mhealth and Young People in South Africa

Transcription

1 mhealth and Young People in South Africa for every child

2 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.

3 TABLE OF CONTENTS ACRONYMS... 3 EXECUTIVE SUMMARY... 4 Methodology... 4 Findings... 4 Recommendations... 5 INTRODUCTION BACKGROUND Snapshot of young people, sexual and reproductive health....8 HIV Incidence is Declining Snapshot of Internet and mobile phone usage in South Africa....8 Young People are Connected Methodology Focus group sites Focus group participant sampling Online survey Limitations YOUNG PEOPLE S MOBILE COMMUNICATION EXPERIENCES AND PREFERENCES Current sources of information Preferred sources of health information Cost of cell phone use Preferred communication approaches Young people are spending time online Gravidity and parity Knowledge of HIV status Missed opportunities for HIV testing DIGITAL SOURCES OF HEALTH INFORMATION IN SOUTH AFRICA Digital sources of health information specifically targeting young people in South Africa Digital services in South Africa whose users include young people Gender composition of mhealth service users Geographical distribution of young people using mhealth services Challenges with obtaining user demographic data mhealth service providers ENGAGING YOUNG PEOPLE ON DIGITAL PLATFORMS Communication approaches...32 Entertainment education approach Use of gaming principles Marketing mhealth services...32 Promotion on digital channels Promotion by health service providers Promotion by role models, champions and peer mentors MHEALTH SERVICES FOR SOUTH AFRICA S YOUNG KEY POPULATIONS Young People Living with HIV Retention in care and adherence support through virtual support groups Mental health support Adolescent girls and young women Young Men who have Sex with Men Other young key populations LESSONS LEARNT AND RECOMMENDATIONS APPENDIX 1: LIST OF KEY INFORMANTS APPENDIX 2: FOCUS GROUP DISCUSSION GUIDE APPENDIX 3: ONLINE SURVEY QUESTIONNAIRE LIST OF REFERENCES

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

6 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 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

7 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 zerorated 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.

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9 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.

10 1.0 BACKGROUND 1.1 SNAPSHOT OF YOUNG PEOPLE, SEXUAL AND REPRODUCTIVE HEALTH HIV Incidence is Declining The 2012 Prevalence Incidence and Behaviour Survey conducted by the HSRC revealed that HIV incidence among year olds is on the decline in South Africa. 1 Among adolescent girls and young women in this age group the incidence has declined by 60% from 5.3% in 2002 to 2005 to 2.1% in However, knowledge levels about HIV have declined between 2008 and 2012 and condom use at last sex, while higher than in other age categories, has also declined among year olds. 1.2 SNAPSHOT OF INTERNET AND MOBILE PHONE USAGE IN SOUTH AFRICA Young People are Connected Data released by the South African Audience Research Foundation (SAARF) for the period running from July 2014 to June 2015 showed increases in access to cell phones in the adult population (aged 15 years and above), ranging from approximately 81% among LSM* 5 7 to 95% among LSM These increases, were not, however, statistically significant. Internet usage is on the rise although there are wide gaps between Internet usage among the lowest and highest LSM. CHART 1: HIV INCIDENCE (%) AMONG YEAR OLDS IN SOUTH AFRICA IS ON THE DECLINE 2.8% 2.3% 1.5% Source: Shisana et al., 2014 CHART 2: CONDOM USE AND HIV KNOWLEDGE HAVE DECLINED AMONG SOUTH AFRICA YOUTH AGED % Condom use Knowledge about HIV 35% 36.2% 29.4% 28.6% 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 ( 8 UNICEF

11 TABLE 1: MOBILE PHONE OWNERSHIP AND USE AMONG SOUTH AFRICAN YOUTH. AGE SEGMENT CURRENT OWNERSHIP OF MOBILE PHONE (2014) USE OF MOBILE PHONE IN PREVIOUS FOUR WEEKS 8 13 years 34% 78% years 69% 92% years 89% 97% Source: Hampshire et al., Almost 17% of LSM 1-4 had used the Internet in the previous seven days in June 2015 compared to 7.5% in June Increases in Internet usage among the other LSM also rose although not as dramatically as with the lower income users. According to a 2014 GSMA report on year old pregnant women and mothers of children up to age two found that 94% of the women classified as bottom of the pyramid in terms of socioeconomic status owned cell phones and the remaining 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 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 phone in the previous week. 4 As expected, younger adolescent ownership was low but young adolescents do have access to mobile phones. 1.3 METHODOLOGY The report includes primary data collected through focus group discussions with young people aged and key informant interviews conducted with individuals involved in the development of the various mhealth services documented in the review. The purpose of the focus group discussions with young people was to understand: the activities for which young people use mobile phones; young people s preferred information sources for sexual and reproductive health; and young people s perceptions about using mobile phones to obtain sexual and reproductive health information. The purpose of the key informant interviews was to understand the experiences of mhealth service providers in reaching adolescents and young people and to document any challenges and lessons learnt from existing services. The list of key informants interviewed is available in Appendix 2. Secondary data on mhealth services was also reviewed and used to inform certain components of the report, namely a framework profiling the characteristics of mhealth interventions in South Africa (see appendix 1) Focus group sites Protea Glen is a suburb in the south of Johannesburg comprised of informal, lower- and middle-income households. It was selected as a site for focus group discussions as it houses a typical heterogeneous population of urban youth. 5 The focus groups were conducted with the support of a community-based organization, Community-based Prevention and Empowerment Strategies for South Africa (COPESSA), which has been operating in the community for several years in the prevention of child abuse and neglect by spearheading community development projects and providing clinical services to victims of child abuse and neglect. 6 COPESSA is well known in the Protea Glen community and has strong relations with community members including youth who use recreational infrastructure provided by COPESSA as well as benefitting from counseling services. In the North West province, the focus group discussion was held at Luka Village, which is located in the Rustenburg Local Municipality. The village is part of the Bafokeng tribal land and lies in an area with high platinum mining activity. 7 The focus groups were conducted with support from the New lovelife Trust (lovelife) which runs a youth centre, the Royal Bafokeng MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 9

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

13 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 using mobile phones to access health information. Twenty participants took part in the two focus group discussions. All focus group participants owned mobile phones (predominantly WAP enabled feature phones and a few smart phones). Focus group participants tended to be young people in school with some out 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. I am the only one out of all my friends who doesn t have a child Female, Gauteng, 19 years old, in-school. Generally, young people particicipating in the focus groups in Protea Glen and ga-luka Village expressed similar experiences of life as youth in South Africa. Feelings of boredom and despondency, a sense of lack of opportunity for accessing higher education or upliftment from poverty, as well as concerns about drug and alcohol abuse and crime in their communities FIGURE 1: MAIN ACTIVITIES ON CELL PHONES REPORTED BY YOUNG PEOPLE Research for School Research on Careers Advice About Sex and Sexuality Information About Health and Wellbeing Social Networking on Facebook Instant Messaging on WhatsApp Source: Focus group discussions MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 11

14 When I was pregnant it was my mother who was giving me information and helping me. Female, North West, 18 were prevalent amongst young people in both groups. Even before finishing secondary school, young people already had the perception of limited opportunities beyond school and were highly preoccupied with career opportunities. In general across both groups, HIV risk perception and interest in HIV-related issues was low with more proximal issues such as experiences of poverty, limited future prospects and perceived social isolation more at the forefront of young people s minds. While considered undesirable, teenage pregnancy was commonplace and viewed as a norm in both communities. The online survey provided a snapshot of the profile of young people using the mobile web. Five hundred and ninety-eight respondents from a target of 1,000 completed the survey. There was a near even gender split with 48% of respondents to the online survey being female and 52% being male. Ninety percent of the 598 survey respondents were aged 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 be a busy time for young people resuming the academic year, the sensitivity of the topics covered in the survey as well as the fact that the research team did not aggressively promote the poll to younger audiences due to ethical considerations. Similarly to findings in the literature, cell-phone ownership amongst survey respondents was high with 95% reporting that they owned their cell phones while five percent share their cell phone with someone else. There were no significant differences in cell phone ownership between males and females. (See Chart 3 below.) Just over half (53%) of respondents in the online survey reported being in the education system, while a third (30%) reported that they were out of school and unemployed. Nearly one in five (17%) were out of school and employed. TABLE 3: AGE DISTRIBUTION OF ONLINE SURVEY RESPONDENTS AGE NO. OF RESPONDENTS CHART 3: MOBILE PHONE OWNERSHIP AMONG SURVEY RESPONDENTS (1%) Female Male (9%) (90%) Grand Total 598 I own it I share it with someone else 12 UNICEF

15 TABLE 4: OCCUPATIONAL STATUS OF RESPONDENTS BY AGE AGE GROUP IN-SCHOOL (PRIMARY, SECONDARY, COLLEGE OR UNIVERSITY) OUT OF SCHOOL (NOT WORKING) OUT OF SCHOOL (WORKING) GRAND TOTAL (1%) 1 (<1%) 0 7 (1%) (8%) 1 (<1%) 3 (<1%) 51 (9%) (44%) 176 (29%) 100 (17%) 540 (90%) Grand Total 317 (53%) 178 (30%) 103 (17%) 598 (100%) 2.1 CURRENT SOURCES OF INFORMATION Focus group participants mentioned friends, the Internet, and to a lesser extent, family and school as the main sources of information that young people turn to. Family members (especially mothers) were however, an important source of information and practical support for young mothers. Young people recognized that information from friends could be unreliable or potentially inaccurate because they had the same life exposure and context as each other, although advice about sex, contraception and substance abuse from friends based on their personal experiences was deemed trustworthy. Friends were also important sources of social support, with widespread use of instant messaging on WhatsApp to provide each other with emotional and informational support. Both groups identified health workers and health facilities as being unfriendly to youth seeking sexual and reproductive health information or services and one young mother relayed how she had received particularly bad treatment from health workers during her antenatal visits. if I talk to my mom about how I want to go into aeronautics and producing (music), you know what she ll say? Go to church and pray about it. And that that doesn t help me, you know? Male, North West, 19 years old, out of school Young people admitted to spending much of their free time on their phones and the Internet was a popular source of information for (18 out of 20) young people in both groups, with Google being the primary search tool used to access information on a range of general health topics including sexual and reproductive health. A recent study by Hampshire et al (2015) found that of MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 13

16 CHART 4: TOP ACTIVITIES YOUNG PEOPLE AGED DO ONLINE. 15% 262 1% 15 10% 179 Other 18% % 213 2% 33 13% 231 Listen to/download music Instant Messaging Social Networking Browse news and entertainment websites Research for school/work Play games Search health-related information 20% 369 9% 160 Search information on relationships/sex Source: Online Survey TABLE 5: PREFERRED SOURCES OF SEXUAL AND REPRODUCTIVE HEALTH INFORMATION FOR YOUNG PEOPLE AGED IDEALLY, HOW WOULD YOU PREFER TO GET INFORMATION ON SEXUAL HEALTH AND AVOIDING UNPLANNED PREGNANCY? FREQUENCY PERCENTAGE A free service that I can use on my phone % I prefer to go to a clinic or hospital to speak to a doctor or nurse A health professional (who comes to my house, school, work or community) % 92 15% 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 % Source: Online Survey 14 UNICEF

17 the 29% of young people surveyed in South Africa who used a phone to seek health related information in the last 12 months, the most common source of information was internet searching, followed by receiving unsolicited health tips or adverts via SMS. Whereas a 2014 GSMA study of the adult population (16 + years) reported traditional media such as radio and television as the top sources of information on healthcare, fitness and government services, followed by friends and neighbours while less than 5% of the lowest LSM used mobile operator services, the internet and MXit. 3 Following the findings from the focus groups about the main activities for which young people reported using their mobile phones, the question was posed in the online survey to ascertain the top three activities for which young people use their phones. The most frequent activity was social networking, with one in five respondents (20%) mentioning this activity, followed closely by instant messaging (18% of respondents), while 15% of respondents use their phones to listen to or download music. Twenty-two percent of respondents reported using their cell phones to search for information on health (12%) and relationships (10%). The results from the survey are shown below. 2.2 PREFERRED SOURCES OF HEALTH INFORMATION In both focus groups the first mentioned preferred sources of information that young people would like to get information on various issues including sexual health and reproductive health were parents. However, these were identified as being old fashioned, too traditional, and unapproachable or detached from young people s needs and current realities. Young people said that while they were of the view that information from health care workers at health facilities was accurate, there was widespread reticence to go to local clinics for information or services due to perceptions and experiences of unfriendly and judgmental health workers, lack of privacy in clinic settings as well as the possibility that health care workers would breach their confidentiality. All the young people participating in the focus group discussions expressed willingness to use their phones to seek information about sexual and reproductive health on condition that the service was zero-rated. Indeed, the survey found that 84% of young people would use their phone to access health information on the Internet if it were free (see Chart 5). 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 online survey findings reflected the insights from the focus groups as few respondents preferred to obtain health information from family members, peers, teachers or friends. Most participants expressed a preference to use their phones for a free service (35%) or to go to a clinic or hospital and obtain information from a doctor or nurse (34%). Given the findings from the focus groups where young people expressed reservations about health worker attitudes despite being a trusted information source, the survey findings suggest that young people would in all likelihood take up services at health facilities if they were friendlier to youth. MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 15

18 2.3 COST OF CELL PHONE USE Cost was identified as a major consideration for young people using their mobile phones and is the main determinant of what services they choose to subscribe to or utilize. This was the case for both in-school and out-of-school young people. Monthly spending on data and airtime ranged from R30 for feature phone users to R300 for smart phone users. Young people identified various sources of money for airtime and a range of means by which the costs of using their cell phones were met. Young people rely heavily on freely accessible content and platforms with zero-rated services such as the free WhatsApp access for Cell-C users cited by young people in both groups. In the urban area use of free Wi-Fi at malls and other public spaces was common while in the tribal settlement area young people engaged in entrepreneurial activities such as washing 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 84% 502 No I am not sure Source: Online Survey FIGURE 2: SOURCES OF MONEY FOR YOUNG PEOPLE TO OBTAIN AIRTIME AND DATA. Airtime and Data Sharing Gifts from Boy/Girlfriends Allowances from Parents Small Scale Entrepreneurship Source: Focus group discussions 16 UNICEF

19 community and in some instances, begging for small change in order to buy airtime, all activities they referred to as hustling. Young people from both groups identified criminal activities such as pick pocketing, shoplifting and selling drugs as common activities to which young people resort in order to buy airtime and data, as well as to make other purchases. Mobile network operator offerings catering to low-income groups were mentioned as means by which young people obtain airtime. These include airtime advances and pre-paid airtime sharing amongst friends and family members. Boyfriends, girlfriends, sugar mamas and sugar daddies were also mentioned as a common source of financial resources for young people. 2.4 PREFERRED COMMUNICATION APPROACHES The preferred communication approach for young people interviewed in the focus group discussions was predominantly entertainment education. This confirms findings from various social and behaviour change audience research studies that have found that entertainment education is effective as it models desirable behaviours and facilitates social learning by engaging audiences and stimulating discussions. Use of local celebrities to raise awareness of existing services and testimonies of local community champions or positive deviants were highly favored as they are seen as more relatable given their similar contexts. A minority of participants in the focus groups (two of twenty) expressed that they preferred interpersonal communication with trusted professionals such as community-based social workers, youth counselors and nurses at clinics. 2.5 YOUNG PEOPLE ARE SPENDING TIME ONLINE Five hundred and seventeen out of 598 respondents reported that they had gone online in the last seven days aside from participating in the survey. Survey respondents also reported spending significant amounts of time online on their phones, with 46% spending more than 30 minutes each time they go online as shown in the figure below. The online survey posed questions related to health indicators such as ever having given birth and knowledgeof HIV status as well as familiarity with mhealth services. 2.6 GRAVIDITY AND PARITY Of the females who completed the survey, nearly half (48%) reported that they have never been pregnant, a third reported that they have been pregnant before and given birth and 13% reported being currently pregnant. Two-thirds of those who were currently pregnant were pregnant for the first time. Four percent of the respondents have been pregnant before but did not give birth as shown in the figure below. The survey did not ask for reasons for not giving birth due to constraints on 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 11% 5-10 minutes minutes 46% minutes 7% minutes minutes Under 5 minutes 13% 10% Source: Online Survey MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 17

20 online poll. It is thus not known whether the reasons for not giving birth were miscarriages or terminations of pregnancy. CHART 7: RESPONDENT GRAVIDITY. The table below reveals that nearly 40% (99 of 256) of respondents aged have been pregnant before and given birth. 2.7 KNOWLEDGE OF HIV STATUS 3% The vast majority of respondents (84%) reported having been tested for HIV before and one third of these were tested in the last 3 12 months while, more than half (54%) reported having 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 in the same age group who have never been tested for HIV. 32% 4% 9% 4% 48% 2.8 MISSED OPPORTUNITIES FOR HIV TESTING Of the 25 repondents who reported being currently pregnant, 15 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 for HIV in the last three months were pregnant for the first time. Ninety percent (36 out of 40) of the female respondents who have never tested for HIV have never been pregnant either. 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. I've been pregnant before but did not give birth I've been pregnant before and given birth I'm pregnant now - not the first time I'm pregnant for the first time now I'm not sure if I am/have ever been pregnant I've never been pregnant Source: Online Survey TABLE 6: PREGNANCY AND CHILDBEARING AMONG ONLINE SURVEY RESPONDENTS BY AGE GRAND TOTAL I m not sure if I am/have ever been pregnant I m pregnant for the first time right now! I m pregnant now - not the first time I ve been pregnant before and given birth I ve been pregnant before but did not give birth 8 8 I ve never been pregnant Grand Total UNICEF

21 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 yrs old yrs old yrs old No Yes, more than 12 months ago Yes, 3-12 months ago Yes, les than three months ago Source: Online Survey MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 19

22 CHART 9: HIV TESTING AMONG MALES BY AGE yrs old yrs old yrs old No Yes, more than 12 months ago Yes, 3-12 months ago Yes, les than three months ago Source: Online Survey 20 UNICEF

23 MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 21

24 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 PROJECT NAME PROJECT DESCRIPTION B-Wise, NDoH bwisehealth.com 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, gender based violence, chronic diseases (physical and mental disability, violence, trauma and injuries and oral health. Mobisite provides factual information, engagement through polls and live monthly chats with epxerts and will include a clinic finder. Age-gateway functionality to be added to provide age-specific content to users aged years in all provinces. BeingGirlSA, Proctor and Gamble mxitapp.com/beinggirlsa/ signup A service available on MXit, FaceBook and Twitter developed under the Always brand of sanitaryware. The service serves as a space for girls to ask questions related to puberty, development and other issues of interest to them. Choma Magzine, HIVSA choma.co.za CHOMA is an interactive mobile phone magazine targeting South African girl adolescents young women aged years, whether they are at school, unemployed or employed, or single, in a relationship, or married. CHOMA interacts with its target audience through Facebook, Mobi, 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, 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 listen to content free of charge. The purpose of the app is to provide young people with lessons on issues like drug abuse, teenage pregnancy and domestic abuse using an entertainment education approach. Crossroads Generation top-stories/crossroadsgeneration/s Destiny Toll-free line for youth and students Toll free number: com/2015/11/06/ndalomedia-launches-destinyhelpline-for-youth-andstudents Service launched in November 2015 by Ndalo Media under the Destiny Magazine brand in 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, depression, stress, anxiety and issues related to exams, career planning, racial and gender discrimination, social pressure or isolation. Young people can request and access the services provided through a toll free helpline, SMS, please call me, Twitter and Facebook. 22 UNICEF

25 AUDIENCE REACH TARGET AUDIENCE AGE AGE USER/AUDIENCE DATA COLLECTED GEOGRAPHIC LOCATION SEX OCCUPATIONAL STATUS EVALUATION FINDINGS over 100, No Yes No No Not yet evaluated. 345,554 subscribed via FaceBook Adolescent girls and young women 800, No Yes Yes No Not yet evaluated. Data unavailable at time of report Data unavailable at time of report MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 23

26 TABLE 8: MHEALTH SERVICES SPECIFICALLY DEVELOPED FOR YOUNG PEOPLE, CONTINUED PROJECT NAME PROJECT DESCRIPTION FunDza Mobile, Fundza Literacy Trust live.fundza.mobi FunDza mobile is a mobi network aimed at providing teens and young adults from under-resourced 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 via MXit and a mobiste whose use are zero rated for Cell C customers. Readers are encouraged 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, Nike Foundation Girl Effect mobile aims to address the causes of vulnerability in adolescent girls and young women by providing a platform where a network of girls is able to engage with each other, sharing experiences and stories. Girl effect operates by proving girls and young women with knowledge 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, SEED Community girlztalk.mobi/home/ 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 health related issues. A strong emphasis is placed on educational development and support. Recipients of SEED educational loans run the project as a social business aimed at developing their entrepreneurial skills and enabling them to contribute to the development of other girls. Health4Men, ANOVA Health Institute h4m.mobi Aim to increase knowledge, improve health-seeking behaviour and reduce sexual risk-taking among MSM. Health4Men Connect is an interactive mobi-site that provides topical information and allows MSM to send anonymous questions to Health4Men s medical staff. HIV360, Every1mobile hiv360.every1mobile.net Social network support programme with information for those living with HIV/AIDS. HIV360 is a community of young people affected by HIV/AIDS. The site raises awareness, facilitates discussion, improves cross-cultural learning and mobilizes collaborative action on HIV/AIDS amongst young people. There are quizzes and FAQs, educational information, tips on how to talk to bullies, inspiring stories and chat rooms. ilovelife, New lovelife Trust ilovelife.mobi 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 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 including sexual health, interacting with ilovelife content online, taking action in the real world 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

27 AUDIENCE REACH TARGET AUDIENCE AGE AGE USER/AUDIENCE DATA COLLECTED GEOGRAPHIC LOCATION SEX OCCUPATIONAL STATUS EVALUATION FINDINGS 50,000 unique monthly visitors Yes Yes No Not yet evaluated Data unavailable at time of report Not yet evaluated 7,264 subscribed via FaceBook Pending data from ANOVA Unspecified Yes Yes Yes No 15,000 Adolescents and young people Yes Yes Yes No 5, Yes Yes Yes Yes Not yet evaluated MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 25

28 TABLE 8: MHEALTH SERVICES SPECIFICALLY DEVELOPED FOR YOUNG PEOPLE, CONTINUED PROJECT NAME PROJECT DESCRIPTION lovelife call centre, New lovelife Trust Youth line: Parent line: lovelife s call centre is comprised of two national toll-free helplines, the Youth Line and Parent Line that provide reproductive health information and counselling services for both adolescents and parents or guardians. 9 professional counsellors, 9 to 10 groundbreakers and 11 operators staff the Call Centre. groundbreakers and operators provide callers with information on lovelife and basic HIV/Aids information while counselors provide professional counseling services and respond to questions posed on the text based counseling service. Lovelife text-based counseling service, New lovelife Trust mxitapp.com/lovelifemx mgirls, GirlsFootballSA mgirls.org Discreet text-based counselling to highly vulnerable people. An innovative web-based platform allows trained counsellors to provide counselling sessions to young people free of charge. Youth may also send a please call me to the national call centre to request a counselling session. A push text is sent via MXit to a subscriber s phone with an accurate health tip. Content on puberty, SRH, HIV and other topics is developed based on questions raised by girls participating in the GirlsFootballSA soccer workshops at local schools. MSF Online Youth Clubs, Medecins Sans Frontieres Virtual support groups on WhatsApp and FaceBook to provide social support to HIV-infected youth at Site C Clinic in Khayelitsha. Lay counsellors provide support to groups of participants in 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, SHM Foundation shmfoundation. org/?page_id=319 Psychosocial support to HIV positive adolescents (13-18 years old), via mobile-phone in peerled support groups, of participants. Groups run for 3 months. Participants communicate amongst themselves and with a facilitator via text-message about a broad range of topics including disclosure, discrimination, general information, HIV and SRH. SMRTSEX, Every1Mobile smartsex.every1mobile.net A service hosted on MXit providing Q and A s, information manuals on SRH-related topics, quizzes to test knowledge acquisition and routine polls to assess knowledge, attitudes and perceptions of users. Service is available in South Africa, Tanzania, Nigeria, Zimbabwe, Ghana and Kenya. The Smart Sex mobiste is also available as a suggested site on Opera Mini Young Africa Live, Praekelt Foundation youngafricalive.mobi 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 knowledge transfer. The service is no longer active and has been replaced by B-Wise however it included due to its high user reach across South Africa. Young mom support mxitapp.com/ youngmomsupport 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 of pregnancy, adoption, birth, breastfeeding, childcare grants, maintenance, remaining in school as young parent, stigma and general health and relationship advice. 26 UNICEF

29 AUDIENCE REACH TARGET AUDIENCE AGE AGE USER/AUDIENCE DATA COLLECTED GEOGRAPHIC LOCATION SEX OCCUPATIONAL STATUS EVALUATION FINDINGS Approx. 500,000 calls in (youthline) Yes Yes Yes Yes 2012/2013 study found that a large majority of 80% of callers were under 25 years old and 71% lived in informal settlements and rural areas. Respondents reported being satisfied/very satisfied with the service 170, Yes Yes Yes No 65, Yes Yes Yes Approx Yes No Yes Yes Evaluation on-going Approx Yes Yes Yes No Evaluation on-going Average 300,000 a month Unspecfied Yes Yes Yes No Sporadic surveys revealed increased knowledge and increased self efficacy in dealing with topics covered 1,800, Yes Yes Yes No Over 14,000 since 2013 Unspecified MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 27

30 3.2 DIGITAL SERVICES IN SOUTH AFRICA WHOSE USERS INCLUDE YOUNG PEOPLE TABLE 9: ADDITIONAL MHEALTH SERVICES ACCESSIBLE TO YOUNG PEOPLE PROJECT NAME PROJECT DESCRIPTION Project M s3.amazonaws.com/ poptech_uploaded_ files/uploaded_files/27/ original/project_ Masiluleke_Brief.pdf The National AIDS Helpline s name and number appeared on "Please Call Me" that went out, with the call-to-action to phone the Helpline, to access further information and services around HIV and AIDS. Over the first two years over Project Masiluleke's PCM program, over 968 million Please Call Me's were tagged with messages, averaging over a million messages a day. Messages were sent in several languages and addressed several AIDS-related topics, providing comparisons of messages and themes. momconnect za/index.php/momconnect 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 through free stage-based SMS provision. The services are free to the user, and messages are currently available in six languages. Objectives: 1. To register each pregnancy at a government health facility. 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. MAMA askmama.mobi BabyInfo mxitapp.com/babyinfo A mobisite accessible on internet enabled phones provides information to registered new and expectant mothers.the mobisite is free to vodacom customers on Vodafone live. The SMS component of MAMA has been merged with the MomConnect programme and provides free stagebased SMS messages to registered users with confirmed pregnancies. USSD quizzes are sent at a cost to registered women providing personalized weekly quizzes with information about healthy pregnancy and child health. The MAMA service is also available on MXit providing registered users with personalized information on pregancy and child health Information for expectant mothers. : Improve knowledge base of expectant parents to improve maternal and infant health, contributing to a decrease in infant and maternal mortality rates. Information is delivered for free and is customised to their stage of pregnancy. HI4Life, HIVSA hi4life.mobi A mobisite providing HIV-related information as well as general health and well being information. Regular polls and Medical abortion study, University of Cape Town and Cell Life co.za Push sms s were provided to women coaching them through medical abortion. A mobisite with contraception information was introduced and also offered as a service on MXit. 28 UNICEF

31 AUDIENCE REACH TARGET AUDIENCE AGE AGE CURRENT DATA AVAILABILITY GEOGRAPHIC LOCATION SEX OCCUPATION EVALUATION FINDINGS 1 million calls made to national helpline in response to PCM messages Adult population No Yes No No The project was successful in driving calls to the national helpline. Over 780, Yes Yes Yes Currently undergoing evaluation 700, Yes Yes Yes MAMA subscribers' adoption of key behaviors and practices was higher than national averages in South Africa and Bangladesh. Behaviour was changed positively compared to previous pregnancies and babies. 300,000 monthly average Unspecified Not yet evaluated Data embargoed pending publishing of study findings. Data embargoed pending publishing of study findings. Yes Yes Yes Yes Privacy was not a big issue forwomen signing up for the study. Participants were able to complete a self-assessment on their mobile phone, following a short training session. However, due to the complexity of the language required to describe physiological processes it was not clear whether or not the abortion had taken place with 100% success. MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 29

32 3.3 GENDER COMPOSITION OF MHEALTH SERVICE USERS Maintaining a balance of male and female users is difficult and much of the content on mhealth services resonates with girls resulting in user numbers being slightly skewed in favour of girls and young women. On MXit about 52% of users of health content were female 8 while on Young Africa Live, the proportion of females peaked to as much as 60%, resulting in special efforts being made to include more male voices in the content generated to revitalize male participation. 9 Similarly, services such as Fundza and ilovelife have slightly more female than male users even though they target both males and females. 10,11 On Young Africa Live, females demonstrated high levels of engagement, actively involving themselves in the management of the community and reporting undesirable behaviours. 9 Females have also tended to be far more willing to participate in surveys than their male counterparts on MXit, although the reasons for this are not known. In contrast, an evaluation of lovelife s MizzB/MXit text counseling service found that there was a higher proportion of males using the service than females while females preferred direct voice calls with the lovelife call centre. 12 Similarly, according to every1mobile, SmartSex has found about 60% male users necessitating the skewing of promotional activities to balance the gender split by increasing female interest and participation. 13 HIVSA has found that older males in their late teens and early twenties typically use the Hi4life mobisite. 14 The trends in gender are reflective of the closing gap between male and female users of the Internet overall. A South African Network Society survey conducted in 2014 found that although only 46% of all Internet users are women, women constitute more than half of new Internet users GEOGRAPHICAL DISTRIBUTION OF YOUNG PEOPLE USING MHEALTH SERVICES In start up phases, adoption of mhealth services tends to be clustered around urban areas due to marketing, ease of recruitment and high phone penetration in urban areas and oftentimes, pilot projects are conducted with patients of urban facilities. The users of ilovelife are mainly in Gauteng, followed by KwaZulu Natal and Mpumalanga, 10 while every1mobile describes the typical user of HIV360 and SmartSex as urban or peri-urban dwelling. 13 The lovelife Call Centre evaluation found it to be highly effective in providing services to youth in rural and informal settlements, with 71% of its clients calling from rural and informal settlements. 12 Due to ease of access, HIVSA promotes primarily promotes Choma in Gauteng where the organization is based and has found that urban areas enjoy high usership due to the fact that they are more connected than more rural areas. 14 Recognizing this HIVSA has embarked on an initiative to work with schools in Mt Frere to promote Choma amongst youth in this harder to reach geographical area. 14 The geographic distribution of respondents to the online survey mirrors the CHART 9: GEOGRAPHIC DISTRIBUTION OF ONLINE SURVEY RESPONDENTS Limpopo 17% 104 Mpumalanga 10% 57 North West Province 5% 32 Northern Cape 3% 19 Western Cape 9% 53 Eastern Cape 11% 65 Free State 6% 33 Gauteng 24% 144 KwaZulu Natal 15% UNICEF

33 geographic distribution of mhealth users reported by the various mhealth service providers. None of the mhealth service providers interviewed for this review were able to provide information on users disaggregated to district level, making it difficult to ascertain which districts are more or less active than others in terms of use of mhealth services. Further research is required to elucidate this information, as there are presently challenges with producing this data using existing systems as elaborated on below. 3.5 CHALLENGES WITH OBTAINING USER DEMOGRAPHIC DATA While demographic information is vital to ensure equitable programming for young people it is a challenge to obtain accurate demographic data via mobile phones. Information requested from users as they sign up is limited due to the fact that users tend to be reticent to provide personal details on their mobile phones, partly because they find this tedious and to an extent because of the desire to maintain anonymity. While services such as Google Analytics provide fairly accurate demographic data this is limited to smart phones, and most users location data on users of mhealth services is obtained from mobile network operators, particularly in rural areas where network coverage is sparser, resulting in less accurate location data. A potential solution is to request users to provide information such as the school they are enrolled in or the nearest school in the community/neighbourhood (for out of school youth) when they sign up. The location of the school can be identified through the Department of Basic Education, which has a database of GPS coordinates of all schools in South Africa. This method of collecting location data is being used by the Ukufunda learning initiative MHEALTH SERVICE PROVIDERS Seventeen out of 20 mhealth services specifically targeting young people were provided by non-profit organisations, while three of them were run by profit-making organizations as a free services, namely BeingGirlSA by Proctor and Gamble, Crossroads Generation by Deutsche Welle Network and Destiny Toll-free line by Ndalo Media in partnership with the South African Depression and Anxiety Group. The key players in the provision of mhealth services for young people have been the non-profit sector organizations seeking to further their reach or to strengthen existing public health programmes. For example, lovelife uses ilovelife as a supporting component bridging across all its face-to-face youth programmes at various sites across the country, aimed at providing young people with the skills they require to navigate adolescence and the transition into successful adulthood. 10 Similarly, MSF s online youth club and mentorship programmes for young people living with HIV form a part of a broader youth-centered service provided at Site C Clinic in Khayelitsha. The clinic run by the Cape Town Health Department with support from MSF provides youth-friendly sexual and reproductive health services, HIV counseling and testing, immediate point of care CD4 testing and anti-retroviral treatment to eligible adolescents and young people. In addition to monthly support group meetings the virtual support groups exist in order to provide continued support and contact with HIV-infected young people with a view to retaining them in the treatment cascade. 17 The government of South Africa, through the National Department of Health (NDoH), has been very involved in mhealth, in terms of rationalizing the sector by leading the development of a national ehealth strategy for The strategy outlines the countries priorities and key activities for the ehealth domain, in which mhealth is included. 18 NDoH has also worked in partnership with UNICEF, Praekelt Foundation, Wits Reproductive Health Institute and other supporting entities to launch and implement momconnect and B-Wise. The Department of Basic Education, UNICEF and MXit Reach are in partnership to provide teachers, learners and parents with education-related content on the Ukufunda service through the MXit platform. 16 The South African curriculum includes comprehensive sexuality education and life skills based content aimed to build the social and cognitive skills and knowledge of young people to improve their HIV, TB and other health related outcomes. 19 Hence, it would be expected that such content would be available on Ukufunda. Partnerships are critical in implementing mhealth, with expertise from various sectors such as ICT, research and academia and health service providers coming together to implement the projects currently in existence. MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 31

34 4.0 ENGAGING YOUNG PEOPLE ON DIGITAL PLATFORMS 4.1 COMMUNICATION APPROACHES Entertainment education approach Young Africa Live used fictional first person narratives to present 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 This content approach was selected as it makes facts easy to distinguish and locate, while also hooking the attention of the reader using information, which is already familiar and of popular interest. 9 FunDza also uses fictional stories to provide information, allowing readers to comment and provide feedback to the writers as well as stimulating discourse amongst readers. 11 Use of entertainment education or fictional narratives to present facts, start conversations and change attitudes and perceptions has been found to be effective by a number of studies and is met with high acceptability among audiences. This is also supported by the findings from the focus group discussions in young people expressed a preference to receive information this way. It is critical to ensure that accurate information is clearly visible on the site with a call to action to access further information or adopt a specific behaviour. Fundza links to partner sites for further information at the end of each fictional story while Young Africa Live included fact-based articles. 9,11 Use of gaming principles The ilovelife service uses gamification as a means to engage youth, reinforce knowledge transfer and provide incentives for adoption of positive behaviours by using a points system to reward interactions such as participation in knowledge quizzes and self-assessments on the site. 10 Users can also earn points by demonstrating the adoption of health behaviours such as We found that the most successful services were the ones that enabled user interaction and had regular, fresh content. Andrew Rudge, CEO MXit Reach Content must engage, provide unambiguous facts and prompt real-life action by audiences taking an HIV test. Furthermore, the service incentivizes users to continuously engage with the service through entry into competitions to win real world prizes such as airtime and movie tickets. 10 LevelUp, currently under development by MXit Reach, will also follow a similar model, with a focus on incentivizing improved academic performance, improved health knowledge and behaviour and enhanced executive functioning such as problem solving skills and critical thinking. 8 Young Africa Live enabled users to control content by reporting offensive comments, which would then be removed if reported by three users. As users engaged with each other independently, it became possible to identify specific voices rising to the fore in terms of high levels of engagement with the content. 9 Interactivity is a critical feature that supports continued engagement and knowledge transfer. The ability to ask questions, have them responded to immediately, to comment on topics and communicate with other users has contributed to the success of mhealth services such as Young Africa Live, Smart Sex and FunDza to name a few. Sluggish initial uptake of the B-Wise service may be linked to the more static nature of the content compared to other youth services. 4.2 MARKETING MHEALTH SERVICES The online survey revealed that many young people were familiar with a number of mhealth services. Respondents cited having obtained health information from Young Africa Live, ilovelife as well as the lovelife call centre, momconnect, Smart Sex, HI4Life and Health4Men, suggesting that these have been more vigorously promoted. Promotion on digital channels In addition to providing funding to make mhealth services freely available to users, the private sector has played an important role in making the audience aware of the services available. For example, SmartSex appears as a suggested link on the Opera Mini landing page so that anyone opening the web browser is immediately exposed to the service offering, UNICEF

35 while Young Africa Live garnered huge popularity as a service offered to Vodacom subscribers on the VLive platform among other services already used by the target audience. 20 Choma is available nationally and is promoted for free on MXit to users in the Eastern Cape which was the pilot research site 14 while Smart Sex also benefits from free promotion on the MXit platform. 13 Mobile Network Operators (MNOs) have offered advertising on the Please Call Me service where mhealth services providers can pay to promote their services as messages appended to a certain number of please call me s sent by network subscribers. Many mhealth service providers promote their services on social media channels such as Twitter and Facebook, which serve as additional platforms for content exposure and engagement with the audience. Promotion by health service providers Health care providers have been involved in promoting mhealth services to patients, however this requires advocacy for their buy in, as it can be viewed as additional work for an already overloaded health workforce. It also requires for them to be trained on and made familiar with the services so that they can provide accurate information to patients regarding the services. mhealth services have made use of health workers to promote and support recruitment of clients for a variety of services such as medical abortion SMS support services, maternal, neonatal and child health support, and psychosocial support of adolescents and young people living with HIV. Establishing relationships and working with health professionals at clinics to promote digital services is, however an on-going challenge for many mhealth service providers, and has had varying degrees of success in the South African context. Promotion by role models, champions and peer mentors Choma magazine, which has reached almost one million girls and young women, uses a local celebrity ambassador and volunteer peer educators to promote the service 14,24 and indeed young people participating in focus groups identified the use of local ambassadors as a good marketing strategy given their interest in what celebrities have to say. While very active on their mobile phones, the young people participating in the focus group discussion in the North West province were not aware of the full range of mhealth services available to young people including those offered by lovelife despite the fact that they were frequent participants in activities offered by the lovelife youth centre in their community. This suggests the importance of training of face-to-face implementers of youth programmes to raise awareness of mobile services to young people and enhance their information-seeking skills, particularly in rural areas where access to services may be more limited. The ilovelife service was introduced after groundbreakers had already been trained on lovelife s programmes for the year hence their promotion of the service has been inconsistent. 10 Promotion of lovelife s digital programmes will be integrated into groundbreaker orientation and training from 2016 to ensure wide promotion of the digital offerings, given that they are an integral part of lovelife s social and behaviour change model. 10 MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 33

36 5.0 MHEALTH SERVICES FOR SOUTH AFRICA S YOUNG KEY POPULATIONS 5.1 YOUNG PEOPLE LIVING WITH HIV 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 support groups FIGURE 3: QUALITATIVE STUDY FINDINGS OF DIGITAL YOUTH CLUB PARTICIPATION Not Interested in 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 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 were receiving clinical care and attending physical support group 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 monitoring and prevent late initiation on ART, while those stable 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: Preference for Other Platforms Lost Interest in the Chat Room TABLE 10: GOALS OF MSF ONLINE YOUTH CLUBS BEHAVIOUR CHANGE Retention in care at all stages of the treatment cascade Improved adherence to treatment Loss of Password or Phone COGNITIVE AND SOCIAL SKILLS Improved psychological wellbeing Improved social interaction and support Think mxit is for Younger People Source: Patten et al., 2014 Source: Patten et al., UNICEF

37 protected chat room hosted on MXit, where a youth counselor was on hand for an hour every day to provide support, although conversations among group members were able to interact with each other at leisure. Participants were provided with a small airtime voucher in order to enable them to register on MXit. Uptake of the online chat room was low with only one in three youth club members ever visiting the chat room. 25 A qualitative evaluation of the initiative found that youth club members liked the idea of communicating online in between support group meetings and almost half of respondents (45%) preferred to visit when a facilitator was present. 25 Participants indicated that they preferred to interact on platforms such as Facebook and WhatsApp rather than MXit due to certain limitations with MXit. 25 Findings from the Phase 1 pilot evaluation led to the development of a second pilot of online clubs on Facebook and WhatsApp, which were commenced in 2014 with the approximately 200 youth attending physical youth clubs being invited to participate. Evaluation of the Facebook and WhatsApp youth clubs is on-going. Mental health support Project Khuluma: SHM Foundation Project Khuluma was launched in 2013 with a view to providing adolescents infected with HIV aged 13 to 18 with a means to provide and receive emotional support through SMS interactions in a peer environment. 26,27 Closed support groups of participants anonymously engage in discussions on a range of issues ranging from sexual health to career advice, with some sessions facilitated by invited guests. 26,27 Topics of discussion have also included challenges of disclosure, stigma and discrimination. Preliminary evaluation findings have revealed that the youth struggle with treatment compliance, communicating with health professionals about medication, they feel isolated because of their inability to disclose their status and that they value interacting with other young people experiencing similar challenges. 27 Project Khuluma is currently undergoing in-depth evaluation. FIGURE 4: CHALLENGES WITH IMPLEMENTING A MOBILE SERVICE FOR MENTAL HEALTH SUPPORT OF YOUNG PEOPLE LIVING WITH HIV. Limited by Variations in Literacy Levels Participants Experience Language Barriers Confusion Caused by Multiple Conversations Limited Message Length SMS Channel Still Expensive Source: SHM Foundation, 2015 MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 35

38 5.2 ADOLESCENT GIRLS AND YOUNG WOMEN Choma Magazine: HIVSA HIVSA, has, through funding from the Charlize Theron Africa Outreach Foundation, developed Choma, a digital magazine aimed at engaging South African women aged 15 to 25 years on HIV and SRH issues presented integrated in a wide variety of lifestyle content. 24 The magazine makes use of discussion forums, polls and social gaming to create a platform on which users are able to pose questions related to SRH, HIV and AIDS, as well as other general health issues and receive direct feedback. 14,24 Choma magazine has the following behavioural goals: TABLE 11: CHOMA MAGAZINE GOALS BEHAVIOUR CHANGE DEMAND CREATION FOR HEALTH SERVICES AND INFORMATION COGNITIVE AND SOCIAL SKILLS Source HIVSA Delayed sexual debut Increased condom use Increased STI-care seeking behaviour Reduced number of sexual partners Increased demand for HCT Increase demand of SRH services including contraception Create demand for information on HIV and AIDS and increasing dialogue and discussions on related topics Increased self-esteem Improved decision-making skills Improved condom negotiation skills Increased risk perception Choma has 800,000 registered users who are predominantly urban girls in Johannesburg followed by Cape Town then Durban. 14 Sixty percent of its users are on MXit and aged years, 20% are on Facebook and aged years of age while the rest utilize the website and Twitter. 14 The magazine features fashion and lifestyle information and encourages participation through a journal club where girls and young women are able to express themselves, it features an online moderator who provides emotional support, responds to questions and provides links to health providers. 14,24 Using Choma chat on the website and MXit girls are able to interact with the moderator who is given an older sister persona 14,24 HIVSA has also developed Choma smart phone game which builds critical thinking, decision-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 mgirls: Girls and Football SA mgirls, a mobile health app hosted on MXit which was developed for Girls and Football SA, an organisation that uses the medium of sport to provide life skills to adolescent girls aged and young women aged and years. Through the app, health facts related to HIV prevention, teen pregnancy and other sexual and reproductive health issues are pushed to 65,000 subscribers across South Africa on a daily basis. The content is developed in response to questions and feedback raised by girls participating in life skills and football workshops run by Girls and Football SA in Cape Town and Pretoria. While the workshops 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 This is an example of the potential of mhealth to provide information and skills to young people rapidly and at national scale. 5.3 YOUNG MEN WHO HAVE SEX WITH MEN Health4Men Project: Anova Health Institute Anova has trained and mentored over health workers at a network of 200 public clinics across all provinces to provide prejudice-free sexual health treatment and care to gay, bisexual and other men who have sex with men. 28 As a complementary service Anova created a mobisite (h4m.mobi) which offers men who have sex with men information such as where to find their nearest gay-friendly health facility, allows them to anonymously 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 for men who have sex with men who are living with HIV. 28,29 Through the mobisite professionals from Anova provide access to short term counseling to individual MSM and couples on issues 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 in providing services for young men who have sex with men is the paucity of data on this demographic, especially young MSM in detention. 29 The fluid nature of gay identity formation combined with the complexity of transition from childhood to adolescence and then adulthood make it difficult to identify young MSM and provide them with targeted information and services OTHER YOUNG KEY POPULATIONS No specific interventions were found in South Africa addressing young people who inject drugs, young people living with disability and young people who engage in high risk drinking. Topics such as alcohol and substance abuse are included in the content of many mhealth services for young people such as B-Wise, FunDza and Choma. 36 UNICEF

39 6.0 LESSONS LEARNT AND RECOMMENDATIONS LESSONS LEARNT RECOMMENDATIONS Measuring the results of mhealth services Routine data on user registrations or web/ mobisite hits and anecdotal reports of changes in outcomes are insufficient to enable on-going evidence-based learning and decision-making about where and how best to deploy resources for mhealth. Major data gaps exist in terms of audience demographics due to unreliable data collection resulting in limitations in the ability to develop content that is responsive to the heterogeneity of the South African youth market. mhealth services should incorporate rigorous monitoring and evaluation of services into the project design from inception to ensure that the contribution of mhealth to outcomes such as knowledge and attitudinal change as well as health seeking behaviours can be understood. Continuous evaluation must be budgeted for and conducted: formative/ design (beyond audience acceptability to theory of change development based on evidence); process/implementation (assessing dose and fidelity); and impact (making value judgments on interventions, considering the cost and cost effectiveness of mhealth as a tool in an arsenal of 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 mobile networks drives regular user engagement by reducing user costs. Continued engagement and advocacy with MNOs to ensure costs to users are kept low. Promotion of services through placement on the MNO deck helps drives audiences to mhealth services MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 37

40 LESSONS LEARNT RECOMMENDATIONS Ensuring safety of adolescents and young people online Moderation of young people s interactions with each other is important to prevent abuses such as cyber-bullying, harassment, homophobia, hate speech and other forms of abuse Mechanisms to collect accurate information about age and location of users should be put in place to assist in the creation of safe spaces for adolescents and young 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 of engagement required to influence knowledge and skills of young people. As the subscription to services increases, audience management and engagement become more challenging and resource intensive requiring more man-hours to ensure satisfactory experiences and continued trust in the service by young people. Live chats with experts have high valence because young people want to be able to anonymously get information from a professional. Entertainment education is a highly engaging approach to provide young people with information and influence their behaviours. mhealth services should shift away from mere dissemination of information and ensure that content is easily accessible, regularly refreshed and that young people are able to actively engage with the content and each other to reinforce learning. Adequate financial and human resource allocation should be made to allow for continued moderation and response to user requests and feedback to ensure sustained, high quality experiences for users as services scale up. Experts should take care to use non-judgmental language and tone when communicating with youth. Content development should be an iterative and collaborative process between creative specialists and public health or social and behaviour change specialists to ensure that content is scientifically accurate and based on evidence, while presented in a manner that facilitates engagement and learning. 38 UNICEF

41 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

42 APPENDIX 2: FOCUS GROUP DISCUSSION GUIDE OPENING QUESTIONS 1. Tell me about your lives. What do young people in Luka Village get up to? Probes: Where do they socialize? With whom do they socialize? How do young people keep in touch with their friends? 2. What are the aspirations of young people when they think of the future? Probes: Embarking on careers Getting an education Having relationships Starting families 3. How do you think you can help yourselves to achieve those aspirations? Probes: Staying safe Setting goals etc SOURCES OF INFORMATION 4. So it sounds like you need to have a plan for your life and make decisions about what you want out of life and how to do it. How do you decide what to do? Probe: Where do you get information to help you plan for and make decisions about your life? 5. How do young people use phones to get information? 6. What kind of information have you learnt or accessed using your phone? 7. What kind of health information are you interested in and why? Probes: General health Sex and sexuality Family planning, pregnancy 8. (Explain definition of sexual and reproductive health). When it comes to SRH, people have different preferences for getting information or advice. Some people prefer to get information from someone they know, others prefer a professional, others prefer TV, radio, the internet, etc. Where do you prefer to get SR health information? 9. What do you think about the idea of using mobile phones to engage with young people about their health? Probes: Is it a good idea or a bad idea? Why or why not? What would prevent young people from using their phones to get health information? What would encourage young people to seek SR health info using their phones? 10. What are the costs involved in using a mobile phone? Probes: Who pays? How do young people meet these costs? CONCLUSION If I have heard you correctly, you have said that (summarize key points). Is there anything else you would like to add? By show of hands, how many: Own a mobile phone: Share a phone with another person: Have a good network (can make calls inside the house): Have electricity to charge phone: Use a mobile phone to browse the internet: 40 UNICEF

43 APPENDIX 3: ONLINE SURVEY QUESTIONNAIRE Q1 First, a little about you how old are you? Q2 Are you female or male? Q3 Female Male Which of the following best describes your current occupational status? Q4 In-school (primary, secondary, college or university) Out of school (working) Out of school (not working) Do you own your own cellphone or share it with someone else? Q5 Own my own cell phone Share it with someone else In the last 7 days have you used a cell phone to access the internet other than to take this survey? Yes No Q6 Roughly how much time do you spend on the Internet when you go online? (select one) Q7 5 minutes 10 minutes 15 minutes 20 minutes 25 minutes 30 minutes More than 30 minutes What are the top 3 activities that you do when you are online? (select any 3 that apply) I listen to/ download music I use instant messaging or chat services (like WhatsApp, WeChat or MXit) I use social networking services (like FaceBook, MXit or Twitter) I browse news and entertainment websites I do research for school/work I play games 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

44 Q8 Ideally, how would you prefer to get information on sexual health and avoiding unplanned pregnancy? (Pick one) Q9 A health professional (who comes to my house, school, work or community) A peer educator (at school, a community centre or work) My teacher or counselor at school My family member (parent, grandparent, aunt, uncle or sibling) A trusted friend or friends A free service that I can use on my phone I prefer to go to a clinic or hospital to speak to a doctor or nurse Other (field for open text) If you are female, select the option that applies to you Q10 I ve been pregnant before and given birth I ve been pregnant before but did not give birth I m currently pregnant for the first time I m currently pregnant - not the first time I ve never been pregnant I m not sure if I am/have ever been pregnant I m a guy! Q11 momconnect lovelife Call Centre ilovelife Choma Magazine SmartSex HI4Life health4men I Choose When Other (specify) I haven t used my cell phone to access health information If you could use the Internet for FREE on your phone, would you use it to look for information about sexual health? Q12 Yes No I am not sure Have you ever been tested for HIV? (Reminder: this is 100% anonymous) Yes, less than three months ago Yes, 3-12 months ago Yes more than 12 months ago 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

45 LIST OF REFERENCES 1. Shisana O, Reshle T, Simbayi L, Zuma K, Jooste S, Zungu N, et al. South African National HIV Prevalence, Incidence and Behaviour Survey, [Internet]. Cape Town; Available from: 2. South African Audience Research Foundation (SAARF). SAARF s All Media and Products Survey, SAARF AMPS Jun 15 (2015A) GSMA. Understanding the needs and wants of pregnant women and mothers in South Africa, July 2014 [Internet] Available from: women/wp-content/uploads/2014/07/consumer-research- Report.pdf 4. Hampshire K, Porter G, Owusu SA, Mariwah S, Abane A, Robson E, et al. Informal m-health: How are young people using mobile phones to bridge healthcare gaps in Sub- Saharan Africa? Soc Sci Med [Internet] Oct [cited 2016 Jan 25];142:90 9. Available from: 5. City of Johannesburg. Regional Spatial Development Framework 2010/2011 Administrative Region G. [Internet]. Johannesburg: City of Johannesburg; Available from: regiong/section4_sub2a.pdf 6. COPESSA. COPESSA Services [Internet]. COPESSA [cited 2015 Dec 14]. Available from: 7. Rustenburg Local Municipality. Integrated Development Plan [Internet] Available from: rustenburg.gov.za/achieve/sites/all/themes/theme551/docs/ Rustenburg IDP Section 2.pd 8. Rudge A. Insights on MXit mobile platform. Personal communication. [Internet] Available from: Personal communication 9. De Beer T. Insights on Young Africa Live. Personal communication. [Internet] Available from: Personal communication 10. Archer J. Insights on lovelife Digital Programmes. Personal communication. [Internet]. Available from: Personal communication 11. Haden R. Insights on FunDza Literacy Project. Personal Communication. [Internet] Available from: Personal communication 12. Subklew-Sehume F, Venables E. lovelife Call Centre Report. A Quality Assessment and Improvement Study on lovelife s Call Centre [Internet]. Johannesburg; Available from: Amazon-Brown I. Insights on HIV360 and SmartSex. Personal communication. [Internet] Available from: Personal communication 14. Kayle A. Insights on Choma Magazine and HI4Life. Personal communication. [Internet] Available from: Personal communication 15. de Lanerolle I. The New Wave report [Internet]. Johannesburg; Available from: UNICEF. Ukufunda Virtual School Information Pack [Internet]. Pretoria: UNICEF; Available from: van Cutsem G, Nieuwoudt S, Henwood R, Hwang B, Patten G, Hacking D, et al. Evaluation of online youth groups for HIV positive youth in Khayelitsha, Cape Town. Phase Two: Assessment of the acceptability and effect of WhatsApp and Facebook groups. Study Protocol. Cape Town; South Africa National Department of Health. National ehealth Strategy, South Africa 2012/ /17. Pretoria: Republic of South Africa: National Department of Health; South Africa National Department of Basic Eductaion. Department of Basic Education Draft National Policy on HIV, STIs and TB [Internet]. Pretoria: Republic of South Africa: National Department of Basic Education; Available from: DRAFTNATIONALPOLICYONHIVSTIsANDTB/tabid/734/ Default.aspx 20. Yeats P. Insights on Young AfricaLive and B-Wise. Personal communication. [Internet] Available from: Personal communication MHEALTH AND YOUNG PEOPLE IN SOUTH AFRICA 43

46 21. Noar SM, Palmgreen P, Chabot M, Dobransky N, Zimmerman RS. A 10-year systematic review of HIV/ AIDS mass communication campaigns: Have we made progress? J Health Commun [Internet]. Taylor & Francis Group; 2009 Jan 24 [cited 2016 Jan 25];14(1): Available from: abs/ / #.vqxxnfn96cq 22. Glik D, Nowak G, Valente T, Sapsis K, Martin C. Youth performing arts entertainment-education for HIV/AIDS prevention and health promotion: practice and research. J Health Commun [Internet] Jan 1 [cited 2016 Jan 18];7(1): Available from: Entertainment-Education_for_HIVAIDS_Prevention_and_ Health_Promotion_Practice_and_Research 23. The Media Education Company. Shamba Shape Up Series 4 KAP Survey Report 2014 [Internet] Available from: Series_4_KAP_Report_.pdf 24. HIVSA. Choma Overview. Johannesburg: HIVSA; Patten G, Henwood R, Barnett W, Metcalf C, Hwang B, Wilkinson L. Assessment of the acceptability and use of a virtual support group for HIV-positive youth in Khayelitsha, South Africa using the MXit social networking forum. In: Médecins Sans Frontières (MSF) Scientific Day 2014 [Internet] [cited 2016 Jan 25]. Available from: Assessment_of_the_acceptability_and_use_of_a_virtual_support_group_for_HIV-positive_youth_in_Khayelitsha_ South_Africa_using_the_MXit_social_networking_forum 26. Rebecca Levine, Corbacio A, Konopka S, Saya U, Gilmartin C, Paradis J, et al. mhealth Compendium, Volume Five. Arlington, VA; SHM Foundation. Project Khuluma: Making psychosocial support accessible to HIV positive adolescents in South Africa. In: 7th SA AIDS Conference [Internet]. SA AIDS Conferences; Available from: 11 June 2015/Hall 7/Track 4_16h00/pdf/Khuluma presentation SAAIDS (11June2015).pdf 28 Anova Health Institute. Health4Men [Internet] [cited 2015 Nov 18]. Available from: De Swardt G. Insights on Anova Health4Men Project. Personal communication REPORT PHOTOGRAPHY: UNICEF SA

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