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loveLife’s Mobile Conditional Incentive Programme:

iloveLife

23 July 2014

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4 Introduction to loveLife

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loveLife

• Driven by youth volunteers called groundBREAKERs and mpintshis

• Footprint in South Africa:

8000schools

900sites

532 government

clinics

>300 franchised

community-based

organisations22

YouthCentres

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Risk Construct

Individual

• LOW SELF-ESTEEM• NO SENSE OF FUTURE• UNCERTAIN IDENTITY

Helplessness in the face of challenges

Social

• COERCION• PEER PRESSURE• LACK OF PARENTAL

COMMUNICATION• EXPECTATIONS OF

WOMANHOOD• MALE SENSE OF ENTITLEMENT

Pressure to acquiesce

Perception of scant opportunity

HIGH RISK TOLERANCE

Structural

• POVERTY• LOW EDUCATION• MARGINALIZATION• INEQUALITY

Sense of constrained choices

EARLY SEXUAL DEBUTUNSAFE SEXMULTIPLE SEXUAL PARTNERS

RISKY SEXUAL BEHAVIOUR

Possible HIV INFECTION

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loveLife Evidence

RHRU (2011) now WRHI HSRC (2012)

loveLife awareness amongst 12-19 year olds : 85%

loveLife awareness amongst 12-19 year olds : 90%

Reach of loveLife face-to-face programmes to 12-19 year olds : 20%

Reach of loveLife face-to-face programmes to 12-19 year olds: 33,5%

Studies1 show adjusted odds ratio for HIV infection amongst those that participated in a loveLife programme:- 0.61 for young women- 0.60 for young men

1- Pettifor et al., AIDS 19 (2005)

Significant links with participation: - Self-reported HIV negative status- Male circumcision- Male contraceptive use- Self esteem- Decreased stigma- Greater sense of future and self-

efficacy

97% of youths reached say ALL youth should participate in loveLife programmes

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4 Rationale for iloveLife

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HIV and Social Determinants

• Two-year experiment in Zomba, Southern Malawi, using cash incentives in households with schoolgirls aged 13-22

HIV prevalence

Control Group Incentivised Group

3.0% 1.2%

Marriage40% lower

Sexual Activity38% lower

Pregnancy30% lower

Conditional cash transfer results:

• Improve school attendance• Reduce sexual activity• Reduce teenage pregnancy• Reduce early marriage

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Rationale

• Similar approaches conducted in other countries:

• Offered conditional cash, grocery vouchers, nutritional supplements, educational subsidies

• Conditional reward successfully applied worldwide across education, social welfare, and health care with South Africa as a forerunner

2-The impact of conditional in-kind subsidies on preventative health behaviours: Evidence from Western Kenya. July 2005. Pascalis Dupas, EHESS-PSE.

• Study in Kenya2 incentivised visits to healthcare facilities • 117% increase in prenatal care services• 84% increase in HIV testing• 58% increase in follow-up visits to prenatal clinics

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Rationale

• Discovery Health (SA’s largest private health insurer) launched Vitality in 1998

• Incentive and reward based wellness program with statistically significant effects:3

• Lower costs per patient• Shorter hospital stays• Lower admission rates for engaged members• Lower chronic disease costs amongst engaged members

Bottom Line

Three consecutive impact sessions shared a clear association between increased vitality engagement

and lower health care costs

3-Discovery Vitality Journal: Reducing the cost of healthcare through lifestyle intervention. 2008

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• Group identity formation around the concept of a “crew” or “posse.• Girls in crew affirm each other, reinforce positive and negative

behaviours.• Sexually very assertive (e.g. “Foxy Chix”; “Pussy Gals”).• Celebration of femininity and group solidarity.

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Underlying iloveLife Design Principles

Premise for change

• Interrelated individual, social, biological and structural factors associated with high HIV infections amongst young women

• Prevention intervention to address different drivers of sexual risk

• iloveLife design must provide content and activities that address these drivers

Research

• Qualitative and Quantitative research conducted by McPhail et al. (2013) indicated young women found transfer incentives acceptable and feasible

Key Consideration

• Decrease immediate implications of risky sexual behaviour by increasing future reward

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Underlying iloveLife Design Principles

I

Focus on specific age

group

Achieving scale rapidly

Individual, social &

structural drivers of

HIV

New gains to be captured

by doing things

differently

Best evidence & models of

projected impact

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Audience demands

ENGAGEMENTRECOGNITION

REWARDSCONTENT

ENTERTAINMENTSTIMULATIONINFORMATION

SEAMLESS SYSTEMS

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Introducing iloveLife

OverallGoal

Reduce new HIV infections among youth

by 15% over 3 years

• Incentivise young people to engage in healthy behaviours and responsible lifestyle choices

• Increase knowledge and understanding on HIV / AIDS and sexual reproductive health

• Develop self-efficacy among participants to seek helpful services:• Voluntary medical male circumcision (VMMC)• HIV counseling and testing (HCT)• Contraceptives• STI treatment

Main objectives:

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User Journey

• Implemented on mobile phones:– Through USSD technology via subscription – Or sign up via ilovelife.mobi

• Simple sign up process • Create a profile • Access to all content

Sign up

• User rewarded for 2 types of behaviour:• 1. Online activities • 2. Real World activities

Points

• Receive e-voucher from points earned• Redeem e-voucher at store Reward

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Online and Real World Activities

• On site / online activities include:• Reading, commenting on and sharing articles and videos • Taking part in online quizzes and polls • View memes such as bitstrips and images

Online Activities Example Activities Points

Mod 1: Promotion of delayed sexual debut

and condom use at first sex

Reading and sharing/commenting on compelling content that promotes delaying sexual debut

5

Online quizzes 5

Participation in campaigns and competitions 10

loveLife programme participation and activations (i.e., loveLifestyle and games)

25

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Online and Real World Activities

• Real world activities include:• Clinic visits • HIV status check ups • Participation in loveLife events games

• Unique codes are generated for specific real world activities

Real World Activity Example Indicator Expected Outcome Reward Frequency Evidence/

Verification Reward Rating

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4 Programme’s M&E

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Expected Results

Increased sense of access to

things young people

Reduced transactional

sex relationships

Reduced age differences in

sexual

Reduced HIV incidence

among young people

Increased access to Healthcare

services (i.e. HCT, STI etc.)

Increased sense of purpose

among young people

Reduced levels of school drop-

out’s

Increased school

attendanceIncreased number of

young people who complete

Grade 12

Increased self-esteem and positive self-

image

Increased awareness of

riskDelayed sexual

debut

Increased condom use at

first sex

Increased uptake of

VMMC services

Increased consistent

condom use

Results

loveLife contact centre and online-media services

Online Content-messages/interact

ionIncentives

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Theory of Change

Delayed sexual debut

Reduction of sexual partners

Increased VMMC

Increased condom use

Suppressed viral load

Increased uptake of ART

Increase VCT

Reduced HIV incidence in young people (12-19)

Reduced inter-generational and transactional sex Increased school attendance

Impact

Behaviour change

(outcomes)

Predictors of behaviour (outputs)

Increased SRHR

knowledge

Increased awareness of

risk

Changes in attitudes (e.g. shared

responsibility)

Increased self-esteem

Increased self-efficacy to seek help

Increased sense of purpose

Increased sense of access to resources

Key Activities

Provide links to opportunities

Provide self-assessments

Provide forums and facilitate

interactions between users

Provide motivational messages and

motivational talks

Provide online quizzes

Provide content on SRHR

Provide special campaigns and competitions

Providing incentives for HCT and VMMC

Providing incentives for online

participation

Providing incentives for school attendance and school performance

Providing incentives for participation in clinical committees

and health talks

Providing incentives for real world programme participation

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Indicators at Output Level

Intervention Logic Indicators

Increased SRHR knowledge

% of young people (12-19) who both correctly identify ways of preventing sexual transmission of HIV and who reject major misconceptions about HIV transmission (in correlation to time and level of engagement with iloveLIfe)

Change in attitudes regarding discrimination of people living with HIV

% of young people (12-19) who agree with the statement “if a teacher has HIV but is not sick, he or she should be allowed to continue teaching” (in correlation to time and level of engagement with iloveLife)

Increased self-esteem Average score of young people on the Rosenberg Self-Esteem Scale (selected questions) (in correlation to time and level of engagement with the iloveLife)

Increased sense of purpose % of young people who report that they have many opportunities in life and that they have a good idea where they are heading in the future (in correlation to time and level of engagement with iloveLife)

Increased self-efficiency to seek help

% of young people who report that they know where to go if they need advice on SRH (formulation to be tested – in correlation to time and level of engagement with iloveLife)

% of young people who report that they have the confidence to test for HIV (formulation to be tested/defined) (in correlation to time and engagement with iloveLife)

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Indicators at Outcome Level

Intervention Logic Indicators

Condom use

% of young people (12-19) who report that iloveLife motivated them to use condoms more consistently

% of young people (12-19) who report that they always used a condom during sex in the last 12 month (intervention compared to control group)

Increased of HCT

No. of awarded rewards for HCT

% of users of rewards who report that the reward was important to motivate them to test

% of young people who report that they have tested for HIV in the last 12 month (intervention compared to control group or in correlation to engagement with iloveLife )

Reduction of sexual partners

% of young people (12-19) who report that iloveLife motivated them to use condoms more consistently

Self-reported number of sexual partners in the last 12 month (intervention compared to control group or in correlation to engagement with iloveLife)

Reduced transactional sex % of young people who report to have had transactional sex in the last 6 month (intervention compared to control group)

Increase school attendance

No. of awarded rewards

No. of young people who report that the reward motivated them to go to school

Additional indicator to be defined in coordination with the Department of Education

Live Demonstration

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Tel +27 (0)11 523 1000 Fax +27 (0)11 523 1001

48 wierda rd west, wierda valley, sandton, 2196P O Box 45 parklands 2121 south africa

talk@lovelife.org.za www.lovelife.org.za

Thank-you.