Perceptions of Community Stakeholders Regarding the Implementation of the Community-Based Nutrition (CBN) Project in the Kadutu Urban Health Zone, Democratic Republic of the Congo ()
1. Introduction
Community participation is a fundamental principle of health promotion and primary health care. Since the Declaration of Alma-Ata, involving populations in matters concerning their health has been viewed as a way to align interventions more closely with local needs and enhance their acceptability. The Ottawa Charter also underscored the importance of community capacity building and public participation in health promotion [1].
However, community participation is not limited to mobilizing populations to receive or carry out activities. It can extend to problem identification, priority setting, intervention design, implementation, and evaluation. Nevertheless, the literature shows that forms of participation vary and that communities are frequently more involved in implementation than in decision-making processes [2].
A systematic review of community participation in health system interventions in low- and middle-income countries found that communities were far more frequently involved in the implementation of interventions than in the identification and definition of problems. The review also highlights that participation genuinely focused on decision-making power remains relatively rare. These observations are important for assessing the quality of participation in community health projects. This issue is of particular importance for nutrition interventions. In Africa, community-based nutrition interventions mobilize various local stakeholders, including community health workers, local leaders, and beneficiaries. A recent review of community-based nutrition interventions in Africa shows that participation can occur at various stages: problem identification, intervention design, implementation, and evaluation. It also emphasizes that the active engagement of beneficiaries and local stakeholders remains difficult to define and measure consistently [3].
In the Democratic Republic of the Congo, community participation mechanisms rely notably on community focal points, health development committees, and other local structures. However, socio-economic, institutional, and security-related challenges can limit their functioning and their capacity to participate in decision-making processes.
The city of Bukavu offers a particularly relevant context for studying these dynamics. Its urban population lives in an environment characterized by high population density, socio-economic inequalities, and significant health and nutrition needs. Research conducted in disadvantaged urban communities in Kinshasa has highlighted the importance of community perceptions, trust, and the relationship between the population and the health system in determining the acceptability of interventions [4].
In the Kadutu urban health zone, the Community-Based Nutrition (CBN) project relies on various community stakeholders to implement awareness-raising, mobilization, prevention, and monitoring activities. Despite this involvement, the modalities of participation and the perceptions of the various stakeholders remain insufficiently documented.
The objective of this study was to analyze the perceptions of community stakeholders regarding the implementation of the Community-Based Nutrition (CBN) project in the Kadutu urban health zone.
2. Materials and Methods
2.1. Study Setting
The study was conducted in the Kadutu urban health zone, located in the city of Bukavu, South Kivu Province, Democratic Republic of the Congo.
Kadutu is an urban environment characterized by high population density, sociocultural diversity, and socio-economic constraints likely to influence access to health services and population participation in community-based interventions.
The Community-Based Nutrition (CBN) project was implemented in 2024 in the Kadutu health zone, involving various community and health stakeholders.
2.2. Study Type and Period
This was an analytical, qualitative, cross-sectional study.
Data collection took place from September 1 to October 30, 2025.
The qualitative approach was chosen to gain insight into the stakeholders’ experiences, perceptions, and views regarding their involvement in the project.
2.3. Study Population and Sampling
The study population consisted of stakeholders who participated—either directly or indirectly—in the implementation of the NAC project in the Kadutu health zone.
Purposive sampling was used to select individuals with sufficient experience or knowledge of the project.
A total of 23 participants were interviewed: 12 community members, 10 health professionals, and 1 partner involved in project implementation.
Community participants included, among others, community health workers, members of health development committees (CODESA), representatives of community groups, and other individuals involved in mobilization and awareness-raising activities.
2.4. Selection Criteria
1) Inclusion criteria: being at least 18 years old; having participated directly or indirectly in the NAC project; residing in the area concerned or working in organizations involved in the project; having participated in the implementation, monitoring, or evaluation of activities; and voluntarily agreeing to participate in the study and providing informed consent.
2) Exclusion criteria: having no connection to the NAC project; being under 18 years of age; refusing to participate in the study; failing to provide informed consent; and lacking sufficient experience with the activities under study.
2.5. Data Collection
Data were collected through semi-structured individual interviews with the 23 participants. Interviews were conducted primarily in French and Swahili and, where necessary, in Shi, to enable participants to express themselves in the language with which they were most comfortable. The interviews were conducted by the principal researcher with the assistance of a collaborator trained in qualitative interviewing techniques.
Each interview lasted approximately 30 to 60 minutes.
The interviews focused primarily on: forms of community participation; the level of community involvement; factors facilitating or hindering participation; perceived effects of the project; relationships between community stakeholders and health facilities; and prospects for the sustainability of activities.
Interviews were recorded with the participants’ consent. Data collection continued until thematic saturation was reached, defined as the point at which no new significant information emerged during successive interviews.
2.6. Data Analysis
The recorded interviews were transcribed verbatim and then reviewed several times.
A thematic analysis was conducted using NVivo software.
The analysis process involved: familiarization with the data, coding of meaning units, grouping of similar codes, identification of categories, construction of themes, and interpretation of results in relation to the study objectives.
Four main themes emerged: the forms and level of community participation; factors facilitating or limiting participation; perceived effects of the NAC project; and conditions for the ownership and sustainability of the interventions.
The themes were discussed among the researchers to strengthen the consistency of the data interpretation. The presentation of results was guided by transparency principles recommended for qualitative research—specifically the COREQ framework, which advises clearly documenting the research team, study design, and data collection, analysis, and presentation.
2.7. Ethical Considerations
The study protocol was reviewed and approved by the Ethics Committee of the Higher Institute of Medical Techniques of Bukavu (ISTM Bukavu) under reference ISTM BKV/3200/CE/006/2025, dated August 20, 2025. All participants were informed about the study objectives, participation procedures, data confidentiality, and their right to withdraw from the study at any time. Informed consent was obtained prior to each interview. Data were anonymized and used exclusively for scientific purposes.
3. Results
Participant Characteristics
The study included 23 participants involved in the NAC project, comprising 12 community members, 10 health professionals, and one representative from a technical partner involved in the project’s implementation. The diversity of participants allowed for a comparison of the perceptions held by community stakeholders, health professionals, and a project partner. Analysis of the interviews revealed four main themes: the level and forms of participation, factors influencing participation, perceived project effects, and conditions for the sustainability of interventions.
Participation Primarily Focused on Implementation
The results show that community participation was a significant factor in the implementation of the NAC project. Community outreach workers, CODESA committees, and other local structures played a central role in mobilizing households, raising awareness, and monitoring beneficiaries.
One participant explained: “We have been involved from the start, primarily in mobilizing families to bring their children for malnutrition screening.”
Participants also described their involvement in raising household awareness and disseminating messages regarding nutrition, hygiene, and prevention.
However, this participation was far more significant during the execution phase than during the project design stage.
One participant noted: “The population was not consulted at the outset regarding the identification of needs.” These results suggest that community participation was primarily operational and consultative, with limited involvement in planning and decision-making processes.
The Role of Community Structures in Implementation
Community outreach workers and other local structures served as a vital link between the population and health services.
As one participant noted: “Community outreach workers come from the community itself; it is the community reaching out to the community.” This geographical and social proximity facilitated communication with households and helped build trust between beneficiaries and project stakeholders.
Participants also reported a revitalization of certain community structures: “The project revived structures like the IYCF groups, which had been all but forgotten.”
Socio-Economic and Institutional Constraints
Despite active participation, several factors limited community engagement. Economic constraints were frequently cited; community activities sometimes competed with daily subsistence activities.
One participant noted: “Community activities hinder our daily activities.”
The lack of incentive or compensation mechanisms was also reported as a factor likely to dampen the motivation of community stakeholders.
Participants also cited insecurity and constraints related to living conditions as obstacles to the continuity of activities. Certain inequalities regarding women’s social and economic responsibilities were also mentioned as factors that could limit their availability for specific community activities.
Perceived Effects of the NAC Project
Participants reported several positive effects associated with the implementation of the NAC project.
Community Ownership
Community ownership of the project is one of the key outcomes reported.
Participants felt that raising awareness and involving local stakeholders had strengthened the community’s sense of responsibility regarding nutrition-related activities.
One participant explained: “Community ownership of the project, building resilience so the community itself can sustain these activities, and improving health outcomes and indicators.” This perception suggests that participation helped strengthen local capacity and the sense of collective responsibility.
Behavioral Change
Participants also reported perceived changes in behaviors related to nutrition and prevention.
One participant noted: “Community ownership of the project, disseminating the message within the community to improve health outcomes and indicators—and above all, to drive behavioral change through community groups like the CAC.”
Awareness-raising activities thus appear to have facilitated the spread of knowledge and encouraged the adoption of health-promoting practices.
Use of Health Services
Some participants reported increased utilization of health services, particularly those for pregnant women and children.
One participant stated: “Health services have improved, in that there has been a marked increase in the utilization of services for women (prenatal care) and children (well-child care).”
Relations between the Community and Health Facilities
Community participation also appears to have helped improve relations between the population and health facilities. The proximity of community outreach workers to households facilitated the dissemination of messages and strengthened trust in the project’s activities.
4. Discussion
This study highlights, through the perceptions of the stakeholders interviewed, the importance of community participation in the implementation of the NAC project in the Kadutu health zone. However, it also reveals that participation is primarily concentrated on the execution of activities, with more limited involvement in needs assessment, planning, and decision-making.
This observation aligns with the findings of George et al., who demonstrated in a systematic review of health system interventions in low- and middle-income countries that communities were far more frequently involved in implementation than in the identification and definition of problems. The authors also emphasize that truly community-led interventions remain relatively rare [5].
The situation observed in Kadutu can also be interpreted in light of Arnstein’s concept of participation. In her model, different levels of participation correspond to increasing degrees of citizen power in shaping programs and decisions [6]. In our study, the significant role played by communities in mobilization and implementation demonstrates genuine participation; however, the lack of systematic involvement in design and decision-making suggests that participation remains limited in terms of decision-making power.
This distinction is particularly important in the field of nutrition. A review focusing specifically on community-based nutrition interventions in Africa shows that participation can occur at various stages of the intervention cycle: problem identification, design, implementation, and evaluation [6]. Our findings indicate that, in the case of the NAC project in Kadutu, participation appears to take place primarily at the implementation stage. The positive effects perceived by participants relate notably to project ownership, nutritional and preventive behaviors, relationships with health facilities, and service utilization. These results align with the work of Rifkin, who highlights that participation can contribute to improving health programs by strengthening local engagement and capacity, and by tailoring interventions to community realities [7].
However, a distinction must be made between perceived effects and measured effects. Participants reported a reduction in malnutrition and increased utilization of certain services; however, our qualitative study does not allow us to causally attribute these changes to the NAC project. In particular, the lack of quantitative data from before and after the intervention makes it impossible to directly verify changes in indicators regarding malnutrition, vaccination, or service utilization.
The results also show that the social proximity of community outreach workers acts as a facilitating factor. Individuals from the communities can serve as intermediaries between the population and health facilities by adapting messages and facilitating their dissemination. This proximity can help build trust and increase the acceptability of interventions.
The economic barriers reported in this study are also significant. Community actors sometimes have to choose between their involvement in project activities and their daily livelihood activities. This situation aligns with findings in the literature indicating that resource constraints, lack of training, insufficient information, and limited financial sustainability can hinder community participation [8].
In the field of nutrition, recent literature also emphasizes that local participation should be viewed as a continuum ranging from passive involvement to community ownership and empowerment. The results from Kadutu suggest that while the project achieved significant community mobilization, there is still room for improvement in reaching forms of participation that involve greater decision-making power [9].
Populations may have diverse needs and complex relationships with health services. A study conducted in impoverished urban communities in Kinshasa demonstrated the importance of community perceptions, trust, and experience with interventions in shaping the relationship between populations and the health system [10]. In this context, community mechanisms must be flexible enough to account for the social and economic diversity of the populations. Thus, the study’s findings suggest that the effectiveness of community participation depends not only on the number of activities carried out by local stakeholders but also on the role they are assigned in decision-making processes.
5. Study Limitations
This study has several limitations:
First, it was conducted in a single urban health zone. Consequently, the results primarily reflect the specific context of Kadutu and cannot be directly generalized to all health zones in the Democratic Republic of the Congo.
Second, the sample was purposive and relatively small; while consistent with the objectives of a qualitative study, this does not allow for the statistical generalization of the findings.
Third, the data relied primarily on participants’ self-reports. Some responses may therefore have been influenced by social desirability bias, particularly among stakeholders directly involved in the project.
Fourth, the reported effects regarding reduced malnutrition, improved vaccination coverage, and increased service utilization reflect participants’ perceptions. They do not constitute a quantitative measure of the project’s impact. Comparative or longitudinal quantitative studies would be required to verify these effects.
Finally, the study does not allow for an assessment of how participation evolves over time or its sustainability following the cessation or scaling back of project activities.
Finally, the urban context must be taken into account in disadvantaged urban environments.
6. Conclusions
This qualitative study highlights significant community participation in the implementation of the NAC project in the Kadutu urban health zone. Community outreach workers, CODESA committees, and other local structures played a vital role in mobilizing and raising awareness among beneficiaries, as well as in monitoring them. Participants reported greater ownership of the interventions, strengthened local capacity, perceived changes in nutrition-related behaviors, and improved utilization of health services.
However, participation remains primarily focused on activity implementation, while community involvement in needs assessment, design, planning, and decision-making remains limited. Socio-economic constraints, insecurity, and inadequate incentive mechanisms also pose obstacles to sustainable participation.
These findings suggest a need to shift community participation from a primarily operational role toward a more decision-oriented one, integrating communities into the design, planning, monitoring, and evaluation of nutritional interventions.
What Is Known
1) Community participation is a key element in the implementation of health and nutrition interventions.
2) Community actors play a significant role in mobilization, raising awareness, and bridging the gap between the population and health services.
3) However, the literature shows that participation often focuses more on activity implementation than on decision-making.
New Contribution
1) The study describes the practical modalities of community participation in an urban community-based nutrition project in Kadutu.
2) It shows that community actors perceive several positive effects of the project, particularly regarding ownership, behavior change, and the use of health services.
3) It highlights a disparity between relatively high operational participation and still-limited decision-making participation.
4) It identifies several contextual constraints that can influence participation, notably economic hardship, insecurity, and inadequate incentive mechanisms.
Author Contributions
Lunanga Itulamya Félix: study design, data collection, analysis, interpretation of results, and initial manuscript drafting. Mapendano Sirika André: critical revision and improvement of the manuscript. Kazungu Mashaliza Théodore: critical revision and improvement of the manuscript. Kyamusugulwa Milabyo Patrick: scientific supervision and critical revision of the manuscript. Bailanda Mumbere Pascal: supervision of scientific writing, final revision, and submission of the manuscript to the journal. All authors have read and approved the final version of the manuscript.
Acknowledgements
The authors thank all study participants and the community and health stakeholders in the Kadutu health zone for their availability and contribution to the conduct of this research.