J, et al., editors. Does gamification work?\u2014a literature review of empirical studies on gamification. 2014 47th Hawaii international conference on system sciences; 2014: Ieee.","DOI":"10.1109\/HICSS.2014.377"},{"issue":"4","key":"pdig.0000358.ref040","article-title":"The effects of feedback on online quizzes","volume":"15","author":"M Butler","year":"2008","journal-title":"International Journal for Technology in Mathematics Education"},{"key":"pdig.0000358.ref041","doi-asserted-by":"crossref","first-page":"184","DOI":"10.1016\/j.jebo.2015.02.020","article-title":"Risking it all for love? Resetting beliefs about HIV risk among low-income South African teens.","volume":"118","author":"S Datta","year":"2015","journal-title":"Journal of Economic Behavior & Organization."},{"issue":"4","key":"pdig.0000358.ref042","first-page":"1","article-title":"Soap operas and fertility: Evidence from Brazil.","volume":"4","author":"E La Ferrara","year":"2012","journal-title":"American Economic Journal: Applied Economics."},{"key":"pdig.0000358.ref043","doi-asserted-by":"crossref","DOI":"10.3386\/w26096","volume-title":"The entertaining way to behavioral change: Fighting HIV with MTV","author":"A Banerjee","year":"2019"},{"key":"pdig.0000358.ref044","author":"J Pulerwitz","year":"2006","journal-title":"Promoting more gender-equitable norms and behaviors among young men as an HIV\/AIDS prevention strategy"}],"container-title":["PLOS Digital Health"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pdig.0000358","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,10,16]],"date-time":"2023-10-16T17:31:28Z","timestamp":1697477488000},"score":1,"resource":{"primary":{"URL":"https:\/\/dx.plos.org\/10.1371\/journal.pdig.0000358"}},"subtitle":[],"editor":[{"given":"Laura M.","family":"K\u00f6nig","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"editor"}]}],"short-title":[],"issued":{"date-parts":[[2023,10,16]]},"references-count":44,"journal-issue":{"issue":"10","published-online":{"date-parts":[[2023,10,16]]}},"URL":"https:\/\/doi.org\/10.1371\/journal.pdig.0000358","relation":{},"ISSN":["2767-3170"],"issn-type":[{"value":"2767-3170","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,10,16]]}}}