Perceptions of young people in the Democratic Republic of Congo on the factors influencing their intention to use mobile health applications for comprehensive sex education: A descriptive qualitative study

This descriptive qualitative study of 21 students in Bukavu, DRC, reveals that young people's intention to use mobile health applications for comprehensive sex education is driven by a need for reliable information and perceived educational benefits, yet is heavily contingent on overcoming structural and economic barriers through adaptive strategies and social support.

The Gist

Imagine a group of young people in Bukavu, a city in the Democratic Republic of Congo (DRC), trying to learn about a very sensitive and important topic: how their bodies work, how to stay safe from diseases, and how to navigate relationships.

In many places, schools and parents might be too shy, too busy, or too traditional to talk about these things openly. It's like trying to find a map in a library where all the relevant books are locked behind a door marked "Do Not Enter."

This study is about how these young people are trying to find that map using their smartphones. They want to use mobile health apps (like a digital encyclopedia for sex education) to fill the gaps. But the researchers wanted to know: Do they actually want to use them? What stops them? And how do they get around the problems?

Here is the story of their journey, broken down into simple parts:

1. The Thirst for Knowledge (The "Why")

The young people are incredibly thirsty for reliable information. They aren't just curious; they are desperate to understand their bodies, avoid unwanted pregnancies, and protect themselves from HIV.

• The Analogy: Imagine you are driving a car at night, but your headlights are broken. You are scared of hitting a pothole or a deer. These young people see a mobile app as a flashlight. They want to use it to see the road clearly so they don't crash. They don't want to guess; they want facts.

2. The Mountain of Obstacles (The "But...")

Even though they want these apps, the path to getting them is full of giant boulders.

• The Cost: Data is expensive. It's like trying to buy gas for a car, but the price changes every hour and eats up your whole paycheck.
• The Power Outages: Electricity is unreliable. It's like trying to charge your phone in a house where the power goes out every time you plug it in.
• The Fear: They are worried about privacy. They fear that if they download an app about sex, someone might see their screen, or the app might show them something scary or inappropriate (like porn) that they didn't ask for. It's like walking into a library where you're afraid the librarian might judge you or that the books might contain things that make you uncomfortable.

3. The "MacGyver" Spirit (The Solutions)

This is the most amazing part of the study. Instead of giving up, these young people are like digital MacGyvers. They are incredibly creative in solving these problems.

• The Hustle: To pay for internet data, they sell tomatoes, do odd jobs, or even bet on sports games. They are turning small efforts into fuel for their education.
• The Trade-offs: Some kids skip their bus fare to walk to school so they can save the money to buy data. They are choosing to walk miles rather than stay ignorant.
• The Workarounds: They use neighbors' free Wi-Fi, buy portable batteries (power banks) to survive blackouts, and charge their phones at community charging stations.
• The Analogy: If the road to the library is blocked by a river, they aren't waiting for a bridge to be built. They are building their own rafts, swimming across, or finding a shallow spot to cross. They are adapting to survive.

4. The Village Support System (The "Who Helps")

You might think they are doing this alone, but they have a secret weapon: their families and friends.

• The Silent Nod: Because talking about sex is taboo (a big "no-no" in their culture), parents often can't talk about it directly. But they give a "silent nod." They might buy the data or install the app without asking too many questions. It's like a parent handing you a key to a room they can't enter themselves, trusting you to go in and learn.
• The Friends: Their friends encourage them. If one person says, "Hey, this app is cool," the whole group wants to try it. It's like a trend that spreads through a school, but instead of a cool sneaker, it's a cool way to stay safe.

5. What They Want the App to Be (The Wishlist)

If you were to build this app for them, here is what they are screaming for:

• Offline Mode: It must work without the internet. Like a book you can read in a cave.
• Free or Cheap: It shouldn't cost a fortune to open.
• Safe & Private: No one should know you are using it. It needs to be a "secret garden" where they can learn without fear of judgment.
• Real Info: They want facts, not rumors. If the info is wrong, they will delete the app immediately.

The Big Takeaway

This study tells us that young people in the DRC are not passive victims of their circumstances. They are active architects of their own health. They are willing to walk extra miles, sell their time, and navigate complex social rules just to get the knowledge they need.

The Lesson for the World:
If we want to help them, we can't just throw a high-tech app at them and hope it works. We need to build tools that fit their reality: tools that work when the power is out, that don't cost a fortune, and that respect their privacy. Most importantly, we need to listen to them and build these tools with them, not just for them.

In short: The young people have the desire and the ingenuity. They just need the right tools to unlock the door.

Technical Summary

1. Problem Statement

Despite the critical role of Comprehensive Sex Education (CSE) in improving sexual and reproductive health (SRH), access remains severely limited in the Democratic Republic of Congo (DRC). Only 17% of young people had access to CSE in 2021 due to sociocultural taboos, gender inequality, and a lack of tailored services. This deficit contributes to high rates of unwanted pregnancies (80%), unsafe abortions, early marriages, and low contraceptive use.

While digital environments offer a promising solution, existing literature on mobile health (mHealth) for CSE suffers from two major gaps:

1. Geographic/Linguistic Bias: Most research is conducted in English-speaking or high-income contexts, with a scarcity of data from French-speaking sub-Saharan Africa (FSSA).
2. Focus on Experience vs. Intention: Existing studies focus on the experience of using digital tools rather than the intention to use them, which is a critical predictor of actual adoption and engagement.

This study addresses these gaps by investigating the perceptions of Congolese youth regarding the factors influencing their intention to use mHealth applications for CSE in Bukavu, a city affected by humanitarian crises and infrastructure challenges.

2. Methodology

• Study Design: A descriptive qualitative study utilizing an inductive thematic analysis approach.
• Theoretical Framework: The study was guided by the Unified Theory of Acceptance and Use of Technology (UTAUT), which informed the interview guide structure (focusing on performance expectancy, effort expectancy, social influence, and facilitating conditions) without acting as a rigid coding grid.
• Setting and Participants:
  • Location: Eight public secondary schools in Bukavu, South Kivu, DRC.
  • Sample: 21 students (13 girls, 8 boys) aged 15–24 years.
  • Sampling: Purposive sampling based on gender, residence, and school type.
• Data Collection:
  • Semi-structured, face-to-face individual interviews conducted in fall 2024.
  • Interviews lasted 30–60 minutes and were audio-recorded.
  • Data collection continued until thematic saturation was reached (confirmed at the 21st interview).
• Data Analysis:
  • Transcripts were analyzed using Braun and Clarke's six-step inductive thematic analysis.
  • Software: MAXQDA Pro 24.8.0 was used for coding and organization.
  • Rigor was ensured via triangulation, reflexivity, and adherence to the COREQ guidelines.
• Ethics: Approved by the Université de Montréal and DRC National Health Ethics Committees. Informed consent was obtained from participants (and parental/guardian consent for minors via school principals).

3. Key Contributions

• Contextual Insight: Provides rare empirical data on mHealth intentions in a French-speaking, low-income, conflict-affected setting (DRC), contrasting with the dominance of English-speaking African studies.
• Agency and Adaptation: Shifts the narrative from viewing youth as passive victims of structural barriers to recognizing their active agency. The study documents "ingenious" adaptive strategies youth employ to overcome economic and technical constraints.
• Gender Nuance: Highlights distinct gendered perceptions regarding barriers, support systems, and content preferences, which are crucial for designing inclusive interventions.
• Theoretical Extension: Suggests that standard technology acceptance models (like UTAUT) require adaptation to include contextual factors specific to humanitarian crises, armed conflict, and local infrastructure instability.

4. Key Results

The analysis yielded six main themes and 20 subthemes regarding the factors influencing the intention to use mHealth for CSE:

Theme 1: Intention Based on Personal Need

• Youth view mHealth as essential for understanding their bodies, preventing pregnancy/STIs, and navigating social expectations.
• There is a strong desire for continuous and regular use driven by the need for reliable, discreet information not available elsewhere.

Theme 2: Structural, Economic, and Psychosocial Obstacles

• Technical/Infrastructure: Unstable internet, frequent power outages, and lack of electricity for charging devices.
• Financial: High cost of mobile data (megabytes) and smartphones.
• Psychosocial: Fear of inappropriate/pornographic content, concerns about confidentiality, and risks of cybercrime/data leakage.
• Gender Note: Girls expressed more concern regarding content safety and privacy; boys focused more on technical connectivity.

Theme 3: Adaptive Financial Strategies

Despite barriers, youth demonstrated remarkable resilience through:

• Revenue Generation: Engaging in small businesses (selling tomatoes, baking, music, welding) to fund data purchases.
• Resource Reallocation: Cutting back on other expenses (e.g., skipping bus fare to walk to school) to buy data.
• Alternative Access: Using neighbors' free Wi-Fi, community charging stations, and external power banks (power banks).
• Desire for Independence: A strong motivation to finance their own health education to avoid reliance on parents.

Theme 4: Family and Peer Influences

• Implicit Parental Support: Parents often tacitly approve of app usage because they are uncomfortable discussing sexuality directly due to cultural taboos. Some provide financial or technical support (installing apps, buying data).
• Peer Validation: Positive reinforcement from friends and partners encourages usage. WhatsApp groups serve as spaces for sharing and normalizing digital CSE.

Theme 5: Perceived Educational Usefulness

• Crisis Relevance: Apps are seen as vital alternatives during humanitarian crises (war, displacement) when healthcare services are disrupted or perceived as unsafe/intrusive.
• Gap Filling: Viewed as a necessary substitute for poor or non-existent CSE at home and school.
• Prevention: High value placed on HIV/STI prevention, contraception, and managing sexual violence.

Theme 6: Conditions for Digital Engagement

• Ease of Use: Applications must be simple to install, navigate, and visually appealing.
• Accessibility: Critical requirements include offline access (to bypass data costs/connectivity issues) and free or low-cost data.
• Reliability: Content must be accurate and credible; otherwise, users will delete the app.
• Gender Note: Girls prioritized offline access and visual appeal; boys prioritized content clarity and reliability.

5. Significance and Implications

• For Policy and Practice: The study argues for the co-design of mHealth solutions with youth. Interventions must be offline-capable, low-cost, and culturally sensitive to the local reality of power outages and data scarcity.
• Humanitarian Context: Digital CSE is identified as a critical lifeline in conflict zones where traditional health services are inaccessible or stigmatized.
• Gender-Specific Design: Interventions should address the specific fears of girls (privacy, inappropriate content) and the specific needs of boys (reliability, general prevention) to maximize adoption.
• Future Research: Calls for adapting technology acceptance models to include "adaptive strategies" and "humanitarian context" as key variables in low-resource settings.

Conclusion:
Congolese youth possess a strong intention to use mHealth for CSE, driven by a need for reliable information and empowerment. While significant structural barriers exist, youth actively develop adaptive strategies to overcome them. Successful digital interventions must be co-created with these users, prioritizing offline functionality, affordability, and trustworthiness to bridge the gap in sexual health education.