With the results of the group discussion sessions a general model was constructed that shows the relation of PAR and CD (Fig. 1). Figure 1 shows the causal relations, feedback loops, control, and target variables for the PAR-CD relation. For example, if you have a good quality of planning and implementation, there will be a higher involvement of the community. Figure 1 demonstrates that the success of PAR-CD depends on control variables (critical factors) such as policy, community knowledge, context based for cultural-social, ethical, available resources, definition of the outcome indicators, common goals, and diversity of stakeholders. These components can be influenced and considered in the design of the project.
Source: GMB sessions
Table 1 displays the detailed results of the document assessment compared with the system dynamic model PAR-CD. The numbers reflect the gaps in each phase (1 bad or non-addressed, 2 addressed very basic, 3 fully addressed). Principles of existence does quite well with an average value of 2.46 and a standard deviation of 0.84 shows a reasonable parity between the model and what was implemented. Table 1 shows that the three phases of a project that should include participation of a diversity of stakeholders have an average of 1.70 and the standard deviation of 0.90 reflecting a high discrepancy of what was implemented or considered in the project and the GMB model. Some missing elements that highlight these gaps in the documents are dynamics of time, evidence base, cost-effectiveness, availability of resources, feasibility, replicability, sustainability, and scalability.
Table 1. Document assessment of seven case-studies for measuring the level of community participation
The projects were assessed in a Likert scale going from 1 to 3. Being 1 bad or non-addressed, 2 being addressed very basic, 3 fully addressed.
Source: Own elaboration based on project documents assessment
Principles of existence
GMB sessions highlighted these principles as not all projects involve a participatory process. These guide the entire project, gain accountability and a stronger participation (table 1). Principles of empowerment, knowledge transfer, equity, sustainability, leadership, and Country’s policy (1, 7, 12) guide a project. Moreover, a diversity of significant actors of the community or stakeholders need to participate for accountability, including local authorities (municipality, health, education), community leaders, medical practitioners, organizations and local business members and others. And this provides a wider vision of the project process (12–15). Document assessment showed that few included a diversity of stakeholders, the rest included the target population only.
Theory of change (ToC) or improved behavior is a key part of promotion and prevention projects regarding health (14, 16, 17) and leads to CD. However, project document revision showed that most of the projects did not have an explicit ToC although the community movement clearly intended to improve health for adolescents.
The discussion group mentioned that a situation analysis (quantitative and qualitative approach) of the community is important to know the problems, the protective factors, and its long-term plans. Some Latin American countries do not have accessible or detailed enough statistics to observe these aspects; therefore, a longitudinal cross-sectional survey is important to assess this (1, 2). The participation of a trained facilitator is key to bringing the different stakeholders from the community together (2, 18) engaging them under the premises of a common goal, leadership, and authority endorsement (2, 18).
An important feedback loop is the dynamics of time for involving different actors (12–15): 1) present, the process needs to be adapted to the current external factors (PESTEL) and address the existing crucial threats, 2) projection, the furthest away in time the problem is, the more difficult it is to imagine a threat; hence, more complicated to engage the population today, 3) uncertainty, it is difficult to imagine the consequences of a non-take action now when the consequences are only visible in a few number of persons or in the future generation. These three characteristics play a strong role in the process of decision-making. It is also important to consider the cognitive bias for engaging or not in the community actions. For instance, positivism is the idea that “the problem will not reach me”, the bystander “it is better that someone else works for the solution”, or fixating “staying in the same situation is easier” (19).
Project document revision showed that needs assessment was mainly based on simple statistics (basic) while others were based on a cross-sectional survey that later was used to evaluate the change (t0 and t1). None of the projects elicited dynamics of time. And some did not include a diversity of stakeholders for the need’s assessment (table 1).
Planning and Implementation
The discussion group mentioned that planning is an important phase to list the interventions. This because communities may not be pleased with activities that do not fit their socio-cultural acceptance or are ineffective for their context. Hence, it was suggested to work thinking “with the community, from the community and for the community” in order to improve health and development (20). The project can include a bidirectional contribution where the community can inform about their natural practices and science can inform on better ways to do (theory informing practice -evidence based, and practice informing theory -experimental practice). This twofold approach is valuable for lessening the limitations of the implementation plan.
Planning has five inputs: 1) the report of the needs’ assessment that includes a robust ToC and goals tailored for this report, 2) bidirectional contribution that includes community knowledge, 3) activities that are contextualized for cultural-social and ethical that supports validation, 4) evidence based that supports effectiveness, 5) available resources. The facilitator can extract in the group discussion a common vision of the problem, the explicit and implicit knowledge, values, fears, social cohesion or conflicts, perspectives, financial power, etc.
The group agreed that activities of intervention should consequently be, preferable, evidence-based and work in connection with the objectives. This means, that the activities need to be controlled by their contribution to the desired outcome (ToC) in a reliable way. In addition, it was mentioned the importance to check if each activity chosen adjusts to characteristics of the community, if it is cost-effective, and if the community would have all the resources needed for its implementation (12, 21). “To maintain efficiency, the ideal way it is to look for effective interventions that proved to work, then adapt these interventions to the specific community. This adaption could be a part of the implementation research process” (GMB participant).
Document review shows that not all prioritize activities according to a bidirectional contribution, or socio-cultural base. Some projects have actions not based on evidence, ethics, cost-effectiveness, or resources oriented (table 1).
Monitoring and Evaluation (M&E)
To keep accountability, several control points can be planned for each activity (output indicators) to observe if activities are accepted or need to be replaced to reach the expected results which is called effectiveness and validation of strategies. Monitoring the advancement and behavioral change needs to be dynamic and multidimensional, this means, evaluating not only the target population but its surroundings and supporting actors. If health centers, schools, community, authorities are changing into an enabling environment, the intervention is leading to a community development. Aspects that show causal loops towards change may include intermediate results (outputs) and final results (outcomes) (2, 4, 20) and dissemination of partial and final results have to be constant.
It was mentioned that vague indicators like improvement of health or happy patients are not easy to measure and the community may not know how to collect this information without bias. For instance, the indicator of high teen pregnancies is difficult to attribute to a project, thus it is better the number of students that go to the consultancy room installed by the project, number of workshops done per classroom, etc. Also, it was noted that cost-effectiveness is critical for feasibility, replicability, sustainability, and scalability. And the participation of stakeholders can help to have better estimate of the cost-effectiveness and this helps prioritization of strategies to implement, etc.
Document revision showed that aspects like clear indicators measured dynamically and multidimensionally, periodical dissemination, feasibility, replicability, sustainability, and scalability are missing in the projects (Table 1).