WorkingPapersSeries

INTRODUCTIONTOTHECULTURALECOLOGYOFHEALTHANDCHANGE

By

TonyL.Whitehead,Ph.D.,MS.Hyg.ProfessorofAnthropologyandDirector,CuSAG

DepartmentofAnthropology

UniversityofMarylandCollegePark,Maryland20742

September11,2002.©TonyL.Whitehead.DonotduplicateordistributewithoutthepermissionofDr.Whiteheadattwhitehe@anth.umd.edu,or301‑405‑1419

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TableofContents

1. INTRODUCTION..............................................................................................................................3

2. ABRIEFINTRODUCTIONTOTHETHEORETICALPARADIGMSOFTHECEHC ......42.1. THECULTURALSYSTEMSPARADIGM(THECSP). ........................................................................42.2. THECULTURALSYSTEMSAPPROACHTOCHANGE(THECSAC) ...............................................52.3. THECULTURALSYSTEMSAPPROACHTOPROGRAM,PLANNINGANDIMPLEMENTATION(THECSAPPE) ..........................................................................................................................................9

3. THECEHCAPPLIEDRESEARCHANDTECHNICALASSISTANCESUBSYSTEMSANDPROGRAMS ....................................................................................................................................93.1. PROGRAMSOFTHEETHNOGRAPHICALLYINFORMEDCOMMUNITY&CULTURALASSESSMENTRESEARCHSYSTEM(THEEICCARS).................................................................................93.1.1. TheEICCARSApproachtoCommunityAssessmentResearch...............................................93.1.2. TheCEHCApproachtoCulturalSystemsAnalysis. .............................................................10

3.2. THECEHCPROGRAMINCOMMUNITYBASEDINTERVENTIONPROJECTDESIGNANDIMPLEMENTATIONPLAN(PDIP):THEPROJECTCULTUREDEVELOPMENTWORKSHOP ..................103.3. THECEHCSYSTEMINPROJECTIMPLEMENTATIONPROGRAMS(PIPS)...................................113.3.1. CSACINPUTProgramsinCBIImplementation ..................................................................113.3.2. TheCEHCPrograminPHASICProjectImplementation .....................................................123.3.3. TheFULLCEHCPrograminProjectImplementation. .........................................................13

3.4. THECEHCETHNOGRAPHICASSESSMENTEVALUATIONSYSTEM(EAES):EVALUATINGFORCBISUCCESSRATHERTHANʺFAILUREʺ ...............................................................................................133.4.1. AddressingPotentialConceptualandEthicalIssuesinOfferingTechnicalAssistance

FollowingEvaluationRecommendations...............................................................................133.4.2. EAESFormativeEvaluationPrograms ..................................................................................133.4.3. EAESPrograminProcessEvaluationandProjectMonitoring ............................................143.4.4. TheEAESPrograminOutcomeEvaluation ..........................................................................143.4.4a.EAESʹsProgramUsingMoreTraditionalApproachestoCBIOutcomeEvaluation...........153.4.4b.EAESPrograminCBIOutcomeEvaluationwithTechnicalAssistanceandProject

Monitoring .............................................................................................................................153.4.5. TheConceptualDifferenceBetweenOutcomeandImpactEvaluationasUsedintheEAES

................................................................................................................................................153.4.6. EAESProgramsinImpactEvaluation ...................................................................................15ReferencesCitedandRelatedLiterature ..............................................................................................16

APPENDIX1:ACRONYMGLOSSARY .............................................................................................17

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1. Introduction

heCulturalEcologyofHealthandChange (orCEHC) isa systemofanthropologybased theoreticalparadigms, and research and technical assistance programs that I have been developing for several

years1. The paradigms and programs of the CEHC evolved from 35 years of involvement as ananthropologist incommunitybased initiatives (CBIs) in theUnitedStatesandabroad2.During this longcareerofworkingwithotherprofessionals,organizations,groups,andactivists involvedinresearch,andtheplanning,implementation,andevaluationofCBIs,Ihavefoundthatnon‑anthropologistcolleaguesandcommunitygroupsviewedmycontributionsashavingthegreatestvalueinthefollowingareas:

providing cultural theoretical foundations thatwouldhelp inunderstanding communitystructuresandCBIplanningandimplementationdynamics;

bringinganthropologicalperspectivesandresearch(ethnographic)methodstocommunityassessmentresearchactivitiesthatwouldprovidedatafortheplanning,implementation,andevaluationofeffective3CBIs;and

bringing anthropological perspectives and methods to the planning, implementation, andevaluationofeffectiveCBIs.

Assuch,overtheyears,Ihavecontinuedtodeveloptheoreticalparadigms,programs,methods,materials,andorganizationalstructures toenhancethosecontributions,andtobeabletobettercommunicateandtransferthebenefitsgainedfrommyknowledge,skills,andexperiencestomystudents,non‑anthropologists,otheranthropologists,andmembersofthecommunitieswithwhomIworked.Thepurposeofthisworkingpaperistoprovideabrief introductiontothetheoreticalparadigmsandprogramsoftheCEHC.DiscussionofCEHCMaterialsandorganizationalstructureswillbeaddedlater.

TheCEHCinitsentiretyisanappliedresearchandtechnicalassistancesystemwithaprimaryfocusontheplanning, implementation,andevaluationofCBIs.TheCEHCdiffers,however, fromothermodelswithsimilarpurposes,inthatit:

useconceptualparadigmsbasedontheoriesofculture thataddress thecomplexitiesofthesocio‑culturalcontexts,processes,andmeaningsystemsthatinfluenceindividualideas(knowledge, attitudes, values, beliefs, etc.) and behaviors, including health relatedbehaviors, and should therefore, be considered in the design, implementation, andevaluationofCBIs;

ismade up of four interrelated systems (SeeAppendix 2, Figure 14), eachwithmultipleprograms that integrate community assessment research, and strategies ofCBI design,implementation,andevaluation;and

committed to the development of Program Technical Manuals (workbooks), andmonographs thatarebeingdesigned for the transferofCEHCknowledgeandskills tothoseinvolvedinthedesign,implementation,andevaluationofCBIs;

1WhiletheconceptualparadigmsoftheCEHCevolvedsolelyfromDr.Whitehead’swork,variouscolleaguesandstudentshaveassistedinthedevelopmentofCEHCprograms.

2Acommunitybasedinitiativemaybedefinedasanactivitythathasthefollowingcharacteristics:(1)goalsthatincludealleviatingor improving a select health or social problem within or among a targeted community or population; and (2) a high level ofinvolvementbymembersofthecommunityorpopulationtargetedbythatactivityinitsplanning,implementationandevaluation.

3Thetermeffectiveisusedheretorefertotheplanning,implementation,andevaluationofCBIsthatscorehighlyinachievingtheeventualoutcomesdesiredbythoseinvolvedintheirimplementationandplanning.

4Otherparadigms fordesigning, implementing,orevaluatingCBIsdonot integrate these threeactivities ina single interrelatedsystem.TheCEHCdoessoandisvisuallyillustratedinAppendix2,Figure1.

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TheCEHCintotalisacultural,ecologicalandsocialchangeparadigmormodelthatisinformedbymultipletheoretical approaches cutting across several disciplines: anthropology, health behavior and promotion,communications,socialpsychology,andsoon.However,theCEHCismadeupofthreedistinct,buthighlyinterrelated theoretical paradigms: (1) the Cultural Systems Paradigm (or CSP); (2) the Cultural SystemsApproachtoChange(orCSAC);and(3)theCommunityBasedApproachtoProgramPlanning,Implementation,andEvaluation(orCSAPPE).ThefourappliedresearchandtechnicalassistancesubsystemsoftheCEHCare:

(1) TheEthnographicallyInformedCommunityandCulturalAssessmentResearchSystems(EICCARS)

(2) TheCEHCSysteminProjectDesignandImplementationPlan(PDIP).(3) TheCEHCProjectImplementationPrograms(PIPs);and(4) EthnographicAssessment&EvaluationSystems(EAES)

The remainder of this working paperwill present a brief introduction to the CEHC Paradigms and itsapplied research and technical assistance subsystems. More detail discussion of these paradigms andsubsystemsarefoundinworkingpapersandPTMsdedicatedtospecificparadigmsandsubsystems.

2. A Brief Introduction to the Theoretical Paradigms of the CEHC

2.1. TheCulturalSystemsParadigm(theCSP).

TheCSPwasthefirstoftheCEHCparadigmstoevolve,havingitsrootsinmygraduatetraininginpublichealthandanthropologyinthelate1960sandearly1970s,andearlyethnographicfieldworkexperiencesofthe1970s5.Itwashighlyinfluencedbymy12yearsofworkattheSchoolofPublicHealthattheUniversityofNorthCarolina. When I arrived there in January of 1976, as a sort of phenomenologically orientedanthropologist inaninedepartment schoolwithpredominantlypositivist scientists, Ioften felt likeanalien in a strange land. While the majority of my colleagues could demonstrate their work throughmeasurement andmethodological cookbooks, Iwasoftenmade to feel like anon‑scientist (read“non‑academic)asIstruggledtoexplaintheprimary,butnon‑standardizedconceptsandmethodsinmyfield,suchas“culture”and“ethnography.“Assuch,theCSPhastwoprimaryfunctions,it

(1) operationalizestheconceptofcultureandhowtheconceptmightbeusedintheplanning,implementation,andevaluationofcommunitybasedinitiatives;and

(2) provides a framework for the design and implementation of ethnographic research,including ethnographic research thatmight be used in the planning, implementation ofCBIs.

TheCSPofferseightlargeanalyticalcategoriesforanalyzingthehumancondition:

(1) TheHumanIndividualasabiological,social,cultural,andcognitivebeing;(2) IndividualandNormativeBehavioralPatterns.(3) IndividualandShared ʺIdeaʺorʺIdeationalʺStructures (knowledge,beliefs,attitudinal

systems, values, ʺsignificant symbolismsʺ), which frame interpretations and meaningsthatunderliebehaviors,includingillnessriskbehavior,aswellasalltheothercategoricalcontentswithintheCSPthatarebrieflypresentedhere.

(4) Significant Social Systems including: (a) domestic units (households or residentialcompounds); (b)extraresidentialgroupingsanddyads (ethnicgroups, socialnetworksand

5 There is another CEHC working paper that focuses primarily on the CSP, and thus, the various theories that underlie theparadigm.Ourdiscussionhere,however,isabriefintroductiontotheparadigm..

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kinship systems, voluntary associations/organizations, symmetrical dyads such asfriends, coworkersor real/and fictivekindyads, asymmetricaldyadsuchas employer‑employee,patron‑client, etc.); (c) thepoliciesandpracticesof institutionsandagencies ofthewidercommunity/society;and(d)intersocietalsystemsandinfluences.

(5) MaterialCultureincludingvarioushumanmadeobjects,technologies,andartifacts.(6) ThePhysicalEnvironment,inwhichthehumangroupresidesandthatgroupʹscultural

systemprovidesasuccessfulexploitationof lifesustainingelements,protectionagainstelements which have the potential of threatening life, and finds ways to overcomeelements that constrain life sustaining activities. Cultural meaning which influencesbehavior, including health risk behavior,might be influenced directly or indirectly byenvironmental elements and/or shared or individual ways of interacting withenvironmental elements.Environmental factorsmightaffect the incidenceofdisease inotherways. For example, intestinal parasites that abound inAfrican environment aresuggestedbyFeldman(1990)tobepossiblecofactorsinthetransmissionofHIV.

(7) RealandPerceivedNeedsthathumangroupsandindividualmembersnavetomeetinorder to achieve physical and socio‑psychological functioning. Such needs are furthercategorizedintheCSPas:(a)organic(i.e.reproduction,consumptionoffood,waterandother energy sources,waste elimination, disease prevention and cure, protection fromhazardous climate conditions, and physical space); (b) instrumental (economic,educational/socializing, governance or political and legal, and communal); and (c)expressive (cognitive [meaning and orderly world view], affective [social status andacceptance,beinglovedorliked,selfandgroupidentityetc];andcommunicative(needtoexplain,communicate,etc).

(8) SignificantHistoricalProcessesandEventsthatmaybebiophysical(e.g.floods,droughts,etc)orsociocultural (coups,wars,neweconomicormarketingsystems,etc.) thateitherinstitutionalize or sustain a cultural system, or a part of that system, or result in aʺregeneratedʺorsyncretized(new,combined)culturalform.

Whiletheeightmajorcategorieswillbedescribedanddiscussedinmoredetail—withdescriptiveexamplesin theCSPWorkingPaper, themajorpoint tonotehere is that the eight categories are theorized to exist inallhumanculturalgroups.TheCSPmaintainsthatitisthejoboftheanthropologistorethnographertodiscoverthecontents of the eight major cultural analysis categories as expressed by specific human groups, and how differentgroups,andindividualswithingroupsvaryintheirexpressionsofthecontentsofthesecategories.Assuch,theCSP gives greater analytical power to the concept of culture by directing us to assess how humans aredifferent before moving on to how they are different. The broad categories of human similarities alsofacilitatesthedesignandimplementationofcommunityandorganizationalethnographies,andtheanalysisofthedatafromsuchresearch,byprovidingsomewhatstandardizedcategories,thatareflexibleasmoreislearnedaboutthephenomenaunderstudy.

2.2. TheCulturalSystemsApproachtoChange(theCSAC)

TheCSACwasthesecondCEHCparadigmtoevolve.ItsevolutionwasalsoheavilyinfluencedbymyexperiencesatUNC.WhilethetheoreticalandmethodologicalfoundationsoftheCSPresidedwithmygraduatetrainingandethnographicexperiencespriortocomingtoUNC,theCSPdidnotemergeasawell‑articulated theoretical and methodological paradigm until I began my food related research in NorthCarolina.DuringmyearlyyearsatUNC,oneofthedominantresearchfociintheSchoolofPublicHealthwasinriskfactorsforhypertensionandothercardiovasculardiseases,forwhichfoodbehavior,ordietwasconsideredakeyrisk.Becauseofthestronghealthpromotionanddiseaseprevention(HPDP)orientationof

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the school, a primary reason for health researchwas to informHPDP programs. After several years ofepidemiological and ethnographic research in one rural county (See Whitehead 1984, 1992, 2002), ) itbecameapparenttome,thatifoneexpectedtoattempttochangefoodbehaviorinsuchcommunities,thensuchbehaviorhadtobestudiedaspartofacomplexsystemwithcultural,social,economic,historical,andpsychologicalcomponents(SeeWhitehead1984).Thiswasapositiontakenbynutritionalanthropologistsworkinginotherculturalsettings.Forexample,theculturalecologicalviewoffoodresearchadvocatedbyJerome,KandelandPelto(1980)wasquiteinfluentialonmyownthinkingatthistime:

ʺFood, byvirtue of its pivotal place inhuman experience is at once, a bundle of energy andnutrientswithin thebiological sphere,acommoditywithin theeconomicsphere,andasymbolwithin thesocialandreligiousspheres.Foodideasandattitudes,socioeconomicstructure,patternsofresourceallocation,dietary intake, and nutritional status [have] to be studied holistically as part of a single system.Techniques of food production affect the natural environment, which in turn influence dietaryrequirements. Patternsof land tenure, fooddistributionwithin the society, family traditional cuisines,personaltastes,andfinancialpressureswillinfluencewhatpeoplewilleatandhowwellnourishedtheywillbe. Differentialnutritionalstatus,bymakingsomepeoplemorefitthanothershaswidesweepingsocial,political,andeconomicimplications.”(Kandel,Jerome,andPelto1980:)

ItwastheNorthCarolinafoodresearchthatledtooneofthecoretheoreticalassumptionsoftheCSP,andthatis.

Ifaparticularbehaviororideationispracticedorheldbyasignificantnumberwithinahumancommunity,andovermultiplegenerations,thanitisquitelikelythatthisbehaviororideationispartofaculturalsystem.

Thisparticular assumptionof theCSP led to a theoretical assumption aboutplanning change throughCBIs:

ifaparticularideationorbehaviorispartofaculturalsystem,thanifthatbehavioristobechanged,programsorientedtowardssuchchangemusttakeaculturalsystemsapproachtochange.

This particular assumption led to the emergence of the CSAC, which is a comprehensive model forconceptualizingtheplanning,implementation,andevaluationofeffectivecommunitybased,orculturallysystemic6plannedchange.

In thisworkingpaper, theprimarycategoriesof theCSACarebrieflypresented.Similar to theCSP, more detailed discussions of these categories are provided in a CSAC Working Paper, and invariousCEHCprograms inwhich theCSAC isused. Following theorientationof change initiative incommunitiesorother social system, theCSAChas threemajor conceptual categories (SeeAppendix1,Figure3,whichare:

(1) theDesiredOutcomes(ultimategoalsand/orobjectives);(2) Process Input Programs that must be carried out throughout various phases of a

changeinitiative,ifdesiredoutcomesaretobeeffectivelyachieved;and(3) Instrumental Input Programs that must be put in place in the early phases of a

changeinitiativeiftheprojectʹsdesiredoutcomes,processinputprograms,andotherinstrumentalinputprogramsaretobeeffectivelyimplementedandachieved.

Theadoptionof“DesiredOutcomes”asamajorCSACcategoryevolvedfrommyworkwithcommunitybased organizations, assisting themwith project planning. In helping themunderstandwhatultimate 6Thephrase,culturalsystemic, isusedtosuggest that theCSPisusedtocarryoutanalysisofculturalsystemsbeyondsimplylocalcommunities,totalsocieties,ethnicornationalgroups,orcommunities.(SeeSection3.1.2.fordiscussionofotherculturalsystems).

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goals or objectiveswere, Iwould ask themwhat did they desire to eventually come from their variousproject activities. Thus, desired outcomes, is a generic termused for ultimate goals or objectives of aproject.

From the literature and my many years working with CBIs, the ultimate goals/objectives of mostcommunityinitiativesfallinthefollowingsixareas(SeerightcolumnofFigure).

(1) Changes in Knowledge (about the targeted problem, how to avoid or prevent theproblem,orhowtoovercomeit).

(2) Change inAttitudes (that put persons at risk for the particular problem, or preventthemfromovercomingtheproblem).

(3) ChangesinBehaviors(e.g.decreaseinbehaviorsthatputsoneatriskfordiabetes,orincreaseinbehaviorstoovercomesuchproblems,ortheirimpact).

(4) ChangeinatargetedHealthProblem(e.g.,increaseinthemorbidityormortalityfromthetargethealthorsocialproblem)

(5) Empowerment (capacity building) or enhancement in the capacity of individuals,families, and/or communities to effectively respond to a health problem, e.g.,AIDS,anditsdeleteriousimpact.

(6) SustainabilityorInstitutionalizationofthechanges(knowledge,attitudinal,behavioral,healthstatus,and/orempowerment)initiatedbyacommunitybasedintervention.

(7) DiffusionofthechangesinitiatedbyacommunitybasedinterventionprojectbeyondthoseoriginallyexposedtotheCBI’sintervention

The achievement of the various outcomes is dependent on the achievement of the project’sinterventionstrategies,orinputprograms.Asbrieflymentionedabove,Ihavedividedinputprogramsintotwocategories: InstrumentalInputPrograms(thosethathave tobeput inplace in theearlyphasesofaprogramforitssuccess)andProcessInputPrograms(thosethatareongoingthroughseveralphasesofaprogram, ifnot throughout itsduration). AmongCSACʹs Instrumental InputProgramcategoriesare thefollowing:

(1) Resource Development refers to the fiscal, spatial, personnel, technological, and otherresourcesneededtocarryouttheproposedproject.Itaddresses,inparticulartheissueofproject financingandtrainingthatanumberofscholarsthinkarecritical toaprojectnotonlybeingabletoachieveitsdesiredoutcomes,butalsotosustainability(e.g.,seeShediac‑RizkallahandBone(1998).

(2) Community Involvement/Participation refers to the involvement of members of thecommunityorpopulationtargetedbythepopulation,thestrategiestosecurecommunityinvolvement,aswellasstrategiestodeveloppartnershipsandcoalitionsinthedesignandimplementationoftheproject.

(3) The Development of ʺCulturallyʺ and ʺCommunity/Population Appropriate Materialsʺ.TheCSACholds that in order for aCBI to achieve its desiredoutcomes, itwill need todevelopmaterials for all of its input programs (.i.e.materials for resource development,community participation/coalition development, intervention development andimplementation,staffmonitoring,researchandevaluationactivities,andmaterialsforthedevelopmentofmaterials).TheCSACalsoholdsthateffortsmustbemadetomakesurethatprojectmaterialsforallprojectmaterialsareculturallyandcommunityappropriate7.

7TheCSACusestheconceptofculturalappropriatenesstoincludeotherrelatedconceptssuchasculturalcompetency,relevancy,and sensitivity. TheCSAC considers community (local) appropriateness to be as important as cultural appropriateness. Forexample,onemightconsideraprojectcarriedoutamongLatinosinLosAngelestobeculturallyappropriateforAmericanLatinosin general. However, such a project might not be community appropriate for Latinos inWashington, D.C., and may not be

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(4) TheDevelopmentof ʺCulturallyʺandʺCommunity/PopulationAppropriateʺ InterventionPrograms. Consideration for the cultural appropriateness of interventions is now astandardinmostCBIscarriedoutintheUnitedStates,andisnecessarygiventheextensivecultural,social,economic,andregionaldiversityintheU.S.

IncludedamongtheCSACProcessInputProgramsare:

(1) TheMonitoringandContinualAssessmentofStaffNeeds.ThenumerousinputprogramsoftheCSACneedsanarrayofdifferenttypesofstaffskillsandabilities,carriedoutoverdifferentperiodsofprojectimplementation.TheCSACalsosuggeststhatthesuccessofaCBI is dependent of an ongoing process of mutual learning and compromise between thecultureofthecommunityorpopulationbeingtargetedbytheproject,andthecultureoftheproject.Assuch,theCSACadvocatescontinuousassessmentofstaffneedsduringdifferentphasesofthelifeofaCBI.

(2) Research andEvaluation. In theCSAC, research and evaluation (R&E) is viewed as anongoingprocessthatinformsthedevelopmentandimplementationofallInputPrograms.Community and cultural assessment carried out during the early phases of a projectoverlaps with formative evaluation, and formative evaluation evolves into processevaluation,process evaluation intooutcomeevaluation, andoutcomeevaluationevolvesinto impact evaluation8. The research methods include a range of qualitative andquantitative methods described in detail in Program Technical Manuals (PTM) for twoCEHC Systems, “Ethnographically Informed Community and Culture AssessmentResearch Systems” (EICCARS) and “EthnographicAssessment andEvaluation Systems”(EAES)(presentedlaterinSection3ofthisworkingpaper).

(3) ImplementingCulturallyandCommunity/PopulationAppropriateInterventionMaterialsandMethods.OfallofaCBI’sinputprograms,themostrelevanttoachievingitsdesiredoutcomesis the implementationof theculturallyandcommunity/populationappropriateinterventionmaterialsandmethodsaftertheyaredeveloped.

(4) ʺEnergizingʺCommunityCulturalSystemsisaCSACProcessInputProgramthatisrelatedto the Instrumental Input Program of Community Participation/Involvement, and theDesiredOutcomesofEmpowerment (orcapacitybuilding),Sustainability,andDiffusion.The CSAC concept of energizing community cultural systems means that communityinvolvementdoesnotstopsimplywithidentifyingcommunityresidentstoparticipateinaCBI, or calling on their expertise in the design and implementation of culturally andcommunity/population appropriate materials and methods of intervention.Community/population involvement includes the development and implementation ofstrategiesforenergizingorenhancingcommunityenthusiasmforaCBI,astheprojectgoeson.Enhanced community enthusiasm as the project proceeds, will result in enhancedcommunity participation as well, and will enhance the prospects for empowerment,sustainability, and diffusion.We return to the CSP for defining a communityʹs culturalsystems asnot simply a reference of thedifferent ethnic groups thatmay existwithin acommunity;buttothesignificantsocialsystemsofacommunityorpopulation,anditsideational,behavioralandmaterialsystems.InthecaseofaCBI,thefocusareonthosesocial,ideational,behavioral,andmaterialsystemsthatarerelevanttothehealthorsocialissue(s)thatis/arebeingtargetedbyaspecificCBI.

culturallyappropriatebecauseLatinosarenotamonotliticculturalgroupnationally,andtheyarenotamonolithicculturalgroupinlargemetropolitanareas,asLatinoscomefromdifferentnationsinLatinAmerica.

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2.3. TheCulturalSystemsApproachtoProgram,PlanningandImplementation(theCSAPPE)

The third and final theoreticalparadigmof theCEHC is the “Cultural SystemsApproach toProgram,Planning and Implementation” (the CSAPPE). I received my PhD from a traditional department ofanthropology,andstudiedwithsomeoftheleadingculturalanthropologytheoristsatthetime(GeorgePeterMurdock, JohnGillin,Alexander Spoehr,HugoNutini, and others), and theCSP and theCSACdemonstrated the usefulness of this training in the non‑anthropological setting that I found myselfworking at theUniversity ofNorth Carolina.However, theorizing about community based initiativeswerenot enough in this setting, particularly in thedepartment inwhich Iworked, theDepartment ofHealth Behavior and Health Education (HBHE). During most of the time that I was at HBHE, thedepartmentwaschairedbyGuySteuart,alongwithotherfacultylikeJohnHatch,LeonardDawson,andAllenSteckler,theorientationwasoverwhelmingcommunityaction.Workingwiththeseguys,IcouldnotstopwiththeCSPandtheCSACastheoreticalmodels,butneededtodemonstratehowthebenefitsof these paradigms into instruments of change,whichwas only possible through the transfer of theircapacities, to those in the communities being targeted for change. As such, whereas the CSAC isprimarilyaparadigmforconceptualizingeffectivecommunitybasedchange,theCSAPPEisprimarilyaparadigmforoperationalizingthecategoriesoftheCSACinordertoeffectivelyachievedesign,implement,andevaluateeffectiveCBIs.Inotherwords,theCSAPPEprovidestheprocessesusedincarryingoutallCEHCprograms.ThatopreationalizationoftheCSACandCSPcategoriesaretheprogramsoftheCEHC,andwillbebrieflyoutlinedinthediscussionofthoseprograms,providedinSection3below.Theseprogramsarediscussedingreaterdetailintheworkingpapersoneach.

3. The CEHC Applied Research and Technical Assistance Subsystems and Programs

3.1. ProgramsoftheEthnographicallyInformedCommunity&CulturalAssessmentResearchSystem(theEICCARS).

There are two programs in the Ethnographically Informed Community And Cultural AssessmentResearchSystem(theEICCARS):(1)TheEICCARSApproachtoCommunityAssessmentResearch;and(2)TheCEHCApproachtoCulturalSystemsAnalysis.

3.1.1. TheEICCARSApproachtoCommunityAssessmentResearch

TheEICCARSisamulti‑methodresearchsysteminformedbytheCSP.TheEICCARSisusedtocollectholisticorsystemicdataaboutlocalcommunitiesandotherculturalsystemsthatarethenusedtodesignandimplementchangeinitiatives.TherearetenresearchmethodsprogramsintheEICCARS,anymixofwhichareusedintheassessmentoflocalcommunities.EachoftheseprogramsarebasedononeofthetenresearchmethodsthatareusedintheEICCARS.Theprogramsare:

(1) Establishing Community Profiles with the Analysis of Statistical and other SecondaryData.

(2) The Physical Mapping of Human Communities: Using Maps and GeographicalInformationSystems(GIS)TechnologyinCommunityAssessmentResearch.

(3) UsingtheClassicalEthnographicMethodsofObservation&ParticipantObservationinCommunityAssessmentResearch.

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(4) Using Ethnographic and Semi‑Structured Interviews in Community AssessmentResearch.

(5) UsingFocusGroupInterviewinginCommunityAssessmentResearch.(6) UsingStructuredInterviewsandSurveyMethodsinCommunityAssessmentResearch.(7) Social Mapping: Assessing Domestic Unit, Family, Kinship, and Social Network

CompositioninCommunityAssessmentResearch(8) UsingEthnohistoricalMethodsinCommunityAssessmentResearch.(9) UsingAudio‑VisualTechniquesinCommunityAssessmentResearch.(10) Management,Analysis,andPresentationofEICCARSData.(11) Training inEICCARSMethods forCommunityBasedResearchAssistants,Community

Residents,andthePersonnelofPublicAgenciesandCommunityOrganizations.

Theseprogramsandthemethodsusedineacharediscussedingreaterdetail intheProgramTechnicalManualsthatarebeingdevelopedforeach.

3.1.2. TheCEHCApproachtoCulturalSystemsAnalysis.

Asmentioned earlier, theCSP is used to inform the analyses of cultural systems beyond simply localcommunities, total societies, ethnic or national groups, or communities. For example, theconceptualization of the CSP has allowedme andmy colleagues to be able to treat any of the socialsystems within the CSP (see Figure 2A) as cultural systems, including: (1) residential groups such ashouseholdsandfamilies;(2)extra‑residentialhumansystemsthatmayexistatthelocallevel,theregion,orthewider society, such as ethnic groups, social networks, kinship groups, peer groups,work groups,religiousandotherorganizations,volunteerassociations, service institutions,andgovernmentagenciesandbureaucracies;and(3)inter‑societalassociationsandsystems.

The CSP is used to study these various social systems as cultural systems if they have the followingcharacteristics:(1)havepreferredsocialrelationshipsorstructures;(2)havepreferred(ornormative)ideasystemsandbehaviorpatterns,andpreferredmodesofexpressingtheseideas;(3)havevaluedandotherobjectsthathavebeenproducedbythegroup;(4)existwithincertainphysicalandsocialenvironments;(5)haveasharedsenseofneedsthat thegroupattemptstomeet;and(6)havesharedhistoricaleventsandprocessesthatgroupmemberseitherexplicitlyknow,oraretacitlyinfluencedby.

Theanalysisof anumberof theseother cultural systemsmayalsobe included inanyassessmentof alocal community, either as part of such communities, or as part of wider ecology that affects localcommunities (societal agencies and policies or cross societal environments and relationships). Andfinally,similartothewaytheCSPisusedtostudyvarioussocialsystemsasculturalsystems,theCSACallowsustoconceptualizetheplanning,implementation,andevaluationofprojectscarriedoutbyorinthesesystems,asitalsoinformssimilarchangeactivitiesincommunities.

3.2. TheCEHCPrograminCommunityBasedInterventionProjectDesignandImplementationPlan(PDIP):TheProjectCultureDevelopmentWorkshop

TheCEHCSystemforCBIProjectDesignonlyhasoneprogram,a2½‑day,nine‑sessionworkshopthatIcall the ʺProject CultureDevelopmentʺ (PCD)Workshop. The reason that theworkshop is so titled isbecause frommy threedecadesofworkwithCBIs, I continue to find thatmostCBIpersonnelarenotclearaboutwhat thegoals andobjectivesof theirproject are,orwhat the strategiesneeded toachievethosegoalsandobjectivesshouldbe.EvenwhenCBIʹs leadershipisabletoprovidesomeclarityabouttheseissues,theclarityisusuallynotvoicedorfollowedbyallprojectpersonnelwhomayplaycriticalroles in carryingoutvarious strategies important to theachievementofprojectgoalsandobjectives. I

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have found this ʺsharing of a project cultureʺ to be even more elusive in projects with multiplestakeholdersorcollaborationswithmultiplepartnerorganizations. Partofthiselusivenessseemstoberelated to the fact that the strategies needed to develop a project culture is not considered importantenoughtobuildintotheproposalseekingfunding,andassuchisnotincludedasanimportantactivitytoundertake after the project is funded. Yetmy experience has also taughtme that the exclusion of anactivityearlyinthehistoryoftheimplementationofaCBI,inordertogetthoseimportanttotheprojectʺon thesamepage,ʺ isamajor reason that suchprojectsdonotachieve thesuccess thatwasoriginallyproposedorenvisioned.

ThegoalsofthePDIPissimilartothosefoundin“empowermentevaluation”(SeeFettermanetal1996;Fetterman 2001). However, whereas the empowerment evaluation advocates focus primarily onevaluation, with some discussion of its relationship to program planning, the CEHC is a model thatintegrates program planning with implementation and evaluation, and as such the PDIP works withorganizationsinplanningtheirprogramssothatimplementationandevaluationfollowprogramdesignandimplementationplan.Whereasempowermentevaluationworkshopslastfromacoupleofhourstoahalfday, thePDIP is a 2½‑dayworkshopprovided to the leadershipofCBIs inorder that theymightreviewandincorporatetheconceptsandmethodsof theCSACandCSAPPEintotheirprojectdesigns.TheprojectleadershipwhomightattendPDIPworkshopsincludethefollowing:(1)theprojectdirector,co‑directors, and specificprojectprogramcoordinators; (2) the representativesof all organizations thataretobeinvolvedinprojectimplementation;(3)thecoordinatorsofallprojectimplementationactivities,including all research and evaluation research activities; and (4) any other persons who have majorsupervisoryortechnicalresponsibilitiesforachievingprojecttasks.However,projectleadersmaywanttohaveotherstaffmembersthere,aswellasotherstomakesurethattheyaresocializedintotheprojectdesignfromthestart. Moreover, if theproject issmallorhasasmall leadership,CuSAGrecommendsthat non‑leadership staff may be present in order to create at least 6 small groups of no less than 2memberseach. ThePDIPworkshop isdivided into9 sessionsof short lectures, smallgroupactivities,and smallgroups reportsback to the fullworkshopparticipantgroup.Appendix3provides ageneraloutlineoftheactivitiesthatareusuallyincludedinthePDIPworkshop:

3.3. TheCEHCSysteminProjectImplementationPrograms(PIPs)

TheCEHCSystem in the implementationof community initiatives closely follows the implementationplanthatemergesfromthePDIPworkshop.TheplanisusuallyinformedbythecategoriesoftheCSAC,and results in the creation of a schedule of project activities that are closely followed in projectimplementation.TherearethreecategoriesofprogramsintheCEHCSysteminProjectImplementationPrograms(PIPs):

(1) CSAC INPUT Programs in CBI Implementation based on the CEHC Paradigm, theCulturalSystemsApproachtoChange(theCSAC);

(2) TheCEHCPrograminPHASICProjectImplementation;and(3) TheFULLCEHCPrograminCBIImplementation.

3.3.1. CSACINPUTProgramsinCBIImplementation

Asstatedearlier,inputprogramsintheCSACarethoseproposedinordertoeffectivelyachieveaCBIʹsdesiredoutcomes.ItwasalsostatedthatthereareeightCSACinputprograms,fourInstrumentalInputPrograms and four Process Input Programs. In theCEHC, there have been strategies developed in alleightprograms.Theseprogramsandrelatedactivitiesaresimplyoutlinedbelow.Thefollowingareonly

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outlinesoftheeightprograms.MoreinformationoneachcanbefoundinthemoredetailedCEHCPTMsthatarebeingdevelopedforeachoftheprograms.

ThefourCEHCInstrumentalInputProgramsare:

(1) TheCEHCPrograminProjectResourcesDevelopmentprovidesstrategiestoassistCBIsinputtingtheirfiscal,spatial,personnel,equipment,technological,andotherresourcesinplaceinordertoachieveitsInputProgramsandDesiredOutcomes(goalsandoutcomeobjectives).

(2) TheCEHCProgram inCommunityParticipationandCollaborationprovides strategiesin facilitating the involvement of members or residents of the community/populationtargeted by the CBI, community coalition building and partnership development, andmovingtheCBItowardsfullcommunityownership.

(3) The CEHC Program in the Development of Culturally and TargetCommunity/Population Appropriate/Relevant Materials provides strategies in thedevelopment of culturally and community appropriate and relevant project materialsneededintheimplementationofalleightoftheCEHCINPUTPrograms.

(4) TheCEHCProgramintheDevelopmentofCulturallyAppropriate/RelevantInterventionStrategiesprovidesstrategiesinthedevelopmentofinterventionsthatareculturallyandtargetcommunity/populationappropriateandrelevant.

ThefourCEHCProcessINPUTProgramsare:

(1) TheCEHCPrograminMonitoringCBIStaffNeedsprovidesstrategiesinassessingandaddressingCBIsstaffneedsthroughoutthelifeoftheCBI.

(2) TheCEHCPrograms inResearchandEvaluationprovidesstrategies in: (a)communityassessmentresearchusingtheprogramsandmethodsoftheEICCARS(SeeSection3.1.);and(b)theevaluationofCBIsusingtheEAESprogramsinformative,process,outcome,andimpactevaluation(SeeSection3.4).

(3) CEHCProgramintheImplementationofCulturallyandTargetCommunity/PopulationAppropriate/Relevant Intervention Strategies provides strategies in implementing theculturallyandtargetcommunity/populationinterventionsthathavebeendevelopedbyaCBI.

(4) TheCEHCPrograminʺEnergizingʺCommunityCulturalSystemsprovidesstrategiesinincreasingtheenthusiasmofthetargetcommunity/populationʹsparticipationintheCBI.

3.3.2. TheCEHCPrograminPHASICProjectImplementation

TherearethreemajorstrategiesintheCEHCPrograminPHASICProjectImplementation:

(1) carryingoutaPCDWorkshoptoestablishaphasicprojectdesign;(2) conductingone‑dayPhasicImplementationWorkshops(PIWs)attheendofeachproject

phase;and(3) providingsimple(onepage)ʺProjectBarriersandEnablersRecordingFormsʺ(PBERFs)

tobeusedbyprojectstaffmembersandreturnedtotheCAAorCuSAGforanalysis;(4) analyzing the PBERFs andusing the analysis for facilitatingdiscussions at subsequent

PIWs.

These strategies are discussed in greater detail in the more detailed CEHC PTMs that are underdevelopment

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3.3.3. TheFULLCEHCPrograminProjectImplementation.

TheFULLCEHCImplementationProgramincludesutilizingalloftheotherimplementationprogramsincombination,including:

(1) someoftheEICCARSmethodsusedincarryingoutcommunityassessmentresearch;(2) the PCDWorkshop to help get all project stakeholders and staff on the same page in

termsofhowtheprojectwillbeimplemented;(3) the INPUTImplementationPrograms in termsofactually implementing theproject for

maximumsuccess;and(4) The Phasic Implementation Program to help project stay on course in their efforts to

achievetheiroutcomeobjectivesandlong‑termgoals.

MoreinformationontheFULLCEHCImplementationwillbeprovidedinthemoredetailedPTMthatisunderdevelopment.

3.4. TheCEHCEthnographicAssessmentEvaluationSystem(EAES):EvaluatingforCBISuccessRatherthanʺFailureʺ

3.4.1. AddressingPotentialConceptualandEthicalIssuesinOfferingTechnicalAssistanceFollowingEvaluationRecommendations.

Asseeninthefollowingdiscussionsofformativeandprocessevaluation,theCEHCoffersCBIstechnicalassistance inhelpingthemmeet therecommendationsthatemergefromtheevaluations.SuchoffersoftechnicalassistancearerelatedtoaphilosophyintheCEHCofevaluatingforprojectsuccessratherthanfailure. However, there are some conceptual and ethical issues related to combining evaluation andtechnical assistance. Traditionally, technical assistancewas considered conceptually different exercises(unlessitwastechnicalassistancetoaCBIintermsofhowtoevaluatetheirownprograms).Moreover,for evaluators tooffer technical assistance inmeeting their own recommendations is subject to seriousabuse (e.g., are certain evaluation results offered simply to allow the evaluator tomake further profitfromtheevaluation).WithintheCEHCthereareproceduresthathavebeendevelopedforovercomingsuchproblems,inparticularputtingtheissueoutfrontpriortostartingtheevaluationandlettheclientrejectsuchoffers.

3.4.2. EAESFormativeEvaluationPrograms

TherearetwoEAESFormativeEvaluationPrograms,onethatoverlapswiththeEICCARSandonethatoverlapswiththePDIP.TheEICCARSBasedFormativeEvaluationDesignhasthefollowingstrategies:

(1) Using the EICCARS Program Technical Manuals (PTM) to assess whether a CBI hascarriedoutcommunityassessmentresearchtogainknowledgeaboutacommunityandtoinformitsprojectdesignandimplementationplan,andifsowhatwerethemethodsandfindingsusedinsuchresearch;and

(2) providingrecommendationsbasedontheEICCARSbasedfindings;and(3) offeringtechnicalassistanceinmeetingEICCARSbasedrecommendations.

ThePDIPBasedFormativeEvaluationProgramhassimilarstrategies:

(1) usingthePDIPProgramTechnicalManual(SeeSection4)toassesswhetheraCBIhasaprojectdesign/implementationplan;

(2) ifitisfoundthatthereissuchaplan,determiningwhatthedesiredoutcomes(goalsandlong term objectives) are, and what were the strategies and tasks, task assignments,

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timelines included in the plan, and if therewere any barriers and enablers associatedwiththeplan;

(3) providingrecommendationsbasedonthePDIPassessment;and(4) offeringtechnicalassistanceinmeetingPDIPassessmentrecommendations.

3.4.3. EAESPrograminProcessEvaluationandProjectMonitoring

TheEAESPrograminProcessEvaluationstartswithmanyofthestrategies

includedintheEAESPrograminFormativeEvaluationdiscussedabove,soastoestablishabaselineforcarryingoutaphasicevaluationprocess.Thatis, theEAESPrograminProcessEvaluationincludesthefollowingstrategies:

(1) usingtheEICCARSPTMtoassesswhetheraCBIhascarriedoutcommunityassessmentresearch to gain knowledge about a community and to inform its project design andimplementation plan, and if so what were the methods and findings used in suchresearch;

(2) using the PDIP Manual (See Section 4) to assess whether a CBI has a projectdesign/implementationplan;

(3) if it isfoundthatthereissuchaprojectdesign/implementationplan,determiningwhatthedesiredoutcomes(goalsandlongtermobjectives)are,andwhatwerethestrategiesandtasks,taskassignments,timelinesincludedintheplan,andiftherewereanybarriersandenablersassociatedwiththeplan;

(4) if there isnoprojectdesign/implementationplan,or the existingplan isnotorganizedinto project phases, recommending the immediate implementation of amodified PCDworkshoptodevelopaplanorganizedintophases;.

(4) oncetheprojectdesign/implementationplaniscompletedsothattheprojectcannowbeutilized,carryingouttheEAESphasicevaluationactivities,usingthesametechniquesasusedintheCEHCPhasicImplementationProgram:(1)PhasicWorkshops;and(2)ProjectBarriersandEnablersRecordingForms(PBERFs);

(5) complementing the data from the Phasic Workshops and the PBERFs structuredquestionnairetoassesstheachievementofphasicobjectives;

(6) complementing the previous three sources of datawith other ethnographic techniquessuchasethnographicobservationsandnaturalconversation,keyinformant,indepth,orfocusgroupinterviewswhereappropriate;

(7) reportingattheendofeachphasethelevelofachievementofphaseobjectives,makingrecommendationsasto:(a) howbarriersmightbeovercome,orenablersenhanced;(b) whethermodifications need to bemade in the project design/implementationplan

basedonphasicassessmentfindings;and(c) whether the lessons that seem to be emerging from the assessments of project

implementationmight indicate, that the original outcome objectivesmay not havebeenappropriateforthecommunity/populationtargetedbytheCBI.

3.4.4. TheEAESPrograminOutcomeEvaluation

TherearetwoEAESprogramsinoutcomeevaluation:

(1) EAESProgramUsingMoreTraditionApproachestoCBIOutcomeEvaluation;(2) EAES Program in CBI Outcome Evaluation with Technical Assistance and Project

Monitoring

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3.4.4a.EAESʹsProgramUsingMoreTraditionalApproachestoCBIOutcomeEvaluation

TherearetwoprogramsintheEAEʹsmoretraditionalapproachestoCBIoutcomeevaluationoutcome:

(1) pre‑andpost‑testmeasures;and/or(2) quasi‑experimental methods using experimental and control target

communities/populations.

A major activity in both of these programs is the development of standardized measures and datacollection instruments. For example, in both programs, an ʺExposed Pre‑Test Interview Guidesʺ(EPreIGs)andanExposedPost‑TestInterviewGuide(EPosIG)thatareadministeredtothosewhowereexposedtotheCBI,respectivelyinthepre‑andpost‑testphasesoftheproject.TheQuasi‑ExperimentalProgramalsousesthesameinstruments.Butthisprogramalsoaddscontrolornon‑exposedpopulationsamples,necessitatingthedevelopmentofaNon‑ExposedPost‑TestInterviewGuide(NPosIG).Thetypeof intervention used in a CBI (e.g. an intervention utilizing the mass media versus an interventionutilizinginterpersonalfacilitation)determineshowtheseEAESoutcomeevaluationprogramsarecarriedout,andwhichstructuredinstrumentsareused.MoredetailsonthetechniquesusedintheseoutcomeevaluationprogramsareexplainedingreaterdetailintheFullCEHCManualandtheEAESManual.

3.4.4b.EAESPrograminCBIOutcomeEvaluationwithTechnicalAssistanceandProjectMonitoring

EAESʹsPrograminCBIOutcomeEvaluationwithTechnicalAssistanceandProjectMonitoringincludesmany of the samemethods used in the EAES Traditional Outcome Evaluation Program. The secondCEHC outcome evaluation program also includes, however, some of the technical assistance andmonitoring activities used in the formative evaluation and process evaluation programs outlined inSections 3.4.2 and 3.4.3. above, used as a preface to carrying out these traditional CEHC evaluationapproaches.AllofthetechniquesusedinthissecondevaluationprogramareexplainedingreaterdetailinthefullCEHCManual,andtheEAESManual(SeeSection4).

3.4.5. TheConceptualDifferenceBetweenOutcomeandImpactEvaluationasUsedintheEAES

IntheEAES,theconceptofoutcomeevaluationdiscussedintheprecedingsection(3.4.4.),andouruseofʺimpactevaluation,ʺthatwillbeoutlinedinthenextsection(3.4.6),areinthereverseorderofhowtheyareused in contemporary treatments of these concepts. That is, inmost otheruses of these concepts,impact evaluation isdefined in termsofwhether ornot aCBIhas achieved itsdesiredoutcome (longtermobjectivesandgoals);whereasoutcomeevaluationassessestheeventualoutcomeoftheprojectorthe community. In the EAE on the other hand,we refer to outcome evaluation as the assessment ofwhether a project has achieved its desired outcomes, and impact evaluation is an assessment of theimpact of theCBI on the community towhich theCBI has been administered.Reasons as towhy theEAESdiffers in itsuseof theseconceptsareprovidedinthemoredetailedFullCEHCManualandtheEAESManual.

3.4.6. EAESProgramsinImpactEvaluation

IntheEAES,itisproposedthatitsimpactevaluationstrategiesbecarriedoutatleastoneyearfollowingthe outcome evaluation so as to assess the sustainability, routinization and diffusion of a CBIʹs desiredoutcomesasindicatorsoftruechange.Tomeasuresuchindicators,therearestructuredinstrumentsthataredevelopedandappliedtothosewhowereexposedtotheCBI,calledtheʺExposedImpactInterviewGuideʺ (the EIIG) and the Non‑Exposed Impact Interview Guide (the NIIG). But more qualitative

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ethnographic methods are also used, such as ethnographic observations, natural conversation, keyinformant,andindepthorfocusgroupinterviews.ThesemethodsarealsousedtoassesstheimpactofaCBIonitstargetcommunityorpopulationbeyondtheprojectʹsdesiredoutcomes.MoreinformationontheimpactprogramoftheCEHCisprovidedintheFullCEHCManualandtheEAESManual.

ReferencesCitedandRelatedLiterature

Feldman,DA(1990).Chapter4,“AssessingViral,Parasitic,andSocio‑culturalCofactorsAffectingHIV‑1TransmissioninRawanda,”IN:CultureandAIDS,DAFeldman(ed.),NewYork:Praeger,pps.45‑54.

GreenLW,RichardL,andPotvinL.(1996).“EcologicalFoundationsofHealthPromotion.”AmericanJournalofHealthPromotion,10(4):p.270‑281

SeeWhitehead1984,1992,2002/

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APPENDIX 1: Acronym Glossary

CAR CommunityAssessmentResearch

CBI CommunityBasedInitiative

CEHC CulturalEcologyofHealthandChange

CSP CulturalSystemsParadigm,aCEHCtheoreticalparadigm

CSAC TheCulturalSystemsApproachtoChange,aCEHCtheoreticalparadigm

CSSAPPE TheCulturalSystemsApproachtoProgramPlanning,ImplementationandEvaluation,aCEHCtheoreticalparadigm

CuSAG Cultural Systems Analysis Group, a anthropologically based unit at the University ofMarylandCollegePark

EAES Ethnographic Assessment & Evaluation Systems, the CEHC system of evaluationprograms

EICCARS Ethnographically InformedCommunity&CulturalAssessmentsResearchSystems, theCEHCsystemofcommunity&culturalsystemsresearch

PBERF ProjectBarriersandEnablersRecordingForm

PCD ProjectCultureDevelopment

PDIP TheCEHCSysteminProjectDesignandImplementationPlan

PIPs TheCEHCSystemofProjectImplementationPrograms

PTMs CEHCProgramTechnicalManuals