A range of determinants at multiple socio-ecological levels operate in small farm households' use and handling of hazardous pesticides, suggesting the need for integrated health and agriculture promotion approaches. The aim is to assess changes in health promotion outcomes relevant to highly hazardous pesticide use associated with a multi-component community program. A longitudinal evaluation design using mixed methods was employed in 18 agricultural communities in Ecuador. Over a 7-month period, health education and agricultural interventions focused upon: health risks associated with hazardous pesticides, more adequate use and handling of pesticides, and better crop management techniques. Data collection included field forms, focus groups, structured observations and repeat surveys. In the qualitative analysis, communities were compared by extent of leadership and involvement with the interventions. For the quantitative analysis, hypothesized paths were constructed including factors relevant to pesticide-related practices and use. Testing involved gender-role stratified (household and crop manager) multivariable regression models. Information on pesticide health impacts and the pesticide use and handling, shared in focus groups, showed substantial improvement, as a result of health promotion activities though people were still observed to engage in risky practices in the field. In path models, community leadership and intervention intensity lead to changes in the household managers' pesticide-related knowledge and practices and to reduction in farm use of hazardous pesticides (both significant, p < 0.05). Integrated, community programs can promote pesticide-related risk reduction among small farm households. Changing practices in the use and management of pesticides among crop managers appears limited by deeper structural and cultural factors.