The study adopted a mixed-methods, sequential, exploratory, quasi-experimental design. This approach enabled an initial qualitative phase to explore in depth the accumulated experience in implementing the “Rurankapak” methodology and, based on this evidence, to adapt the intervention and subsequently assess its applicability and acceptability using a before–after quantitative design across diverse target populations.

The mixed-methods and participatory design of the study is consistent with rights-based and critical pedagical approaches, which emphasize dialogue, contextual understanding, and the active involvement of participants in the construction of knowledge (12, 16).

“Rurankapak” (Para Hacerlo – RuranKapak) (20), is a participatory, station-based SRH educational methodology developed in Ecuador in 2012 through collaboration between civil society organizations, Indigenous community groups, and the health and education sectors. The original methodology consists of a structured participatory circuit with eight thematic stations addressing false beliefs and taboos, sexuality, menstrual health, contraceptive methods, sexual and reproductive rights, rights violations, gender-based violence, and nutrition and adolescent care.

The pedagogical approach is grounded in experiential and playful learning, using peer-based activities that promote dialogue, horizontal knowledge exchange, and respect for diversity. The methodology integrates cross-cutting perspectives of human rights, gender, interculturality, and intergenerational dialogue and has been adapted to diverse sociocultural contexts and emergency scenarios.

In this study, a systematically adapted version of Rurankapak was implemented based on qualitative findings. The adapted intervention comprised seven thematic stations with predefined learning objectives and standardized facilitation guidelines. Stations were delivered to groups of 5–7 participants, with an average duration of 12–15 minutes per station, following a standardized participatory sequence.

The research was conducted within the framework of a collaboration between the Obstetrics Program of the Faculty of Medical Sciences at the Universidad Central del Ecuador (UCE), the Law Program of the Universidad Técnica Particular de Loja (UTPL), and UNFPA, the organization that developed and promotes the “Rurankapak” strategy. This interdisciplinary collaboration ensured the integration of public health, educational, and legal perspectives, particularly with regard to the protection and promotion of the rights of Indigenous peoples and nationalities. The “Rurankapak” methodology, created in 2012 through participatory processes with adolescents, has since been implemented in several provinces nationwide. The academic staff of the Obstetrics Program has incorporated “Rurankapak” into its curriculum, facilitating critical analysis, learning, and implementation across diverse settings. This experience underscored the need to evaluate the methodology in culturally differentiated contexts, including rural, urban-marginal, and Indigenous settings.

Three categories of participants were included: (a) key informants with expertise in implementing “Rurankapak” (professionals from health, education, and psychology), (b) Obstetrics undergraduate students selected as facilitators, and (c) workshop participants, including rural-Indigenous adolescents, adolescents from urban-marginal schools, early-year university students enrolled in health-related programs, and parents from rural communities. Experts were recruited using snowball sampling based on referrals provided by UNFPA. Facilitators were selected by convenience from final-year students with demonstrated academic leadership and availability for training. Workshop participants were recruited through local institutions supporting the study.

The use of trained university students as peer facilitators aligns with peer education and experiential learning frameworks, which highlight the value of reduced generational distance and learning through interaction and reflection (18).

Criteria were defined for each participant group to ensure relevance and homogeneity:

Experts (key informants): inclusion criteria comprised documented experience in applying the “Rurankapak” methodology in at least one intervention; exclusion criteria included lack of direct experience with Rurankapak or experience limited to theoretical activities without field implementation.

Snowball sampling was used for experts, purposive sampling based on academic profile for facilitators, and convenience sampling coordinated with local institutions for workshop participants. Prior to full implementation, a pilot test of the knowledge instrument and workshop logistics was conducted with a volunteer group of university students. The pilot allowed refinement of item wording and workshop dynamics and demonstrated adequate internal consistency of the main questionnaire (Cronbach's α = 0.81), supporting its reliability for pre–post measurement. The validated knowledge questionnaire is provided as Supplementary Material.

As this was an exploratory, feasibility-oriented study, no a priori sample size calculation was performed. Sample size was determined by institutional feasibility and participant availability at each implementation site.

The study was conducted in three sequential and interrelated phases. Phase I (qualitative) involved virtual semi-structured interviews with key informants, conducted in two sessions per participant to explore cultural relevance, barriers, and recommendations; findings informed the methodological redesign. Phase II (facilitator training) included 3–4 collaborative workshops and at least two practice-simulation sessions for selected Obstetrics students, during which stations were rehearsed and structured feedback provided; learning perception and satisfaction surveys were administered. Phase III (quantitative intervention) implemented the adapted “Rurankapak” version across the four target groups; participants completed a pretest immediately before the workshop and a posttest upon completion, along with a post-intervention satisfaction survey.

Phase I (qualitative component) included six key informants interviewed through semi-structured key informant interviews. Phase II involved 16 Obstetrics undergraduate students trained as peer facilitators. Phase III included a total of 167 participants distributed across four groups: urban adolescents (n = 49), rural/Indigenous adolescents (n = 40), parents from rural communities (n = 27), and university students in early semesters (n = 51).

Primary instruments included: (a) a semi-structured interview guide for key informants; (b) a 14-item knowledge questionnaire developed ad hoc for the thematic stations of Rurankapak—content-validated by expert reviewers and refined after pilot testing; (c) a satisfaction survey with Likert-scale items and open-ended questions assessing clarity, cultural relevance, and practical utility; and (d) a facilitator self-assessment survey exploring competencies, challenges, and willingness to replicate the methodology. Pilot testing allowed correction of ambiguities and confirmed internal consistency (α = 0.81). Paper-based instruments were administered by trained surveyors.

The qualitative component consisted of six key informant interviews conducted with professionals from the health, education, and psychology sectors who had direct experience implementing the Rurankapak methodology. Interviews were semi-structured, guided by a flexible interview protocol exploring implementation experience, cultural relevance, perceived barriers, and recommendations for adaptation. All interviews were conducted virtually, lasted approximately 45–60 min, and were audio-recorded with participant consent.

Interviews were transcribed verbatim and analyzed using ATLAS.ti v22 to support coding and category organization. A thematic analysis approach was applied, including open coding, category development, and construction of semantic networks to identify patterns and adaptation recommendations. To strengthen analytical validity, independent double coding was conducted by two researchers, discrepancies were resolved through discussion and consensus, inter-coder agreement was documented, and member checking was performed with selected key participants. Triangulation across interviews, methodological documents, and observations from rehearsal sessions enhanced the credibility of qualitative findings.

Quantitative data were processed using IBM SPSS Statistics version 25.0. As pre–post score distributions did not meet normality assumptions across multiple groups, the non-parametric Wilcoxon signed-rank test was applied to compare scores before and after the intervention. Statistical significance was set at p < 0.05, and exact p-values were reported when appropriate (e.g., preliminary analyses showed p ≤ 0.001 in certain subgroups; final values are presented in the Results section). In addition to p-values, effect size measures suitable for non-parametric tests (e.g., r derived from Z statistics) were calculated to estimate the magnitude of observed changes. Quantitative findings were integrated with qualitative evidence to assess the applicability, acceptability, and operational feasibility of the adapted “Rurankapak” version.

To address the study objectives, a convergent triangulation strategy was employed: qualitative findings informed methodological modifications that were operationalized and evaluated quantitatively; discrepancies between qualitative and quantitative results were explored through comparison matrices and consultations with facilitators and experts to interpret findings and refine practical recommendations.

This study was approved by the Human Research Ethics Committee of the Central University of Ecuador (code 004-DOC-FCM-2025). The research was conducted in accordance with the ethical principles of the World Medical Association's Declaration of Helsinki. All participants received written information regarding the study's purpose, procedures, and duration and were informed of their right to withdraw at any time without consequences. Data were used exclusively for research purposes and handled under strict confidentiality to protect participant privacy. Participants who understood and agreed to the guidelines were enrolled after providing informed consent; for minors, assent and authorization from legal guardians were obtained.

Six key informant interviews were conducted with professionals from the health, education, and psychology sectors who had direct experience implementing the Rurankapak methodology. The analysis identified recurrent themes related to methodological structure, content coverage, and contextual implementation challenges.

Key informants reported difficulties in addressing sensitive topics, particularly abortion, HIV, and sexual violence, due to sociocultural resistance and limited institutional preparedness. Participants also highlighted gaps in referral pathways and the absence of clearly defined support networks for cases involving rights violations. Additional concerns included the clarity and cultural appropriateness of certain educational materials, as well as the need for greater flexibility in adapting content to participant age and context. Based on these findings, several methodological adjustments were proposed, including strengthening pre-workshop planning, clarifying learning objectives, improving visual materials, and reinforcing facilitator training processes. The analysis generated key insights that guided the adaptation of the intervention, as summarized in Table 1.

A total of 167 participants completed pre- and post-intervention assessments across four population groups: urban adolescents (n = 49), rural/Indigenous adolescents (n = 40), parents from rural communities (n = 27), and university students (n = 41) in early semesters of health-related programs. The sociodemographic characteristics of participants by group are presented in Table 2.

The internal consistency of the knowledge questionnaire was acceptable (Cronbach's α = 0.81). Pre–post comparisons indicated statistically significant improvements in overall knowledge scores among university students and rural/Indigenous adolescents (Wilcoxon signed-rank test, p < 0.05). No statistically significant changes were observed among urban adolescents or parents. The mean age of school students was 17.3 years (SD: 1.3), while the mean age of young adults was 20.7 years (SD: 1.4). The young adult (university) group showed statistically significant post-intervention improvements across all stations (p = 0.001). Students from rural/Indigenous schools demonstrated significant improvements in Stations 2 and 4, related to sexuality and contraception (p = 0.001), as well as in total scores. No statistically significant pre–post differences were observed in the remaining groups (see Table 3).

Participant satisfaction was assessed using a 5-point Likert-scale questionnaire across six evaluation domains. Mean satisfaction scores were generally high among adolescents and young adults, while lower scores were observed among parents, particularly regarding time allocation (Figure 1).

Eighteen Obstetrics undergraduate students participated as peer facilitators and completed post-intervention evaluations. High levels of agreement (“Quite a lot” and “A great deal”) were reported across all assessed domains, including preparedness for the facilitator role, empathy toward adolescents, interpersonal communication skills, and confidence in delivering sexual and reproductive health education (Figure 2).

Student narratives, summarized in Table 4, highlight a positive appraisal of the facilitator role, underscoring its contribution to vocational reaffirmation, the broadening of professional horizons, and comprehensive training. Within the subcategory Vocational reaffirmation, participants reported that the experience strengthened their commitment to pursuing an empathetic and engaged professional practice, recognizing that “being able to educate others requires a great deal of vocation and confidence,” or that “it helped me envision the kind of professional I want to be: approachable, empathetic, and capable of adapting to people's diverse realities.”

The subcategory Expansion of the professional field captures perceptions reflecting openness to new avenues of professional practice beyond traditional clinical settings, such as “it made me realize that my career has many paths” and “I became aware that there is a vast field of work.” Finally, the subcategory Contribution to comprehensive training indicates that the intervention fostered key practical skills, including effective communication, adaptability, and engagement with diverse populations: “you learn how to manage yourself and respond by adapting to the environment and the people you are working with.”

The Rurankapak strategy demonstrated a strong capacity to adapt to diverse educational and population settings, standing out for its flexibility in responding to contextual differences. The original guide was explicitly designed to be modified according to each community's cultural and social characteristics while preserving its educational essence. This flexibility allowed adjustment of language and examples according to educational level, adaptation of participatory dynamics to urban and rural contexts, and maintenance of the seven thematic stations while optimizing participant flow.

The project successfully articulated a multidisciplinary approach integrating health, education, and rights, combining perspectives from Health Sciences (scientific approaches to contraception, menstrual health, and prevention), Social Sciences (social and cultural determinants of sexuality), Human Rights (a sexual and reproductive rights–based approach), Pedagogy (participatory methodology adapted to different educational levels), and Psychology (emotional and relational dimensions of sexuality). This integration enabled a comprehensive approach that goes beyond traditional biologically centered sexual education.

Data analysis demonstrated a high level of methodological rigor, including systematic processing with digitization, tabulation, and cleaning of 8,050 data points; robust statistical methods using non-parametric tests (Wilcoxon) appropriate for Likert-type scales; transparent handling of missing data with consistent imputation criteria; multidimensional analysis by thematic stations and global score; and methodological triangulation combining quantitative results with satisfaction surveys.

To situate our contribution within the existing evidence base, we reviewed peer-reviewed studies on SRH education and adolescent-focused interventions in Ecuador and Latin America. In Ecuador, prior research has examined mechanisms and barriers for adolescent-friendly SRH services, as well as acceptability of technology-mediated SRH risk-reduction approaches among adolescents (34). Related regional evidence has also documented peer-oriented delivery models and systematic cultural adaptation of school-based sexual health promotion programs in Latin America (31). However, to our knowledge, no peer-reviewed study in Ecuador has evaluated a participatory, station-based “circuit” methodology delivered by peer facilitators and implemented across four distinct sociocultural contexts, as in the present study. This gap underscores the value of documenting not only preliminary outcomes, but also the practical conditions of applicability and acceptability when implementing culturally responsive, peer-facilitated SRH education strategies in heterogeneous settings.

The quasi-experimental design without a concurrent control group limits the ability to attribute observed changes exclusively to the adapted Rurankapak intervention. Although the pre–post approach enabled the assessment of preliminary changes in knowledge and acceptability across groups, causal inferences cannot be established. While implementing the intervention across four distinct sociocultural contexts allowed for comparative benchmarking of applicability and consistency of patterns, this design does not substitute for a true control arm. Future studies should therefore employ more rigorous designs, such as cluster-randomized or stepped-wedge trials with explicit comparison conditions, to strengthen causal inference and estimate intervention effects more precisely.

The study was exploratory and feasibility-oriented; consequently, no a priori sample size calculation was performed. Sample sizes were determined by institutional feasibility and participant availability, which may have limited statistical power to detect changes across all groups, particularly among parents and rural participants. As a result, some non-significant findings should be interpreted with caution. Future research should incorporate formal sample size estimation and larger, balanced samples to improve power and enable subgroup analyses.

Implementation was conducted in specific sociocultural contexts, including rural, Indigenous, and urban-marginal settings in Ecuador. Although Rurankapak is intentionally designed to be adaptable, the context-specific nature of the intervention may limit generalizability to other regions or populations with different cultural, educational, or institutional characteristics. Multi-site studies across diverse geographic and policy environments are warranted to assess transferability and scalability.

The quantitative evaluation focused primarily on knowledge acquisition and participant satisfaction using Likert-type self-reported measures, which are susceptible to social desirability bias and may not fully capture deeper changes in attitudes, behaviors, or real-life decision-making related to sexual and reproductive health. Moreover, the short duration of the intervention relative to the breadth of topics covered may have constrained the magnitude of measurable cognitive change. Future studies should incorporate longitudinal follow-up and complementary outcome measures—such as scenario-based assessments, behavioral indicators, and self-efficacy scales—to better reflect meaningful learning and sustained impact.

Finally, facilitator-related factors, including prior training, motivation, and interpersonal skills, may have influenced participant engagement and learning outcomes. Although standardized training procedures and methodological guides were used to promote fidelity of implementation, variability in facilitation dynamics cannot be entirely ruled out. Future research should examine facilitator effects more systematically and explore the added value of extended training, supervision, and fidelity monitoring mechanisms.

To address identified limitations, the development of more didactic materials for parents is recommended, including visually oriented guides with reduced text and increased iconography, testimonial videos featuring parents from the same community, exercises based on real family situations, glossaries using everyday language, and preliminary familiarization sessions with the methodology.

In parallel, incorporating a greater number of local examples could strengthen identification with the content. This includes community-based narratives and cases, local geographic and cultural references, recognizable characters and situations, adaptation of terminology to local dialectal variants, and explicit linkage of content to sexual and reproductive health (SRH) issues identified within each community.

At the methodological level, future implementations and evaluations would benefit from more explicit reporting of qualitative procedures, including sampling strategies, analytic steps, and criteria used to determine data saturation. Clear documentation of these processes would enhance transparency, credibility, and the reproducibility of qualitative findings across settings.

Looking ahead, subsequent studies should move toward longitudinal designs with follow-up assessments to evaluate sustained knowledge retention and behavioral outcomes. The inclusion of explicit comparison groups would strengthen causal inference, while the use of complementary evaluation tools—such as measures of attitudes, self-efficacy, and real-life decision-making—would provide a more comprehensive assessment of intervention impact. Research conducted in additional geographic and cultural contexts would further inform the scalability and broader applicability of the adapted Rurankapak strategy.