Mhealth and Young People in South Africa

mHealth and Young People in South Africa

for every child ACKNOWLEDGEMENTS

This report has benefited from a wide range of inputs received from various organizations and individuals involved in the development and implementation of programmes for young people in South Africa. Thanks go to the following people who provided valuable information and insights on the mHealth services reviewed in this report: Jesse Coleman (Wits Reproductive Health Institute), Jade Archer (New loveLife Trust), Alex Kayle (HIVSA), Tamsen de Beer and Pippa Yeats (Praekelt Foundation), Rosamund Haden (FunDza Literacy Trust), Glenn de Swardt and Tanya Bencun (Anova Health Institute), Isabelle Amazon-Brown (Every1Mobile), Andrew Rudge and Maru Fourie (Mxit Reach) and Katherine de Tolly.

The author gratefully acknowledges Dr Jackie Mangoma- Chaurura, Ronel Rademayer and Lesego Mokoene (New loveLife Trust), Dr Nobs Mwanda and Ogopoleng Maramela (COPESSA) and Dinah Tshabangu who facilitated the focus group discussions with the young people that informed this report. Special thanks are due to the young people who took the time to participate in focus group discussions and the survey, providing important insights into their lives.

The author of this report is Sandisile Tshuma, with input and support from Dr Sanjana Bhardwaj (UNICEF), Helen Alexander and Peter Benjamin (HealthEnabled).

This report was supported by the MAC AIDS fund. TABLE OF CONTENTS

ACRONYMS ...... 3 3 2. Digital services in South Africa whose users include young people...... 28 EXECUTIVE SUMMARY ...... 4 3 .3 Gender composition of mhealth Methodology ...... 4 service users...... 30 Findings ...... 4 3 .4 Geographical distribution of young people using mHealth services...... 30 Recommendations ...... 5 3 .5 Challenges with obtaining INTRODUCTION...... 7 user demographic data...... 31 3 .6 mHealth service providers...... 31 1 .0 BACKGROUND...... 8 1 .1 Snapshot of young people, sexual 4 0. ENGAGING YOUNG PEOPLE and reproductive health...... 8 ON DIGITAL PLATFORMS...... 32 HIV Incidence is Declining ...... 8 4 .1 Communication approaches ...... 32 1 .2 Snapshot of Internet and mobile Entertainment education approach...... 32 phone usage in South Africa...... 8 Use of gaming principles ...... 32 Young People are Connected...... 8 4 .2 Marketing mHealth services ...... 32 1 .3 Methodology...... 9 Promotion on digital channels...... 32 1 .3 .1 Focus group sites...... 9 Promotion by health service providers. . . . . 33 1 .3 .2 Focus group participant sampling . . . . 10 Promotion by role models, champions 1 .3 .4 Online survey...... 10 and peer mentors...... 33 1 .3 .5 Limitations...... 10 5 0. MHEALTH SERVICES FOR SOUTH AFRICA’S 2 .0 YOUNG PEOPLE’S MOBILE COMMUNICATION YOUNG KEY POPULATIONS ...... 34 EXPERIENCES AND PREFERENCES...... 11 5 .1 Young People Living with HIV...... 34 2 .1 Current sources of information...... 13 Retention in care and adherence support through virtual support groups...... 34 2 .2 Preferred sources of health information. . . 15 Mental health support...... 35 2 .3 Cost of cell phone use ...... 16 5 .2 Adolescent girls and young women. . . . . 36 2 .4 Preferred communication approaches. . . . 17 5 .3 Young Men who have Sex with Men . . . . 36 2 .5 Young people are spending time online. . . 17 5 .4 Other young key populations ...... 36 2 .6 Gravidity and parity ...... 17 6 0. LESSONS LEARNT AND RECOMMENDATIONS. . . . 37 2 .7 Knowledge of HIV status...... 18 2 .8 Missed opportunities for HIV testing . . . . 18 APPENDIX 1: LIST OF KEY INFORMANTS...... 39

3 .0 DIGITAL SOURCES OF HEALTH INFORMATION IN APPENDIX 2: FOCUS GROUP DISCUSSION GUIDE. . . .. 40 SOUTH AFRICA...... 22 APPENDIX 3: ONLINE SURVEY QUESTIONNAIRE. . . . . 41 3 .1 Digital sources of health information specifically targeting young people in South Africa. . . . . 22 LIST OF REFERENCES...... 43

ACRONYMS

AIDS Acquired Immune Deficiency Syndrome COPESSA Community-based Prevention and Empowerment Strategies for South Africa GSMA Global System for Mobile Communications Association HI4LIFE Health Information for Life HIV Human Immunodeficiency Virus HSRC Human Sciences Research Council loveLife New loveLife Trust LSM Living Standards Measure mHealth Mobile health PCM Please Call Me SAARF South African Audience Research Foundation SMS Short Message Service SRHR Sexual and Reproductive Health and Rights UNICEF United Nations Children’s Fund WAP Wireless Application Protocol EXECUTIVE SUMMARY

This report identifies digital resources targeted at providing adolescents and young people in South Africa with sexual and reproductive health and rights (SRHR), family planning and healthy pregnancy information and advice. The report explores young people’s self-reported online behaviours and preferred sources of information on health-related issues and their experiences with using their mobile phones including the enablers and barriers to the use of mobile phones for health-related activities. Data was collected during the period from November to December 2015. The purpose of the report is to understand strengths and limitations of existing mHealth services in reaching adolescents and young people in South Africa, particularly those who are especially vulnerable or marginalised with information and other services that will promote their sexual and reproductive health and wellbeing, including the health and wellbeing of infants and children born to young parents.

METHODOLOGY

Primary data were collected through focus group discussions with young people and an online survey of young people. Furthermore, key informant were interviews conducted with individuals involved in the development of the various mHealth services documented in the review. Secondary data on mHealth services were also reviewed and used to inform certain components of the report, namely a framework profiling the characteristics of mHealth interventions in South Africa, in terms of the type of technology used, target audience, content development, demographic characteristics of audience reached and any evaluation findings and implementation challenges experienced and lessons learnt.

FINDINGS

The study found that young people in urban and rural areas use their mobile phones regularly for communicating socially as well as to seek information on a range of issues such as career advice, entertainment, education and research and health. Eighty-four percent of young people expressed willingness and openness to obtaining sexual health information using their mobile phones, if it was free. Differing views were expressed about whether they would prefer to communicate directly with a professional via text or voice call. Some were in favour of the anonymity of talking to a stranger, while others did not feel comfortable to discuss personal issues and take advice from a stranger. Of those who were in favour of engaging directly with a professional, texting was preferred over voice communication as it offered more privacy. The cost of mobile data and airtime was cited as a major influence on the extent to which young people currently use their phones for information and their willingness to use mHealth services. Most of the young people who reported that they have been tested for HIV have either been pregnant or are currently pregnant. Also most of the young people who reported never having been tested for HIV have either not had children (in the case of females) or are males.

Out of twenty-five services addressing SRHR (including HIV prevention, treatment and care), maternal and child health, nineteen services were specifically aimed at young people and adolescents. The majority of services offered included information aimed at increasing knowledge and shifting norms around sex, sexuality and sexual and reproductive health while some services offered emotional support and counseling, for instance, to young people living with HIV. Significant gaps in information were found with regard to variables such as the numbers of users reached and their demographic characteristics. Many services reported that they had not built in the required systems to collect and monitor this level of information, while other services did not have the information readily available at the time of the report. Few services were developed on the basis of a clearly articulated behaviour change theory or model and none of the services have as yet formally evaluated their impact on health related behaviour and knowledge among young people. Anecdotal evidence from young people interviewed in focus groups suggests that digital health services are not well marketed to their intended audience, limiting their reach.

RECOMMENDATIONS

Existing or future digital health interventions should be strengthened in terms of having sound monitoring and rigorous evaluation systems in order for decisions to be made on the basis of evidence on their efficacy in contributing to young people’s health outcomes. Furthermore, content should be based on social and behaviour change theory and evidence, should conform to international best practice and should be scientifically accurate. Content should be developed with a view to ensuring maximal engagement and interactivity to ensure reinforcement of key messages and desired behaviors and continuous moderation is required to ensure consistency in messaging as well as the safety of young users on digital platforms. Services that are well marketed and zero- rated to users with constantly updated content stand the highest likelihood of high uptake among young people. There is also an opportunity for an mHealth solution to be developed to target boys and young men, as well as girls and young women with information about HIV testing and counseling, which should ideally link them to their nearest testing centre as this demographic has been shown to have low uptake of HTC.

INTRODUCTION

This report was commissioned by HealthEnabled as part of a grant provided by UNICEF South Africa with a view to assessing opportunities and gaps for using digital tools to support HIV prevention and treatment for babies, children and adolescents in South Africa. The report seeks to identify existing sources of information used by adolescents for sexual and reproductive health (SRHR), family planning and healthy pregnancy information and advice, specifically including digital health resources and recommendations for strengthening existing digital health solutions or developing new solutions to address any gaps. This was done to understand not only what existing digital services are available to adolescents and young people but also to profile the demographic characteristics of young people currently using digital services and their online behaviours as well as to understand the enablers and constraints to young people’s use of digital services. 1 .0 BACKGROUND

1 .1 SNAPSHOT OF YOUNG PEOPLE, SEXUAL AND 1 2. SNAPSHOT OF INTERNET AND MOBILE PHONE REPRODUCTIVE HEALTH USAGE IN SOUTH AFRICA

HIV Incidence is Declining Young People are Connected

The 2012 Prevalence Incidence and Behaviour Survey conducted Data released by the South African Audience Research by the HSRC revealed that HIV incidence among 15-24 year Foundation (SAARF) for the period running from July 2014 to olds is on the decline in South Africa 1. Among adolescent girls June 2015 showed increases in access to cell phones in the and young women in this age group the incidence has declined adult population (aged 15 years and above), ranging from approx- by 60% from 5 .3% in 2002 to 2005 to 2 .1% in 2008 – 2012 . imately 81% among LSM* 5 – 7 to 95% among LSM 8 – 10 2. However, knowledge levels about HIV have declined between These increases, were not, however, statistically significant . 2008 and 2012 and condom use at last sex, while higher than in Internet usage is on the rise although there are wide gaps other age categories, has also declined among 15-24 year olds . between Internet usage among the lowest and highest LSM .

CHART 1: HIV INCIDENCE (%) AMONG 15-24 YEAR OLDS IN SOUTH AFRICA IS ON THE DECLINE

2.8%

2.3%

1.5%

2002-2005 2005-2008 2008-2012

Source: Shisana et al., 2014

CHART 2: CONDOM USE AND HIV KNOWLEDGE HAVE DECLINED AMONG SOUTH AFRICA YOUTH AGED 15-24

45% Condom use Knowledge about HIV

35% 36.2%

29.4% 28.6%

2005 2008 2012

Source: Shisana et al., 2014

*Living Standards Measure developed by SAARF to segment the population according to wealth. The measure is scaled from 1 – 10 according to increasing wealth (http://www.saarf.co.za/LSM/lsms.asp).

8 • UNICEF TABLE 1: MOBILE PHONE OWNERSHIP AND USE AMONG SOUTH AFRICAN YOUTH .

CURRENT OWNERSHIP OF MOBILE USE OF MOBILE PHONE IN PREVIOUS AGE SEGMENT PHONE (2014) FOUR WEEKS

8 – 13 years 34% 78%

14 – 18 years 69% 92%

19 – 25 years 89% 97%

Source: Hampshire et al., 2015.

Almost 17% of LSM 1-4 had used the Internet in the previous The purpose of the key informant interviews was to understand seven days in June 2015 compared to 7 .5% in June 2014 . the experiences of mHealth service providers in reaching ado- Increases in Internet usage among the other LSM also rose lescents and young people and to document any challenges and although not as dramatically as with the lower income users . lessons learnt from existing services . The list of key informants interviewed is available in Appendix 2 . Secondary data on According to a 2014 GSMA report on 15 – 49 year old pregnant mHealth services was also reviewed and used to inform certain women and mothers of children up to age two found that 94% components of the report, namely a framework profiling the of the women classified as “bottom of the pyramid” in terms characteristics of mHealth interventions in South Africa (see of socioeconomic status owned cell phones and the remaining appendix 1) . 6% could access a phone within the family 3. A 2014 study by Hampshire and others (2014) found that 50 .8% of 18-year-old 1 .3 .1 Focus group sites South Africans surveyed owned a cell phone in 2014 with up to 70% having ever owned a cell phone and 77 .2% using a cell Protea Glen is a suburb in the south of Johannesburg comprised phone in the previous week 4. As expected, younger adolescent of informal, lower- and middle-income households . It was ownership was low but young adolescents do have access to selected as a site for focus group discussions as it houses a mobile phones . typical heterogeneous population of urban youth 5. The focus groups were conducted with the support of a community-based 1 .3 METHODOLOGY organization, Community-based Prevention and Empowerment Strategies for South Africa (COPESSA), which has been operat- The report includes primary data collected through focus group ing in the community for several years in the prevention of child discussions with young people aged 18 -25 and key informant abuse and neglect by spearheading community development interviews conducted with individuals involved in the devel- projects and providing clinical services to victims of child abuse opment of the various mHealth services documented in the and neglect 6. COPESSA is well known in the Protea Glen review . The purpose of the focus group discussions with young community and has strong relations with community members people was to understand: including youth who use recreational infrastructure provided by COPESSA as well as benefitting from counseling services . • the activities for which young people use mobile phones; In the North West province, the focus group discussion was • young people’s preferred information sources for sexual held at Luka Village, which is located in the Rustenburg Local and reproductive health; and Municipality . The village is part of the Bafokeng tribal land and lies in an area with high platinum mining activity 7. The focus • young people’s perceptions about using mobile phones to groups were conducted with support from the New loveLife obtain sexual and reproductive health information . Trust (loveLife) which runs a youth centre, the Royal Bafokeng

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 9 Youth Centre . The centre provides a variety of youth centred information (both fun and practical), support or conversation . services in line with loveLife’s programming aimed at youth Every1Mobile promoted the survey via SMS and Email to a development and HIV prevention among adolescents and young database of 6000 contacts in South Africa aged 24 and under people . The centre is located in the heart of the community with who were signed up to receive notifications from Every1Mobile . a school nearby . Additionally, the survey was also promoted on Every1Mobile’s social media sites such as FaceBook . Participation in the survey 1 .3 2. Focus group participant sampling was further promoted through an incentive of automatic entry into a comptetition to win one of R500 airtime vouchers .The online sur- COPESSA and loveLife staff in the communities of Protea vey provided a snapshot of the profile of young people using the Glen and Luka Village recruited participants using convenience mobile web illuminating their preferences and online behaviours as sampling of youth in close proximity to or who regularly attend well as collecting information on health indicators such as ever hav- the two centres . Furthermore, to avoid ethical issues related to ing given birth and knowledge of HIV status as well as familiarity consent, the participant sample was limited to those aged 18 with mHealth services . years and older . The following inclusion criteria were used . 1 3. .5 Limitations • Number of participants required: 8-10 The views of young people presented in the report from the • Age range: 18 - 24 years focus group discussions cannot be generalized to the wider population of South African youth although the findings may be • Sex: Male and Female transferable across the different contexts . In order to provide generalizable information on the online behaviours and health • Occupational status: In-and out-of school young people; communication preferences of young people a survey of a employed and unemployed out-of school youth . nationally representative randomized sample of youth who use mobile Internet would have to be conducted . The online dipstick • Other characteristics: Maximum variation in terms of repre- survey by its nature excluded young people who do not go sentation of young people living with disability, young peo- online on mobile phones and is thus not representative of the ple living with HIV, young mothers, gender non-conforming general population of young people in South Africa but rather the young people, etc . if that is possible . sub-set who already access the mobile web . The online survey does, however, provide some useful insights on the profile of • Exclusion criteria: due to their extensive training and expo- young people using the mobile web and their behaviours and sure to youth programming loveLife youth peer educators preferences . The focus group discussions also provide useful (groundBREAKERs and Mpintshis) were excluded in favour of insights on barriers and enablers of young people’s use of cell ordinary young people from the community in Luka Village . phones to access health related information and services .

1 .3 .4 Online survey

An online survey was designed in collaboration with Every1Mobile and conducted over a period of two weeks across five mobisites . The sites are generally used as platforms where users can obtain

TABLE 2: OCCUPATIONAL STATUS OF SURVEY RESPONDENTS BY GENDER

IN-SCHOOL OUT OF SCHOOL OUT OF SCHOOL (PRIMARY, SECONDARY, COL- (NOT WORKING) (WORKING) LEGE OR UNIVERSITY)

Female 144 99 45

Male 173 79 58

Grand Total 317 178 103

10 • UNICEF 2 .0 YOUNG PEOPLE’S MOBILE COMMUNICATION EXPERIENCES AND PREFERENCES

The following section provides insights to young people’s experiences with using mobile phones and their perceptions about “I am the only one out of all my using mobile phones to access health information . Twenty participants took part in the two focus group discussions . All focus friends who doesn’t have a child” group participants owned mobile phones (predominantly WAP enabled feature phones and a few smart phones) . Focus group – Female, Gauteng, 19 years old, participants tended to be young people in school with some out in-school . of school . All of the young people from the focus groups who were out-of-school reported being unemployed and having never been employed post-matriculation . ences of life as youth in South Africa . Feelings of boredom and despondency, a sense of lack of opportunity for accessing Generally, young people particicipating in the focus groups in higher education or upliftment from poverty, as well as concerns Protea Glen and ga-Luka Village expressed similar experi- about drug and alcohol abuse and crime in their communities

FIGURE 1: MAIN ACTIVITIES ON CELL PHONES REPORTED BY YOUNG PEOPLE

Research Research Advice About Sex for School on Careers and Sexuality

Information About Social Networking Instant Messaging Health and Wellbeing on Facebook on WhatsApp

Source: Focus group discussions

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 11 was a near even gender split with 48% of respondents to the “When I was pregnant it was my online survey being female and 52% being male .

mother who was giving me infor- Ninety percent of the 598 survey respondents were aged mation and helping me .” between 18 and 25 years of age . This is attributable to the facts that the survey was launched early in the year, which tends to – Female, North West, 18 be a busy time for young people resuming the academic year, the sensitivity of the topics covered in the survey as well as the were prevalent amongst young people in both groups . Even fact that the research team did not aggressively promote the poll before finishing secondary school, young people already had to younger audiences due to ethical considerations . the perception of limited opportunities beyond school and were highly preoccupied with career opportunities . In general across Similarly to findings in the literature, cell-phone ownership both groups, HIV risk perception and interest in HIV-related amongst survey respondents was high with 95% reporting that issues was low with more proximal issues such as experiences they owned their cell phones while five percent share their cell of poverty, limited future prospects and perceived social isolation phone with someone else . There were no significant differences more at the forefront of young people’s minds . While considered in cell phone ownership between males and females . (See Chart undesirable, teenage pregnancy was commonplace and viewed 3 below .) as a norm in both communities . Just over half (53%) of respondents in the online survey The online survey provided a snapshot of the profile of young reported being in the education system, while a third (30%) people using the mobile web . Five hundred and ninety-eight reported that they were out of school and unemployed . Nearly respondents from a target of 1,000 completed the survey . There one in five (17%) were out of school and employed .

TABLE 3: AGE DISTRIBUTION OF ONLINE SURVEY RESPONDENTS CHART 3: MOBILE PHONE OWNERSHIP AMONG SURVEY RESPONDENTS AGE NO . OF RESPONDENTS

Female 13 - 14 7 (1%) Male

276

15 - 17 51 (9%)

18 - 25 540 (90%) 292

18 12

I own it I share it with Grand Total 598 someone else

12 • UNICEF TABLE 4: OCCUPATIONAL STATUS OF RESPONDENTS BY AGE

IN-SCHOOL (PRIMARY, OUT OF SCHOOL OUT OF SCHOOL AGE GROUP SECONDARY, COLLEGE GRAND TOTAL (NOT WORKING) (WORKING) OR UNIVERSITY)

13 - 14 6 (1%) 1 (<1%) 0 7 (1%)

15 - 17 47 (8%) 1 (<1%) 3 (<1%) 51 (9%)

18 - 25 264 (44%) 176 (29%) 100 (17%) 540 (90%)

Grand Total 317 (53%) 178 (30%) 103 (17%) 598 (100%)

2 .1 CURRENT SOURCES OF INFORMATION “…if I talk to my mom about Focus group participants mentioned friends, the Internet, and to how I want to go into aeronau- a lesser extent, family and school as the main sources of information that young people turn to . Family members (especially tics and producing (music), you mothers) were however, an important source of information and know what she’ll say? Go to practical support for young mothers . church and pray about it . And

Young people recognized that information from friends could be that… that doesn’t help me, unreliable or potentially inaccurate because they had the same you know?” life exposure and context as each other, although advice about sex, contraception and substance abuse from friends based on – Male, North West, 19 years old, their personal experiences was deemed trustworthy . Friends out of school were also important sources of social support, with widespread use of instant messaging on WhatsApp to provide each other Young people admitted to spending much of their free time on with emotional and informational support . Both groups identified their phones and the Internet was a popular source of informa- health workers and health facilities as being unfriendly to youth tion for (18 out of 20) young people in both groups, with Google seeking sexual and reproductive health information or services being the primary search tool used to access information on a and one young mother relayed how she had received particularly range of general health topics including sexual and reproductive bad treatment from health workers during her antenatal visits . health . A recent study by Hampshire et al (2015) found that of

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 13 CHART 4: TOP ACTIVITIES YOUNG PEOPLE AGED 10-25 DO ONLINE .

1% 10% 15 15% 179 262 Other

12% Listen to/download music 213 Instant Messaging

2% Social Networking 18% 33 324 Browse news and entertainment websites

13% Research for school/work 231 Play games

Search health-related information

9% Search information on relationships/sex 20% 160 369 Source: Online Survey

TABLE 5: PREFERRED SOURCES OF SEXUAL AND REPRODUCTIVE HEALTH INFORMATION FOR YOUNG PEOPLE AGED 18 - 25 .

IDEALLY, HOW WOULD YOU PREFER TO GET INFORMATION ON SEXUAL HEALTH AND FREQUENCY PERCENTAGE AVOIDING UNPLANNED PREGNANCY?

A free service that I can use on my phone 208 35%

I prefer to go to a clinic or hospital to speak to a 200 34% doctor or nurse

A health professional (who comes to my house, 92 15% school, work or community)

A family member (parent, grandparent, aunt, uncle, sibling . . ) 33 6%

A peer educator (at school, a community centre or work) 27 5%

A teacher or counselor at school 17 3%

A trusted friend 17 3%

Other 3 0%

Grand Total 597 100%

Source: Online Survey

14 • UNICEF the 29% of young people surveyed in South Africa who used a Young people said that while they were of the view that infor- phone to seek health related information in the last 12 months, mation from health care workers at health facilities was accu- the most common source of information was internet searching, rate, there was widespread reticence to go to local clinics for followed by receiving unsolicited health tips or adverts via SMS . information or services due to perceptions and experiences of Whereas a 2014 GSMA study of the adult population (16 + unfriendly and judgmental health workers, lack of privacy in clinic years) reported traditional media such as radio and television settings as well as the possibility that health care workers would as the top sources of information on healthcare, fitness and breach their confidentiality . All the young people participating government services, followed by friends and neighbours while in the focus group discussions expressed willingness to use less than 5% of the lowest LSM used mobile operator services, their phones to seek information about sexual and reproductive the internet and MXit 3. health on condition that the service was zero-rated . Indeed, the survey found that 84% of young people would use their phone Following the findings from the focus groups about the main to access health information on the Internet if it were free (see activities for which young people reported using their mobile Chart 5) . Differing views were expressed about whether they phones, the question was posed in the online survey to ascer- would prefer to communicate directly with a professional via tain the top three activities for which young people use their text or voice call . Some were in favour of the anonymity of phones . The most frequent activity was social networking, with talking to a stranger, while others did not feel comfortable to dis- one in five respondents (20%) mentioning this activity, followed cuss personal issues and take advice from a stranger . Of those closely by instant messaging (18% of respondents), while 15% who were in favour of engaging directly with a professional, of respondents use their phones to listen to or download music . texting was preferred over voice communication as it offered Twenty-two percent of respondents reported using their cell more privacy . phones to search for information on health (12%) and relationships (10%) . The results from the survey are shown below . The online survey findings reflected the insights from the focus groups as few respondents preferred to obtain health information 2 .2 PREFERRED SOURCES OF HEALTH INFORMATION from family members, peers, teachers or friends . Most participants expressed a preference to use their phones for a free In both focus groups the first mentioned preferred sources of service (35%) or to go to a clinic or hospital and obtain information information that young people would like to get information on from a doctor or nurse (34%) . Given the findings from the focus various issues including sexual health and reproductive health groups where young people expressed reservations about health were parents . However, these were identified as being “old worker attitudes despite being a trusted information source, the fashioned,” “too traditional,” and unapproachable or detached survey findings suggest that young people would in all likelihood from young people’s needs and current realities . take up services at health facilities if they were friendlier to youth .

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 15 2 .3 COST OF CELL PHONE USE which the costs of using their cell phones were met . Young people rely heavily on freely accessible content and platforms with Cost was identified as a major consideration for young people zero-rated services such as the free WhatsApp access for Cell-C using their mobile phones and is the main determinant of what users cited by young people in both groups . services they choose to subscribe to or utilize . This was the case for both in-school and out-of-school young people . Monthly In the urban area use of free Wi-Fi at malls and other public spending on data and airtime ranged from R30 for feature phone spaces was common while in the tribal settlement area young users to R300 for smart phone users . Young people identified people engaged in entrepreneurial activities such as washing various sources of money for airtime and a range of means by cars, performing in the streets for money, doing odd jobs in the

CHART 5: PERCENTAGE OF YOUNG PEOPLE WHO WOULD USE THEIR PHONES TO ACCESS HEALTH INFORMATION IF INTERNET WAS FREE .

If you could use the Internet for FREE on your phone, would you use it to look for information about sexual health?

11% 66

5% 30

Yes

No 84% 502 I am not sure

Source: Online Survey

FIGURE 2: SOURCES OF MONEY FOR YOUNG PEOPLE TO OBTAIN AIRTIME AND DATA .

Airtime and Gifts from Allowances Small Scale Data Sharing Boy/Girlfriends from Parents Entrepreneurship

Source: Focus group discussions

16 • UNICEF community and in some instances, begging for small change in trusted professionals such as community-based social workers, order to buy airtime, all activities they referred to as “hustling .” youth counselors and nurses at clinics . Young people from both groups identified criminal activities such as pick pocketing, shoplifting and selling drugs as common activ- 2 5. YOUNG PEOPLE ARE SPENDING TIME ONLINE ities to which young people resort in order to buy airtime and data, as well as to make other purchases . Mobile network oper- Five hundred and seventeen out of 598 respondents reported ator offerings catering to low-income groups were mentioned that they had gone online in the last seven days aside from as means by which young people obtain airtime . These include participating in the survey . Survey respondents also reported airtime advances and pre-paid airtime sharing amongst friends spending significant amounts of time online on their phones, and family members . Boyfriends, girlfriends, “sugar mamas” with 46% spending more than 30 minutes each time they go and “sugar daddies” were also mentioned as a common source online as shown in the figure below . of financial resources for young people . The online survey posed questions related to health indicators 2 .4 PREFERRED COMMUNICATION APPROACHES such as ever having given birth and knowledgeof HIV status as well as familiarity with mHealth services . The preferred communication approach for young people interviewed in the focus group discussions was predominantly 2 6. GRAVIDITY AND PARITY entertainment education . This confirms findings from various social and behaviour change audience research studies that have Of the females who completed the survey, nearly half (48%) found that entertainment education is effective as it models reported that they have never been pregnant, a third reported desirable behaviours and facilitates social learning by engaging that they have been pregnant before and given birth and audiences and stimulating discussions . Use of local celebrities 13% reported being currently pregnant . Two-thirds of those to raise awareness of existing services and testimonies of local who were currently pregnant were pregnant for the first time . community champions or positive deviants were highly favored Four percent of the respondents have been pregnant before as they are seen as more relatable given their similar contexts . but did not give birth as shown in the figure below . The survey A minority of participants in the focus groups (two of twenty) did not ask for reasons for not giving birth due to constraints on expressed that they preferred interpersonal communication with the number of questions that can be posed in this type of

CHART 6: TIME SPENT ON THE INTERNET EACH TIME YOUNG PEOPLE GO ONLINE .

3% 10%

More than 30 minutes

5-10 minutes 11% 25-30 minutes

46% 20-25 minutes

7% 15-20 minutes

10-15 minutes

Under 5 minutes

13%

10%

Source: Online Survey

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 17 online poll . It is thus not known whether the reasons for not CHART 7: RESPONDENT GRAVIDITY . giving birth were miscarriages or terminations of pregnancy .

The table below reveals that nearly 40% (99 of 256) of respondents aged 18-25 have been pregnant before and given birth . 3% 2 .7 KNOWLEDGE OF HIV STATUS

The vast majority of respondents (84%) reported having been tested for HIV before and one third of these were tested in the 32% last 3 – 12 months while, more than half (54%) reported having 48% been tested for HIV in the last three months . Nearly one in five males (17%) have never been tested for HIV as shown in the table below and 77% (40 out of 52) of these were aged between 18 and 25 years old, compared to only 10% (27 out of 40) of females 4% in the same age group who have never been tested for HIV . 9% 4%

I've been pregnant before but did not give birth 2 .8 MISSED OPPORTUNITIES FOR HIV TESTING I've been pregnant before and given birth Of the 25 repondents who reported being currently pregnant, 15 I'm pregnant now - not the first time had been tested for HIV in the last three months and 23/25 had tested 3-12 months ago . Ten of the 15 women who had tested I'm pregnant for the first time now for HIV in the last three months were pregnant for the first time . I'm not sure if I am/have ever been pregnant Ninety percent (36 out of 40) of the female respondents who have never tested for HIV have never been pregnant either . I've never been pregnant This suggests that it is primarily during antenatal care that many young women get tested . There is thus a gap in providing HIV testing girls and young women who have never been pregnant as well as boys and young men, since overall, more males than females hadn’t been tested for HIV . Source: Online Survey

TABLE 6: PREGNANCY AND CHILDBEARING AMONG ONLINE SURVEY RESPONDENTS BY AGE

GRAND 13 - 14 15 - 17 18 - 25 TOTAL

I’m not sure if I am/have ever been pregnant . . 2 6 8

I’m pregnant for the first time right now! 1 17 18

I’m pregnant now - not the first time 1 6 7

I’ve been pregnant before and given birth 4 99 103

I’ve been pregnant before but did not give birth 8 8

I’ve never been pregnant 4 17 120 141

Grand Total 4 25 256 285

18 • UNICEF TABLE 7: NUMBER AND PERCENTAGES OF MALES AND FEMALES WHO HAVE TESTED FOR HIV .

HAVE YOU EVER BEEN TESTED FOR HIV? FEMALE # (%) MALE # (%)

No 40 (14%) 52 (17%)

Yes more than 12 months ago 28 (10%) 41 (13%)

Yes, 3 - 12 months ago 78 (27%) 84 (27%)

Yes, less than three months ago 142 (49%) 133 (43%)

Grand Total 288 (100%) 310 (100%)

Source: Online survey

CHART 8: HIV TESTING AMONG FEMALES BY AGE .

18-25 yrs old 131 15-17 yrs old

13-14 yrs old

27 27

11 9 5 2 1 2

No Yes, more than 12 Yes, 3-12 Yes, les than three months ago months ago months ago

Source: Online Survey

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 19 CHART 9: HIV TESTING AMONG MALES BY AGE .

18-25 yrs old

15-17 yrs old 122

13-14 yrs old

40 39

10 10 2 3

No Yes, more than 12 Yes, 3-12 Yes, les than three months ago months ago months ago

Source: Online Survey

20 • UNICEF MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 21 3 .0 DIGITAL SOURCES OF HEALTH INFORMATION IN SOUTH AFRICA

3 .1 DIGITAL SOURCES OF HEALTH INFORMATION SPECIFICALLY TARGETING YOUNG PEOPLE IN SOUTH AFRICA

TABLE 8: MHEALTH SERVICES SPECIFICALLY DEVELOPED FOR YOUNG PEOPLE

USER/AUDIENCE DATA COLLECTED TARGET AUDIENCE PROJECT NAME PROJECT DESCRIPTION AUDIENCE EVALUATION FINDINGS REACH AGE GEOGRAPHIC OCCUPATIONAL AGE SEX LOCATION STATUS

Mobisite aims to provide access to age-appropriate information on 10 thematic areas: SRHR, HIV, AIDS & TB, nutrition, fitness and physical activity, alcohol and substance abuse, mental health, 10-14 B-Wise, NDoH gender based violence, chronic diseases (physical and mental disability, violence, trauma and over Not yet 15-19 No Yes No No bwisehealth .com injuries and oral health . Mobisite provides factual information, engagement through polls and live 100,000 evaluated . 20-24 monthly chats with epxerts and will include a clinic finder . Age-gateway functionality to be added to provide age-specific content to users aged 10-24 years in all provinces .

BeingGirlSA, Adolescent A service available on MXit, FaceBook and Twitter developed under the Always brand of 345,554 Proctor and Gamble girls and sanitaryware . The service serves as a space for girls to ask questions related to puberty, subscribed via mxitapp .com/beinggirlsa/ young development and other issues of interest to them . FaceBook signup women

CHOMA is an interactive mobile phone magazine targeting South African girl adolescents young women aged 15-25 years, whether they are at school, unemployed or employed, or single, in Choma Magzine, HIVSA Not yet a relationship, or married . CHOMA interacts with its target audience through Facebook, Mobi, 800,000 15-25 No Yes Yes No choma co. .za evaluated . MXit, twitter and hi4LIFE, a mobile portal operated by HIVSA . Choma provides information on SRH, HIV, AIDS, TB and a host of other health-related issues .

Crossroads Generation Crossroads Generation, is an audio novella broadcast on radio in multpiple languages throughout Africa by the deutsche Welle network . An app was developed for MXit to enable young people to www .dw .com/en/ Data unavailable listen to content free of charge . The purpose of the app is to provide young people with lessons top-stories/crossroads- at time of report on issues like drug abuse, teenage pregnancy and domestic abuse using an entertainment generation/s-100776 education approach .

Destiny Toll-free line for youth and students Toll free number: Service launched in November 2015 by Ndalo Media under the Destiny Magazine brand in 0800 41 42 43 collaboration with the South African Depression and Anxiety Group . Provision of counseling to high school pupils, university students and young out of school youth for treatment of trauma, Data unavailable www .destinyconnect . depression, stress, anxiety and issues related to exams, career planning, racial and gender at time of report com/2015/11/06/ndalo- discrimination, social pressure or isolation . Young people can request and access the services media-launches-destiny- provided through a toll free helpline, SMS, please call me, Twitter and Facebook . helpline-for-youth-and- students

22 • UNICEF TABLE 8: MHEALTH SERVICES SPECIFICALLY DEVELOPED FOR YOUNG PEOPLE

USER/AUDIENCE DATA COLLECTED TARGET AUDIENCE PROJECT NAME PROJECT DESCRIPTION AUDIENCE EVALUATION FINDINGS REACH AGE GEOGRAPHIC OCCUPATIONAL AGE SEX LOCATION STATUS

CHOMA is an interactive mobile phone magazine targeting South African girl adolescents young women aged 15-25 years, whether they are at school, unemployed or employed, or single, in Choma Magzine, HIVSA Not yet a relationship, or married . CHOMA interacts with its target audience through Facebook, Mobi, 800,000 15-25 No Yes Yes No choma .co .za evaluated . MXit, twitter and hi4LIFE, a mobile portal operated by HIVSA . Choma provides information on SRH, HIV, AIDS, TB and a host of other health-related issues .

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 23 TABLE 8: MHEALTH SERVICES SPECIFICALLY DEVELOPED FOR YOUNG PEOPLE, CONTINUED

USER/AUDIENCE DATA COLLECTED TARGET AUDIENCE PROJECT NAME PROJECT DESCRIPTION AUDIENCE EVALUATION FINDINGS REACH AGE GEOGRAPHIC OCCUPATIONAL AGE SEX LOCATION STATUS

FunDza mobile is a mobi network aimed at providing teens and young adults from under-resourced FunDza Mobile, Fundza communities with materials to read for pleasure . The service provides e-libraries with content geared to black teenagers and young adults in multiple languages . The content can be accessed 50,000 unique Not yet Literacy Trust 13- 25 Yes Yes No via MXit and a mobiste whose use are zero rated for Cell C customers . Readers are encouraged monthly visitors evaluated live .fundza .mobi to critique stories and to write their own content for which they are provided with mentorship . Content includes issues on sexual and reproductive health and rights .

Girl Effect mobile aims to address the causes of vulnerability in adolescent girls and young Girl Effect Mobile, women by providing a platform where a network of girls is able to engage with each other, sharing Data unavailable Not yet Nike Foundation experiences and stories . Girl effect operates by proving girls and young women with knowledge 13-19 at time of report evaluated www .girleffect .org and skills that build their resilience, reducing their risk factors and enhancing protective factors such as SRH and HIV knowledge, education and economic security .

GirlzTalk, A mobisite developed by young women for adolescent girls and young women to receive information on lifestyle, career and personal development as well as academic mentorship and 7,264 SEED Community health related issues . A strong emphasis is placed on educational development and support . subscribed via 18 - 24 girlztalk .mobi/home/ Recipients of SEED educational loans run the project as a social business aimed at developing FaceBook girlztalk their entrepreneurial skills and enabling them to contribute to the development of other girls .

Health4Men, ANOVA Aim to increase knowledge, improve health-seeking behaviour and reduce sexual risk-taking Pending data Health Institute among MSM . Health4Men Connect is an interactive mobi-site that provides topical information Unspecified Yes Yes Yes No from ANOVA h4m .mobi and allows MSM to send anonymous questions to Health4Men’s medical staff .

Social network support programme with information for those living with HIV/AIDS . HIV360 HIV360, is a community of young people affected by HIV/AIDS . The site raises awareness, facilitates Adolescents Every1mobile discussion, improves cross-cultural learning and mobilizes collaborative action on HIV/AIDS 15,000 and young Yes Yes Yes No hiv360 .every1mobile .net amongst young people . There are quizzes and FAQs, educational information, tips on how to talk people to bullies, inspiring stories and chat rooms .

A mobisite providing information on life skills and personal development as well as SRH, HIV and STI prevention and other health issues . ilovelife .mobi offers real-world rewards and incentives ilovelife, for health-seeking behaviour . Users engage in loveLife’s youth leadership development journey through a cutting edge mobile tool and earn points for educating themselves on a range of topics Not yet New loveLife Trust 5,997 10 - 24 Yes Yes Yes Yes including sexual health, interacting with iloveLife content online, taking action in the real world evaluated ilovelife .mobi and then proving it — ultimately promoting a positive lifestyle revolution among their peers in the social network . A user’s point’s level then enables them to enter competitions for a range of prizes, with greater rewards for greater interaction .

24 • UNICEF TABLE 8: MHEALTH SERVICES SPECIFICALLY DEVELOPED FOR YOUNG PEOPLE, CONTINUED

USER/AUDIENCE DATA COLLECTED TARGET AUDIENCE PROJECT NAME PROJECT DESCRIPTION AUDIENCE EVALUATION FINDINGS REACH AGE GEOGRAPHIC OCCUPATIONAL AGE SEX LOCATION STATUS

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 25 TABLE 8: MHEALTH SERVICES SPECIFICALLY DEVELOPED FOR YOUNG PEOPLE, CONTINUED

USER/AUDIENCE DATA COLLECTED TARGET AUDIENCE PROJECT NAME PROJECT DESCRIPTION AUDIENCE EVALUATION FINDINGS REACH AGE GEOGRAPHIC OCCUPATIONAL AGE SEX LOCATION STATUS

2012/2013 study found loveLife call centre, New that a large majority of loveLife’s call centre is comprised of two national toll-free helplines, the Youth Line and Parent loveLife Trust 80% of callers were Line that provide reproductive health information and counselling services for both adolescents www .lovelife .org za. under 25 years old and and parents or guardians . 9 professional counsellors, 9 to 10 groundBREAKERS and 11 operators Approx . 500,000 10 – 24 Youth line: Yes Yes Yes Yes 71% lived in informal set- staff the Call Centre . groundBREAKERS and operators provide callers with information on loveLife calls in 2012 (youthline) tlements and rural areas . 0800 121 900 and basic HIV/Aids information while counselors provide professional counseling services and Respondents reported Parent line: respond to questions posed on the text based counseling service . being satisfied/very satis- 0800 121 100 fied with the service

Lovelife text-based Discreet text-based counselling to highly vulnerable people . An innovative web-based platform counseling service, allows trained counsellors to provide counselling sessions to young people free of charge . Youth 170,000 10 - 24 Yes Yes Yes No New loveLife Trust may also send a please call me to the national call centre to request a counselling session . mxitapp .com/lovelifemx

A push text is sent via MXit to a subscriber’s phone with an accurate health tip . Content on mGirls, GirlsFootballSA puberty, SRH, HIV and other topics is developed based on questions raised by girls participating in 65,000 10 - 29 Yes Yes Yes mgirls .org the GirlsFootballSA soccer workshops at local schools .

Virtual support groups on WhatsApp and FaceBook to provide social support to HIV-infected youth MSF Online Youth Clubs, at Site C Clinic in Khayelitsha . Lay counsellors provide support to groups of 10-15 participants in Approx . 70 10 – 24 Yes No Yes Yes Evaluation on-going Medecins Sans Frontieres addition to peer support provided by the participants themselves . Virtual communication enables for continued support in between monthly physical support group meetings held at the clinic .

Khuluma Project, Psychosocial support to HIV positive adolescents (13-18 years old), via mobile-phone in peer- SHM Foundation led support groups, of 10-15 participants . Groups run for 3 months . Participants communicate Approx . 100 13 - 18 Yes Yes Yes No Evaluation on-going shmfoundation . amongst themselves and with a facilitator via text-message about a broad range of topics including org/?page_id=319 disclosure, discrimination, general information, HIV and SRH .

Sporadic surveys A service hosted on MXit providing Q and A’s, information manuals on SRH-related topics, quizzes revealed increased SMRTSEX, Every1Mobile to test knowledge acquisition and routine polls to assess knowledge, attitudes and perceptions Average 300,000 Unspecfied Yes Yes Yes No knowledge and increased smartsex .every1mobile .net of users . Service is available in South Africa, Tanzania, Nigeria, Zimbabwe, Ghana and Kenya . The a month self efficacy in dealing Smart Sex mobiste is also available as a suggested site on Opera Mini with topics covered

Young Africa Live, Mobile entertainment portal designed to engage youth on topics of sexual health . Entertainment education through first person narratives with polls and quizzes to assess and reinformce Praekelt Foundation 1,800,000 16 – 24 Yes Yes Yes No knowledge transfer . The service is no longer active and has been replaced by B-Wise however it youngafricalive .mobi included due to its high user reach across South Africa .

Young mom support A service available on MXit and web teenagers to discuss teen pregnancy and teen motherhood . Service responds to questions by male and female teenagers regarding issues such as termination Over 14,000 mxitapp .com/ Unspecified of pregnancy, adoption, birth, breastfeeding, childcare grants, maintenance, remaining in school as since 2013 youngmomsupport young parent, stigma and general health and relationship advice .

26 • UNICEF TABLE 8: MHEALTH SERVICES SPECIFICALLY DEVELOPED FOR YOUNG PEOPLE, CONTINUED

USER/AUDIENCE DATA COLLECTED TARGET AUDIENCE PROJECT NAME PROJECT DESCRIPTION AUDIENCE EVALUATION FINDINGS REACH AGE GEOGRAPHIC OCCUPATIONAL AGE SEX LOCATION STATUS

2012/2013 study found loveLife call centre, New that a large majority of loveLife’s call centre is comprised of two national toll-free helplines, the Youth Line and Parent loveLife Trust 80% of callers were Line that provide reproductive health information and counselling services for both adolescents www .lovelife .org .za under 25 years old and and parents or guardians . 9 professional counsellors, 9 to 10 groundBREAKERS and 11 operators Approx . 500,000 10 – 24 Youth line: Yes Yes Yes Yes 71% lived in informal set- staff the Call Centre . groundBREAKERS and operators provide callers with information on loveLife calls in 2012 (youthline) tlements and rural areas . 0800 121 900 and basic HIV/Aids information while counselors provide professional counseling services and Respondents reported Parent line: respond to questions posed on the text based counseling service . being satisfied/very satis- 0800 121 100 fied with the service

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 27 3 .2 DIGITAL SERVICES IN SOUTH AFRICA WHOSE USERS INCLUDE YOUNG PEOPLE

TABLE 9: ADDITIONAL MHEALTH SERVICES ACCESSIBLE TO YOUNG PEOPLE

CURRENT DATA AVAILABILITY TARGET PROJECT NAME PROJECT DESCRIPTION AUDIENCE REACH AUDIENCE EVALUATION FINDINGS GEOGRAPHIC AGE AGE SEX OCCUPATION LOCATION

Project M The National AIDS Helpline’s name and number appeared on "Please Call Me" that went out, with the s3 .amazonaws .com/ 1 million calls made call-to-action to phone the Helpline, to access further information and services around HIV and AIDS . The project was successful poptech_uploaded_ to national helpline Adult Over the first two years over Project Masiluleke's PCM program, over 968 million Please Call Me's No Yes No No in driving calls to the national files/uploaded_files/27/ in response to PCM population were tagged with messages, averaging over a million messages a day . Messages were sent in several helpline . messages original/Project_ languages and addressed several AIDS-related topics, providing comparisons of messages and themes . Masiluleke_Brief .pdf

Aims to promote earlier antenatal care, monitor the quality of maternal and child health services, improve education and health literacy for new and expecting mothers with confirmed pregnancies momConnect through free stage-based SMS provision . The services are free to the user, and messages are www .health .gov . currently available in six languages . Objectives: Over 15-49 Yes Yes Yes Currently undergoing evaluation za/index .php/mom- 1 . To register each pregnancy at a government health facility . 780,000 connect 2 . To send stage-based, personalised SMSs to each mom in the registry . 3 . To allow women to engage with the health system through help desk tools and feedback services on the quality of health services they received .

A mobisite accessible on internet enabled phones provides information to registered new and MAMA subscribers' adoption of expectant mothers .The mobisite is free to vodacom customers on Vodafone live . The SMS key behaviors and practices was component of MAMA has been merged with the MomConnect programme and provides free stage- higher than national averages in MAMA based SMS messages to registered users with confirmed pregnancies . USSD quizzes are sent at 700,000 15-49 Yes Yes Yes South Africa and Bangladesh . askmama .mobi a cost to registered women providing personalized weekly quizzes with information about healthy Behaviour was changed positively pregnancy and child health . The MAMA service is also available on MXit providing registered users compared to previous pregnan- with personalized information on pregancy and child health cies and babies .

Information for expectant mothers . : Improve knowledge base of expectant parents to improve BabyInfo 300,000 monthly maternal and infant health, contributing to a decrease in infant and maternal mortality rates . Unspecified mxitapp .com/babyinfo average Information is delivered for free and is customised to their stage of pregnancy .

HI4Life, HIVSA A mobisite providing HIV-related information as well as general health and well being information . Not yet 15-49 hi4life .mobi Regular polls and evaluated

Privacy was not a big issue for- women signing up for the study . Participants were able to com- Medical abortion Data plete a self-assessment on their study, University embargoed Data embargoed mobile phone, following a short of Cape Town and Push sms’s were provided to women coaching them through medical abortion . A mobisite with pending pending publishing Yes Yes Yes Yes training session . However, due to Cell Life contraception information was introduced and also offered as a service on MXit . publishing of study findings . the complexity of the language of study www .ichoosewhen . required to describe physiolog- findings . co .za ical processes it was not clear whether or not the abortion had taken place with 100% success .

28 • UNICEF TABLE 9: ADDITIONAL MHEALTH SERVICES ACCESSIBLE TO YOUNG PEOPLE

CURRENT DATA AVAILABILITY TARGET PROJECT NAME PROJECT DESCRIPTION AUDIENCE REACH AUDIENCE EVALUATION FINDINGS GEOGRAPHIC AGE AGE SEX OCCUPATION LOCATION

HI4Life, HIVSA A mobisite providing HIV-related information as well as general health and well being information . Not yet 15-49 hi4life .mobi Regular polls and evaluated

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 29 3 .3 GENDER COMPOSITION OF MHEALTH der are reflective of the closing gap between male and female SERVICE USERS users of the Internet overall . A South African Network Society survey conducted in 2014 found that although only 46% of all Maintaining a balance of male and female users is difficult and Internet users are women, women constitute more than half of much of the content on mHealth services resonates with girls new Internet users .15 resulting in user numbers being slightly skewed in favour of girls and young women . On MXit about 52% of users of health con- 3 .4 GEOGRAPHICAL DISTRIBUTION OF YOUNG tent were female8 while on Young Africa Live, the proportion of PEOPLE USING MHEALTH SERVICES females peaked to as much as 60%, resulting in special efforts being made to include more male voices in the content gener- In start up phases, adoption of mHealth services tends to be ated to revitalize male participation 9. Similarly, services such as clustered around urban areas due to marketing, ease of recruit- Fundza and ilovelife have slightly more female than male users ment and high phone penetration in urban areas and oftentimes, even though they target both males and females 10,11. On Young pilot projects are conducted with patients of urban facilities . The Africa Live, females demonstrated high levels of engagement, users of ilovelife are mainly in Gauteng, followed by KwaZulu actively involving themselves in the management of the commu- Natal and Mpumalanga,10 while every1mobile describes the nity and reporting undesirable behaviours 9. Females have also typical user of HIV360 and SmartSex as urban or peri-urban tended to be far more willing to participate in surveys than their dwelling 13. The loveLife Call Centre evaluation found it to be male counterparts on MXit, although the reasons for this are not highly effective in providing services to youth in rural and infor- known . In contrast, an evaluation of loveLife’s MizzB/MXit text mal settlements, with 71% of its clients calling from rural and counseling service found that there was a higher proportion of informal settlements 12. Due to ease of access, HIVSA promotes males using the service than females while females preferred primarily promotes Choma in Gauteng where the organization direct voice calls with the loveLife call centre 12. Similarly, accord- is based and has found that urban areas enjoy high usership ing to every1mobile, SmartSex has found about 60% male users due to the fact that they are more connected than more rural necessitating the skewing of promotional activities to balance areas 14. Recognizing this HIVSA has embarked on an initiative the gender split by increasing female interest and participation 13. to work with schools in Mt Frere to promote Choma amongst HIVSA has found that older males in their late teens and early youth in this harder to reach geographical area 14. The geographic twenties typically use the Hi4life mobisite 14. The trends in gen- distribution of respondents to the online survey mirrors the

CHART 9: GEOGRAPHIC DISTRIBUTION OF ONLINE SURVEY RESPONDENTS

North West Province Mpumalanga 5% 10% 32 57 Northern Cape 3% 19 Western Cape 9% Limpopo 53 17% 104 Eastern Cape 11% 65

Free State 6% 33

Gauteng 24% KwaZulu Natal 144 15% 91

30 • UNICEF geographic distribution of mHealth users reported by the various African Depression and Anxiety Group . The key players in the mHealth service providers . None of the mHealth service provid- provision of mHealth services for young people have been the ers interviewed for this review were able to provide information non-profit sector organizations seeking to further their reach or on users disaggregated to district level, making it difficult to to strengthen existing public health programmes . For example, ascertain which districts are more or less active than others in loveLife uses iLoveLife as a supporting component bridging terms of use of mHealth services . Further research is required to across all its face-to-face youth programmes at various sites elucidate this information, as there are presently challenges with across the country, aimed at providing young people with the producing this data using existing systems as elaborated skills they require to navigate adolescence and the transition on below . into successful adulthood 10. Similarly, MSF’s online youth club and mentorship programmes for young people living with HIV 3 .5 CHALLENGES WITH OBTAINING USER form a part of a broader youth-centered service provided at Site DEMOGRAPHIC DATA C Clinic in Khayelitsha . The clinic run by the Cape Town Health Department with support from MSF provides youth-friendly While demographic information is vital to ensure equitable pro- sexual and reproductive health services, HIV counseling and gramming for young people it is a challenge to obtain accurate testing, immediate point of care CD4 testing and anti-retroviral demographic data via mobile phones . Information requested treatment to eligible adolescents and young people . In addition from users as they sign up is limited due to the fact that users to monthly support group meetings the virtual support groups tend to be reticent to provide personal details on their mobile exist in order to provide continued support and contact with phones, partly because they find this tedious and to an extent HIV-infected young people with a view to retaining them in the because of the desire to maintain anonymity . While services treatment cascade 17. such as Google Analytics provide fairly accurate demographic data this is limited to smart phones, and most users’ location The government of South Africa, through the National data on users of mHealth services is obtained from mobile Department of Health (NDoH), has been very involved in network operators, particularly in rural areas where network mHealth, in terms of rationalizing the sector by leading the coverage is sparser, resulting in less accurate location data . A development of a national eHealth strategy for 2012-2017 . The potential solution is to request users to provide information strategy outlines the countries priorities and key activities for such as the school they are enrolled in or the nearest school in the eHealth domain, in which mHealth is included 18. NDoH has the community/neighbourhood (for out of school youth) when also worked in partnership with UNICEF, Praekelt Foundation, they sign up . The location of the school can be identified through Wits Reproductive Health Institute and other supporting enti- the Department of Basic Education, which has a database of ties to launch and implement momConnect and B-Wise . The GPS coordinates of all schools in South Africa . This method Department of Basic Education, UNICEF and MXit Reach are of collecting location data is being used by the Ukufunda in partnership to provide teachers, learners and parents with learning initiative 16. education-related content on the Ukufunda service through the MXit platform .16 The South African curriculum includes compre- 3 .6 MHEALTH SERVICE PROVIDERS hensive sexuality education and life skills based content aimed to build the social and cognitive skills and knowledge of young Seventeen out of 20 mHealth services specifically targeting people to improve their HIV, TB and other health related out- young people were provided by non-profit organisations, while comes 19. Hence, it would be expected that such content would three of them were run by profit-making organizations as a be available on Ukufunda . Partnerships are critical in implement- free services, namely BeingGirlSA by Proctor and Gamble, ing mHealth, with expertise from various sectors such as ICT, Crossroads Generation by Deutsche Welle Network and Destiny research and academia and health service providers coming Toll-free line by Ndalo Media in partnership with the South together to implement the projects currently in existence .

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 31 4 .0 ENGAGING YOUNG PEOPLE ON DIGITAL PLATFORMS

4 .1 COMMUNICATION APPROACHES Content must engage, provide Entertainment education approach unambiguous facts and prompt Young Africa Live used fictional first person narratives to present real-life action by audiences desired behaviours and negative behaviours as cautionary tales and linked content to topical themes emerging in current affairs in the entertainment world to stimulate debate amongst users 9,20. taking an HIV test . Furthermore, the service incentivizes users This content approach was selected as it makes facts easy to to continuously engage with the service through entry into distinguish and locate, while also hooking the attention of the competitions to win real world prizes such as airtime and movie reader using information, which is already familiar and of popular tickets 10. LevelUp, currently under development by MXit Reach, interest 9. FunDza also uses fictional stories to provide information, will also follow a similar model, with a focus on incentivizing allowing readers to comment and provide feedback to the writers improved academic performance, improved health knowledge as well as stimulating discourse amongst readers 11. and behaviour and enhanced executive functioning such as problem solving skills and critical thinking 8. Young Africa Live Use of entertainment education or fictional narratives to present enabled users to control content by reporting offensive com- facts, start conversations and change attitudes and perceptions ments, which would then be removed if reported by three users . has been found to be effective by a number of studies21–23 and As users engaged with each other independently, it became is met with high acceptability among audiences . This is also possible to identify specific voices rising to the fore in terms of supported by the findings from the focus group discussions in high levels of engagement with the content 9. young people expressed a preference to receive information this way . It is critical to ensure that accurate information is clearly vis- Interactivity is a critical feature that supports continued engage- ible on the site with a call to action to access further information ment and knowledge transfer . The ability to ask questions, have or adopt a specific behaviour . Fundza links to partner sites for them responded to immediately, to comment on topics and further information at the end of each fictional story while Young communicate with other users has contributed to the success Africa Live included fact-based articles .9,11 of mHealth services such as Young Africa Live, Smart Sex and FunDza to name a few . Sluggish initial uptake of the B-Wise Use of gaming principles service may be linked to the more static nature of the content compared to other youth services . The ilovelife service uses gamification as a means to engage youth, reinforce knowledge transfer and provide incentives for 4 2. MARKETING MHEALTH SERVICES adoption of positive behaviours by using a points system to reward interactions such as participation in knowledge quizzes The online survey revealed that many young people were famil- and self-assessments on the site .10 Users can also earn points iar with a number of mHealth services . Respondents cited hav- by demonstrating the adoption of health behaviours such as ing obtained health information from Young Africa Live, iLoveLife as well as the loveLife call centre, momConnect, Smart Sex, “We found that the most HI4Life and Health4Men, suggesting that these have been more vigorously promoted . successful services were the ones that enabled user Promotion on digital channels interaction and had regular, In addition to providing funding to make mHealth services fresh content .” freely available to users, the private sector has played an important role in making the audience aware of the services – Andrew Rudge, CEO available . For example, SmartSex appears as a suggested link MXit Reach on the Opera Mini landing page so that anyone opening the web browser is immediately exposed to the service offering,13

32 • UNICEF while Young Africa Live garnered huge popularity as a service services is, however an on-going challenge for many mHealth offered to Vodacom subscribers on the VLive platform among service providers, and has had varying degrees of success in the other services already used by the target audience 20. Choma is South African context . available nationally and is promoted for free on MXit to users in the Eastern Cape which was the pilot research site14 while Promotion by role models, champions and peer mentors Smart Sex also benefits from free promotion on the MXit platform 13. Mobile Network Operators (MNOs) have offered Choma magazine, which has reached almost one million girls advertising on the Please Call Me service where mHealth and young women, uses a local celebrity ambassador and services providers can pay to promote their services as volunteer peer educators to promote the service14,24 and indeed messages appended to a certain number of please call me’s young people participating in focus groups identified the use of sent by network subscribers . Many mHealth service providers local ambassadors as a good marketing strategy given their inter- promote their services on social media channels such as Twitter est in what celebrities have to say . While very active on their and Facebook, which serve as additional platforms for content mobile phones, the young people participating in the focus group exposure and engagement with the audience . discussion in the North West province were not aware of the full range of mHealth services available to young people includ- Promotion by health service providers ing those offered by loveLife despite the fact that they were frequent participants in activities offered by the loveLife youth Health care providers have been involved in promoting mHealth centre in their community . This suggests the importance of train- services to patients, however this requires advocacy for their ing of face-to-face implementers of youth programmes to raise buy in, as it can be viewed as additional work for an already over- awareness of mobile services to young people and enhance loaded health workforce . It also requires for them to be trained their information-seeking skills, particularly in rural areas where on and made familiar with the services so that they can provide access to services may be more limited . The ilovelife service accurate information to patients regarding the services . mHealth was introduced after groundBREAKERs had already been trained services have made use of health workers to promote and on loveLife’s programmes for the year hence their promotion support recruitment of clients for a variety of services such as of the service has been inconsistent 10. Promotion of loveLife’s medical abortion SMS support services, maternal, neonatal and digital programmes will be integrated into groundBREAKER ori- child health support, and psychosocial support of adolescents entation and training from 2016 to ensure wide promotion of the and young people living with HIV . Establishing relationships and digital offerings, given that they are an integral part of loveLife’s working with health professionals at clinics to promote digital social and behaviour change model 10.

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 33 5 .0 MHEALTH SERVICES FOR SOUTH AFRICA’S YOUNG KEY POPULATIONS

5 .1 YOUNG PEOPLE LIVING WITH HIV FIGURE 3: QUALITATIVE STUDY FINDINGS OF DIGITAL YOUTH CLUB PARTICIPATION Two of the projects included in this review specifically targeted young people living with HIV . Young people infected with HIV have been found to have the high rates of loss to follow up after diagnosis as well as following enrolment on ART .

Retention in care and adherence support through virtual Not Interested in support groups Social Media

Online Youth Clubs: Medécins Sans Frontières In 2012, Medécins Sans Frontères (MSF) piloted a virtual youth club on the MXit platform to provide peer-to-peer social support to HIV-positive youth aged 12-25 receiving clinical care at Site C clinic in Khayelitsha, Cape Town . The youth club participants were all young people who had been diagnosed with HIV and Preference for were receiving clinical care and attending physical support group Other Platforms meetings at the clinic . The purpose of the virtual chat group was to provide a means for young people to stay connected with each other in between club meetings which occurred on either a monthly or a bi-monthly basis 25. Youth clubs were comprised of 15 to 20 HIV-positive youth who were a mix of ART-ineligible youth and youth who were either newly initiated on ART or stable on ART .25 The rationale was that pre-ART members could receive support from those on ART to remain in routine clinical care and Lost Interest in monitoring and prevent late initiation on ART, while those stable the Chat Room on ART could provide those newly initiated on ART with advice and encouragement based on their experiences of being on ART 25. The objectives of the youth groups were as follows:

TABLE 10: GOALS OF MSF ONLINE YOUTH CLUBS

Loss of • Retention in care at all stages of Password or Phone BEHAVIOUR the treatment cascade CHANGE • Improved adherence to treatment

• Improved psychological wellbeing COGNITIVE AND • SOCIAL SKILLS Improved social interaction and support Think mXit is for Younger People

Source: Patten et al., 2014 Source: Patten et al., 2014

34 • UNICEF protected chat room hosted on MXit, where a youth counselor Mental health support was on hand for an hour every day to provide support, although conversations among group members were able to interact with Project Khuluma: SHM Foundation each other at leisure . Participants were provided with a small air- Project Khuluma was launched in 2013 with a view to providing time voucher in order to enable them to register on MXit . Uptake adolescents infected with HIV aged 13 to 18 with a means of the online chat room was low with only one in three youth club to provide and receive emotional support through SMS inter- members ever visiting the chat room 25. A qualitative evaluation actions in a peer environment .26,27 Closed support groups of of the initiative found that youth club members liked the idea 10-15 participants anonymously engage in discussions on a of communicating online in between support group meetings range of issues ranging from sexual health to career advice, and almost half of respondents (45%) preferred to visit when a with some sessions facilitated by invited guests 26,27. Topics facilitator was present .25 Participants indicated that they preferred of discussion have also included challenges of disclosure, to interact on platforms such as Facebook and WhatsApp rather stigma and discrimination . Preliminary evaluation findings have than MXit due to certain limitations with MXit 25. revealed that the youth struggle with treatment compliance, communicating with health professionals about medication, Findings from the Phase 1 pilot evaluation led to the devel- they feel isolated because of their inability to disclose their opment of a second pilot of online clubs on Facebook and status and that they value interacting with other young people WhatsApp, which were commenced in 2014 with the approx- experiencing similar challenges 27. Project Khuluma is currently imately 200 youth attending physical youth clubs being invited undergoing in-depth evaluation . to participate . Evaluation of the Facebook and WhatsApp youth clubs is on-going .

FIGURE 4: CHALLENGES WITH IMPLEMENTING A MOBILE SERVICE FOR MENTAL HEALTH SUPPORT OF YOUNG PEOPLE LIVING WITH HIV .

Limited by Variations Participants Experience Confusion Caused by in Literacy Levels Language Barriers Multiple Conversations

Limited SMS Channel Message Length Still Expensive

Source: SHM Foundation, 2015

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 35 5 .2 ADOLESCENT GIRLS AND YOUNG WOMEN mGirls: Girls and Football SA mGirls, a mobile health app hosted on MXit which was devel- Choma Magazine: HIVSA oped for Girls and Football SA, an organisation that uses the HIVSA, has, through funding from the Charlize Theron Africa medium of sport to provide life skills to adolescent girls aged Outreach Foundation, developed Choma, a digital magazine 10-14 and young women aged 15 – 19 and 20-29 years . Through aimed at engaging South African women aged 15 to 25 years on the app, health facts related to HIV prevention, teen pregnancy HIV and SRH issues presented integrated in a wide variety of life- and other sexual and reproductive health issues are pushed to style content 24. The magazine makes use of discussion forums, 65,000 subscribers across South Africa on a daily basis . The con- polls and social gaming to create a platform on which users are tent is developed in response to questions and feedback raised able to pose questions related to SRH, HIV and AIDS, as well by girls participating in life skills and football workshops run by as other general health issues and receive direct feedback .14,24 Girls and Football SA in Cape Town and Pretoria . While the work- Choma magazine has the following behavioural goals: shops have reached 3,000 girls with limited contact since 2010, the app has provided continued information to 65,000 girls since it was launched n 2014 . This is an example of the potential of TABLE 11: CHOMA MAGAZINE GOALS mHealth to provide information and skills to young people rapidly and at national scale . • Delayed sexual debut BEHAVIOUR • Increased condom use 5 3. YOUNG MEN WHO HAVE SEX WITH MEN CHANGE • Increased STI-care seeking behaviour • Reduced number of sexual partners Health4Men Project: Anova Health Institute Anova has trained and mentored over 3 000 health workers at a network of 200 public clinics across all provinces to provide • Increased demand for HCT prejudice-free sexual health treatment and care to gay, bisexual DEMAND • Increase demand of SRH services and other men who have sex with men 28. As a complementary CREATION including contraception service Anova created a mobisite (h4m .mobi) which offers men FOR HEALTH SERVICES AND • Create demand for information on who have sex with men information such as where to find their INFORMATION HIV and AIDS and increasing dialogue nearest gay-friendly health facility, allows them to anonymously and discussions on related topics post questions related to their sexual health and mental wellbeing to Anova clinical and psychosocial and provides information about other services for MSMS such as online and physical support • Increased self-esteem for men who have sex with men who are living with HIV 28,29. COGNITIVE • Improved decision-making skills Through the mobisite professionals from Anova provide access to AND SOCIAL SKILLS • Improved condom negotiation skills short term counseling to individual MSM and couples on issues Increased risk perception pertaining to their sexual health . Visitors to the mobisite are also invited to the various social media channels such as Facebook and Twitter . A key challenge identified by Anova Health Institute Source HIVSA in providing services for young men who have sex with men is the paucity of data on this demographic, especially young MSM Choma has 800,000 registered users who are predominantly in detention .29 The fluid nature of gay identity formation combined urban girls in Johannesburg followed by Cape Town then with the complexity of transition from childhood to adolescence Durban 14. Sixty percent of its users are on MXit and aged 13 – and then adulthood make it difficult to identify young MSM and 17 years, 20% are on Facebook and aged 25 – 30 years of age provide them with targeted information and services 29. while the rest utilize the website and Twitter 14. The magazine features fashion and lifestyle information and encourages partic- 5 .4 OTHER YOUNG KEY POPULATIONS ipation through a journal club where girls and young women are able to express themselves, it features an online moderator who No specific interventions were found in South Africa addressing provides emotional support, responds to questions and provides young people who inject drugs, young people living with disabil- links to health providers 14,24. Using Choma chat on the website ity and young people who engage in high risk drinking . Topics and MXit girls are able to interact with the moderator who is such as alcohol and substance abuse are included in the content given an older sister persona14,24 HIVSA has also developed of many mHealth services for young people such as B-Wise, Choma smart phone game which builds critical thinking, deci- FunDza and Choma . sion-making, goal-setting and self efficacy for behaviour change in young adolescents and girls Plans are underway to evaluate the project’s effectiveness in reaching desired outcomes 14.

36 • UNICEF 6 .0 LESSONS LEARNT AND RECOMMENDATIONS

LESSONS LEARNT RECOMMENDATIONS

Measuring the results of mHealth services

• Routine data on user registrations or web/ • mHealth services should incorporate rigorous monitoring mobisite hits and anecdotal reports of changes and evaluation of services into the project design from in outcomes are insufficient to enable on-going inception to ensure that the contribution of mHealth to evidence-based learning and decision-making outcomes such as knowledge and attitudinal change as well about where and how best to deploy resources as health seeking behaviours can be understood . Continuous for mHealth . evaluation must be budgeted for and conducted: formative/ design (beyond audience acceptability to theory of change • Major data gaps exist in terms of audience development based on evidence); process/implementation demographics due to unreliable data collection (assessing dose and fidelity); and impact (making value resulting in limitations in the ability to develop judgments on interventions, considering the cost and content that is responsive to the heterogeneity cost effectiveness of mHealth as a tool in an arsenal of of the South African youth market . interventions aimed at reducing young people’s vulnerability .

• There is a need for developers of mHealth services to work with various stakeholders such as the public service providers to find innovative ways to overcome the technological limitations that result in unreliable and inconsistent data .

• There is also a need to conduct research on the needs of young people not currently reached by existing interventions to understand if and how mHealth can provide them with information and services . These may include young people living with disabilities, young people who inject drugs, young people living in extremely remote rural areas and others .

Cost is important and Mobile Network Operators are critical partners

• Free access to mHealth services through • Continued engagement and advocacy with MNOs to ensure mobile networks drives regular user engage- costs to users are kept low . ment by reducing user costs .

• Promotion of services through placement on the MNO deck helps drives audiences to mHealth services

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 37 LESSONS LEARNT RECOMMENDATIONS

Ensuring safety of adolescents and young people online

• Moderation of young people’s interactions with • Mechanisms to collect accurate information about age each other is important to prevent abuses such and location of users should be put in place to assist in as cyber-bullying, harassment, homophobia, the creation of safe spaces for adolescents and young hate speech and other forms of abuse people online .

• Cyber safety literacy should be incorporated in mHealth service offerings and young people should be educated on identifying and reporting unsafe behaviours

Young people value interactivity

• Social features are key to promoting the levels • mHealth services should shift away from mere dissemination of engagement required to influence knowl- of information and ensure that content is easily accessible, edge and skills of young people . regularly refreshed and that young people are able to actively engage with the content and each other to reinforce learning . • As the subscription to services increases, audience management and engagement • Adequate financial and human resource allocation should be become more challenging and resource made to allow for continued moderation and response to intensive requiring more man-hours to ensure user requests and feedback to ensure sustained, high quality satisfactory experiences and continued trust in experiences for users as services scale up . the service by young people . • Experts should take care to use non-judgmental language • Live chats with experts have high valence and tone when communicating with youth . because young people want to be able to anonymously get information from a professional . • Content development should be an iterative and collaborative process between creative specialists and public health or • Entertainment education is a highly engaging social and behaviour change specialists to ensure that approach to provide young people with informa- content is scientifically accurate and based on evidence, tion and influence their behaviours . while presented in a manner that facilitates engagement and learning .

38 • UNICEF APPENDIX 1: LIST OF KEY INFORMANTS

Jade Archer Head of Digital Programmes, New loveLife Trust

Andrew Rudge CEO, MXit Reach

Maru Fourie MXit Reach

Tamsen deBeer Head of Content, Praekelt Foundation

Pippa Yeats Praekelt Foundation

Katherine de Tolly Independent mHealth Consultant

Alex Kayle mHealth Programme Manager, HIVSA

Glenn de Swardt Senior Programme Manager, Anova Health

Rosalind Haden FunDza Mobile

Isabelle Amazon-Brown Every1Mobile

Jesse Coleman Programme Manager: mHealth Wits Reproductive Health & HIV Institute

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 39 APPENDIX 2: FOCUS GROUP DISCUSSION GUIDE

OPENING QUESTIONS 8 . (Explain definition of sexual and reproductive health) . When it comes to SRH, people have different prefer- 1 . Tell me about your lives . What do young people in ences for getting information or advice . Some people Luka Village get up to? prefer to get information from someone they know, Probes: others prefer a professional, others prefer TV, radio, Where do they socialize? the internet, etc . Where do you prefer to get SR health With whom do they socialize? information? How do young people keep in touch with their friends? 9 . What do you think about the idea of using mobile 2 . What are the aspirations of young people when they phones to engage with young people about their health? think of the future? Probes: Probes: Is it a good idea or a bad idea? Why or why not? Embarking on careers What would prevent young people from using their phones Getting an education to get health information? Having relationships What would encourage young people to seek SR health Starting families info using their phones?

3 . How do you think you can help yourselves to achieve 10 . What are the costs involved in using a mobile phone? those aspirations? Probes: Probes: Who pays? Staying safe How do young people meet these costs? Setting goals etc CONCLUSION SOURCES OF INFORMATION If I have heard you correctly, you have said that… (summarize 4 . So it sounds like you need to have a plan for your life key points) . Is there anything else you would like to add? and make decisions about what you want out of life and how to do it . How do you decide what to do? By show of hands, how many: Probe: Where do you get information to help you plan for and Own a mobile phone: make decisions about your life? Share a phone with another person: 5 . How do young people use phones to get information? Have a good network (can make calls inside the house): 6 . What kind of information have you learnt or accessed using your phone? Have electricity to charge phone:

7 . What kind of health information are you interested in Use a mobile phone to browse the internet: and why? Probes: General health Sex and sexuality Family planning, pregnancy

40 • UNICEF APPENDIX 3: ONLINE SURVEY QUESTIONNAIRE

Q1 Q6

First, a little about you — how old are you? Roughly how much time do you spend on the Internet when you go online? (select one) Q2 5 minutes Are you female or male? 10 minutes Female 15 minutes Male 20 minutes Q3 25 minutes Which of the following best describes your current occupational status? 30 minutes

In-school (primary, secondary, college or university) More than 30 minutes

Out of school (working) Q7

Out of school (not working) What are the top 3 activities that you do when you are online? (select any 3 that apply) Q4 I listen to/ download music Do you own your own cellphone or share it with someone else? I use instant messaging or chat services (like WhatsApp, Own my own cell phone WeChat or MXit)

Share it with someone else I use social networking services (like FaceBook, MXit or Twitter) Q5 I browse news and entertainment websites In the last 7 days have you used a cell phone to access the internet other than to take this survey? I do research for school/work

Yes I play games

No I search for information about my health

I search for information about relationships and sex

Other (open field to specify)

MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA • 41 Q8 momConnect

Ideally, how would you prefer to get information on sexual health loveLife Call Centre and avoiding unplanned pregnancy? (Pick one) ilovelife A health professional (who comes to my house, school, work or community) Choma Magazine

A peer educator (at school, a community centre or work) SmartSex

My teacher or counselor at school HI4Life

My family member (parent, grandparent, aunt, uncle health4men or sibling) I Choose When A trusted friend or friends Other (specify) A free service that I can use on my phone I haven’t used my cell phone to access health information I prefer to go to a clinic or hospital to speak to a doctor or nurse Q11

Other (field for open text) If you could use the Internet for FREE on your phone, would you use it to look for information about sexual health? Q9 Yes If you are female, select the option that applies to you No I’ve been pregnant before and given birth I am not sure I’ve been pregnant before but did not give birth Q12 I’m currently pregnant for the first time Have you ever been tested for HIV? I’m currently pregnant - not the first time (Reminder: this is 100% anonymous)

I’ve never been pregnant Yes, less than three months ago

I’m not sure if I am/have ever been pregnant Yes, 3 - 12 months ago

I’m a guy! Yes more than 12 months ago

Q10 No

Which of the following mobile phone services that provide information to young people on health and other issues have you used or are you familiar with? Tick all that apply

Young Africa Live

B-Wise

MAMA

42 • UNICEF LIST OF REFERENCES

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