
































A Model for Involving Local Communities in Global Health Interventions 

Review by Margaret A. Graham

Community Participatory Involvement: A Sustainable Model for Global Public Health

by Linda M Whiteford & Cecilia Vindrola-Padros

Left Coast Press, 2015

Anthropologists  who collaborate with communities and organizations to bring about positive social

change and improve public health will be very interested in this concise, but detailed, case study of an

international effort to control a cholera epidemic in the Ecuadorian highlands in 1994-1995. So will

faculty,  researchers,  NGOs and others engaged in global  efforts  to enhance health and well-being.

Cholera, an acute bacterial infection of the intestine, is spread through contaminated food or water, or

contact with contaminated feces, thus it disproportionately affects the poor and the marginalized who

lack access to clean water and sanitation systems. After disappearing from Latin America for almost

100 years, cholera reappeared in Peru in January 1991 and spread rapidly. It reached Ecuador a few

weeks later on 20 February 1991 when a Peruvian fisherman from Tumbez traveled across the border to

the  south  coastal  region  of  Ecuador  to  collect  shrimp  larvae  (p.  79-80)  and  spread  quickly.  The

epidemic was controlled relatively quickly in the urban areas with classic public health educational

campaigns that encouraged handwashing, the avoidance of street foods and raw and undercooked fish,

and sanitary feces removal. The campaigns were not as successful in the highland communities where

cholera continued to be transmitted. The Community Participatory Involvement (hereafter CPI) model

—the subject of this book – was employed to address the transmission of cholera in four communities

in the Ecuadorian Andes.

The first four chapters of the book provide the conceptual background of the model (chapters 1-3), and

background on the epidemiology of cholera in South America (chapter 4). Chapter 1 introduces the key



theoretical  and  methodological  bases  of  the  CPI  model,  especially  its  emphasis  on  leadership

development  and  capacity  building  at  the  community  level,  and  describes  how the  model  can  be

employed to address a wide range of global health issues. Chapter 2 locates the CPI model within the

scholarship of behavior change and compares CPI to other health intervention models (e.g., the Health

Belief Model, Theory of Planned Behavior model, and the Transtheoretical model), most of which

focus on the role of the individual and motivation to predict behavior change. In contrast, the medical

ecology theory that underlies the CPI model employs a broader view that highlights the complexity of a

person’s  social  contexts  as  well  as  the  multiple,  interconnected  factors  (biological,  physical,  and

political economic) that influence a person’s health. The authors also discuss in chapter 2 how the CPI

model differs from other Community-based Participatory (CBP) models in that “its focus lies in the

relationships community members are able to establish with different sectors of the state and civil

society. In this model, even though the engagement of community members is seen as intrinsic in the

generation of changes, these changes are seen as requiring input and support from a wide range of

stakeholders. Local community needs are seen as the responsibility of community members, different

levels of political and civil authority, and non-governmental organizations” (p. 43). Local engagement

with these other levels requires the active involvement of multiple stakeholders and builds leadership

and capacity building at the local level. Chapter 3 describes the CPI model—its theoretical model, key

concepts, and methodology – in depth. The authors trace the evolution of the CPI model, developed

and  funded  by  USAID,  from  earlier  versions  (Community  Involvement  in  the  Management  of

Environmental Pollution (CIMEP) and the Community Participatory Intervention (CPI) models) that

recognized that any sustained change “must include the community into its design and implementation”

(p. 53). The five key elements of the CPI model include (p. 53):

<ol>

<li>The role of effective community engagement</li>

<li>The elicitation and validation of local beliefs</li>

<li>The generation of base-line and follow-up epidemiological data</li>

<li>A scale up with local, region, and national authorities</li>

<li>Sustained capacity building</li>

</ol>

In chapter 5 the authors provide a case study of the CPI Cholera Project in Ecuador and descriptions of

the four selected rural communities. The goals of the project were to identify the beliefs and behaviors

related to the spread of cholera, namely water treatment, especially water storage and re-use practices,

hand washing, and food treatment, and to make recommendations for community-based involvement to



change  those  beliefs  and  behaviors  in  culturally  appropriate  ways.  The  long-term  goals  were  to

facilitate  the  development  of  leadership  at  the  local  levels  that  could  help  sustain  the  changes.

Whiteford  and  Vindrola-Padros  discuss  in  detail  the  steps  involved  in  the  project  planning  and

development stage, and then proceed to describe the activities used in the implementation of the field

project.  The  project  was  carried  out  by  three  interlocking  CPI  teams:  the  Technical  Team  (TT)

composed of national and international advisors from Ecuadorian Ministry of Health and USAID; the

Regional Teams (RT) of Ecuadorians from regional or municipal govern departments and NGOs; and

Community  Teams (CT) made up of  members  of  the four  affected communities.  The project  was

careful to expand the leadership roles in the CTs and to include those—women, younger adults—who

would normally not be considered for leadership roles in these communities based on their  gender

and/or age. At the community level, several innovative methods were used to collect and disseminate

information  during  the  twelve-month  project.  These  methods  and  tools—community  assemblies,

ethnographic interviews and visual monitoring of water-handling practices including water storage and

re-use, perception mapping, and workshops—were all critical to the success of the project. Based on

the findings and workshop discussions, each community designed a specific cholera control project that

the community itself would implement, sustain, and monitor. The community members were not just

respondents  but  were  themselves  trained  in  ethnographic  techniques  that  included  structured

interviews,  observational  techniques,  and  surveys.  The  technical  team  also  provided  funds  for

household  water  containers  (<em>bidones</em>),  inexpensive  water  disinfectants,  public  garbage

containers, and local health fairs to support the community projects. The appendices include copies of

the workshop materials and tools.

Chapter 6 discusses with rich ethnographic detail the outcomes of the intervention and its evaluation by

the community and technical teams. Comparing baseline with the follow-up survey shows that people

changed the way they understood disease transmission and changed their behaviors. Three of the four

communities showed marked changes in beliefs and behaviors that were targeted for change and in the

spread of cholera. For example, people had a better understanding of how diseases like cholera are

transmitted in contaminated water and the percentage of households that washed dishes with clean

water and soap increased by 42%. One of the most successful interventions was the provision of new,

five-gallon water containers that have spigots and tight-fitting lids that kept water clean, which were

lovingly  covered  with  special  clothes  to  keep  the  exterior  of  the  container  clean.  Most  of  the

communities also experienced an increased closeness and improved sense of community. The most

isolated community did not show the same degree of improvement, but did respond in a less expected



but nonetheless very interesting way by coming together and identifying the need for a community

childcare center where mothers can take turns caring for young children while the other women worked

10-hour days in the fields. To meet the high demand, the mothers got together and requested another

water container and disinfectant so children would have access to clean water. The authors state, “The

development of the Pompeya community childcare center exemplified the very skills that we hoped to

see emerge from the project: initiative and partnership combined with local leadership to treat a locally

identified need” (p.  126).  It  also underscores  a central  premise of the CPI model:  that  small  rural

communities are not carbon copies and that local needs and voices must be considered when attempting

interventions of any kind.

Chapter 7 is organized around take-away messages and lessons learned. There are many important

lessons learned but the focus on expanding local leadership and capacity building is one of the most

critical and exciting aspects of the CPI model. Too often the community voices heard in participatory

research are those already in the power structure, those who hold the traditional authority for making

decisions on the part of the whole. This model explicitly rejects that model of leadership and includes

the voices and perspectives of people who are often excluded from decision-making and leadership

roles.  As  this  case  study  shows,  opening  up  leadership  and  building  individual  skills  is  key  to

developing true community and regional leaders who are an integral part of and truly committed to

creating sustainable social change.

Applied  medical  anthropologists  and  those  working  in  non-governmental  and  governmental

organizations concerned with global health issues will be very interested in this case study. The book

would make an excellent addition to upper-division or graduate classes in medical anthropology, global

health,  and community-based participatory  research  methods.  Each chapter  concludes  with  a  brief

summary and in-class exercises related to the concepts and themes addressed in the preceding chapter.

The appendices include workshop materials, research instruments, list of resources and health related

databases, and a link to a ten-minute video from the research site. I recommend complementing the

book with Wellin’s classic study of water use in  a Peruvian town published in 1955 for a  critical

discussion of public health interventions, historical racism, structural violence, persistent economic and

health inequalities, and why poor, marginalized Andean communities still lack access to clean water

and sanitation systems 60 years later.

References Cited



Wellin,  E.  (1955).  Water  boiling  in  a  Peruvian  town.  In  Paul,  B.  D.  (Ed.),  Health,  culture  and

community (pp. 71-106). New York, NY: Russell Sage.

Margaret A. Graham is an Associate Professor of Anthropology at The University of Texas Rio Grande

Valley (formerly The University of Texas-Pan American) and Adjunct Associate Professor at the Texas

A&amp;M School of  Public  Health.  Dr.  Graham’s  research focuses on health and nutrition issues

impacting low-income populations, especially those living on the Texas-Mexico border. With expertise

in  applied  medical  anthropology,  she  is  involved  currently  in  a  community-based  participatory

research project that is working collaboratively on the design of information resources to communicate

the health hazards associated with the consumption of PCB-contaminated fish from a local Superfund

site to residents in neighboring colonias. She also conducted fieldwork on household food consumption

patterns in farming communities in the southern Peruvian Andes. Her research has been published in

Public  Health  Nursing,  Social  Science  and  Medicine,  Journal  of  Immigrant  and Minority  Health,

Journal of Tropical Pediatrics, Field Methods, and Ecology of Food and Nutrition among others.

© 2016 Margaret A. Graham


