Coping with COVID-19: Using Behavioral Science and Digital Health to Promote Healthy Families (2020-2021)


Around the globe, physical distancing has been implemented to reduce transmission of the novel coronavirus, SARS-CoV-2. These measures have flattened the curve in many places, but they have also resulted in prolonged social isolation, reduced access to health services and economic hardship. The rapidly evolving nature of the pandemic has left organizations unprepared to respond to the needs of families coping with significant adversity.

During the pandemic, a secondary mental health crisis has emerged, and family relationships can be a major source of risk or protection. Many families are facing disrupted routines, financial stress from job loss, pressures to work from home while caring for children and illness. During a time like this, family conflict, conflict within couples and parenting challenges are inevitable. The ways in which families address conflict and support one another makes a difference in mental health outcomes among both children and adults.

Evidence-based interventions exist to improve couples and family relationships to prevent mental health consequences and family violence. However, relatively few people in low-resource settings have access to these, as they are often delivered through strong health systems with availability of professionals. Access is further limited during the pandemic as in-person services are very limited. There is an urgent need for accessible interventions that can feasibly be scaled in low-resource settings.

Project Description

This project team will help address the need for feasible, scalable interventions to strengthen family relationships in low-resource settings during this pandemic. Team members will engage in two primary projects one domestic and one global to adapt and pilot evidence-based intervention strategies for virtual delivery in North Carolina, Kenya and India.

Project 1: Virtual Family Interventions Delivered by Lay Providers in North Carolina

The aim of this project is to develop an intervention that can be delivered by lay providers that reduces conflict and improves problem-solving, connection and supportiveness within families. Team members will develop an approach that a) serves families experiencing high levels of relationship distress coupled with other socioeconomic vulnerabilities and b) is feasible and scalable in areas with low access to mental healthcare including rural communities. This subgroup will have three specific aims:

  1. Conduct community-based participatory research to a) identify community partners who work with families and children and are positioned to deliver family-based interventions and b) work with partners to identify specific needs and ideas for delivering family interventions in ways that fit with their values and normal operations.
  2. Develop an intervention that can be delivered by a wide range of providers, including lay providers without previous mental health training. This intervention will be developed using participatory methods with partners identified by the group. It will also draw from the lay provider-delivered interventions already implemented by Dr. Puffer and her colleagues in Kenya and other low- to middle-income country settings. The intervention will be adapted for virtual delivery.
  3. Conduct a small pilot trial with community partners and evaluate implementation outcomes related to feasibility and acceptability. Team members will also conduct a pre/post evaluation on clinical outcomes as preliminary data on efficacy of the intervention.
Project 2: Promoting Healthy Families via Remote Engagement in Kenya and India

The aim of this project is to develop and test a behavior change communication intervention for promoting health and resilience among couples and families. The team will leverage Dr. Green’s involvement with a digital health start-up called Nivi to reach thousands of families in Kenya and India. Dr. Green and his team have developed an automated chat service, askNivi, that is available for free through SMS, Facebook Messenger and WhatsApp. askNivi makes it simple and fun for men, women and youth to learn about key health topics and take action and has more than two million users in India, Kenya and South Africa. The company recently launched a global chat service in response to the COVID-19 pandemic.

Team members will work remotely with the Nivi team to develop and test new automated conversations based on Dr. Puffer’s existing in-person intervention content. We will recruit adult participants through opt-in Facebook advertising, screen for eligibility via askNivi and randomly assign enrolled participants to two or more study arms. The control arm will be invited to engage with Nivi’s existing COVID content. The treatment arm will have access to the same content but will also be invited to engage with the new family intervention content. It is possible that the team will be able to develop several treatment arms that compare the efficacy of different engagement strategies (e.g., text only, text + images, text + images + video). The primary outcome will be self-reported relationship behavior change and well-being.

Anticipated Outputs

Virtual intervention and plan for delivery by lay providers; datasets; academic publications


Fall 2020 – Summer 2021

Project 1
  • Fall 2020: Begin community-based participatory research (Project 1); develop intervention; initiate small pilot trial of intervention
  • Spring 2021: Complete pilot trial; analyze data
  • Summer 2021: Write manuscript for publication
Project 2
  • Fall 2020: Develop intervention content; upload content to ask Nivi and run pilot test; develop recruitment strategy; begin trial
  • Spring 2021: Continue trial; analyze data
  • Summer 2021: Write manuscript for publication


COVID-19 and Global Mental Health

This Team in the News

A Family Support Model Developed in Kenya Comes to North Carolina

Eight Duke Scholars Examining the Mental Health Effects of the Pandemic

Faculty Perspectives: Gabriela Nagy

Digital health.

Team Leaders

  • Eric Green, Duke Global Health Institute
  • Eve Puffer, Arts & Sciences-Psychology and Neuroscience
  • Amber Rieder, Duke Global Health Institute

/graduate Team Members

  • Savannah Johnson, Psychology-PHD
  • Mahgul Mansoor, Global Health - MSc
  • Kaitlin Quick, Global Health - MSc
  • Justin Rasmussen, Psychology-PHD

/undergraduate Team Members

  • Emily Duerr
  • Sierra Jones, Psychology (AB)
  • Pippa Lother
  • Sara Mehta
  • Preetha Ramachandran, Cultural Anthropology (AB), Neuroscience (BS2)

/yfaculty/staff Team Members

  • David Eagle, Duke Global Health Institute
  • Gabriela Nagy Carrasquel, School of Medicine-Psychiatry and Behavioral Sciences
  • Rae Jean Proeschold-Bell, Duke Global Health Institute
  • Tiarney Ritchwood, School of Medicine-Family Medicine and Community Health

/zcommunity Team Members

  • Nivi
  • West End Community Foundation
  • Together for Resilient Youth (TRY)