World Health Organization - Malawi

Despite the great potential of agricultural innovations, the uptake by smallholder farmers in sub-Saharan Africa seems to be slow. We reviewed existing theories and frameworks for the uptake of agricultural innovations and found that these tend to emphasize the role of extrinsic factors such as the characteristics of the adopter and the external environment in the decision-making process. In this paper, we argue that intrinsic factors such as the knowledge, perceptions and attitudes of the potential adopter towards the innovation play a key role, but this has been less studied. We present an analytical framework that combines both extrinsic and intrinsic factors in farmers' decisions to adopt new agricultural technologies and apply the framework to agroforestry adoption as a case study. We review the literature on agroforestry adoption in sub-Saharan Africa and identify the extrinsic and intrinsic variables affecting the uptake of agroforestry technologies. We conclude that the uptake of agricultural technologies is a complex process influenced by both extrinsic and intrinsic variables, and recommend that future studies aiming to understand the adoption process of agricultural innovations take into account both sets of variables. A mechanistic understanding of how intrinsic and extrinsic factors interact and drive adoption can help in targeting technologies appropriately to ensure sustainability.

Abstract Body-mass index (BMI) has increased steadily in most countries in parallel with a rise in the proportion of the population who live in cities 1,2 . This has led to a widely reported view that urbanization is one of the most important drivers of the global rise in obesity 3–6 . Here we use 2,009 population-based studies, with measurements of height and weight in more than 112 million adults, to report national, regional and global trends in mean BMI segregated by place of residence (a rural or urban area) from 1985 to 2017. We show that, contrary to the dominant paradigm, more than 55% of the global rise in mean BMI from 1985 to 2017—and more than 80% in some low- and middle-income regions—was due to increases in BMI in rural areas. This large contribution stems from the fact that, with the exception of women in sub-Saharan Africa, BMI is increasing at the same rate or faster in rural areas than in cities in low- and middle-income regions. These trends have in turn resulted in a closing—and in some countries reversal—of the gap in BMI between urban and rural areas in low- and middle-income countries, especially for women. In high-income and industrialized countries, we noted a persistently higher rural BMI, especially for women. There is an urgent need for an integrated approach to rural nutrition that enhances financial and physical access to healthy foods, to avoid replacing the rural undernutrition disadvantage in poor countries with a more general malnutrition disadvantage that entails excessive consumption of low-quality calories.

Two-thirds of the world's HIV-infected people live in sub-Saharan Africa, and more than 1.5 million of them die annually. As access to antiretroviral treatment has expanded within the region; early pessimism concerning the delivery of antiretroviral treatment using a large-scale public health approach has, at least in the short term, proved to be broadly unfounded. Immunological and virological responses to ART are similar to responses in patients treated in high-income countries. Despite this, however, early mortality rates in sub-Saharan Africa are very high; between 8 and 26% of patients die in the first year of antiretroviral treatment, with most deaths occurring in the first few months. Patients typically access antiretroviral treatment with advanced symptomatic disease, and mortality is strongly associated with baseline CD4 cell count less than 50 cells/mul and WHO stage 4 disease (AIDS). Although data are limited, leading causes of death appear to be tuberculosis, acute sepsis, cryptococcal meningitis, malignancy and wasting syndrome. Mortality rates are likely to depend not only on the care delivered by antiretroviral treatment programmes, but more fundamentally on how advanced disease is at programme enrollment and the quality of preceding healthcare. In addition to improving delivery of antiretroviral treatment and providing it free of charge to the patient, strategies to reduce mortality must include earlier diagnosis of HIV infection, strengthening of longitudinal HIV care and timely initiation of antiretroviral treatment. Health systems delays in antiretroviral treatment initiation must be minimized, especially in patients who present with advanced immunodeficiency.

Abstract High blood cholesterol is typically considered a feature of wealthy western countries 1,2 . However, dietary and behavioural determinants of blood cholesterol are changing rapidly throughout the world 3 and countries are using lipid-lowering medications at varying rates. These changes can have distinct effects on the levels of high-density lipoprotein (HDL) cholesterol and non-HDL cholesterol, which have different effects on human health 4,5 . However, the trends of HDL and non-HDL cholesterol levels over time have not been previously reported in a global analysis. Here we pooled 1,127 population-based studies that measured blood lipids in 102.6 million individuals aged 18 years and older to estimate trends from 1980 to 2018 in mean total, non-HDL and HDL cholesterol levels for 200 countries. Globally, there was little change in total or non-HDL cholesterol from 1980 to 2018. This was a net effect of increases in low- and middle-income countries, especially in east and southeast Asia, and decreases in high-income western countries, especially those in northwestern Europe, and in central and eastern Europe. As a result, countries with the highest level of non-HDL cholesterol—which is a marker of cardiovascular risk—changed from those in western Europe such as Belgium, Finland, Greenland, Iceland, Norway, Sweden, Switzerland and Malta in 1980 to those in Asia and the Pacific, such as Tokelau, Malaysia, The Philippines and Thailand. In 2017, high non-HDL cholesterol was responsible for an estimated 3.9 million (95% credible interval 3.7 million–4.2 million) worldwide deaths, half of which occurred in east, southeast and south Asia. The global repositioning of lipid-related risk, with non-optimal cholesterol shifting from a distinct feature of high-income countries in northwestern Europe, north America and Australasia to one that affects countries in east and southeast Asia and Oceania should motivate the use of population-based policies and personal interventions to improve nutrition and enhance access to treatment throughout the world.

Abstract Most research on gender difference or inequities in capture fisheries and aquaculture in Africa and the Asia‐Pacific focuses on the gender division of labour. Emerging research on globalization, market changes, poverty and trends in gendered employment within this sector reveals the need to move beyond this narrow perspective. If gleaning and post‐harvesting activities were enumerated, the fisheries and aquaculture sector might well turn out to be female sphere. A livelihoods approach better enables an understanding of how employment in this sector is embedded in other social, cultural, economic, political and ecological structures and processes that shape gender inequities and how these might be reduced. We focus on four thematic areas – markets and migration, capabilities and well‐being, networks and identities, governance and rights – as analytical entry points. These also provide a framework to identify research gaps and generate a comparative understanding of the impact of development processes and socioecological changes, including issues of climate change, adaptation and resilience, on gendered employment. Without an adequate analysis of gender, fisheries management and development policies may have negative effects on people’s livelihoods, well‐being and the environment they depend on, or fail altogether to achieve intended outcomes.

BACKGROUND: Chronic non-communicable diseases (NCDs) are becoming significant causes of morbidity and mortality, particularly in sub-Saharan African countries, although local, high-quality data to inform evidence-based policies are lacking. OBJECTIVES: To determine the magnitude of NCDs and their risk factors in Malawi. METHODS: Using the WHO STEPwise approach to chronic disease risk factor surveillance, a population-based, nationwide cross-sectional survey was conducted between July and September 2009 on participants aged 25-64 years. Socio-demographic and behaviour risk factors were collected in Step 1. Physical anthropometric measurements and blood pressure were documented in Step 2. Blood cholesterol and fasting blood glucose were measured in Step 3. RESULTS AND CONCLUSION: A total of 5,206 adults (67% females) were surveyed. Tobacco smoking, alcohol drinking and raised blood pressure (BP) were more frequent in males than females, 25% vs 3%, 30% vs 4% and 37% vs 29%. Overweight, physical inactivity and raised cholesterol were more common in females than males, 28% vs 16%, 13% vs 6% and 11% vs 6%. Tobacco smoking was more common in rural than urban areas 11% vs 7%, and overweight and physical inactivity more common in urban than rural areas 39% vs 22% and 24% vs 9%, all with p<0.05. Overall (both sexes) prevalence of tobacco smoking, alcohol consumption, overweight and physical inactivity was 14%, 17%, 22%, 10% and prevalence of raised BP, fasting blood sugar and cholesterol was 33%, 6% and 9% respectively. These data could be useful in the formulation and advocacy of NCD policy and action plan in Malawi.

Jatropha curcas L. attracts a lot of interest as a biofuel crop, triggering large investments and rapid expansion of cultivation areas, and yet, it should still be considered as a (semi-)wild, undomesticated plant. To use the full potential of Jatropha and to support further expansion and systematic selection, breeding and domestication are a prerequisite. This review reveals and identifies gaps in knowledge that still impede domestication of Jatropha. Prebreeding knowledge is limited. In particular, the regeneration ecology and the degree of genetic diversity among and within natural populations in and outside the center of origin are poorly studied. There is only a limited understanding of the Jatropha breeding system and the effect of inbreeding and outbreeding. This review presents all currently available and relevant information on the species distribution, site requirements, regeneration ecology, genetic diversity, advances in selection, development of varieties and hybridization. It also describes possible routes to a better Jatropha germplasm, gives recommendations for tackling current problems and provides guidance for future research. We also discuss the participatory domestication strategy of Jatropha integration in agroforestry.

This study examined farmers' attitudes towards tree planting on farms in Malawi, using the theory of planned behaviour as a conceptual framework. Questionnaires containing a scale that measures attitudes, subjective norms, and perceived behavioural control in relation to tree planting were administered to 200 farmers in Chiradzulu and Mzimba districts in Malawi. Farmers who reported planting trees in the last five years had more positive attitudes, subjective norms and perceived behavioural control compared to farmers who have not planted trees. A hierarchical logistic regression analysis showed that membership of a farmer group and attitudes had a significant positive influence on reported behaviour. Nevertheless, many farmers considered household needs such as buying food and agricultural inputs, as well as children's education, as more urgent than investing their scarce resources in tree planting, suggesting that poverty is a barrier to tree planting.

BACKGROUND: Cancer is a leading cause of morbidity and mortality worldwide with a majority of cases and deaths occurring in developing countries. While cancer of the lung, breast, colorectum, stomach and prostate are the most common types of cancer globally, in east and southern Africa these are less common and comprehensive data to inform policies are lacking. METHODS: Nationwide cancer registry was conducted between September and October 2010 in Malawi. New cancer cases registered from 2007 to 2010 were identified from hospital and clinic registers of 81 out of 84 health facilities providing cancer diagnosis, treatment or palliative care services. Demographic and cancer data were extracted from registers and case notes using a standard form. RESULTS: A total of 18,946 new cases of cancer were registered in Malawi from 2007-2010. Of these 55.9% were females, 7.2% were children aged less than 15 years, 76.5% were adults aged 15-59 years and 16.4% were elderly aged 60 years or more. Only 17.9% of the cases had histologically verified diagnosis, 33.2% were diagnosed clinically and 49.6% based on clinical and some investigations. Amongst females, cancer of the cervix was the commonest accounting for 45.4% of all cases followed by Kaposi sarcoma (21.1%), cancer of the oesophagus (8.2%), breast (4.6%) and non-Hodgkin lymphoma (4.1%). In males, Kaposi sarcoma was the most frequent (50.7%) then cancer of oesophagus (16.9%), non-Hodgkin lymphoma (7.8), prostate (4.0%) and urinary bladder (3.7%). Age-standardised incidence rate per 100,000 population for all types of cancer in males increased from 31 in 1999-2002 to 56 in 2007-2010. In females it increased from 29 to 69. Kaposi sarcoma and cancer of the oesophagus, cervical cancer and Kaposi sarcoma were the main causes for the increased incidence in males and females respectively. It was estimated that, annually at least 8,151 new cases of cancer (all types) occur in Malawi. CONCLUSIONS: This study provided data on common types and trends of cancer that could be used to focus prevention, treatment and control interventions in the context of limited resources. The problem of under-reporting and misdiagnosis of cancer cases has been highlighted.

Abstract The Miombo, the most extensive tropical woodland formation of Africa directly supports the livelihoods of over 100 million people through the provision of many tree products and ecosystem services essential to both the rural and urban communities. While the destruction of the Miombo has often been blamed on the rural communities dwelling near the forest resources, many urban dwellers depend heavily on the various products derived from the woodlands. This paper highlights the importance of the Miombo in the livelihoods of rural people, the potential threats to this ecosystem and opportunities for its sustainable management. About 70% of energy consumed in southern Africa is in the form of fuelwood or charcoal. The economic importance of the Miombo especially from non‐timber forest products (NTFPs) is usually understated due to their perceived non‐economic value yet they play an important role in sustaining livelihoods of forest dependent people in the miombo ecoregion. The Miombo also contributes to health services through the use of medicinal plant and products, in some cases, contributing up to 80% to rural health, including helping in coping with effects of HIV/AIDS, malaria and several diseases. The possibility of developing payment for environmental services schemes through public–private partnerships, and community‐based sustainable management models are proposed. Through conservation and commercialization of some of the products and services, there is a potential to provide income and improve the livelihood of people involved in the trade along the value chain.

Seed potato systems in East Africa are described and opportunities for improvement identified on the basis of interviews with potato producers in Kenya, Uganda and Ethiopia, and an assessment of Ralstonia solanacearum and virus disease levels in Kenya. 3% of seed potato sold in Kenyan markets was virus free. Ralstonia solanacearum was found in 74% of potato farms. Less than 5% of the farmers interviewed source seed potato from specialized seed growers. Over 50% rely entirely on farm-saved seed. Current seed potato prices justify this behavior. To improve the system the local and specialized chain need to be tackled simultaneously. To improve the local chain ware potato farmers require training on seed quality maintenance and managing bacterial wilt and viruses. Research into virus resistance and the effect of mixed virus infection on yield deserves attention. Private investment in seed potato production could increase volumes produced and reduce prices.

The occurrence of Ebola virus (EBOV) in West Africa during 2013-2015 is unprecedented. Early reports suggested that in this outbreak EBOV is mutating twice as fast as previously observed, which indicates the potential for changes in transmissibility and virulence and could render current molecular diagnostics and countermeasures ineffective. We have determined additional full-length sequences from two clusters of imported EBOV infections into Mali, and we show that the nucleotide substitution rate (9.6 × 10(-4) substitutions per site per year) is consistent with rates observed in Central African outbreaks. In addition, overall variation among all genotypes observed remains low. Thus, our data indicate that EBOV is not undergoing rapid evolution in humans during the current outbreak. This finding has important implications for outbreak response and public health decisions and should alleviate several previously raised concerns.

This Malawi study examines whether agroecology can be effectively used by smallholders to address food sovereignty. We build on the concept of the metabolic rift, arguing that repairing this rift includes social relations. Agroecological methods can be important strategies, but are labour and knowledge intensive, and require addressing power dynamics within and beyond households in order to address food sovereignty. The case study included participatory methods of dialogue, experimentation and horizontal learning to foster change. We argue that feminist concepts of intersectionality and participatory praxis are central to mobilizing agroecology to build food sovereignty and work to transform social relations.

BACKGROUND: In most countries of the sub-Saharan Africa, health care needs have been increasing due to emerging and re-emerging health problems. However, the supply of health care resources to address the problems has been continuously declining, thus jeopardizing the progress towards achieving the health-related Millennium Development Goals. Namibia is no exception to this. It is therefore necessary to quantify the level of technical inefficiency in the countries so as to alert policy makers of the potential resource gains to the health system if the hospitals that absorb a lion's share of the available resources are technically efficient. METHOD: All public sector hospitals (N = 30) were included in the study. Hospital capacity utilization ratios and the data envelopment analysis (DEA) technique were used to assess technical efficiency. The DEA model used three inputs and two outputs. Data for four financial years (1997/98 to 2000/2001) was used for the analysis. To test for the robustness of the DEA technical efficiency scores the Jackknife analysis was used. RESULTS: The findings suggest the presence of substantial degree of pure technical and scale inefficiency. The average technical efficiency level during the given period was less than 75%. Less than half of the hospitals included in the study were located on the technically efficient frontier. Increasing returns to scale is observed to be the predominant form of scale inefficiency. CONCLUSION: It is concluded that the existing level of pure technical and scale inefficiency of the district hospitals is considerably high and may negatively affect the government's initiatives to improve access to quality health care and scaling up of interventions that are necessary to achieve the health-related Millennium Development Goals. It is recommended that the inefficient hospitals learn from their efficient peers identified by the DEA model so as to improve the overall performance of the health system.

BACKGROUND: Malawi has the highest cervical cancer incidence and mortality in the world with age-standardized rate (ASR) of 75.9 and 49.8 per 100,000 population respectively. In response, Ministry of Health established a cervical cancer screening programme using visual inspection with acetic acid (VIA) and treatment of precancerous lesions with cryotherapy. This paper highlights the roll out, integration with family planning services and HIV ART Programme, uptake and challenges of VIA and Cryotherapy programme. METHODS: We analyzed program data, supportive supervision, quarterly and annual reports from the National Cervical Cancer Control Program. We evaluated the uptake and challenges of screening services by age, HIV serostatus and trends over a five year period (2011-2015). RESULTS: Between 2011 and 2015, number of cervical cancer screening sites, number of women screened and coverage per annum increased from 75 to 130, 15,331 to 49,301 and 9.3 % to 26.5 % respectively. In this five year period, a total of 145,015 women were screened. Of these, 7,349 (5.1 %) and 6,289 (4.3 %) were VIA positive and suspect cancer respectively. Overall 13,638 (9.4 %) were detected to be VIA positive or had suspect cancer. Of the 48,588 women with known age screened in 2015; 13,642 (28.1 %), 27,275 (56.1 %) and 7,671 (15.8 %) were aged 29 or less, 30-45, 46 years or more. Among 39,101 women with data on HIV serostatus; 21,546 (55.1 %) were HIV negative, 6,209 (15.9 %) were HIV positive and 11, 346 (29.0 %) status was unknown. VIA positivity rate and prevalence of suspect cancer were significantly higher in HIV positive than HIV negative women (8.8 % vs 5.0 %, 6.4 % vs 3.0 %); in women aged 30-45 years than women aged 29 years or less (5.6 % vs 2.3 %, 2.6 % vs 1.2 %) respectively, all p <0.05). The main challenge of the programme was failure to treat VIA positive women eligible for cryotherapy. Over the five year period, the programme only treated 1,001 (43.3 %) out of 2,311 eligible women and only 266 (31.8 %) of the 836 women with large lesion or suspect cancer who were referred, received the health care at the referral centre. The reasons for failure to provide cryotherapy treatment were stock out of gas, faulty/broken cryotherapy machine (usually connectors or probes) or no cryotherapy machine at all in the whole district. For women with large lesion or suspect cancer; lack of loop electrosurgical excision procedure (LEEP) machine or inadequate gynaecologists at the referral centre, were the major reasons. Cancer radiotherapy services were not available in Malawi. CONCLUSIONS: This study provided data on VIA positivity rate, prevalence of suspect cancer, failure rate of cryotherapy and challenges in the provision of cryotherapy and LEEP treatment in Malawi. These data could be used as baseline for monitoring and evaluation of Human Papillomavirus (HPV) vaccination programme which the country introduced in 2013, the linkage of cervical cancer screening and women on HIV ART and the long term effect of ART, voluntary male medical circumcision on the prevalence and incidence of cervical cancer.

BACKGROUND: Data Envelopment Analysis (DEA) has been used to analyze the efficiency of the health sector in the developed world for sometime now. However, in developing economies and particularly in Africa only a few studies have applied DEA in measuring the efficiency of their health care systems. METHODS: This study uses the DEA method, to calculate the technical efficiency of 89 randomly sampled health centers in Ghana. The aim was to determine the degree of efficiency of health centers and recommend performance targets for the inefficient facilities. RESULTS: The findings showed that 65% of health centers were technically inefficient and so were using resources that they did not actually need. CONCLUSION: The results broadly point to grave inefficiency in the health care delivery system of public health centers and that significant amounts of resources could be saved if measures were put in place to curb the waste.

BACKGROUND: Growing scientific evidence points to the pervasiveness of inequities in health and health care and the persistence of the inverse care law, that is the availability of good quality healthcare seems to be inversely related to the need for it in developing countries. Achievement of the Millennium Development Goals is likely to be compromised if inequities in health/healthcare are not properly addressed. OBJECTIVE: This study attempts to assess trends in inequities in selected indicators of health status and health service utilization in Malawi using data from the Demographic and Health Surveys of 1992, 2000 and 2004. METHODS: Data from Demographic and Health Surveys of 1992, 2000 and 2004 are analysed for inequities in health/healthcare using quintile ratios and concentration curves/indices. RESULTS: Overall, the findings indicate that in most of the selected indicators there are pro-rich inequities and that they have been widening during the period under consideration. Furthermore, vertical inequities are observed in the use of interventions (treatment of diarrhoea, ARI among under-five children), in that the non-poor who experience less burden from these diseases receive more of the treatment/interventions, whereas the poor who have a greater proportion of the disease burden use less of the interventions. It is also observed that the publicly provided services for some of the selected interventions (e.g. child delivery) benefit the non-poor more than the poor. CONCLUSION: The widening trend in inequities, in particular healthcare utilization for proven cost-effective interventions is likely to jeopardize the achievement of the Millennium Development Goals and other national and regional targets. To counteract the inequities it is recommended that coverage in poor communities be increased through appropriate targeting mechanisms and effective service delivery strategies. There is also a need for studies to identify which service delivery mechanisms are effective in the Malawian context.

Mapping crop types and land cover in smallholder farming systems in sub-Saharan Africa remains a challenge due to data costs, high cloud cover, and poor temporal resolution of satellite data. With improvement in satellite technology and image processing techniques, there is a potential for integrating data from sensors with different spectral characteristics and temporal resolutions to effectively map crop types and land cover. In our Malawi study area, it is common that there are no cloud-free images available for the entire crop growth season. The goal of this experiment is to produce detailed crop type and land cover maps in agricultural landscapes using the Sentinel-1 (S-1) radar data, Sentinel-2 (S-2) optical data, S-2 and PlanetScope data fusion, and S-1 C2 matrix and S-1 H/α polarimetric decomposition. We evaluated the ability to combine these data to map crop types and land cover in two smallholder farming locations. The random forest algorithm, trained with crop and land cover type data collected in the field, complemented with samples digitized from Google Earth Pro and DigitalGlobe, was used for the classification experiments. The results show that the S-2 and PlanetScope fused image + S-1 covariance (C2) matrix + H/α polarimetric decomposition (an entropy-based decomposition method) fusion outperformed all other image combinations, producing higher overall accuracies (OAs) (&gt;85%) and Kappa coefficients (&gt;0.80). These OAs represent a 13.53% and 11.7% improvement on the Sentinel-2-only (OAs &lt; 80%) experiment for Thimalala and Edundu, respectively. The experiment also provided accurate insights into the distribution of crop and land cover types in the area. The findings suggest that in cloud-dense and resource-poor locations, fusing high temporal resolution radar data with available optical data presents an opportunity for operational mapping of crop types and land cover to support food security and environmental management decision-making.

In response to the declining soil fertility in southern Africa and the negative effects that this leads to, such as food insecurity besides other developmental challenges, fertilizer tree systems (FTS) were developed as technological innovation to help smallholder farmers to build soil organic matter and fertility in a sustainable manner. In this paper, we trace the historical background and highlight the developmental phases and outcomes of the technology. The synthesis shows that FTS are inexpensive technologies that significantly raise crop yields, reduce food insecurity and enhance environmental services and resilience of agro-ecologies. Many of the achievements recorded with FTS can be traced to some key factors: the availability of a suite of technological options that are appropriate in a range of different household and ecological circumstances, partnership between multiple institutions and disciplines in the development of the technology, active encouragement of farmer innovations in the adaptation process and proactive engagement of several consortia of partner institutions to scale up the technology in farming communities. It is recommended that smallholder farmers would benefit if rural development planners emphasize the merits of different fertility replenishment approaches and taking advantage of the synergy between FTS and mineral fertilizers rather than focusing on ‘organic vs. inorganic’ debates.

Abstract Climate change is projected to have severe implications for smallholder agriculture in Africa, with increased temperatures, increased drought and flooding occurrence, and increased rainfall variability. Given these projections, there is a need to identify effective strategies to help rural communities adapt to climatic risks. Yet, relatively little research has examined the politics and social dynamics around knowledge and sources of information about climate-change adaptation with smallholder farming communities. This paper uses a political ecology approach to historically situate rural people's experiences with a changing climate. Using the concept of the co-production of knowledge, we examine how Malawian smallholder farmers learn, perceive, share and apply knowledge about a changing climate, and what sources they draw on for agroecological methods in this context. As well, we pay particular attention to agricultural knowledge flows within and between households. We ask two main questions: Whose knowledge counts in relation to climate-change adaptation? What are the political, social and environmental implications of these knowledge dynamics? We draw upon a long-term action research project on climate-change adaptation that involved focus groups, interviews, observations, surveys, and participatory agroecology experiments with 425 farmers. Our findings are consistent with other studies, which found that agricultural knowledge sources were shaped by gender and other social inequalities, with women more reliant on informal networks than men. Farmers initially ranked extension services as important sources of knowledge about farming and climate change. After farmers carried out participatory agroecological research, they ranked their own observation and informal farmer networks as more important sources of knowledge. Contradictory ideas about climate-change adaptation, linked to various positions of power, gaps of knowledge and social inequalities make it challenging for farmers to know how to act despite observing changes in rainfall. Participatory agroecological approaches influenced adaptation strategies used by smallholder farmers in Malawi, but most still maintained the dominant narrative about climate-change causes, which focused on local deforestation by rural communities. Smallholder farmers in Malawi are responsible for &lt;1% of global greenhouse gas emissions, yet our results show that the farmers often blame their own rural communities for changes in deforestation and rainfall patterns. Researchers need to consider differences knowledge and power between scientists and farmers and the contradictory narratives at work in communities to foster long-term change.