This study is part of a broader research initiative employing a learning site methodology to explore and evaluate co-produced health interventions in FASP. The overarching study aims to document and assess the processes, outcomes, and sustainability of co-produced interventions, with a specific focus on enhancing health literacy and community resilience. This manuscript presents the evaluation of a co-produced radio discussion intervention implemented under the Radio for ReBUILD for Resilience program in Sierra Leone. The evaluation focused on understanding the implementation process, local perceptions of the intervention, and its perceived effectiveness in improving health literacy. In the context of this manuscript, health literacy is defined as the ability of individuals and communities to access, understand, and use information to make informed health decisions and adopt behaviours that promote health and well-being. This includes the capacity to engage with health information disseminated through radio discussions and apply it to improve personal and community health outcomes.

The study was conducted in Moyamba and Kailahun districts in Sierra Leone, two regions with significant health challenges. Moyamba, located in the Southern Province, is characterized by high rates of maternal and child mortality, limited healthcare infrastructure, and widespread poverty. ¹² Kailahun, in the Eastern Province, was one of the epicentres of the 2014–2016 Ebola outbreak, which further weakened its already fragile health system. ¹² Both districts face challenges related to healthcare access, low health literacy, and vulnerability to disease outbreaks. ⁸ Health literacy is particularly important in these districts, as it enables communities to make informed health decisions, adopt preventive behaviours, and effectively engage with healthcare services. Radio is a widely used medium in Sierra Leone, including in Moyamba and Kailahun, where it serves as a critical platform for information dissemination and community engagement. Several radio stations operate in these districts, broadcasting programs that address health, education, and social issues. However, prior to this intervention, existing radio discussions were often top-down in design, with limited input from local communities. The ReBUILD for Resilience intervention sought to address this gap by co-producing radio content with local stakeholders, ensuring that the programs were tailored to the specific needs and priorities of the communities.

While radio has significant potential for reaching diverse populations, several challenges may influence its effectiveness in these settings. Access to radio equipment can be uneven, particularly in remote or economically disadvantaged areas, potentially limiting the reach of broadcasts. Additionally, literacy rates in Sierra Leone remain relatively low, particularly among women and marginalized groups, which may affect how individuals interpret and act on the information provided. ³ However, the use of radio as an audio-based medium can also be advantageous in reaching illiterate populations who might otherwise be excluded from written communication channels. Marginalized groups, including those in rural areas, may face further barriers to engagement due to social or cultural factors that limit their participation in community discussions. ³ These challenges highlight the importance of designing inclusive and accessible programs, such as using local languages, incorporating culturally relevant content, and actively involving diverse stakeholders in the development and dissemination of radio messages.

Participants for this study were selected using purposive sampling to ensure the inclusion of diverse perspectives of key stakeholders involved in the intervention design. Stakeholders included community members, including marginalised groups, local leaders, healthcare workers, radio producers, and program implementers ( Table 1). In this study, ‘marginalised groups’ refers to individuals or populations at risk of exclusion from health decision-making, such as persons with disabilities, women and girls, and youth from disadvantaged backgrounds. ‘Community representatives’ are individuals selected by their communities to articulate collective interests, including local leaders, women’s leaders, youth leaders, and disability advocates. Recruitment was conducted locally in collaboration with community representatives and district health authorities. Initial contact was made through local networks, and participants were invited to participate based on their involvement in or exposure to the radio intervention. While the study primarily engaged community leaders and representatives, this approach was chosen due to logistical constraints and the need for broad community representation. Direct involvement of all community members was not feasible within the study’s scope. We acknowledge this as a limitation and plan to incorporate more direct beneficiary perspectives in future evaluations.

Informed consent was obtained from all participants before data collection began. The consent process was conducted in the participants’ preferred language, ensuring they fully understood the purpose and scope of the study. Written informed consent was obtained from participants who were literate. For participants who were not literate, verbal consent was provided, and this was documented by the research team. The verbal consent process involved reading the consent form aloud in the participant’s preferred language, ensuring comprehension, and confirming their agreement to participate. Consent was reaffirmed at each stage of data collection, and participants were informed of their right to withdraw from the study at any time without consequences. Anonymity and confidentiality were maintained throughout the research process.

Data were collected using semi-structured tools, including interview and Focus group discussion (FGD) prompts, which were specifically designed to capture participants’ experiences, perceptions, and insights related to the radio intervention. These tools explored key aspects of the intervention, such as the co-production process, the content and delivery of the radio programs, and participants’ views on its effectiveness and sustainability. The research team recognized the potential for power imbalances among participants, particularly between formal leaders and members of marginalized groups. To mitigate this, facilitators used local languages, encouraged contributions from all participants, and structured workshops to promote inclusive discussion. These strategies aimed to ensure equitable participation and amplify the voices of those who might otherwise be underrepresented. The data collection process involved both in-depth interviews and FGDs, enabling a comprehensive understanding of the intervention’s impact.

The co-production process was central to the design and implementation of the radio intervention and was deliberately structured to be participatory, ensuring that participants were in the “driver’s seat” throughout. This process began with community consultations, during which diverse stakeholders including marginalized groups, local leaders, healthcare workers, and other community representatives were invited to identify priority issues affecting their communities. These consultations informed the selection of themes and topics for the radio programs. During these consultations, stakeholders identified and prioritized health topics most relevant to their communities. The highest-priority issues included malaria prevention, maternal health (with a focus on facility-based deliveries), sanitation and hygiene, and adolescent drug use. Stakeholders reached consensus on these topics through group discussions, ensuring that the selected themes reflected both community needs and health system gaps. Topics such as non-urgent non-communicable diseases were considered less immediately relevant and were deprioritized for the radio discussions.

Participants were actively involved in shaping the content and delivery of the radio programs. For example, during co-design workshops, stakeholders worked collaboratively with radio producers and program implementers to refine the messaging, format, and structure of the broadcasts. These workshops provided a platform for participants to voice their preferences, ensuring that the programs were culturally relevant, accessible, and aligned with community needs. Stakeholders also played a role in determining the language(s) used in the programs and the inclusion of local storytelling and music to enhance engagement.

Beyond the initial design phase, participants continued to play an active role in the implementation and adaptation of the radio programs. Feedback mechanisms, such as community listening groups and follow-up discussions, were established to gather ongoing input from listeners. This feedback was used to refine the content and ensure that the programs remained responsive to community needs. For example, topics that resonated strongly with listeners were explored in greater depth in subsequent broadcasts, while less relevant topics were deprioritized.

This participatory approach ensured that the intervention was not only co-produced but also co-owned by the community. By involving stakeholders at every stage from prioritization to content development and feedback the process exemplified a model of participatory engagement that empowered communities to shape and sustain the intervention in ways that were meaningful to them.

A total of 39 semi-structured interviews were conducted, with 19 interviews taking place in Moyamba district and 20 in Kailahun district. Each interview lasted approximately one hour and involved participants who were community leaders (both formal and informal), stakeholders engaged in the participatory action research process, or individuals holding leadership roles within their communities. The interviews focused on a range of topics, including participants’ roles, their perceptions of the radio discussions, the challenges and successes of the intervention, observed changes (both planned and unplanned), and recommendations for improving community engagement and ensuring the sustainability of the intervention. Please refer to the supplementary file for the interview guide/questionnaires used for the study.

In addition to the interviews, two FGDs were conducted one in Kailahun district and one in Moyamba district. Each discussion lasted approximately two hours and included participants who were familiar with or had listened to the radio discussions, as well as those directly or indirectly involved in the participatory action research process. The FGDs provided an opportunity for participants to share their perceptions of the radio discussions, their engagement with the health system, and their views on the intervention’s effectiveness. Participants were also encouraged to reflect on the inclusivity of the intervention, discuss how diverse community voices could be better integrated into health planning and emergency response, and offer suggestions for improving the intervention. All interviews and FGDs were conducted in Krio language which is the predominantly common language in Sierra Leone and were later transcribed verbatim before the analysis. Also, the interviews and FGDs were audio-recorded with participants’ consent and later transcribed and translated for analysis.

The data were analysed using a framework analysis approach, guided by the theoretical framework of the ReBUILD for Resilience program. ¹³ This approach involved organizing data around pre-determined dimensions related to the program’s objectives. Deductive coding was then applied to categorize and interpret the data within these dimensions, ensuring that the analysis remained aligned with the program’s theoretical underpinnings. This method allowed for a structured exploration of the data while maintaining a focus on the key themes and concepts relevant to the intervention. This framework is specifically designed to evaluate interventions in FASP by focusing on key components such as community engagement, health literacy, and resilience. These nodes provided a structured lens for analyzing the intervention’s processes and outcomes, ensuring alignment with the study’s aim of understanding how co-produced radio programs can strengthen health systems and community resilience.

The ReBUILD for Resilience framework guided the data analysis in several ways. First, it informed the development of a thematic framework that included predefined themes and sub-themes related to the intervention’s core objectives, such as fostering community ownership, improving health literacy, and addressing local health priorities. These themes were used to systematically code and organize the data, allowing the research team to evaluate how the intervention aligned with the framework’s principles. Second, the framework emphasized the importance of identifying connections between community engagement activities and broader resilience-building outcomes, which helped to interpret the findings in the context of strengthening health systems in FASP.

While the analysis was primarily deductive, the research team remained open to identifying emergent themes and new meanings that were not explicitly covered by the framework. This hybrid approach allowed for a more comprehensive understanding of the intervention, capturing both anticipated and unanticipated insights. For example, themes related to stakeholder motivations and the challenges of sustaining community engagement emerged as critical factors influencing the intervention’s success.

By grounding the analysis in the ReBUILD for Resilience framework, the study was able to document how the intervention was implemented, the perceptions of those involved in organizing and delivering it, and the views of community members on its effectiveness and sustainability. This approach not only ensured a structured and theory-driven analysis but also facilitated linking the findings to broader implications for designing and implementing participatory health interventions in FASP contexts. The framework’s focus on resilience and community engagement provided a foundation for discussing how such interventions can contribute to long-term health system strengthening in resource-constrained and crisis-prone settings.

Stakeholders across districts expressed a shared sense of community responsibility and duty, which motivated their participation in the radio talk shows. This sense of “community one-ness” was consistently highlighted as a driving force for involvement. A participant noted, “We feel responsible for the health and wellbeing of our communities. It’s our duty to act when we see issues affecting them” (KAI 011).

However, there were slight variations in how this motivation was framed. In Moyamba district, stakeholders emphasized their personal connection to the community, while in others, the focus was on professional responsibility. For example, one stakeholder explained, “ We know that lack of knowledge leads to bad outcomes. The radio program helps us bridge that gap and bring solutions to the people” (MOY 006), reflecting a more technical and professional perspective.

The platform’s role in increasing visibility and credibility was a common theme across districts, with participants recognizing the opportunity to position themselves at the center of health system issues. One participant from Kailahun stated, “ The radio program gives us a voice to share our challenges and successes with the larger community. It shows that we are part of the solution” (KAIL 014). While this view was widely shared, some stakeholders in Moyamba placed greater emphasis on the program’s role in amplifying their voices, which they felt were often overlooked. As one stakeholder from Moyamba explained, “ Before the program, it felt like no one was listening to us. Now, we feel heard, and our concerns are taken seriously” (MOY 012).

External factors, such as political, economic, and social influences, may have also played a role in shaping the outcomes of the radio program and stakeholders’ motivations. For instance, political support or advocacy for health initiatives could have encouraged participation, while economic constraints or resource limitations may have posed challenges to sustaining engagement. Social dynamics, such as community trust in health stakeholders or prevailing cultural norms around health-seeking behaviour, likely influenced how the program was received and the extent to which stakeholders felt empowered to act. Including these external factors in the discussion could provide a more nuanced understanding of the program’s success and the broader context in which it operated.

The radio talk shows were universally perceived as a critical tool for disseminating health information, raising awareness, and sensitizing the public on key health issues. Stakeholders across districts emphasized the platform’s ability to communicate the activities and priorities of the District Health Management Team (DHMT). A participant shared, “Through the radio, we can reach more people than we ever could in smaller meetings. It’s a way to educate the public and let them know what we are doing” (MOY 018).

While the overarching goals were consistent, some differences emerged in the emphasis placed on bi-directional communication. In Kailahun, a district with more robust community engagement, stakeholders highlighted the program’s role in fostering dialogue between communities and authorities. As one stakeholder remarked, “ People call in and tell us what they need. It’s an opportunity for us to listen and act” (KAI 002). In contrast, in Moyamba with limited caller participation, the focus was more on the unidirectional dissemination of information. A participant stated that “ The radio program helps us share important health messages with the community, even if they’re not calling in as much. It’s about making sure the information reaches everyone,” (MOY 010).

The processes surrounding the radio discussions were generally described as well-organized and inclusive across districts. Stakeholders consistently reported that topic selection was collaborative, with group members deciding on discussion topics and panellists to ensure balance and relevance. One participant explained, “We plan the topics together, and everyone agrees on who should be on the panel. It’s a fair process that reflects expertise” (MOY FGD).

However, there were differences in the execution of these processes. In Moyamba district with better logistical support, panellists were able to prepare more thoroughly, and discussions were more dynamic. Conversely, in districts like Kailahun, where transportation and technical challenges such as poor reception during adverse weather conditions were prevalent, stakeholders reported difficulties in maintaining the same level of organization. These logistical challenges affected the equity and inclusiveness of the intervention by limiting access to radio discussions for some community members, particularly those in remote areas, thereby reducing their ability to benefit equally from the program’s messages and opportunities for engagement. A participant stated, “Sometimes it’s hard to get to the station because of transportation issues, and when it rains, the reception is very poor” (KAI 016).

The use of local languages, including Mende, Krio, and Kisi, was universally praised as a key factor in ensuring community engagement. A participant noted, “Speaking in the local language makes the discussion accessible to everyone, even those who cannot read or write” (KAI 015). This approach was consistent across Moyamba and Kailahun and was seen as essential to the program’s success.

4.1 Knowledge and empowerment

Stakeholders across districts reported that the radio discussions contributed to addressing knowledge gaps within communities and empowered individuals to engage with health stakeholders. This perception was consistent, with one participant sharing, “The program gives people the confidence to speak to health workers about their needs. It’s a platform for their voices to be heard” (MOY 006). While these observations are encouraging, it is important to note that the extent of these changes has yet to be formally measured. Future evaluations will be necessary to substantiate these claims and provide a more comprehensive understanding of how the program influenced community knowledge and engagement levels.

4.2 Behavioural changes

Participants reported perceived behavioural changes in their communities during the intervention period, with specific examples varying by district. In Moyamba, there were reports of more consistent bed nets use during malaria campaigns and improved sanitation practices were frequently mentioned. One participant remarked, “We’ve seen people change their behaviour, like using bed nets properly and keeping their surroundings clean” (MOY 011). In Kailahun, stakeholders noted an increase in facility-based deliveries for maternal health. One stakeholder said that “ In the past, many women gave birth at home, but now more are going to health facilities because they trust the care provided there,” (KAIL 005).

4.3 Improved health service utilization

Stakeholders perceived that the discussions may have contributed to increased engagement with formal health services and a redefinition of roles among traditional providers. This was a consistent theme across districts, though the extent of collaboration with traditional providers varied. A participant explained, “Traditional providers are now working with us instead of against us. They understand their role in supporting the health system” (KAI 019). Moyamba district with stronger health system engagement reported more significant shifts in traditional providers’ roles. One participant stated that “Traditional healers now refer complicated cases to the health facilities instead of trying to handle them on their own. This partnership is saving lives,” (MOY 014).

4.4 Health outcomes

Positive perceived health outcomes were reported across all districts, including fewer reported maternal deaths during the program’s duration and strengthened surveillance of maternal health issues. One stakeholder noted, “Since the radio program started, we’ve had no maternal deaths. It’s a big achievement for us” (KAI 002). Other outcomes, such as better food hygiene practices and a decline in adolescent drug use, were more prominently reported in Moyamba district, where targeted campaigns addressed these issues. One participant stated that “ The campaigns have taught people about proper food hygiene and the dangers of drug use among adolescents. We’re seeing real changes in behaviour,” (MOY 008).

Stakeholders across districts highlighted financial constraints as a significant barrier to the sustainability of the radio talk shows. The key costs airtime fees, transportation for panellists, and logistical support were consistently mentioned. A participant stated, “The biggest challenge is funding. Without financial support, it will be hard to continue the program” (MOY 006).

Despite these challenges, there were differences in the proposed strategies for sustainability. In Kailahun districts, stakeholders emphasized the potential for integrating the program into the corporate social responsibility initiatives of radio stations. One stakeholder noted that “ We believe the radio stations can take ownership by including the program in their corporate social responsibility plans. This will ensure it continues even after external funding ends,” (KAIL 012). In Moyamba, the focus was on exploring DHMT funding. A participant suggested, “We need to engage the DHMT to support this program. It’s a cost-effective way to strengthen the health system” (MOY 011). These variations reflected the differing levels of local resources and partnerships available across the districts.

The findings of this study have several implications for practice and policy. The relative success of the radio talk shows underscores the potential value of participatory approaches in health communication. However, important questions remain regarding their reach and the extent to which they have directly contributed to the observed outcomes. Further investigation is needed to better understand their causal impacts and overall effectiveness. Policymakers and practitioners should consider integrating similar platforms into health system strengthening efforts, particularly in resource-constrained settings. Second, the use of local languages and culturally relevant content should be prioritized to ensure inclusivity and accessibility. Third, addressing sustainability challenges will require innovative financing models and stronger institutional commitments, including the integration of such programs into national health strategies.

While this study provides valuable insights, it has several limitations that should be acknowledged. A key limitation of this study is the context-specific nature of the findings, as well as the reliance on stakeholder perceptions rather than direct beneficiary input or quantitative outcome data. These factors limit the generalizability and causal inference of our results. Future research should address these gaps by including direct community member voices and employing mixed methods approaches for more robust evaluation. Additionally, while the qualitative approach was appropriate for exploring stakeholder perceptions and experiences, a key limitation is the absence of direct input from community beneficiaries, whose perspectives would have provided a more comprehensive understanding of the program’s perceived impact. Future research should prioritize including the voices of beneficiaries to better capture the community-level effects of similar participatory interventions. Furthermore, assessing the scalability of such interventions in diverse settings and examining their long-term effects on specific health outcomes, such as maternal mortality rates or antenatal care coverage, remains an important area for future inquiry. Incorporating quantitative methods, such as controlled trials or longitudinal studies, could complement qualitative findings and provide a more rigorous evaluation of the program’s impact on health service utilization and measurable health outcomes.