A participatory systems approach in community health promotion: Lessons learnt from an overall evaluation of a program to reduce health inequities

To address the complexity and multi-level dynamics in health promotion, participatory and systems approaches have recently gained attention. We combined these into a participatory systems approach, which actively involves stakeholders in the planning, implementation, and evaluation of health promotion initiatives. This approach promotes cross-sector collaboration, shared understanding, joint decision-making, empowerment, and acknowledges the dynamic, interconnected factors that influence health over time. However, practical guidance on how to implement and evaluate such complex programs remains limited, particularly on aligning implementation and evaluation. We applied a participatory systems approach to the planning and implementation of an overall evaluation of a program aimed at enhancing the health of families in vulnerable positions in the Netherlands, with the goal of sharing lessons learnt from this process. From the program, four projects in four municipalities were selected for this study. We studied the processes and results of the overall evaluation in four iterative steps: conducting participatory action research with the four projects, semi-structured interviews with the four case managers, three consortium reflection and learning sessions and document analysis. We identified five themes: flexibility; research and practice needs; research capacity; roles of stakeholders and defining boundaries. The main lessons from our participatory systems approach are: flexibility is needed to realise stakeholder participation; balance research with practice; ensure adequate research capacity; define the roles of stakeholders and explore system boundaries continuously. The implementation of these lessons is supported by a reflection and learning culture. These lessons are relevant for practitioners, researchers, policymakers and citizens in effectively planning, implementing and evaluating health promotion programs.