Social Science & Medicine 164 (2016) 89e99

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Social Science & Medicine

journal homepage: www.elsevier.com/locate/socscimed

Agroecology and sustainable food systems: Participatory research to

improve food security among HIV-affected households in northern
Malawi
Hanson Nyantakyi-Frimpong a, *, Faith Nankasa Mambulu b, Rachel Bezner Kerr c,
Isaac Luginaah d, Esther Lupafya e
a
The Integrative Agroecology Group, University of Toronto, Scarborough, 1265 Military Trail, Toronto, Ontario, M1C 1A4, Canada
b
Centre for Health Policy, University of the Witwatersrand, Johannesburg, South Africa
c
Department of Development Sociology, Cornell University, Ithaca, NY, United States
d
Department of Geography, The University of Western Ontario, London, Ontario, Canada
e
Soils, Food and Healthy Communities Project, Ekwendeni Hospital, Malawi

a r t i c l e i n f o a b s t r a c t

Article history: This article shares results from a long-term participatory agroecological research project in northern
Received 8 May 2015 Malawi. Drawing upon a political ecology of health conceptual framework, the paper explores whether
Received in revised form and how participatory agroecological farming can improve food security and nutrition among HIV-
22 March 2016
affected households. In-depth interviews were conducted with 27 farmers in HIV-affected households
Accepted 19 July 2016
in the area near Ekwendeni Trading Centre in northern Malawi. The results show that participatory
Available online 21 July 2016
agroecological farming has a strong potential to meet the food, dietary, labour and income needs of HIV-
affected households, whilst helping them to manage natural resources sustainably. As well, the findings
Keywords:
Malawi
reveal that place-based politics, especially gendered power imbalances, are imperative for understanding
Agroecology the human impacts of the HIV/AIDS epidemic. Overall, the study adds valuable insights into the literature
Sustainable food systems on the human-environment dimensions of health. It demonstrates that the onset of disease can radically
Food security transform the social relations governing access to and control over resources (e.g., land, labour, and
Gender capital), and that these altered social relations in turn affect sustainable disease management. The
HIV/AIDS conclusion highlights how the promotion of sustainable agroecology could help to partly address the
Political ecology of health socio-ecological challenges associated with HIV/AIDS.
© 2016 Elsevier Ltd. All rights reserved.

1. Introduction
Among the several developmental challenges confronting the
global community today, perhaps none is more overwhelming than
the prevalence and impacts of HIV/AIDS. According to the most
recent report from the Joint United Nations Program on HIV/AIDS
(UNAIDS), almost 36.7 million people are currently suffering from
HIV/AIDS (UNAIDS, 2016). Indeed, one of the most striking features
of the HIV epidemic is its uneven geography in terms of regional
prevalence. Across all world regions, the rate of people living with
HIV is substantially higher in East and Southern Africa (19 million
people), compared with Asia and the Pacific (5.1 million), Eastern
* Corresponding author.
E-mail address: hansonkojo@gmail.com (H. Nyantakyi-Frimpong).
Europe and Central Asia (1.5 million), Latin America and the
Caribbean (2 million), Middle East and North Africa (230,000
million), and West and Central Africa (6.5 million) (UNAIDS, 2016).
In sub-Saharan Africa, there are eight countries where HIV/AIDS
prevalence rates are more than 10 percent of the population, and all
these countries are located in southern Africa, including Botswana
(26.3%), Lesotho (24.8%), Malawi (10.8%), Mozambique (12.5%),
Namibia (17.2%), South Africa (19.9%), Swaziland (28.6%), and
Zimbabwe (17.5%) (UNAIDS, 2015, p. 485e486). In these countries,
agriculture plays an important role in providing income, food, and
nutrition (FAO, 2014).
Over a decade of scholarship has shown the multifaceted nature
of the HIV/AIDS epidemic, and how it shapes, and is in turn shaped
by, smallholder farming, nutrition, food security, and gender re-
lations (Aberman et al., 2014; Kalipeni et al., 2004; Mojola, 2014). A
number of studies have also explored the complex and interlinked

http://dx.doi.org/10.1016/j.socscimed.2016.07.020
0277-9536/© 2016 Elsevier Ltd. All rights reserved.
90 H. Nyantakyi-Frimpong et al. / Social Science & Medicine 164 (2016) 89e99
social, cultural, political, economic, and geographical relationships
between HIV/AIDS and livelihoods (e.g., Kalipeni et al., 2004;
Wiegers et al., 2006). These studies have shown that increased
HIV rates have compromised food security in agrarian populations,
as the number of healthy adults providing farm labor has reduced
(Aberman et al., 2014; Bryceson and Fonseca, 2006; Weiser et al.,
2007). Household labor is affected in several ways with the entry
of HIV. First, at least one person, often an adult, has less energy to
devote to farming, although with the dramatic scaling up of Anti-
Retroviral Treatment (ART) in the last decade, HIV-positive mem-
bers can make significant contributions to farm labor (Aberman
et al., 2014). Second, household members who are healthy often
have to care for the person who is ill, including taking them to the
hospital and staying for longer periods of time. Third, the cost of
treating HIV/AIDS, including medicine and nutritional re-
quirements, puts added pressure on a household's livelihood and
may often lead to loss of capital assets (Mather et al., 2005).
Beyond the issue of household labor for farming, several studies
have documented the ways in which poverty interacts with HIV/
AIDS to worsen food security, with differentiated gendered impacts
(e.g., Mojola, 2014; Mtika, 2001; Shackleton and Shackleton, 2012;
Thangata et al., 2007; Tsai et al., 2011; Twine and Hunter, 2011).
Gender relations are often a crucial factor in understanding the
implications of HIV/AIDS for food security, with highly unequal
divisions of labor, particularly for care of the ill, and thus exacer-
bating food insecurity and poverty for AIDS-affected households. As
well, with the extraordinary rise in the number of HIV/AIDS-related
orphans (UNAIDS, 2015), the burden of orphan care oftentimes falls
disproportionately on women, including grandmothers who have
lost all their sons and daughters-in-law to AIDS (Mojola, 2014;
Wiegers et al., 2006).
While there is increased availability of ART to reduce AIDS-
related deaths, hunger, food insecurity, and poor diets shape the
efficacy of these medications. Research has shown that food inse-
curity has been a considerable barrier to using ART to manage HIV/
AIDS because ART requires not only adequate, but also nutritious
food (Kalofonos, 2010; Young et al., 2014). In parts of sub-Saharan
Africa where ART is being scaled-up, hunger has been a major
complaint among people on these medications (Kalofonos, 2010).
Another emerging side-effect of ART is related to labour, as the
frequency of these treatments limits the ability of HIV-positive
members to engage in farming in order to improve their own
food security (Young et al., 2014; Kaler et al., 2010). Thus, the HIV
pandemic is reworking smallholder agriculture, food security, and
nutrition in an interlinked and complicated set of ways.
One of the greatest challenges confronting sub-Saharan Africa is
how to address these interlinked processes in the context of the HIV
pandemic. In particular, scholars and policy makers have pondered
the question of agricultural methods that may best support HIV-
affected households to improve food security and nutrition. There
are currently raging debates about this question, especially in the
context of African agriculture more broadly. Some analysts have
called for the use of ‘Green Revolution’ methods, particularly
biotechnology, fertilizers, hybrid seeds, and pesticides to address
issues of hunger and food insecurity in sub-Saharan Africa (e.g., see
Hartmann, 2012; Juma, 2011). Other scholars have suggested that
more diverse farming systems, combined with attention to
inequality at multiple scales, are more effective ways to address
food security as well as have positive environmental benefits
(Moseley et al., 2016; Snapp et al., 2010).
Against the foregoing background, this paper addresses two
main research questions. First, what type of agriculture is appro-
priate for the food security and nutritional needs of HIV-affected
households? Second, can smallholder agroecological farming
address the labour challenges, environmental, and political
economic dynamics affecting agricultural production of HIV-
affected households? We address these questions by drawing
upon a case study from Malawi in southern Africa. Malawi offers an
insightful case study because it has one of the highest HIV preva-
lence rates in the world (UNAIDS, 2015). In addition, most Mala-
wians rely on farming as their primary livelihood and food source
(FAO, 2014), and thus questions about the linkages among agri-
culture, HIV/AIDS and food security are crucial.
Conceptually, we address the research questions by drawing
upon and contributing to scholarship in nature-society geography,
especially political ecologies of health (Jackson and Neely, 2015;
King, 2015). This conceptual lens allows us to pay crucial atten-
tion to both the micro- and macro-level politics of farm manage-
ment practices in the context of the HIV/AIDS epidemic. We seek to
demonstrate that for vulnerable HIV-affected households, agro-
ecological farming methods hold greater potential for addressing
the environmental, as well as the political factors undermining
nutrition and food security. Overall, the paper contributes to un-
derstanding the socio-ecological dimensions of HIV/AIDS, and
seeing the pandemic as an issue that is more than a medical
problem. Further, the study adds deep and valuable insights into
the current literature on the human-environment dimensions of
health (Jackson and Neely, 2015; King, 2015). More specifically, our
findings demonstrate that the onset of disease can radically
transform the social relations governing access to and control over
resources (e.g., land, labour, capital), and that these altered social
relations in turn affect sustainable disease management.
Throughout the paper, we use the term food security to refer to a
condition that exists when people have adequate, safe, and nutri-
tious food that is not only culturally acceptable, but also meets
dietary needs and food preferences for an active and healthy life
(Misselhorn et al., 2012). Dietary diversity refers to the number of
food groups consumed over a given time, and it is an important
measure of nutritional status or dietary quality (Swindale and
Bilinsky, 2006). We also use the term agroecology to refer to a set
of farming practices that attempt to mimic natural systems through
in-depth knowledge of crop, insect and disease ecology, increased
agrobiodiversity, and attention to interactions with adjacent nat-
ural landscapes (Gliessman, 2015; Kremen et al., 2012). As well,
agroecology puts stronger emphasis on the social, economic, and
political dynamics shaping agricultural production systems (Altieri
et al., 2012).
The rest of the paper is organized as follows. The next section
outlines our political ecology of health framework. We follow this
discussion with a brief historical, political, environmental, and so-
cial context of Malawi. In addition, we introduce the HIV/AIDS
intervention program that forms the basis of this case study.
Attention then shifts to our research methodology, including data
collection and analysis. The case study results are subsequently
presented. The last section discusses the research findings and
provides a concluding commentary outlining the theoretical and
policy significance of the study.
2. Political ecologies of health
Conceptually, we draw upon a political ecology of health
approach (hereafter PEH) (King, 2015; Richmond et al., 2005) to
analyze resource access, farmland management practices, and food
security among HIV-affected household in northern Malawi. The
PEH approach is a sub-field of political ecology, which is a multi-
disciplinary lens concerned with the complex relations between
nature and society (Blaikie and Brookfield, 1987; Perreault et al.,
2015; Watts, 2000). Political ecology is not a theory per se, but a
conceptual framework used in the social sciences to examine
“forms of access and control over resources and their implications
 H. Nyantakyi-Frimpong et al. / Social Science & Medicine 164 (2016) 89e99
for environmental health and sustainable livelihoods” (Watts,
2000, p. 257). The strengths of this approach lie in its capacity to
analyze local-level social relations and environmental problems
while recognizing broad-scale political economic realities (Blaikie
and Brookfield, 1987; Perreault et al., 2015). Although highly var-
ied with respect to substantive focus and epistemology (e.g., see
Perreault et al., 2015), there are several common threads that
broadly underlie the political ecology framework. Three of these
threads include “(1) a focus on the land users and the social re-
lations in which they are entwined; (2) tracing the linkages of these
local relations to wider geographical and social settings; and (3)
historical analysis to understand the contemporary situation”
(Neumann, 1992, p. 87).
For health geographers working in the field of political ecology,
a key research question is how human diseases and health are
shaped by history, regional political economy, the physical envi-
ronment, and micro-level politics within households (Jackson and
Neely, 2015; King, 2015; Richmond et al., 2005). King (2015) has
cogently summarized the PEH framework, noting that health and
wellbeing are not only complex, but also are highly dependent on
government policies, as well as place-specific environmental con-
straints (see also Jackson and Neely, 2015). What precisely distin-
guishes PEH from mainstream political ecology is the explicit focus
on broad health outcomes in human-environment interactions.
Using the PEH framework, many scholars have documented how
poor health is produced and reproduced through the links between
environment, economy, and society, in the context of the global
north (e.g. Richmond et al., 2005) and the global south (e.g.,
Mkandawire et al., 2013). This paper builds upon and extends the
work of these scholars. We specifically seek to show “how socio-
cultural and environmental contexts, political economic structures,
and the materiality of life” (Jackson and Neely, 2015, p.4) shape the
nutrition, health, and wellbeing of HIV-affected households in
northern Malawi.
Since PEH is inherently broad (e.g., see recent reviews in Jackson
and Neely, 2015; King, 2015), it is useful from the outset to clearly
specify the politics in our work, the ecological concerns being
addressed, how political economy is being theorized, and for what
particular health outcomes. In this case study, we focus on food
security and nutrition, related factors in ensuring positive health
outcomes generally, and for HIV positive people in particular. As
noted above, there are complex linkages between HIV status, food
security and nutrition, particularly in agrarian communities. A key
political issue addressed in our case study is the micro-level land
contestations between HIV-affected widows and their in-laws. We
further seek to show that for HIV-affected households, the labour
question (who is available to work, when, and for how long) is
deeply political, and is shaped by household politics and the gender
division of labour. The ecology in our PEH framework is specifically
linked to how low-input agroecological farming could be used to
build soil health among HIV-affected households lacking not only
labour, but also financial resources to practice high-input agricul-
ture. Finally, we theorize political economy by placing our study
within Malawi's historical geography, including neoliberal struc-
tural adjustment programs, and how these have shaped the ability
of vulnerable groups to access key agricultural resources.
3. The case study context
3.1. Malawi: A brief historical, political, environmental, and social
context
Malawi is a small country in southern Africa, with a population
of close to 16 million people (FAO, 2014; Government of Malawi,
2012). The country's current adult HIV prevalence rate is
91
estimated at 12.9% of the population, and infection rates are highest
amongst young women between the ages of 15 and 49
(Government of Malawi, 2012; UNAIDS, 2015). Over 70% of Mala-
wians live below the poverty line, with higher rates in rural areas
(World Bank, 2014). Approximately one-third of Malawian house-
holds experience severe food insecurity and calorie deficiencies
(Ecker and Qaim, 2011), and almost half of children under age five
are stunted (FAO, 2014; National Statistical Office and MACRO,
2011).
The political, economic, environmental, and historical back-
ground of Malawi helps to explain the higher rates of food inse-
curity and malnutrition in the country. The post-colonial
government implemented a dual agricultural strategy, increasing
landholdings and promoting cash crops for estate holders, while
providing smallholders with subsidized fertilizer, agricultural
credit, rural depots to supply inputs and markets, and extension
services (Bezner Kerr, 2014). Following a debt crisis and transition
to democracy in the 1990s, structural adjustment policies were
implemented, which included market liberalization, removal of
fertilizer subsidies, agricultural credit, and other public expendi-
tures on agriculture (Sahn and Arulpragasam, 1991; Harrigan,
2008). Inequality worsened and poverty rates increased, with es-
timates that estateholders' income increased by 44%, while small-
holders' income declined by 25% (Bryceson and Fonseca, 2006;
Dorward and Kydd, 2004; Sahn and Arulpragasam, 1991). The
removal of subsidies led to a dramatic surge in fertilizer prices, and
combined with several drought years and government misman-
agement, maize production fell drastically (Ellis and Manda, 2012;
Chirwa and Dorward, 2013).
In 2006, the state implemented a national agricultural input
subsidy program (AISP) that provided coupons to the majority of
farming households to purchase fertilizer and hybrid maize seed at
significantly reduced prices compared to commercial rates. This
program has continued since that time, with varying numbers of
recipients each year. The AISP has increased national maize pro-
duction and food security (Chirwa and Dorward, 2013), but the
majority of producers remain net buyers of maize (Chirwa and
Dorward, 2013). Several studies have documented the differential
impact of the AISP, with better-off households receiving more
coupons, applying more fertilizer, and having more significant
changes in food security than poor households (Chibwana et al.,
2012). Debates about appropriate agricultural approaches hinge
in part on environmental concerns associated with technologically-
intensive approaches, such as declining biodiversity and water
pollution. In Malawi, for example, there are high levels of defor-
estation and considerable land degradation from land clearing, lack
of organic matter application and soil erosion (Jumbe and Angelsen,
2007). The AISP has decreased crop diversity, with evidence of
reduced legume production and varietal diversity (Chibwana et al.,
2012). Lower crop diversity can increase risk of crop failure, reduce
dietary diversity, and provide less organic material for soil structure
and fertility (Snapp et al., 2010).
3.2. The Soils Food and Healthy Communities (SFHC) project
The Soils, Food and Healthy Communities (SFHC) project was
borne out of the high levels of food insecurity and high fertilizer
prices of the late 1990s. In 2000, a group of Canadian and Malawian
researchers and staff at Ekwendeni Hospital in northern Malawi
began SFHC as a participatory project to test whether legume
diversification options, previously tested under more scientifically-
controlled methods, could improve food security, soil fertility and
child nutrition under smallholder conditions (Msachi et al., 2009).
The project originators initially approached seven villages near the
Ekwendeni Hospital, and asked households to consider
92 H. Nyantakyi-Frimpong et al. / Social Science & Medicine 164 (2016) 89e99
experimentation with various sustainable agricultural methods to
improve food security, soil fertility, and child nutrition. The
emphasis was on farmer-to-farmer teaching and a participatory
action research model, with equal inputs from both women and
men. Overtime, research with these villages demonstrated that
farmer experimentation with legume diversification, combined
with nutrition education, could improve not only food security, but
also child nutrition, reduced reliance on fertilizer, and enhanced
ecosystem services (Msachi et al., 2009; Snapp et al., 2010).
In 2007 and 2008, the team conducted extensive qualitative
research with AIDS-affected households (Shumba and Bezner Kerr,
2008), and the results showed that this vulnerable group could be
more effectively integrated into SFHC activities. Beginning in 2010,
a concerted effort to involve AIDS-affected households began, with
identification made through the Ekwendeni Hospital AIDS Pro-
gram. Through this concerted effort, over one thousand AIDS-
affected households have participated in SFHC activities. This new
participatory research program explicitly focused on AIDS-affected
households as a group that had not effectively been reached, and
that faced particular challenges in improving food security and
nutrition. AIDS-affected households were recruited into SFHC ac-
tivities through hospital programs, community meetings, and links
to People Living with HIV/AIDS support groups. A more detailed
account of the origination and activities of SFHC has been reported
in Msachi et al. (2009), and Bezner Kerr et al. (2016). In the next
section of this article, we focus our attention on the methodology
used to conduct the research with HIV-affected households work-
ing under SFHC.
4. Methodology
This study draws upon a qualitative research methodology
(Miles et al., 2014; Patton, 2014). We adopted this research
approach in keeping with the methodological tradition of political
ecology, which requires a sensitivity to context, multiple views and
social relations (Neumann, 1992; Watts, 2000), as well as the first-
hand experiences of what Blaikie and Brookfield (1987) call the
“land managers.” The primary fieldwork took place from May to
August 2013, with a team comprising two of the authors, together
with two research assistants (one male and one female). The study
is part of a larger on-going project, and the results presented here
come from a subset of the findings involving twenty-seven in-
depth interviews. The respondents were purposively sampled from
five villages in northern Malawi, including Ekwendeni (n ¼ 6),
Chilida (n ¼ 6), Ng'ongo (n ¼ 6), Matheni (n ¼ 4) and Enyezini
(n ¼ 5) (see Fig. 1).
In-depth interviews lasted between 40 and 80 min, and were
conducted with an interview checklist. The interview questions
were written in English, translated into the local language, and then
reviewed for clarity. The checklist included questions on de-
mographic characteristics, health status, farming practices, and the
impacts of HIV/AIDS on food security and dietary diversity. Ques-
tions were also included to assess whether the SFHC agroecological
interventions have played any role in the experiences of food se-
curity and dietary diversity. The checklist also contained questions
to measure the food security and dietary diversity status of each
household.
We measured food security by adopting a standardized set of
nine questions from the Household Food Insecurity Access Scale
(HFIAS) (Coates et al., 2007). These HFIAS questions sought to
assess the availability and accessibility of food in a given household
over a thirty-day period. Each of the HFIAS questions was followed
by affirmative and frequency questions, from which four levels of
food security were computed, namely: (1) food secure, (2) mildly
food insecure, (3) moderately food insecure, and (4) severely food
insecure (Coates et al., 2007).
Dietary diversity was measured by adopting a standardized set
of questions for a 24 h dietary recall (Swindale and Bilinsky, 2006).
These questions sought to establish whether a household member
had eaten food items from 11 food groups over a 24 h period,
including cereals, eggs, fish and seafood, fruits, meat and poultry,
milk products, oil and fats, legumes and nuts, root and tubers, sugar
and honey, and vegetables (Swindale and Bilinsky, 2006). From the
24-h dietary recall, Household Dietary Diversity Scores (HDDS)
were calculated by counting the number of food groups consumed
by each household. The HDDS ranged from a minimum of 0 to a
maximum of 11. We further classified the households into three
levels of HDDS, namely Low HDDS (if households consumed 0 to 2
food groups); Medium HDDS (if households consumed 3 to 4 food
groups); and High HDDS (if households consumed 5 to 11 food
groups).
All the study participants provided informed consent before
taken part in the research. Research ethics approval was granted by
the Non-Medical Research Ethics Board at the University of West-
ern Ontario, Canada (Protocol No.103609). All interviews were
conducted in ChiTumbuka, which is the native language of the
people in the study area. The interviews were audiotaped with
permission, and then transcribed into English for analysis.
In order to ensure continued and deep immersion in the qual-
itative data (Miles et al., 2014; Patton, 2014), the analysis was
conducted manually by using hand-coding, rather than relying on a
computer software. The analysis generally followed procedures
suggested by Miles et al. (2014). By reading and rereading through
the raw data line-by-line, we inductively derived codes and orga-
nized and linked emergent codes into seven broader themes (Miles
et al., 2014). The frequency of each emerging theme was recorded,
as well as the number of participants who articulated a particular
theme. Three of the authors were directly involved in the data
analysis, with one independently coding the data, and two others
checking rigorously for consistency and accuracy. All in-
consistencies were resolved through frequent discussions.
To help strengthen the accuracy, credibility, and validity of our
qualitative findings (Miles et al., 2014; Patton, 2014), results were
shared with research participants in three informant feedback
workshops. All the three feedback workshops were organized at a
conference hall in Ekwendeni Hospital, northern Malawi. The first
feedback workshop was held on 19th August 2013, when pre-
liminary findings were discussed with the study participants. The
second feedback workshop was held on 15th January 2014, when
analytic categories and interpretations were discussed with the
research participants. In both workshops, participants were asked
to comment on the accuracy of the study findings, and to evaluate
whether we have correctly documented the experiences of HIV-
affected households. The feedback from these member-checking
exercises led to further refinement of the study results and the
drafting of this article. A final informant feedback workshop was
held on 6th August 2015, when the drafted article and response to
the first set of peer-review comments were discussed with study
participants. At the final feedback workshop, participants fully
endorsed the validity of the findings reported in the following
section.
5. Results
Before presenting results from the in-depth interviews, it is
important to take a brief closer look at some descriptive charac-
teristics of our sample. Table 1 provides a summary of these char-
acteristics, including age, marital status, household size, HIV-
related health concerns, food security status, and household di-
etary diversity. Participants’ age ranged between 20 and 79 years.
 H. Nyantakyi-Frimpong et al. / Social Science & Medicine 164 (2016) 89e99
Fig. 1. Map of the study area.
Source: Map drawn by Karen Van Kerkoerle, Cartographic Specialist, The University of Western Ontario, Canada.
Almost 56% were married, while 44% were widowed as a result of
HIV/AIDS. Household size ranged from 1 to 9 members, with an
average of 4 members per household. In 41% of the cases, both the
principal interview respondents and their spouses were HIV-
positive.
Results from the in-depth interviews are organized and pre-
sented in two formats; firstly, a summary table showing theme
counts (Table 2); and secondly, verbatim interview quotations
serving as low-inference descriptors (Miles et al., 2014). Indeed, the
idea of “counting” or reporting numerical data has always been
contentious in qualitative research (Maxwell, 2010). Here, we
would like to stress that while the summary table shows the per-
centage of participants who articulated a particular emerging
theme, the core study results are the verbatim quotations illus-
trating how participants attached meaning to each theme.
We present the interview themes under three sub-sections. The
first sub-section is an account of the environmental and gendered
micro-politics that shape the food security and dietary diversity of
HIV-affected households. In the second sub-section, we present
evidence showing how HIV-affected farmers describe the impor-
tance of smallholder agroecological farming. We focus attention on
how these farmers are using cereal-legume intercropping, manure
application, as well as composting, to address challenges related to
farm labour needs, seed and fertilizer purchase, food security, and
dietary diversity. The last sub-section of the results describes the
challenges of using agroecology to improve food security in the
93
context of HIV/AIDS. To protect confidentiality, all study partici-
pants are only identified by pseudonyms.
5.1. Farming decisions and access to farmland and labour in the
context of HIV/AIDS
During interviews, the respondents described several factors
influencing food security, crop choices, and soil fertility manage-
ment. Gendered inequalities in household decision-making
emerged as one of the most important constraints to farming,
especially in the context of a devastating AIDS epidemic. In 10
percent of the interviews, respondents reported collaboration in
farm decision-making, as illustrated in the following account:
My three sons, my wife and I participate in all the farming ac-
tivities; we all make ridges, mend the ridges, weed and harvest
[Bengo, male, age 51].
In 63 percent of cases, however, women indicated their lack of
involvement in farming decision-making. This concern was
expressed acutely in both monogamous and polygamous house-
holds, with participants reporting that husbands make all farming
decisions. The following comment is typical of these concerns:
Our husband is the head of all the households [with 3 wives], he
makes decisions on where and what each wife is planting
[Nyadaba, female, age 61].
94 H. Nyantakyi-Frimpong et al. / Social Science & Medicine 164 (2016) 89e99

Table 1 fertilizer for the tobacco fields yet the food crops he ignored also
Descriptive data for the interview participants (n ¼ 27). feed our grandchildren [Nasimbwi, female, age 43].
Characteristics Number (%)

Age (years) This problem is made worse when HIV-affected families have no
20e29 1 (4)
financial means to hire labour or purchase fertilizer. In describing
30e39 7 (26)
40e49 10 (37) the challenges facing day-to-day farming practices, the male re-
50e59 4 (15) spondents stressed that indeed when there is no money to hire
60e69 3 (11) labour or purchase fertilizer, women “suffer alone” in cultivating
70e79 2 (7) the field. One study participant expressed this point by saying:
Marital status
Married 15 (56) I burn charcoal at the mountains and sell in Ekwendeni or
Widowed 12 (44)
Mzuzu. The money from this business is used to buy fertilizer or
Household size
1e3 members 5 (19)
hire farm labour since among other crops we grow tobacco and
4e6 members 16 (59) maize. I have managed to buy fertilizer [for the tobacco] but the
7 þ members 6 (22) money will not be enough to hire labour [to weed the maize]
HIV-related health concerns which is not a good thing since I burn charcoal in the weeding
Only principal respondent is HIV-positive 11 (41)
period thereby my wife suffers alone [Botha, male, age 47].
Both principal respondent and the spouse are HIV-positive 11 (41)
A different household member is HIV-positive 4 (15)
No HIV-related concern in household a 1 (3)
Household grows tobacco
In addition to unequal household decision-making between
Yes 9 (33) men and women, 30 percent of respondents noted gendered and
No 18 (67) insecure access to farmlands, with implications for the food secu-
Facing intra-household land struggles rity of HIV-affected households. HIV-affected female household
Yes 8 (30)
heads were those who often reported difficulties in accessing land.
No 19 (70)
Agroecological farming methods being used)b In all instances, these women complained that land was either
Cereal-legume intercropping or legume rotation with maize 12 (44) taken away from them, or was controlled by their late husband's
Use crop residues to improve soil fertility 9 (33) relatives:
Composting/manure 16 (59)
None 4 (15) A few weeks ago, I just found some people clearing my land.
Household Food Security Status When I asked them, they said the land has been rented to them
Food Secure 15 (56) by my brother in-law. I cannot do a thing, it is their family land
Mildly food insecure 9 (33)
Moderately food insecure 3 (11)
and I am just here because this is where I married. If my husband
Severely food insecure 0 (0) was alive I do not think they could have done this [Tsankho,
Household Dietary Diversity Score (HDDS) widow, age 37].
Low HDDS (0e2 food groups) 0 (0)
Medium HDDS (3e4 food groups) 10 (37)
High HDDS (5 þ food groups) 17 (63) Aside from insecure land rights, participants who were widows
a
HIV-positive member died three weeks after we started the data collection. stressed that their lives are made extremely difficult by constant
b
Some households were using more than one agroecological farming method. threats from in-laws. The following quotation is a typical concern
Data source: Compiled from fieldwork: May to August 2013. often raised by widows:
My in-laws tell me to leave; they say ‘what are you doing here
when your husband is dead’ ( …)? They are proposing that I
Interview narratives also revealed a gendered cropping pattern, should leave. Sooner or later, I would have to leave and I'll take
with men focusing heavily on the production of cash crops such as my children with me [Jese, widow, age 39].
tobacco, and women focusing on food crops. Given this gendered
cropping practices and unequal decision-making, women re-
Among the respondents who were widows (44%), two used to
spondents stressed that their husbands direct all available farming
live in cities, but had returned to the rural village after their hus-
resources into the cultivation of tobacco, whilst neglecting food
bands' death. Similarly, three indicated that they used to live in
crops that are crucial for dietary diversity and food security:
cities, but brought their husbands to the village after critical HIV-
We grow tobacco [cash crop], maize, groundnuts, ground beans, related illness, and these men have subsequently died and been
cassava, sweet potatoes and vegetables [food crops]. It was hard buried. In all these cases, the widows reported that they sold all
to make it through with the other crops [food crops] this year their property and assets to take care of their late husbands when
since my husband only hired labour and directed much of the they were ill. As such, these women returned to the villages

Table 2
Summary of responses from in-depth interviews.

Response Number and % of participants who mentioned this response (n ¼ 27)

Unequally intra-household decision-making between women and men 17 (63%)

Land grab and gendered access to farmlands in the context of HIV/AIDS 8 (30%)
Lack of labour 12 (44%)
Agroecology improves food security of HIV-affected households 15 (56%)
Agroecology improves dietary diversity of HIV-affected households 18 (67%)
Agroecology improves incomes of HIV-affected households 11 (41%)
Challenges with agroecological farming in the context of HIV/AIDS 12 (44%)

Source: Derived from in-depth interviews, following analytical steps suggested by Miles et al. (2014).
 H. Nyantakyi-Frimpong et al. / Social Science & Medicine 164 (2016) 89e99
without any assets, and were very vulnerable to food insecurity
given constant threats of land eviction by in-laws. Farm labour was
another crucial concern mentioned by the HIV-affected house-
holds. Labour constraints were of particular burden for widows and
households that could not hire labour. Respondents typically talked
about the need to balance farm work with the responsibilities of
caring for sick family members. Others described critical labour
challenges, especially in contexts where both couples are HIV-
positive:
My husband and I have been HIV positive since 2007. His other
wife is also infected (…). This means none of us is strong enough
to do farming [Nyadaba, female, age 61].
The high levels of HIV-related deaths further complicate labour
shortages, with farm work being performed mainly by orphans
mostly below age ten, as well as the elderly, most of whom are
themselves living with HIV/AIDS. Because of the amount of farm
work to be done, some HIV-affected single parents indicated that
they cannot exempt young children from farm labour. Lack of access
to labour was also said to be influenced by polygamous relation-
ships. For HIV-affected women in polygamous marriages, one of
their greatest concerns was their husbands' dedication to second or
third wives:
Nowadays, I farm alone most of the time, since my husband is
busy with his other wife who only has one child and I have 5
children with him. This year, all my husband's farming was at
the second wife's farm plot (…) I received no help and this
affected how much I could produce [Nyabanda, female, age 36].
Participants described the fact that such labour constraints,
brought about in part by gender inequalities within marriage, in-
crease vulnerability to food insecurity. Moreover, the study par-
ticipants reported serious side-effects from ART, with the most
common problems being numbness and swelling of legs. These
side-effects from ART were reported to further complicate labour
constraints, as described by one widow:
We are advised to avoid overworking. We realize that the
medication [ART] is not effective when one's body is weak so we
minimize our farming periods so that our bodies are fit for the
treatment. If one farmed 5 h straight before, they are advised to
take a break after 2 h and continue later; moreover, some of us
are not that strong anymore [Nyamwene, widow, age 58].
Thus, although ART is helping to reduce AIDS-related deaths, it
nonetheless reduces the ability to perform physical work, including
farm labour among HIV positive individuals. Interview participants
described a vicious cycle suggesting that if HIV positive individuals
are too weak to farm, they are also likely to be food insecure, which
also affects the effectiveness of ART.
5.2. The benefits of agroecology in the context of HIV/AIDS
To help improve food security and the farming challenges con-
fronting HIV-affected households, SFHC has introduced a number
of agroecological farming practices in northern Malawi. The com-
mon practices include legume relay and intercropping, for example,
adding pigeon peas, groundnuts, and soya beans to maize cropping
systems, or rotating legume crops with maize (see Fig. 2). Partici-
pating HIV-affected farmers are asked to make their own choices of
legumes to be added to the typical maize-based monocropping in
Malawi. Some farmers have participated in the SFHC project since
95
the year 2000, and based upon their cumulative knowledge, they
offer suggestions to new farmers regarding which legumes are
most suitable for the area. Another agroecological method is the
burying of legume residue to strengthen soil structure and fertility.
A seed bank has also been created by SFHC, where farmers freely
access local seeds, without purchasing hybrid varieties every
farming season. This seed bank is managed by farmer leaders
within SFHC.
In the in-depth interviews, each participant was asked to
explain how they became members of the SFHC project, the
training they received, and whether the project has been beneficial
in addressing farming challenges and food insecurity. About 90
percent of the respondents said that they heard about the project
through their AIDS support networks. One farmer shared the
following story, an experience similar to that of other participants:
In 2010, I was called to Ekwendeni Hospital where they trained
me to intercrop legumes, bury residues and then plant maize.
The project gave me pigeon peas and groundnuts to intercrop. In
addition, I was instructed to identify 5 people from our support
group who were interested in this farming intervention and
could receive the seed for intercropping [Tchaya, male, age 47].
All the study participants stressed that the project has contrib-
uted immensely to improving food security and dietary diversity.
More than half of the respondents (56 percent) reiterated that
before the introduction of the SFHC project, they had no money to
purchase both fertilizer and good seeds to improve household food
security. However, with the introduction of the SFHC agroecological
project, these farmers mentioned that they no longer need to
purchase commercial fertilizer, or buy seeds. Repeatedly, the HIV-
affected farmers stressed that farming has not only been less
stressful, but there have been significant improvements in food
security. The farmers reported improved soils and greater crop
yields. As shown below, crop yield improvements were typically
highlighted by comparing yields before and after joining the SFHC
agroecological project:
I received groundnuts and pigeon peas in 2010 and intercropped
right away. The following growing season (2011) was the year of
reaping from burying the residues; I managed to harvest 15 tins
of maize instead of the usual 7 tins and (the harvest lasted until)
the 2012 growing season [Ziliwe, female, widow, age 36].
About 41 percent of participants also talked about increased
incomes, which although modest, helped to address labour and soil
fertility constraints:
With SFHC double legume intercrop, I harvested a lot of
groundnuts and soybeans, which I sold for MK 20,000 (about
$US 50). I used MK 12,500 (US$31) of the money to buy fish,
beans, rice and wheat flour, which I sell in my village. At the
moment my business is worth more than MK 30,000 ($US 76). I
can buy basic needs (…) and hire labour [Chimwemwe, wid-
owed, age 27].
Similarly, the HIV-affected farmers talked at length about the
labour benefits of legume intercropping. Study participants made
specific reference to the fact that with agroecological farming, there
is less need for labour, or to purchase costly artificial fertilizers. One
HIV-affected farmer expressed this concern more forcefully:
Farming is a labour intensive activity despite whatever crop I
grow. However, the [SFHC's] emphasis on groundnuts and soya
beans has given us a crop that needs less labour and needs no
96 H. Nyantakyi-Frimpong et al. / Social Science & Medicine 164 (2016) 89e99

Fig. 2. Agroecological farming practices by HIV-affected households.

Source: Photos taken by the authors (July 2013; July 2014; and August 2015).

fertilizer. The soybean seed can survive without banding but you
cannot do the same with maize [Zeliya, female, age 37].
Among the households that have benefitted from the SFHC
project, this study also showed that most of them have embarked
upon their own seed sharing networks, spreading news about their
successes, and encouraging others to adopt agroecology. There
were some related health outcomes from using these agroecolog-
ical methods. The study respondents spoke about feeling better and
harvesting enough food that could last over twelve months. More
than half of the respondents (56%) reported that their households
are food secure (Table 2), meaning they have access to adequate,
safe and nutritious food that meet dietary and health requirements.
Not only did the HIV-affected farmers talk about food security, but
dietary diversity also emerged as a recurring interview theme. For
example, in describing the benefits from the project, 67 percent of
the participants stressed that their food options have increased
significantly. This is so because the farmers currently cultivate three
or more crops, including cereals (mostly maize) and legumes (e.g.,
soya, groundnuts and pigeon pea). Thus, instead of the maize-based
diet common in most Malawian households, our study participants
reported eating a diverse range of diets, often mixing legumes and
cereals:
Last year, we ran out of food in November ( …). We finished our
maize in November while groundnuts lasted until October
which is a good improvement than we used to have. For soybean
we still have it because we do not use it at once but we mix it
with maize for porridge so it lasts longer [Ziba, male, age 55].
Data from our 24 h dietary recall shows that the majority of the
study households (63 percent) have a higher dietary diversity,
consuming an average of more than 5 food groups (Table 1). The
remaining 37 percent have a medium level dietary diversity,
consuming an average of 3e4 food groups.
 H. Nyantakyi-Frimpong et al. / Social Science & Medicine 164 (2016) 89e99
5.3. Challenges with agroecological farming among HIV-affected
households
The above dietary diversity and food security benefits
notwithstanding, 44 percent of the HIV-affected farmers outlined
the challenges they continue to face. One of the recurring concerns
was the issue of crop pests and how they affect legume intercrop-
ping. Seven farmers indicated that because of persistent pest attack,
they do not like intercropping with a legume called pigeon pea. One
of these respondents summarized this problem by saying:
I've tried to intercrop but now I've given up on pigeon peas.
There're some insects which stick to the pigeon peas flowers
soon after they start blooming and that restrict the peas from
bearing. I reported this to the SFHC officers and they told me
that I should hand pick the insects early in the morning and
burn them but they keep on coming each morning [Loyaki,
female, age 46].
In other cases also, the HIV-affected households had access to all
the necessary seeds and farming inputs, but poor health prevented
the satisfactory usage of agroecological farming:
I was recruited into SFHC in 2006, I received groundnuts which I
planted very early, however, I harvested less since I was sick to
work on farm and I am afraid to request for other seeds from the
project since returning the seed will be impossible if I get sick
again [Mughogho, male, age 42].
The interview findings showed that despite the food security
and dietary diversity benefits, farmers who are very sick of HIV/
AIDS are unable to take active part in this type of agroecological
intervention.
6. Discussion and conclusion
Our main findings show that participatory agroecological
farming has the potential to improve food, dietary, and income
needs of HIV-affected households. Many farmers reported rela-
tively higher yields, greater food security, and dietary diversity as a
result of legume intercropping. The higher yields further enhanced
farmers' confidence in agroecological practices, even given several
socio-ecological constraints. These findings are important for two
major reasons. Firstly, food security and dietary diversity are critical
for the health and well-being of HIV-affected households. Dietary
diversity contributes to good nutrition, which is essential for
building the health and immune system of people living with HIV/
AIDS (Diniz et al., 2011). Inadequate access to food is a significant
barrier to ART, and the anti-retroviral medication could improve an
individual's immunity only when diets contain sufficient micro-
nutrients (Weiser et al., 2010).
Secondly, HIV/AIDS could severely impact a person's ability to
earn a living. It perpetuates poverty and results in devastating
outcomes for nutrition, ART, and overall social wellbeing (Bezabhe
et al., 2014; Feulefack et al., 2013). Incomes of the poorest are often
the worst affected with the onset of the HIV/AIDS epidemic
(Feulefack et al., 2013), and with declining income, the ability to
secure healthy foods also declines. Thus, it is encouraging that our
respondents reported improvements in cash incomes through ag-
roecology, as well as the sale of leguminous crops. These extra in-
comes mean that HIV-affected families could access clinical care or
ART, which are often hindered by cost-related barriers (Bezabhe
et al., 2014). The ability to access ART, alongside good nutrition,
also has complementary benefits for smallholder agriculture. These
97
benefits have been shown in other studies suggesting that pro-
ductivity increases with ART, especially in terms of increased
output and participation in farm-related tasks (Thirumurthy et al.,
2008).
The findings also show that agroecological farming reduces the
labour burden of HIV-affected households. Research from different
parts of Africa indicates that labour loss is one of the critical means
through which HIV/AIDS can reduce resources devoted to small-
holder farming (Asenso-Okyere et al., 2010). Labour loss occurs not
only as a result of sickness, but also as a result of its reallocation to
care giving. The fact that legumes are not labour intensive is
important for deprived HIV-affected households who are torn be-
tween seeking healthcare, nursing sick family members, and
farming for subsistence. The resulting impact of the SFHC project on
farmer capacity building is also worth noting. By encouraging active
participation through farmer research groups, the project has
fostered an enabling environment for HIV-affected households to
network, co-learn, and share information with members who un-
derstand their needs.
Consistent with previous literature on political ecologies of
health (e.g., Nyantakyi-Frimpong et al., 2016; Richmond et al.,
2005) we found that place-based sociocultural processes are
crucial for environmental health and human well-being. In partic-
ular, our interviews underscore the fact that the onset of disease
interacts with the social relations governing resource use in a given
place. There is a confluence at multiple scales between gender re-
lations, health, economic processes, and the environment. In the
context of HIV/AIDS, critical social and economic relations include
poverty, unequal decision-making, gendered land rights, and con-
trol over labour. When these social relations are transformed, they
in turn rework how HIV-affected households are able to manage
the biophysical landscape (e.g., weeding and building soil health)
and transform their food security. Agroecological methods are not
the ‘panacea’ to addressing these structural inequalities, but rather
efforts to address food security must encompass social and eco-
nomic inequalities, such as access to land and unequal decision-
making. Although gender is a key theme in the broader political
ecology literature (e.g., see Elmhirst, 2015), it has not been a
prominent feature of the literature in the sub-field of political
ecology of health. Our study, therefore, contributes to the political
ecologies of health literature by drawing attention to the fact that
gendered power imbalances are imperative for population health
and well-being, especially in the context of the HIV/AIDS epidemic
and food security.
Our findings about land contestations between widows and in-
laws corroborate evidence from other parts of Africa. Empirical
research from patrilineal kinship systems in Eastern and Southern
Africa shows that women are frequently chased away by in-laws or
are denied the use of lands when a husband dies of HIV/AIDS (e.g.,
see Aliber and Walker, 2006; Okuro, 2008). This form of asset
stripping is one of the social mechanisms that lead to increased
risks of HIV acquisition, as some widows are compelled to exchange
sex for food and incomes (Weiser et al., 2007). Among our study
participants, many women reported losing access to land after they
had invested labour in building soil health through agroecological
methods. This finding draws attention to the need to protect
women's land rights in the context of HIV/AIDS in Malawi, as well
as elsewhere in sub-Saharan Africa. Secure access to land may
empower women and men to invest resources in sustainable
farming practices. In a recent United Nations report, De Schutter
(2014) drew attention to the fact that Malawi's lack of legislation
to address land inequalities is a major policy gap that must be
addressed to ensure food security for the poor majority. De Schutter
(2014) further called for greater investment in agroecological
methods as a long-term strategy to improve rural livelihoods and
98 H. Nyantakyi-Frimpong et al. / Social Science & Medicine 164 (2016) 89e99
environments.
Whilst our results are important for debates around food and
nutrition security in the context of HIV/AIDS, the findings need to
be considered with respect to some methodological issues. Firstly,
the qualitative nature of the study and the sample size (n ¼ 27)
mean that the findings cannot be generalized beyond the study
communities, or in similar contexts in Malawi. However, we want
to stress that most interview themes reached saturation, indicating
that interview numbers were sufficient enough to draw conclu-
sions from the sample (Miles et al., 2014; Patton, 2014). Secondly, a
major limitation is the fact that all the study participants are ben-
eficiaries of the SFHC project. Hence, the expectation of continued
support from SFHC likely contributed to bias. We tried to limit this
bias by clearly explaining the purpose of the study to participants,
and by using different probes to check answers for accuracy.
Thirdly, given the qualitative nature of the study, we could not
include non-HIV-affected households as a control group.
Notwithstanding these limitations, our study lays the groundwork
for future research using quantitative analyses and a representative
sample.
We conclude with the recommendation that participatory ag-
roecological farming has the potential to increase food and nutri-
tional security, while enhancing sustainable use of resources
among HIV-affected households. It also addresses multiple con-
straints facing these households, including labour, social support,
and access to reproduceable seeds. Policy support for this type of
sustainable agriculture may help to alleviate many of the looming
challenges associated with the HIV/AIDS epidemic in sub-Saharan
Africa.
Acknowledgements
We thank the study participants for their valuable inputs into
this research. The fieldwork was carried out with the aid of a grant
from McKnight Foundation. We are grateful to Laifolo Dakishoni,
Lizzie Shumba, Zachariah Nkhonya, Rogers Msachi, and Penjani
Kanyimbo for significant contributions during data collection. The
Soils, Food and Healthy Communities (SFHC) project has been
supported over the years by the International Development
Research Centre, Canada; the Canadian FoodGrains Bank; and the
Presbyterian Church of Canada. Many thanks to Karen Van Ker-
koerle for cartographic assistance. Finally, we thank four anony-
mous reviewers whose critical and detailed comments helped to
sharpen the quality of the paper.
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