Johannesburg is a divided city. Skyscrapers rise from the central business district, towering over the suburbs which flow in all directions from its busy core. Away on the sprawling city outskirts townships jostle for space, swelled by their expanding populations all hoping for something better but meanwhile scraping to survive in a city where every fourth person is unemployed.
The nutrition gap
Among the myriad issues facing South Africans unlucky enough to be at the lower end of the Living Standards Measure (LSM) is the costly and confusing business of feeding their children. All too often mothers rely on ‘pap’, a maize based porridge often served with little else. Meat and vegetables are expensive while widespread understanding of nutrition is poor. While staples such as pap are good at delivering calories, they’re less good at delivering the vitamins and minerals children need to grow and thrive. According to UNICEF, in South Africa malnutrition is responsible for almost two thirds of child deaths under five years old, and as many as a fifth suffer from stunted growth. Moreover, many children are weaned onto solids such as pap too soon, further impacting their development.
But while many mothers in South Africa and elsewhere around the world may not have access to the healthy foods they need to feed their families, almost all of them have access to something else: a mobile phone.
Starting smart in South Africa
Across South Africa, more than 100,000 people have signed up for a new government-backed service, called StartSmart. This initiative by the Global Alliance for Improved Nutrition (GAIN) provides mothers with information on how to better nourish their babies and young children.
Launched in October 2013, StartSmart is a digital campaign active across three main platforms: a mobile, or ‘mobi’, website, through popular South African messaging platform Mxit and through an interactive USSD based platform. Accessible from all GSM phones, USSD is an interactive, text-based service which lets users interact with the database in a ‘live’ session by picking options from a menu. No matter which platform they’re using, once registered users can then engage with the content further. So far this content has been predominately information based, but the team is now expanding more into quizzes to help incentivise deeper understanding and behaviour change. StartSmart is part of a wider program called NutriMark which focuses on the ‘1,000 day window of opportunity’ for child and infant nutrition, measured from the start of a woman’s pregnancy until her child’s second birthday. It was born out of GAIN’s collaboration with the national Department of Health on their ‘Feeding Smart from the Start’ optimal feeding campaign. With 85% of people in South Africa owning or having access to a mobile phone, GAIN saw an opportunity to widen the scope of the campaign. “Cell phones are no longer just a tool; they’re part of the fabric of our lives, our social structure” says Dominic Schofield, Director and Senior Technical Advisor at GAIN, when explaining where the idea behind StartSmart came from. “When technology first started to be used it was primarily for data gathering, not social mobilisation. But the fact that it’s already at the heart of social mobilisation means we don’t have to create anything; we just have to harness it. But how do you use it for something as hard to communicate as nutrition?” The answer, as it turns out, revolves around incentives, networks and messaging.
Finding the right incentives
As well as the mobile website, StartSmart also uses messaging platform MXit, standard SMS messages and longer USSD messages to communicate. StartSmart’s project manager, Kevin Peddie, explains that the multi-pronged approach was devised in order to reach the widest possible audience. But just because a platform exists doesn’t mean people will use it.
“The original plan had been to offer vouchers as an incentive for sign-up and profile completion” remembers Kevin. However, the government was understandably reluctant to be associated with a scheme that appeared to favour a particular product or company. As a result, Kevin and the team at Thumbtribe, a local digital marketing agency brought in to develop the new mobile platform, had to find an alternative incentive – and what they hit upon turned out to be better than any product voucher: airtime. Transferable, tax-free and highly valuable, airtime is a powerful currency in South Africa in its own right, explains Dominic. Stephen O’Donoghue from Thumbtribe agrees: “We really underestimated how many hoops people would jump through in order to get to the airtime”.
The power of social networks
Within a week of launching the campaign had gone viral. After a year there are now over 100,000 registered users – compared to an initial target of just 10,000. So just how did the team at GAIN and Thumbtribe manage to deliver a 10 fold increase in user registration? Stephen reveals that the key to this unprecedented success lay in harnessing the power of an existing and widely trusted messaging network. Highly popular in South Africa, MXit has delivered an astounding 90% of total sign-ups, making it single handedly responsible for the additional 90,000 sign ups above and beyond the initial 10,000 target user base.
Getting the message right
“A new mum will be at a clinic getting her child immunised and she’ll get all kinds of messaging about how to look after her child” recounts Dominic. “On her way home she’ll pass by a kiosk and be confronted by more messaging about different products, and then perhaps an NGO worker will knock on the door with yet more messaging. A new mum is so vulnerable to all this information, and the messaging can often be contradictory.”
A scenario that GAIN sees all too often, it’s also one which can be so easily changed by making the messaging consistent and accessible. “We wanted to create something which mothers could have on hand all the time” says Dominic “–not just information on posters at the clinic.”
Mobiles provide the perfect platform to do this, and the intention with StartSmart has always been to create a model which can be adapted or translated to any other context or country.
From South Africa to South Asia
But can this approach be applied to other countries? What if access to mobiles isn’t so high or the government more wary about trying new things? Encouragingly, the answer still seems to be yes. Vietnam is a country of 86 million people with an estimated 6.5 million children aged under five years old. Just less than 30% of these children are anaemic and almost as many suffer from stunted growth. Vitamin A deficiency stands at almost 15% while some 20% of mothers with young children suffer from chronic energy deficiency. In response to these issues, GAIN has been working with the government to pilot a new program which aims to supplement the diets of 24,000 children under five with sachets containing essential micronutrients which can then be added to home cooked meals.
Newly branded with support from GAIN, the Bibomix formula is being distributed by trained health workers through local government sponsored health centers in four provinces. Where mobile technology is being used in South Africa to target mothers and caregivers directly, in Vietnam mobiles are instead being used to disseminate training updates to 990 intermediary health workers – with airtime again being used as an incentive to engage with training quizzes.
A plan for the future
Interestingly, StartSmart is now developing where the Bibomix project is beginning: by using quizzes to further extend the project and encourage more direct engagement with the educational content available. “We hope that by rewarding correct answers to quizzes with airtime we’ll be able to have a real impact on feeding practices – since the more educated they are the more likely they are to change their behaviour” says Kevin. There are also plans mooted to expand the StartSmart concept to the wider southern Africa region. As Stephen points out, when it comes to harnessing mobile technology there’s not necessarily a right place to start: you simply “begin where there is an opening” and expand the program from there. But wherever these projects start or finish, there can be no doubt that these exciting developments in “mNutrition” feed directly into the broader mHealth trend which is now sweeping the developed and developing world.
So what now for mobile technology and child and infant nutrition?
“We’ve barely scratched the surface” Dominic muses. “There’s so much we can do now. Really, it’s revolutionary.”
– Malnutrition is responsible for almost 2/3 child deaths under five in South Africa
– One in five of children under five in South Africa have stunted growth
– 85% of South Africans own or have access to a mobile phone
– StartSmart has had over 100,000 user sign ups in a year
– Around 30% of children under five in Vietnam are anaemic and suffer from stunted growth
– 15% of children under five in Vietnam are deficient in Vitamin A
– 20% of Vietnamese mothers with young children suffer from chronic energy deficiency
– The Bibomix pilot is targeting 24,000 children under five in Vietnam