Logic and participation: Theory of Change as participatory tool to address health disparities in a urban neighborhood in the Netherlands.

Background: Health disparities closely correlate with social and economic inequality, and participatory strategies are increasingly adopted to address these issues. However, meaningful citizen involvement in policymaking remains challenging. Our research uses the Theory of Change (ToC) to co-create policy strategies that address health disparities in partnership with citizen-researchers. The ToC is a participatory method to visualize a step-by-step pathway to reaching a shared vision. By making explicit the contextual factors and underlying assumptions behind each step, the ToC provides a rationale why a certain pathway will lead to certain goals. In this study, we show how a ToC was co-produced with residents, demonstrating its potential as a collaborative tool for sustainable, community-driven health policy. Approach: Our study focuses on single parents since they, and their children, are disproportionally confronted with health disparities. We collaborated with six single parent citizen-researchers, both single mothers and fathers, with a diverse background with respect to ethnicity, religion, education, occupation and employment status. They all live in a marginalized urban area in one of the major cities in the Netherlands. We conducted eight sessions to map the interrelated social and health issues underlying health disparities in the area. Building the ToC was an iterative process where we had group sessions or focused interviews with the citizen-researchers and the researchers translated the insights into a visualized ToC model; in each consecutive session, the step-by-step pathways, contextual factors and underlying assumptions were validated and refined by citizen-researchers until a final ToC was agreed upon. Results: The impact of social and economic inequality on residents’ lives is overwhelming and resulted in a structural lack of trust in the government and formal institutions. Support for residents in vulnerable positions demands a completely new approach to care and support, centered around preventive action and informal care by residents as peer-experts. The ToC made explicit that the formal system, the complex of the municipality and the local social welfare and healthcare organizations, should collaborate with peer-experts and how the experiential knowledge and expertise of peer-experts should be protected from system forces. The ToC demonstrates that current initiatives in the neighborhood can be tweaked to better serve the needs of residents, demonstrating that improvements are feasible within current policy frameworks. Implications: By visualizing residents’ needs and ideas in a structured and logically model grounded in the local context and current policy framework, feasible suggestions for immediate action can be established. By explicating the underlying assumptions, the logic behind each step becomes apparent, bridging the gap between community insights and policy expectations. This co-production process may offer a practical model for integrating resident perspectives into policy, addressing the need for meaningful, collaborative approaches in health and social care.