Short-Term Health and Safety Outcomes Associated With Digital Hotline Use at Interpersonal Violence-Focused Agencies

Abstract

Community organizations strive to help survivors of intimate partner violence (IPV), stalking, sexual assault and human trafficking address health and safety needs. Hotline, offered by local agencies, is the first line of support for survivors to address needs. Increasingly, hotline is offered in digital formats (chat and text) to meet the emergent needs of survivors. Despite the growing use of digital hotline, little is known about short-term health and safety changes associated with use. Partnering with 2 local agencies in a Southern state, we recruited first-time digital hotline participants to an online baseline and follow-up (6 weeks later) assessment (n = 237) to examine changes in health (e.g. physical health, depression, PTSD) and safety (tools related to safety, perception of safety). Descriptive statistics, paired sample t-tests, chi-square, and regression modeling were used for data analysis. At 6 weeks post-digital hotline use, depression and PTSD symptoms had significantly decreased, and hope and feelings of safety had significantly increased. No changes were observed for physical health. Repeated hotline use after baseline was associated with revictimization, sustained health needs, and reduced perception of internal tools related to safety. Longer-term and expanded study are needed of digital hotline to further examine potential impacts, however these findings suggest that hotline is not merely a conduit to other services, but a potentially impactful intervention into itself.

Introduction

Interpersonal violence, such as intimate partner violence (IPV), sexual assault, stalking, and human trafficking have serious and long-lasting health and safety consequences. Indeed, survivors of interpersonal violence are at increased risk for a host of physical and mental health problems, including cardiac disease, reproductive health concerns, ¹ depression, anxiety, and PTSD. ² Moreover, rates of re-victimization are alarmingly high, ³ which further negatively affects the health of survivors. While help-seeking is relatively rare, ⁴ survivors may seek help from informal (e.g., friends, family) and formal (e.g., community, legal or medical services) support based on their individual circumstances, the types of violence experienced, and their specific health and safety needs.^{5 -7} For example, while survivors in the initial stages of coercive or controlling relationships may first turn to informal support, those in increasing threatening situations (e.g., experiencing severe physical violence) with immediate safety needs and fear of continued harm are more likely to seek help from community, medical, and legal systems.^5,7,8 Increasingly, survivors turn to online disclosure for support, both to identify resources and seek empathic connection. ⁹ People with safety concerns often need emergency shelter or safe housing, and assistance with legal protections such as protective orders. ¹⁰ Additionally, health needs, such as counseling, emergency medical care, access to forensic examinations, and psychoeducation about health needs, drive formal help-seeking. ¹¹

To address the health and safety needs of survivors of IPV, sexual assault, stalking, and trafficking, there are over 2000 community-based organizations that offer shelter, advocacy, supportive counseling, hotline, and other resources. ¹² A growing body of research indicates that community-based services for interpersonal violence are effective at providing timely referrals, improving mental health impacts, and reducing risks for revictimization.^{4,13 -16} Hotlines or helplines are often the point of entry for survivors seeking additional formal support. ¹⁷ Offered in phone, digital (chat/text), and TTY formats, hotlines provide immediate access to a trained advocate who provides tailored feedback, emotional support, and access to additional resources including shelter, legal, and emotional support.^18,19

National hotlines in the U.S. have long been an established public health intervention for survivors of multiple forms of interpersonal violence. For example, in 2022, the National Domestic Violence Hotline had nearly 450 000 contacts, The National Sexual Assault Hotline reports 30 000 annual calls, ²⁰ while the National Human Trafficking Hotline has over 15 000 annual contacts. ²¹ While these national hotlines provide a crucial safety net, most of the front-line services are offered in local community-based programs. On 1 single day, these local agencies across the country took 23 348 hotline contacts, ¹² which provide timely support to address immediate safety needs and provide resources for ongoing health and resource concerns. Despite their robust and consistent use, hotline services have rarely been evaluated. Studies have generally been limited to frequency of use and type of services accessed (e.g., mental health and legal resources are common referrals), ¹⁸ as well as satisfaction with services (i.e., highly satisfied).^18,22,23

Theoretical Frameworks for Hotline

Conservation of Resources (COR) and crisis intervention theories^{24 -26} provide a useful lens for examining survivor experiences and potential hotline impact. COR posits that in the wake of trauma and violence, survivors experience a range of individual, interpersonal, and social resource losses caused by a disruption in coping mechanisms, reduction of social, emotional, and financial support, and mental and physical health crises. ²⁶ Crisis intervention is time-limited, present-focused, and aims to resolve resource loss by stabilizing the current situation and mobilizing an individual’s strengths and resources to cope.^25,27 In a COR perspective, hotline advocates work to mitigate resource loss by providing support, targeted resources, and guidance. This support is meant to counteract the impact of trauma and minimize long-term consequences through resource gains. ²⁴ Crisis intervention theory and COR directly informs hotline services by emphasizing immediate safety, support, and empowerment.^25,27

Digital Hotline

Digital approaches, including computer chat and SMS based text, have become increasingly deployed in hotline services for interpersonal violence survivors over the previous decade,^23,28 as online disclosure has grown due to increased immediate access to potential sources of support. ²⁹ Digital modalities became especially prevalent during the COVID 19 pandemic, where survivors were often stuck at home with partners using violence. ³⁰ Digital approaches provide access to survivors like adolescents and emerging adults who generally prefer communicating via text,^{31 -33} survivors who are deaf and hard of hearing^34,35 and those who cannot safely audibly reach for support. ³⁶ Further, accessing services digitally may be more accessible to people who feel uncomfortable discussing sensitive issues, due to a disinhibition impact of this form of communication.^9,30,37 Thus, the digital hotline service model provides rapid access to support, identification of options, expanded understanding of health impacts of violence, increased access to health and safety supports, and safety planning for an audience that otherwise may not have accessed hotline services.^19,37 While the limited research on this method indicates that service participants value its anonymity and accessibility,^19,23,36,37 little is known about end-user outcomes and experiences of digital hotlines.

The Current Study

While hotlines are ubiquitous in community-based agencies for survivors of violence, the service has seldomly been studied related to participant experiences and changes in survivor health and safety. Additionally, digital hotlines, a growing modality, has not been examined for outcomes for service participants on key survivor needs like improved safety and health. We address these gaps in the literature through the study objectives of examining the short-term health and safety changes associated with first-time digital hotline use at 2 local violence-focused service agencies.

Methods

Approach

We leveraged data from a longitudinal, mixed methods multi-site evaluation on digital hotlines at the interpersonal violence focused agencies. In phase 1, we worked collaboratively with community partners serving survivors of interpersonal violence to develop a digital hotline service model. We then developed and tested the fidelity, use, and acceptability of this service model (see Wood et al ³⁸ for more information). In phase 2, we conducted a longitudinal study with first time digital hotline service users, with follow up assessments timed to match expected outcomes from the initial phase. Both phases were informed by community-centered evaluation approaches ³⁹ and the RE-AIM framework, ⁴⁰ in regards to community engagement, assessment of implementation context, and documentation of outcomes. We partnered with 2 large agencies operating in urban areas in Texas. Both agencies provided comprehensive services, including a 24/7 dedicated phone hotline, shelter, counseling, services in English and Spanish, and post-shelter housing. Relevant to the current study, both agencies have been providing digital hotline services via chat and text for at least 3 years.

Data Collection

We partnered with practitioners at the agencies to develop the survey that measured potential outcomes of digital hotline services. We then recruited participants through a brief promotional message offered at the end of their digital hotline service interaction. The study was advertised as an evaluation of the hotline service. We then routed interested participants who met eligibility requirements (i.e., first time using digital hotline, aged 16+, spoke English or Spanish) to the baseline survey. After completing the brief baseline survey (15 minutes on average) we collected preferred contact information for the 6-week follow-up online survey. We conducted retention checks by email, text, or phone (based on participant safety needs and preferences) between the first and second survey. Follow-up surveys were conducted via an online survey platform. We provided participants with a $30 electronic gift card for each survey (baseline and follow up) completed.

Measures

In addition to demographic questions developed from previous studies with violence survivors^14,15 and the first phase of the work ³⁸ (i.e., age, gender, race/ethnicity, education, employment, income, and housing situation), we asked participants about experiences with interpersonal violence, mental and physical health, and perceptions of safety, hope, and support.

We assessed IPV with 12 behaviorally specific items adapted from the National Intimate Partner and Sexual Violence Survey. ⁴¹ Types of IPV included physical (e.g., slapped, pushed, shoved, hit, slammed, or kicked you), sexual (e.g., made you have sex when you didn’t want to), and psychological (e.g., insulted, humiliated, or made fun of you in front of others). On the baseline survey, we queried participants on whether they experienced that type of harm in their lifetime and in the last 6 months. We asked participants at the 6-week follow-up if they had experienced each type of harm since their last survey. We considered participants to have experienced sexual or physical IPV if 1 or more of those items were endorsed, and psychological IPV if they experienced 2 or more items.

We assessed sexual assault by using 5 behaviorally specific items from the revised Sexual Experiences Survey, ⁴² that had been adapted for brevity including recent (last 6 month) and lifetime experiences of sexual violence (e.g., a person used physical force or threats of physical harm to put their fingers or an object in your vagina or anus).

We measured human trafficking with 6 questions from an adapted version of the Human Trafficking Screening Tool (HTST), with yes/no responses to assess for both sex and labor trafficking experiences in the last 6 months and over their lifetime (e.g. were you ever been unable to leave a place you worked or talk to people you wanted to talk to, even when you weren’t working, because the person you worked for, an intimate partner, or a family member threatened or controlled you). ⁴³ At the follow-up, we assessed for human trafficking over the prior 6 weeks.

We assessed stalking with 4 yes/no questions from NISVS (e.g., watched or followed you from a distance, or spied on you with a listening device, camera, or GPS [global positioning system]). ⁴¹ Participants endorsed 2 or more items were considered to have experienced stalking .

We assessed depression using a version of the Patient Health Questionnaire (PHQ-9), a 9-item self-report instrument used to assess the frequency of depressive symptoms over the past 2 weeks. ⁴⁴ For this study, we used eight of nine items, omitting the suicidal ideation question. Items are rated on a 4-point Likert scale ranging from 0 (“Not at all”) to 3 (“Nearly every day”), with total scores ranging from 0 to 24. ⁴⁵

We assessed symptoms of Post-Traumatic Stress Disorder (PTSD) with the PCL-5. ⁴⁶ Participants self-reported yes/no responses to 5 questions (e.g., been constantly on guard, watchful, or easily startled) on the experiences they have had in the last month. The items were summed to create a total score and we considered participants with total scores of 4 or greater as probable for PTSD.

We measured Physical Health with a single item from the Short Form Health Survey (SF-36) in which participants rated their overall perception of health on a scale from poor and excellent. ⁴⁷

We assessed participant Hope using the abbreviated Hope Hearth Scale,^48,49 which is a 7-item (e.g., I have a positive attitude toward life) scale where participants rate items on a 5-point Likert scale ranging from 1 “Not at all” to 5 “A great deal.”

We used subscales from Measure of Victim Empowerment Related to Safety (MOVERS) ⁵⁰ to assess participant safety-related empowerment to assess internal tools (e.g., I know what my next steps are on the path to keeping safe), and expectations of support (e.g., I feel comfortable asking for help to keep safe) . Participants responded to each item using a 5-point Likert scale anchored by 1 “never true” and 5 “always true.”

Service Engagement and Experience

Participants reported prior phone hotline use at baseline and repeated phone or digital hotline use at follow-up. We also queried participants about service engagement in other services provided by the hotline agency and at other organizations. At baseline, participants reported on their perceptions of their connection to the advocate^51,52 and a study-developed measure for reasons for reaching out to the hotline (Wood et al ³⁸ for peer review).

Data Analysis

We used descriptive statistics to provide a demographic profile of the study sample. We estimated study measures for both baseline and short-term follow-up (6 weeks) using incidence rates, means, and standard deviations. We used paired sample t-tests and McNemar’s chi-square tests to estimate within person change for continuous and categorical study outcomes respectively. We used regression modeling to estimate the association of demographic and service factors (i.e., repeat hotline use, past hotline use, housing needs, and connection to advocate) with the short term change in health (i.e., depressive symptoms, PTSD symptoms, general health, and hope) and safety (i.e., IPV, human trafficking, sexual assault, self-reported perception of safety, internal tools related to safety, and expectation of support related to safety). We used linear regression for continuous outcomes measures and logistic regression for binary outcomes. We entered all factors for a given outcome into a single model. We determined statistical significance using the Wald test with type I error set at 0.05. We developed the analytic plan a priori.

Results

The baseline sample was 307 participants. For the current study, we included the participants who completed the baseline and follow up survey (n = 237; 77% retention rate). No differences emerged between those retained in the study and those lost to follow-up. As shown in Table 1, participants were primarily female (91.4%), with a mean age of 34 (range of 17-65), and identified as Black (27%), White (30%), and Hispanic (32%). Participants were evenly distributed between the agencies (54% vs. 46%). At baseline, 74.1% had experienced IPV in the past six, 16.6% of experienced past human trafficking in the past 6 months; 39.7% had experienced stalking in the past 6 months; and 38.8% had experienced sexual assault in the past 6 months. In table 1, we show both the baseline sample and the baseline and follow up sample.

Table 1.

Participant Demographics at Baseline.

Demographic category	Baseline sample (n = 307)		Baseline and FU sample (n = 237)
	n	%	n	%
Gender
Female	279	90.9	215	91.4
Additional categories	38	9.1	22	8.6
Race and ethnicity
Black/African American	73	23.8	64	27.0
Hispanic/Latina	93	30.3	72	31.6
White/Caucasian	96	31.3	75	30.4
Multiracial	31	10.1	20	8.4
Asian/Pacific Islander	14	4.5	6	2.5
Sexual orientation
Gay/lesbian	15	4.9	12	5.0
Bisexual/pansexual	64	20.9	50	21.1
Queer/additional	18	5.8	11	4.7
Straight/heterosexual	209	68.3	164	69.2
Current housing
House or apartment owned	32	10.5	24	10.2
House of apartment rented	114	37.4	86	36.6
Stay with friends or family	66	21.6	49	20.9
Housing voucher/program	10	3.3	13	5.5
IPV shelter	14	4.6	11	4.7
Hotel/motel	18	5.9	17	7.2
Vehicle	19	6.2	13	5.5
Outside/abandoned building	14	4.6	10	4.3
Other	16	5.2	12	5.1
Monthly income
Less than $500	120	39.3	91	38.6
$501-1000	49	16.1	37	15.7
$1001-2000	55	18.0	45	19.1
$2001-3000	31	10.2	26	11.0
$3001-4000	19	6.2	12	5.1
$4001 or more	21	10.2	25	10.6
Employment status
Full-time	86	28.1	67	28.4
Part-time	48	15.7	39	16.5
Gig or seasonal	19	6.2	16	6.8
Not employed, looking	92	30.1	74	31.4
Not employed, not looking	20	6.5	11	4.7
Not employed, caregiver	30	9.8	22	9.3
Other	11	3.6	7	2.9
Violence experiences
IPV (last 6 months)	229	76.3	172	74.1
Sexual assault (last 6 months)	117	39.3	90	38.8
Stalking (last 6 months)	126	41.6	93	39.7
Human trafficking	51	17.8	37	16.6

At baseline, 80.6% of the participants indicated that they felt somewhat or very connected to their hotline advocate. At baseline, 44% had used phone hotline previously.

Health Changes

As shown in Table 2, decreases emerged in symptoms of severe depression (21.5% vs 12.5%, P = .01) and probable PTSD (73.1% vs 60.6%, P < .001) from baseline to 6-week follow-up, respectively. Feelings of hope significantly increased from baseline to 6-week follow-up (2.4 vs 2.5, P = .007). We did not observe changes in general physical health.

Table 2.

Health and Safety Changes at 6 Weeks.

Outcome	Baseline (n)%	6 week follow-up (n)%	Test for within-person change
			Test statistic chi-square	P-value
Depression classification			22.5 (10) 1	.01 1
None	(33) 14.8	(44) 19.6
Mild	(53) 23.8	(61) 27.2
Moderate	(38) 17.0	(52) 23.2
Moderately severe	(51) 22.9	(39) 17.4
Severe	(48) 21.5	(28) 12.5
Probable PTSD	(166)73.1	(132) 60.6	3.88 1	<.001 1
General health			12.7 (10) 1	.24 1
Poor	(22) 9.3	(23) 9.7
Fair	(54) 22.8	(47) 19.8
Good	(82) 34.6	(85) 35.9
Very good	(54) 22.8	(59) 24.9
Excellent	(25)10.5	(23) 9.7
Perception of safety			28.4 (10) 1	.002 1
Very unsafe	(25) 10.7	11 (4.7)
A little unsafe	(37) 15.8	17 (7.2)
A little safe	(46) 19.7	46 (19.5)
Safe	(72) 30.8	85 (36.0)
Very safe	(54) 23.1	77 (32.6)
	Mean (SD)	Mean (SD)	Test statistic t-test	P-value 2
Depression symptoms	12.8 (7.3)	10.8 (6.6)	4.5	<.001
Overall hope score	2.4 (1.1)	2.5 (1.0)	−2.7	.007
Expectations of support (MOVERS)	2.0 (1.1)	2.3 (1.1)	−3.6	<.001
Internal tools (MOVERS)	2.3 (1.0)	2.4 (1.0)	−2.6	.009

¹McNeMar’s chi-square test (for more than 2 categories, Bowkers-McNemar’s used).

²Paired t-test.

Violence Experiences at Follow-Up

Rate of violence at baseline used a 6 month recall while rates at follow up used a 6 week follow up, therefore a direct comparison of change cannot be made. At follow-up, 54.5% had experienced IPV in the past 6 weeks; 16.4% had experienced trafficking in the past 6 weeks; 23.5% had experienced stalking in the past 6 weeks; and 25% had experienced sexual assault in the past 6 weeks.

Safety Outcomes

At follow-up, participants felt safer (P = .002), reported higher levels of internal tools related to safety (P = .009), and increased external support related to safety (P = .001).

Demographic and Safety Factors Associated With Changes in Health and Safety

Table 3 provides the estimated associations of each of the demographic and safety factors to changes in health, including depressive symptoms, PTSD symptoms, general health, and hope. Repeat hotline use was significantly associated with changes in PTSD symptoms (P = .004). Participants reporting subsequent hotline use were 0.59 higher on their change from baseline of PTSD symptoms than those who did not report repeat hotline use after baseline. No other demographic or safety factors were found to be significantly related to any of the other health outcomes.

Table 3.

Association of Demographic and Service Factors to Health Changes.

Factors	Change in depressive symptoms			Change in PTSD symptoms			Change in general health			Change in hope scale
	Beta	SE	P-value	Beta	SE	P-value	Beta	SE	P-value	Beta	SE	P-value
Age
16-25 (ref)
26-39	−.03	1.01	.97	−.21	0.27	.45	.04	0.17	.83	.11	0.14	.41
40+	1.23	1.12	.27	−.06	0.30	.85	.11	0.18	.56	.01	0.15	.93
Race/ethnicity
White (ref)
Black	−.09	0.97	.93	−.19	0.27	.48	.17	0.16	.29	−.11	0.13	.40
Hispanic	−1.28	0.94	.18	−.03	0.26	.90	.10	0.15	.53	.02	0.13	.88
Multi/other	−.50	1.23	.68	−.60	0.36	.10	.12	0.21	.57	−.07	0.17	.71
Sexual orientation
Heterosexual	−.77	0.82	.35	−.06	0.22	.80	−.06	0.13	.66	.03	0.11	.81
Income
Less than $500 (ref)
$500-$2000	−1.01	0.87	.25	−.31	0.24	.20	−.13	0.14	.38	−.10	0.12	.40
$2001+	.67	0.96	.48	.05	0.26	.86	−.05	0.16	.74	−.23	0.13	.07
Repeat hotline use	1.34	0.73	.07	.59	0.21	.004	.13	0.12	.28	−.02	0.10	.81
Past hotline use	−.20	0.76	.79	−.03	0.21	.90	−.13	0.12	.31	−.13	0.10	.19
Housing need	.61	0.91	.51	−.24	0.25	.33	.09	0.15	.55	−.01	0.12	.93
Connection to hotline advocate	−.28	0.34	.41	.10	0.10	.30	.02	0.06	.72	.01	0.05	.90

Note. All models are adjusted for the baseline value of the dependent variable. Linear regression models presented; all factors entered into a single model.

As demonstrated in Table 4, survivors who had repeat hotline use had 1.91 (P = .02) the odds of experiencing IPV than those who did not use the hotline after baseline. No factors were linked to the 6-week incidence of human trafficking. Participants between the ages of 26 to 39 and those aged 40+ were less likely to experience subsequent sexual assault less likely to experience sexual assault compared to those in the 16 to 25 years old range (OR = 0.35, P = .01 and OR = 0.37, P = .03, respectively).

Table 4.

Association of Demographic and Service Factors to Subsequent Violence Experience.

Factors	Any IPV at 6 weeks				Human trafficking at 6 weeks				Sexual assault at 6 weeks
	OR	95% CI		P-value	OR	95% CI		P-value	OR	95% CI		P-value
Age
16-25 (ref)
26-39	0.70	0.34	1.47	.35	1.39	0.46	4.20	.56	0.35	0.16	0.79	.01
40+	1.37	0.59	3.16	.46	1.81	0.56	5.80	.32	0.37	0.15	0.91	.03
Race/ethnicity
White (ref)
Black	1.69	0.81	3.55	.16	1.86	0.74	4.67	.19	1.76	0.79	3.94	.17
Hispanic	0.84	0.42	1.69	.63	0.60	0.21	1.71	.34	0.69	0.29	1.63	.40
Multi/other	0.55	0.21	1.47	.24	1.26	0.30	5.30	.75	1.04	0.32	3.38	.96
Sexual orientation
Heterosexual	1.38	0.75	2.51	.30	1.11	0.48	2.58	.81	1.24	0.61	2.54	.55
Income
Less than $500 (ref)
$500-$2000	1.36	0.71	2.62	.36	1.72	0.73	4.04	.22	0.99	0.48	2.08	.99
$2001+	1.25	0.61	2.56	.54	0.67	0.23	1.96	.46	0.80	0.34	1.90	.62
Repeat hotline	1.91	1.09	3.35	.02	1.08	0.51	2.30	.84	1.59	0.84	3.02	.15
Past hotline	1.01	0.57	1.79	.97	1.21	0.56	2.62	.62	1.43	0.74	2.75	.28
Housing need	1.55	0.79	3.05	.21	2.10	0.92	4.80	.08	2.01	0.97	4.13	.06

Note. Logistic regression models presented; all factors entered into a single model.

OR = odds ratio.

As shown in Table 5 we did not observe any associations between perceived safety or expectation of support related to safety. However, age was significantly associated with changes to internal tools, with participants 40 + having a higher change in their internal tools score relative to those aged 16 to 25 (beta = .32, P = .05). Similarly to other study outcomes, past hotline use was significantly associated with a decrease in the internal tools related to safety score (−.29, P = .01) relative to participants who did not use the hotline again after baseline.

Table 5.

Association of Demographic and Service Factors and Safety Factors.

Factors	Change in safety			Change internal tools			Change in expectation of support
	Beta	SE	P-value	Beta	SE	P-value	Beta	SE	P-value
Age
16-25 (ref)
26-39	0.05	0.19	.77	0.25	0.15	.10	−0.11	0.18	.55
40+	−0.09	0.21	.68	0.32	0.17	.05	−0.02	0.20	.93
Race/ethnicity
White (ref)
Black	0.24	0.18	.18	0.07	0.15	.64	−0.06	0.18	.73
Hispanic	0.06	0.17	.73	−0.07	0.14	.61	−0.02	0.17	.92
Multi/Other	−0.14	0.24	.55	0.02	0.20	.91	−0.04	0.24	.87
Sexual orientation
Heterosexual	−0.06	0.15	.69	−0.07	0.12	.54	0.10	0.15	.49
Income
Less than $500 (ref)
$500-$2000	−0.19	0.16	.24	0.10	0.13	.43	−0.03	0.16	.85
$2001+	−0.13	0.18	.48	−0.03	0.14	.86	0.08	0.18	.66
Repeat Hotline	−0.16	0.14	.25	−0.16	0.11	.16	0.00	0.14	.99
Past Hotline	−0.11	0.14	.44	−0.29	0.12	.01	−0.07	0.14	.64
Housing Need	−0.15	0.16	.36	0.06	0.13	.67	0.10	0.16	.56

Note. All models are adjusted for the baseline value of the dependent variable. Linear regression models presented; all factors entered into a single model.

Subsequent Hotline Service Use

Based on the results of our regression analysis, we examined characteristics of post-hotline use. At follow-up, 45.9% of participants had used hotline in digital or phone format again. Participants who used hotline again did not differ significantly on age, sexual orientation, or race and ethnicity, but differed on income. Over 42% of those making $500 or less using hotline again versus 35.4% of those who did not. Further, those who used hotline again endorsed high levels of IPV, sexual assault, stalking or trafficking in the past 6 weeks (62.6) compared to those who did not use hotline again (47.2%).

Discussion

Hotlines are typically the first, and often only, service an interpersonal violence survivor may use when seeking help for IPV, human trafficking, stalking, or sexual assault. In our study of 237 first time service hotline participants surveyed at initial use, and 6 weeks later, we found that digital (chat/text) hotline provided by community-based violence-focused agencies was associated with improvements in health and safety for survivors of violence. Six weeks after initial use, significant reductions in probable depression and PTSD were observed, and hope increased, suggesting that immediate supportive connections and information may have helped to reduce stress and increase safety, supporting mental health improvement. Notably, hope is positively related to positive mental health changes in violence survivors, including reduced psychological distress, improved coping, and enhanced overall well-being.^53,54 Changes in severe depression are particularly notable as depression has been associated with increased risk of revictimization and difficulty engaging in safety planning or accessing services.^53,55,56 Furthermore, reductions in PTSD, one of the most common mental health challenges among those with histories of interpersonal violence, could indicate associated improvement in health and functioning, which are essential for navigating legal, housing, and social service systems that may also facilitate revictimization risk reduction.^57,58 That we observed these changes after only 6 weeks is encouraging. Further, our findings support COR and crisis intervention theoretical perspectives that resource gains from digital hotline help future health and safety losses. This study joins recent research to indicate that both online disclosure ²⁹ and non-residential services provided by violence-focused agencies are effective at addressing safety needs, resource access, and health needs, including mental health support.^{4,13 -15}

Few demographic factors were related to post-hotline related changes; however, younger participants (16-25) were noticeably more likely to experience sexual assault in the short follow up period. This finding mirrors previous studies that indicate an increased risk for sexual violence among adolescents and emerging adults.^{59 -61} Digital hotline participants also reported increases in positive perception of safety, internal tools, or personal efficacy related to safety, and expectations of social and material support related to safety. This finding was especially noticeable among older survivors (40+). While these safety-related changes may be in part to shifting circumstances, they are also likely related to 2 core facets of the digital service model: safety planning and supportive connections. ¹⁹ Our results build on prior research illustrating that individualized and real-time safety planning enhances survivors’ ability to manage risk, reduce feelings of distress, and promote long-term well-being.^{19,23,36,37,62}

At 6 week follow up, nearly half of the study participants reported accessing hotline services (either by phone or digital means) since their baseline assessment. Repeated use was associated with lower income levels and internal tools related to safety, and higher levels of PTSD and IPV at follow-up. Unsurprisingly, repeated hotline use appears to be connected to ongoing safety and health needs, and indicates that survivors with evolving safety and resource contexts require multiple doses of hotline services to address their needs. Additionally, given that community-based services for violence survivors often are understaffed, underfunded, and experience wait times, ¹² it could be that some survivors are still waiting for additional services 6 weeks later, but hotline is uniquely accessible. While repeated hotline use is likely associated with ongoing safety and health needs meriting additional support, it may also be connected to a lack of service access due to limited agency capacity. Of note, human trafficking increased significantly from baseline to 6 weeks follow up, which could be in part due to the evolving coercion in IPV relationships, ongoing sexual assault leading to trafficking behaviors, changing vulnerabilities among the safety status of some survivors creating risks for polyvictimization, ⁶³ or increased knowledge of what constitutes trafficking (perhaps related to their baseline call). Study findings join other recent work ⁶⁴ indicating a focus on trafficking experiences and risks when seeking violence-focused services is needed to address risks for victimization.

Implications

Present findings have important implications for hotline use. First, improved safety and connection highlights the efficacy of the service model as a rapid intervention. While this service should be paired with on-going support as needed, it serves as a crucial front door and provides an opportunity for engagement in potentially critically important post-violence (or even pre-violence) window when outcomes are most up in the air. Second, the importance of service access in preferred formats helps facilitate a survivor-centered and trauma-informed model, a hallmark of best practices in the interpersonal violence services.^26,36 This model may be preferable in certain environmental (e.g. public health emergency); safety (e.g. proximity to partner) and developmental (e.g. age) contexts, which should be explored at greater lengths. Third, our study reiterates the intense work conditions of hotline staff, and the need for training and support to staff. Given the potential impact of hotline, services should be staffed experienced advocates who are well compensated for their work and receive robust agency support. Future research should explore how demographic and service use uniquely impacts potential hotline impacts, and should extend to programs outside the U.S. Finally, our findings underscore the urgent need for more longitudinal investigation on hotline (in phone and digital formats), with a comparative group and quasi-experimental designs, to understand service impact. Research is urgently needed to understand for whom hotline is an effective single session intervention, and which participants benefit from repeated dosage. This information could help modify assessment tools used on hotline and address waits for other services (e.g. counseling, shelter).

Limitations

While our project has many strengths, including being one of the first longitudinal studies of digital hotline use for IPV, sexual assault, human trafficking, and stalking survivors, there a few limitations to note. We collected data from a single state in the U.S. and 2 sites in large urban areas, limiting our understanding of rural and suburban groups. The current study lacks a comparative group, making causal inherences limited. Our study did not include a comparative group that had not used digital hotline services, and some participants had used phone hotline previously. We were not able to collect data before participants’ first digital hotline service indication. Finally, our data is limited by the inherent challenges with self-report data.

Conclusions

Hotline in phone or digital forms is a critical first service for survivors of intimate partner violence, sexual assault, human trafficking, and stalking. In our study, positive health and safety changes were observed 6 weeks after hotline use, indicating the potential for this service to address the timely needs of violence survivors. Given the primary role of hotline and helpline in the movement to end interpersonal violence, these study findings indicate that short term gains may occur from this low-barrier service. Study findings indicate the potential for digital hotline to rapidly address timely health and safety needs, thus potentially reducing the need for additional services or aiding the service path to longer-term help. Longer-term and expanded study is needed of digital hotline to further examine potential impacts, however these findings suggest that hotline is not merely a conduit to other services, but a potentially impactful intervention into itself.