A woman and child in Khayelitsha, Cape Town
A woman and child in Khayelitsha, Cape Town. Photo credit: Gregor Röhrig (www.gregorrohrig.com)

Accelerating achievement for Africa’s adolescents

As a social worker, Lucie Cluver saw first-hand how the AIDS crisis had caused 12 million children to become orphaned in South Africa.

Determined to make a difference, she changed careers and is now Professor of Child and Family Social Work at the University of Oxford. She also leads an £18.5 million research hub aimed at helping 20 million adolescents across Africa to fulfil their potential.

Lucie spoke to Mark Pollard, Professor of Archaeological Science, about her team’s work with adolescents in and outside South Africa, and with the policymakers who shape their lives.

Mark Pollard – So, how did you get into policy, and what benefits has it given you in terms of your academic research?

Lucie Cluver – Back in 2003, I was working as a social worker in South Africa, at the height of the AIDS epidemic. At the time there were 12,000,000 children orphaned by AIDS. We didn't have any anti retro-virals yet, for adults or for children - everyone was dying.

I was working for Cape Town Child Welfare and I asked them what they needed. They said research and evidence. So, in 2004, I was lucky to get doctoral funding from the ESRC and did a D.Phil to get some evidence for them.

I spent most of my time driving around the townships collecting data. We interviewed 1,000 children, about half of whom were orphaned by AIDS, and we got some very stark findings.

At the time, I had an informal mentor – the Dean of Research at the University of the Western Cape. His name was Renfrew Christie, and he had done his doctorate at Oxford, supposedly on the electrification of South Africa. But he was actually a spy for the African National Congress and he’d identified that the apartheid government was planning to develop a nuclear weapon. He had been on death row for seven years in the cell next to the now Minister of Social Development. I sent him this dreadful policy brief, which I would be ashamed to look at now.

He called me and said: 'What are you doing right now?' I was in a township, doing a focus group with a bunch of kids – and everyone was covered in green paint.

And he said, 'Can you be at the Belgian ambassador’s cocktail party in an hour? I want you to meet the Minister of Social Development.'

I bought a dress for 40 rand, which is about £2.50, in the local market, and drove to the Belgian ambassador’s cocktail party. The Minister – Dr Zola Skweyiya – asked to see me the next day in his office in Parliament. I can remember shaking.

The minister’s response was that what I’d done was not good enough. Research needed to be carried out not just in one province, but across multiple provinces in the country – and everything went from there. We ended up extending the survey to a new study - Young Carers SA, carried out between 2008-2012. The aim was to look at the impact on children's wellbeing of being young carers in families affected by AIDS. We interviewed more than 6,000 children and 2,500 caregivers. And we followed on with large-scale studies of over a thousand adolescents living with HIV – the Mzantsi Wakho Study.

Our new study is of adolescent mums in Africa. It's called HEY BABY - Helping Empower Youth Brought up in Adversity with their Babies and Young children. We found a gap in the literature and the policy, whereby everyone wants to prevent adolescent pregnancy but once you are pregnant, or a mum, you kind of drop off a cliff. There are no support services. We've just finished the first round of fieldwork, collecting data on 1,000 adolescent mums and their children, and we have seen that many are struggling so much. What’s great is that international agencies and governments are really engaged – the problem is that they want results now and we are still frantically cleaning the data!

So, they needed more, and you did that. Presumably that was borne out of a desire to make a change and make things better?

For me, that’s the only reason why you would ever do this job. Generating knowledge is not what drives me. It’s generating evidence that leads directly to change.

If you’re going to address a problem of that scale, you have to go to a national and international level.

So, it was actually fairly circumstantial, the way in which you got into a position where you had the ear of ministers? A chain of events?

My unexpected meeting with a government minister gave me the confidence to walk into a meeting of very high-level policy makers and ask them genuinely what they want. My role is to understand what they need to do the things that they want to achieve - and then to go back and turn that into an answerable research question.

It led to a really longstanding set of partnerships with South Africa, with different government departments. We worked with Health and with Basic Education and with Social development, and with the National AIDS Council; and have done now for 15 years.

I always feel awkward when people ask: 'What was your strategy?' There wasn’t one – not at the beginning, certainly. There's much more now.

Generating knowledge is not what drives me. It’s generating evidence that leads directly to change.

So, can you tell us more about your work and engagement with policy in Africa?

In 2011, at a meeting in Addis Ababa, Ethiopia, the United Nations Children's Fund (UNICEF) asked me to carry out research into whether social support grants could reduce HIV risks amongst young girls.

Many teenage girls living in desperate poverty felt that they had little choice but to find an older boyfriend to help them pay for food and basic items for their families. It's very much as transactional relationship which puts young women at high risk from HIV.

We found that introducing a government social benefit of around $20 per month reduces the need for girls to enter relationships with 'Sugar Daddies' as a way of helping their families deal with desperate poverty. Family cash benefits could reduce girls' risk of infection by up to 50%.

I am also part of Parenting for Lifelong Health (PLH) – a project we lead with the World Health Organisation and UNICEF, which provides non-commercial parenting programmes to help prevent violence in deprived places. At Oxford, Professor Frances Gardner and Dr Jamie Lachman are also leading this, with colleagues at University of Cape Town, Stellenbosch and Bangor Universities. That programme has gone viral and the scale-up went about 10 years faster than we expected.

We had planned to trial these programmes in several different countries before we released them, but governments strongly disagreed with that; they felt that these programmes had the best evidence available, and it was immoral for us to withhold the programmes for more testing. It was a challenge, but I could totally see their point of view.

We’ve managed five randomised trials and some pre-post studies in South Africa, Lesotho, South Sudan, Montenegro, India, the Czech Republic, North Macedonia, Republic of Moldova and Romania the Philippines and Thailand, and the programmes are now being used in 25 countries across Africa, Asia, Eastern Europe and the Caribbean.

Can you tell us more about how your work has improved children's lives?

Well, we expect that Parenting for Lifelong Health will prevent 600,000-700,000 cases of severe child abuse by 2025. To date, we think it has prevented around 80,000-90,000 cases.

It's good that we've engaged with 300,000 families, but there’s 1 billion children a year who are victims of abuse globally. Most of it is not because their parents are malicious – it’s because they're stressed, exhausted, poor, struggling or sick.

We are actually in the process of starting to turn this group-based programme into an online intervention, into some kind of app. Rates of smartphone access are rising exponentially in low and middle income countries – within the next five years a digital parenting programme could reach millions of families who need it. We’re working with UNICEF and WHO to plan this, and raising cash to test it. Providing something for free, which anyone can use across the world, is our next big challenge. We’ve got to make it work.

This project is part of a much wider initiative - a new UK-Africa research hub called the UKRI GCRF Accelerating Achievement for Africa’s Adolescents. The Hub is working closely with UN agencies to help countries with the Decade of Action to reach the Sustainable Development Goals. We are finding services that can improve adolescent lives not just in one sphere but across many SDGs at the same time. This means working with partners across Africa and the UK, and across academic disciplines. It is part of the Global Challenges Research Fund – and the single largest investment by UKRI in a research programme. It is an amazing opportunity and a major responsibility to get this right.

And which policies has your research informed?

There's one policy we co-wrote with government from beginning to end: The Adolescent and Youth Health Policy for South Africa (2017-2021). Our studies are used a lot in guidance and reports of UNAIDS, UNICEF, the World Health Organisation and PEPFAR- USAID. But policy is only part of the story – the next crucial step is making those policies and guidelines into action.

So, what advice would you give to early career researchers on successful engagement with policymakers?

Early career researchers often tell me they want to work on projects which will impact policy, but they don't always identify, or engage with, policymakers beforehand. It's partly because they feel nervous, partly because they don’t know where to start, and partly because they just don’t think to do it.

The fundamental thing is that you are genuine in your wish and desire to help a policymaker and that you prove yourself to be useful. Once you set that cycle, then you get fantastic relationships.

But there's nothing to lose. If a policymaker says no, you move onto the next one. But sometimes they will see something you haven't, help you re-think, or offer opportunities to build your work into something of greater value.

If you go in at the beginning, they will be bought in when you finish. And then your capacity to have influence is so much greater.

Beyond that, for me the fundamental thing is that you are genuine in your wish and desire to help a policymaker and that you prove yourself to be useful. Once you set that cycle, then you get fantastic relationships.

But if you have an ulterior motive, or you have an agenda which is about your career or something else, these people will see through it in an instant. They are not academics, but by the time they’ve got to where they are, they are extremely clever.

It's also important to think about how you present research findings, both to policymakers, and the people involved in the research.

To make the research relevant?

Yes. What policymakers need is something that tells them not the process of what you did, but what it means for their practice. And to present it in a way that is clear to someone who does not have training in the discipline that you are in. When a researcher puts up a slide with hundreds of words, or giant tables of odds ratios, every policymaker in the room looks down at their emails.

Something else that has really made a difference is thinking about presenting your findings in a way that respects that place. I realised that when I gave a talk at the Southern African Aids Conference, which is a big one for policy and advocacy.

I was terrified because before me had been a famous AIDS advocate, and people had been standing up and singing anti-apartheid songs. I thought, 'Oh hell, I’m a white lady with graphs. This is going to be terrible.'

And I was really wrong, because the fundamental message of our research was that young women in Africa were not being promiscuous, they were not having risky sex because they were uneducated or irresponsible. They were having it because they didn’t have enough money to bring groceries home for the family.

And I put up a graph that showed that, and 5,000 people stood up and started chanting about power to the people. I realised that science showed a kind of respect towards that people. It was not about blame.

So, in light of your experience, what changes, if any, would you like to see in policy in Africa?

What policymakers need is something that tells them ... what it means for their practice ... in a way that is clear to someone who does not have training in the discipline that you are in. 

I think it's beyond that. We have a demographic boom coming. In the next 30 years there’s going to be half a billion adolescents in Africa. And they have the most remarkable potential. They have intelligence, drive, dynamism, creativity, and a technological knowledge which surpasses ours greatly. I think that Africa could make some very strategic investments and reap the rewards in GDP over the next 30 years, which is an enormous opportunity. African could be the next China or India. And I think recognising that is where we all need to start.