A systematic review of studies evaluating Australian indigenous community development projects: the extent of community participation, their methodological quality and their outcomes
Community development is a health promotion approach identified as having great potential to improve Indigenous health, because of its potential for extensive community participation. There has been no systematic examination of the extent of community participation in community development projects and little analysis of their effectiveness. This systematic review aims to identify the extent of community participation in community development projects implemented in Australian Indigenous communities, critically appraise the qualitative and quantitative methods used in their evaluation, and summarise their outcomes.
Methods
Ten electronic peer-reviewed databases and two electronic grey literature databases were searched for relevant studies published between 1990 and 2015. The level of community participation and the methodological quality of the qualitative and quantitative components of the studies were assessed against standardised criteria.
Results
Thirty one evaluation studies of community development projects were identified. Community participation varied between different phases of project development, generally high during project implementation, but low during the evaluation phase. For the majority of studies, methodological quality was low and the methods were poorly described. Although positive qualitative or quantitative outcomes were reported in all studies, only two studies reported statistically significant outcomes.
Discussion
Partnerships between researchers, community members and service providers have great potential to improve methodological quality and community participation when research skills and community knowledge are integrated to design, implement and evaluate community development projects.
Conclusion
The methodological quality of studies evaluating Australian Indigenous community development projects is currently too weak to confidently determine the cost-effectiveness of community development projects in improving the health and wellbeing of Indigenous Australians. Higher quality studies evaluating community development projects would strengthen the evidence base.
Keywords
Community developmentIndigenousAboriginalTorres Strait IslanderHealth promotionCommunity participationEmpowermentMethodological qualityQualitativeQuantitative
Background
The health gap between Indigenous and non-Indigenous Australians has been well documented [1–3]. Systematic literature reviews, however, have consistently concluded that evaluations of interventions aimed at reducing this health gap lack methodological rigour [4–12]. In addition to improving the methodological quality of the evidence-base, the need for greater community participation in, and control of, Indigenous health promotion research have been advocated [13–15].
Community participation has long been argued as being an essential factor in successful health promotion initiatives [16–18]. A recent meta-analysis concluded that community participation is effective when used in health promotion projects because it engenders greater community motivation and increases the sustainability of projects [19]. Although the review did not include Indigenous communities, the principle of community participation is highly relevant to Indigenous Australians and has great potential to improve Indigenous health. The history of dispossession and disempowerment experienced by Indigenous people highlights the importance of the full and active participation of community members to develop plausible solutions to the problems they themselves have identified [9, 20–25]. The community development approach strives to empower Indigenous communities to develop and utilise skills that will enable them to more directly address the risk factors that determine their health status [26].
Despite the potential of community development approaches for improving Indigenous health outcomes, there has been no systematic examination of the extent to which they have engendered community participation and little analysis of their effectiveness. The only existing systematic review of Indigenous community development, published in 2007, evaluated 17 projects implemented in Indigenous communities in Australia, Canada, New Zealand and the United States [9]. This review emphasised that high levels of community participation were a critical factor in the success with which community development projects were implemented, however, it did not assess the level of community participation nor systematically assessed the methodological qualities of the studies. This lack of project evaluation has made it difficult to confidently estimate the extent to which community development projects have improved the health and life expectancy of Indigenous People.
This systematic review aims to identify the extent of community participation in community development projects implemented in Australian Indigenous communities, critically appraise the qualitative and quantitative methods used in their evaluation, and summarise their outcomes.
Methods
Identification of publications
The peer-reviewed and grey literature were searched to identify studies evaluating Indigenous community development projects in Australia, published between 1990 and 2015. Twenty-five years of community development projects was judged to be sufficient to provide an overview of the most recent projects. Figure 1 summarises the databases searched, the search terms used, the eligibility criteria and the classification process based on the PRISMA flow diagram [27].
Fig. 1
PRISMA flow diagram: systematic search identifying evaluation studies of Australian Indigenous Community Development projects
Ten peer-reviewed databases were searched: Health and Society, Aboriginal and Torres Strait Islander Health Bibliography (ATSIHealth), AIATSIS, APAIS-AIATSIS, FAMILY-ATSIS, ProQuest, Scopus, CINAHL, PsychINFO, and Medline/Pubmed. Two grey literature databases were searched: HealthInfonet and Closing the Gap Clearinghouse. The electronic database search identified 3623 publications and 411 duplicates were removed. Reference lists of the identified publications were scanned which identified an additional 20 publications. Another 11 publications were received from researchers in the field. The resulting 3243 publications were organised in Reference Manager Endnote [28].
Screening and eligibility
The titles and abstracts of the identified 3243 publications were read to determine their eligibility for inclusion against three criteria: 1) relevance to a community development project, including: projects focusing on community ownership, empowerment, local leadership and decision making, adopting a long-term strategy, having a focus on sustainability or having a bottom up approach (i.e. starting from the community) [29, 30]; 2) published between 1990 and 2015; and 3) a primary focus on Indigenous communities in Australia. A total of 231 publications met all three criteria. The full text versions of these 231 publications were sought for detailed review, of which 112 were available and relevant to this review.
Classification
One hundred and twelve publications were classified into four categories derived from previous research reviewing Indigenous health initiatives [4, 10, 31], defined as follows. Measurement research: the development, testing or evaluation of measurement tools. Evaluation research: an evaluation of an Indigenous community development project or policy. Review: including summaries, critical or systematic reviews and/or meta-analysis; and Discussion paper: general discussion of Indigenous community development. Thirty one publications identified as studies evaluating community development projects in Indigenous Australian communities were critically appraised.
Extent of community participation
Replicating previous analyses [32, 33], the extent of community participation was assessed using Pretty’s participation typology, which describes seven levels of community participation ranging from no participation to self-mobilisation (i.e. completely top-down to completely bottom-up) [32, 34]. Given community participation can vary during the lifetime of a project, the extent of participation was assessed separately for four phases of project development: diagnosis (identifying a community’s priorities); development (of appropriate strategies to address the priorities); implementation (of the strategies); and evaluation (of the effectiveness of the project) [32, 35, 36]. The level of community participation in the 31 studies were assigned a score between 1 and 7 for each phase of project development. Detailed descriptions of different levels of community participation in relation to scores 1 to 7, and with respect to all four phases, are provided in Table 1 and are summarised as follows: no participation (score 1); passive participation (score 2 – the community was only informed about the project); participation by information (score 3 – information was collected from the community without their participation and without providing feedback); participation by consultation (score 4 – information was collected from the community, feedback was given and further inclusion of community was sought); functional participation (score 5 – community collaboration, but on outsiders’ terms); interactive participation (score 6 – collaboration on mutually defined terms); and self-mobilisation (score 7 – outsider’s work in community on community’s terms). This scoring was independently conducted by two of the authors (MS and AW), which resulted in agreement for 22 studies (71 %). The nine studies on which authors disagreed were blindly reviewed by a third author (ASt). For four studies, the score allocated by the third reviewer was the same as the score allocated by one of the first two reviewers and so that score was used, increasing the agreement rate to 84 % for 26 of the 31 studies. For the five studies where there was no agreement, the scores allocated by the first author (MS) were used.
Table 1
Definitions of the seven levels of community participation in the four phases of project development
Seven levels of community participation
Four phases of project development
Diagnosis
Development
Implementation
Evaluation
1. No participation
Completely top-down, community is not informed about or asked about issues in their community.
Top-down, community is not informed about the development of the project.
Top-down, community is not informed about the implementation of the project, only about activities they’re involved in
Top-down, community receives no information about evaluation.
2. Passive participation
Outsiders decide on the issues that need to be addressed, community is informed.
Outsiders control development, community is informed, but has no input.
Outsiders control the implementation, community is informed, but has no input.
Outsiders control the evaluation, community is informed, but has no input.
3. Participation by information
Outsiders have control, community participates by providing information about their community. No feedback to the community and no checking for agreements.
Outsiders have control over development, community potentially provides information about what they want, but outsiders don’t necessarily respond to this.
Outsiders control implementation, community might provide information useful for implementation, but outsiders don’t necessarily listed to this.
Outsiders control evaluation, community provides information through surveys and/or interviews, focus groups. Findings are not shared or checked for accuracy.
4. Participation by consultation
Outsiders define problems and consult with community about their agreement, using outsider defined processes.
Outsiders consult with community about potential projects to develop, but outsiders make final decision.
Community participates in activities decided upon by the outsiders
Outsiders define evaluation process, community provides information and might make suggestions for improvement and feedback provided
5. Functional participation
Outsiders have predetermined goals and community assists in defining issues within those goals, outsiders make final decisions.
Community works together with outsiders to develop projects decided upon by the outsiders.
Community and outsiders work towards implementation of projects, based on outsiders’ goals and processes.
Community and outsiders work together in evaluation, based on goals as set by the outsiders.
6. Interactive participation
Outsiders and community work together to identify the issues in the community and set goals for the project.
Outsiders and community work together to develop suitable projects to address the agreed upon goals.
Community and outsiders implement the developed projects together, community has control and uses local resources.
Evaluation methods are decided upon together and conducted in partnership.
7. Self-mobilisation
Completely bottom-up, community identifies their own issues and sets their own goals, might contact outsiders to assist them where needed.
Bottom-up, community makes decisions about project development, apply for funding and potentially contact outsiders where needed
Community implements projects, contacts outsiders for resources where needed, but remains in control over resources.
Community conducts evaluations, potentially contacts outsiders for assistance, but stays in control over evaluation.
Source: adapted from Pretty (1995) and Wagemakers et al. (2008)
Critical appraisal of methodology
Qualitative methods
The methodological quality of the qualitative study components was assessed by adapting Long and Godfrey’s qualitative study evaluation tool, which was developed to appraise evaluations of health and social care interventions [37]. This tool has 4 sections: 1) phenomenon studied and context; 2) ethics; 3) data collection, analysis and potential research bias; and 4) policy and practical implications. The latter two were used in this review because they relate specifically to evaluation issues. Data collection includes the need for clear descriptions of the data collection process (e.g. recruitment strategies, data collection procedures, specifying the interview questions, methods of recording data and the extent to which the data collection process was tailored to specific communities). Data analysis includes the description of the data analysis, the provision of adequate evidence to support the analysis (including data extracts, triangulations and descriptions of reliability) and whether the findings are interpreted in line with existing theories and literature. Potential researchers’ bias assesses whether the position of the researcher is outlined in the study and its potential influence on the data collection and analysis. The policy and practical implications include an analysis of the populations and settings to which the findings are generalisable, the implications for policy or practice, and the extent to which the methods justify the conclusions.
Quantitative methods
The methodological quality of the quantitative study components was appraised using the Dictionary for Effective Public Health Practice Project Quality Assessment tool for Quantitative studies [38], which was developed to review public health studies and has been used in other systematic reviews in the Australian Indigenous health field [4, 10]. Sections A-F (A - selection bias, B - study design, C - confounders, D - blinding, E - data collection methods, F - withdrawals and drop-out) are rated categorically as strong, moderate or weak. Sections G (intervention integrity) and H (analysis appropriateness) comprise summaries of the relevant information rather than categorical ratings. In addition to sections A-H, this tool advocates a summary rating defined as weak (two or more weak scores are given), moderate (1 weak score is given) or strong (no weak scores are given).
Scoring for critical appraisal of methodology
Scores against both the qualitative and quantitative evaluation criteria were allocated by author MS. A random selection of 25 % of studies were assessed by a blinded coder (ASt). There was agreement for 70 % of these studies. Disagreements were resolved in consultation between the two coders.
Outcomes of the studies
The outcomes of the studies evaluating Indigenous community development projects are summarised.
Results
Thirty-one studies evaluating Indigenous community development projects in Australia were identified. Ten (32 %) were published in the peer reviewed literature [39–48].
Extent of community participation
Table 2 summarises the level of community participation across the four phases of project development for each study. Table 3 summarises the number of studies relevant to each of the seven levels of community participation, separately for the four phases of project development. The highest levels of participation (level 5 to level 7), were found in the Diagnosis phase for ten studies (32 %) [39, 43, 44, 48–54], in the Development phase for 13 studies (42 %) [39–44, 46, 49–52, 54, 55], in the Implementation phase for 17 studies (55 %) [39–44, 46, 48–54, 56–58] and in the Evaluation phase for 7 studies (22 %) [39, 40, 43, 44, 50, 53, 59]. Four studies (13 %) had at least level 5 participation in all phases of the project [39, 43, 44, 50]. The participation of the community was described with insufficient detail to be assessed (unknown category) for ten studies in the Diagnosis phase (32 %) [42, 45, 57, 58, 60–65], seven in the Development phase (23 %) [47, 48, 57, 60, 61, 64, 66], four (12.9 %) in the Implementation phase [47, 61, 63, 66] and two (7 %) in the Evaluation phase [46, 67].
Table 2
Level of community participation in each phase of project development for each study
aPossible scores range from 1 to 7: 1 = no participation; 2 = passive participation; 3 = participation by information; 4 = participation by consultation; 5 = functional participation; 6 = interactive participation; 7 = self-mobilisation, UNK = unknown [32, 34]
bParticipation varied within the phase
cParticipation was somewhere in between these levels
Table 3
Number of studies across the levels of community participation and phases of project development
Seven levels of community participation
Four phases of project development
Diagnosis
Development
Implementation
Evaluation
1. No participation
7
2. Passive participation
1
3
2
3. Participation by information
2
3
6
4. Participation by consultation
1
5
10
14
Least active involvement sub-total (levels 1–4)
11
11
10
22
5. Functional participation
1
4
8
4
6. Interactive participation
3
4
5
3
7. Self-mobilisation
6
5
4
0
Most active involvement sub-total (levels 5–7)
10
13
17
7
Unknown
10
7
4
2
Total
31
31
31
31
Note: No participation = community did not participate
Passive participation = the community was only informed about the project
Participation by information = information was collected from the community without their participation and without providing feedback. Participation by consultation = information was collected from the community, feedback was given and further inclusion of community was sought
Functional participation = community collaboration on outsider’s terms
Interactive participation = collaboration on mutually defined terms
Self-mobilisation = outsider’s work in community on community’s terms [32, 34]
Methods used in studies
Twenty-one studies (67 %) used qualitative methods only [39–41, 48, 49, 51, 52, 55–57, 59–69], two (7 %) used quantitative methods only [46, 47], and eight (26 %) used mixed methods [42–45, 53, 54, 58, 59]. Qualitative data were collected using semi-structured interviews in 24 studies [39, 40, 42, 43, 45, 49–53, 55–58, 60–69], document analysis (n = 15 [42, 49, 51, 52, 55–57, 60–66, 68]), focus groups (n = 9 [39, 40, 43, 45, 48–50, 53, 58]), participant observation (n = 6 [42, 43, 53, 54, 58, 69]) and photovoice [70] (n = 2 [50, 53]). Quantitative data collection methods included surveys in three studies [45, 48, 58], hospital/clinical records (n = 4 [43, 44, 47, 53]), school records (n = 2 [42, 58]), police records (n = 1 [42]), store records (n = 1 [43]) and ABS census data (n = 1 [46]).
Methodological quality of studies with a qualitative component
All 29 studies with a qualitative component (including mixed methods studies) provided some description of the evaluation methods used (Table 4). Twelve studies (41 %) gave detailed descriptions of the data collection process, including participant recruitment, focus group procedures and a clear description of which data were recorded [39, 41, 49–51, 53, 58, 60–63, 67]. Four of these twelve studies (14 %) provided the interview questions [51, 58, 60, 67] and one study (4 %) described in detail how the data collection methods were tailored to ensure their cultural appropriateness [49]. The data analysis methods were described in detail in seven studies (24 %) [39, 42, 50, 54, 58, 67, 69]. The potential for researcher bias was described in seven studies (24 %) [39, 44, 45, 49, 53, 58, 69]. Three studies (10 %) did not discuss the implications of their findings [52, 59, 65].
Table 4
Critical appraisal of qualitative components of studies evaluating Indigenous community development projects (n = 29)
Methodological quality of studies with a quantitative component
The summary ratings for all ten studies with a quantitative component were classified as weak (Table 5). The likely extent of selection bias was unclear for six studies (60 %) because description of the participant and community selection procedures was absent or insufficiently detailed [42–44, 46, 47, 59]. Five studies (50 %) used a cohort design without a control group [43–45, 53, 54], one study (10 %) used a time series design [47] and the evaluation design of the remaining four studies (40 %) was unclear [42, 46, 58, 59]. No study adequately controlled for confounding variables. None of the studies used blinding procedures. Two studies (20 %) used validated outcome measures [45, 58]. No study discussed the validity or reliability of their outcome measures.
Table 5
Critical appraisal of quantitative component of studies evaluating Indigenous community development projects (n = 10)
Many youth involved in the interventions, no information on consistency, other community initiatives were running simultaneously (including stricter supply controls and rewards linked to school attendance).
Community-level allocation and analysis. Statistical methods described in other publication. Dates of data collection (2001–2004) do not line up with dates of intervention (2003–2005), no post-test data.
No description of who was exposed to the project and who weren’t, nor of possible external influences on outcomes.
Allocation on community and individual level. Evaluation on community, organisational and individual level. No statistical analysis (outcomes as percentages only).
All participants were part of the project; not all participants attended every session; it is likely that the results were influenced by other interventions put on the families.
Individual-level allocation and analysis; statistical analyses (frequencies and t-test) were appropriate; analysis performed on actual intervention status.
All evaluation participants were exposed to intervention; consistency was not measured; outcomes likely influenced by other factors.
Project was allocated at organizational level, data were collected on community level, cannot be sure whether changes at community level are caused by changes at the organizational level. No statistical analysis
No description of exposure to intervention or consistency in delivery. Outcomes may be influenced by other factors
Community-level allocation and analysis. Appropriate statistical analysis.
Weak
Note: Appraised using the Dictionary for Effective Public Health Practice Project Quality Assessment tool [38]
a Published in peer-reviewed literature
One study (10 %) described withdrawals and drop outs at the community level [46]. One study (10 %) described withdrawals and drop outs at the participant level [53]. Drop outs at the participant level were not applicable for the six studies (60 %) that used either routinely collected data or a one-off survey [42–44, 47, 54, 58]. Two studies (20 %) did not report drop outs [45, 59]. No study described the fidelity of the project. Three studies (30 %) reported on the exposure of participants to the project [45, 54, 58]. Inferential statistical analyses were reported by four studies (40 %) [42, 47, 53, 58].
Outcomes
A summary of the aims and key outcomes for each study is provided in Table 6. All studies using qualitative methods concluded that community members reported positive project impacts for their community. Two studies (7 %) reported quantitative outcomes that were statistically significant: a reduction in injuries [47] and a reduction in cannabis use among females aged 13–36 and males aged over 16 years [42].
Table 6
Aims and outcomes of studies evaluating Indigenous community development project (n = 31)
Community empowerment through arts and cultural practice
Social issues addressed; Non-indigenous staff reported improved understanding Indigenous issues; community members acquiring new skills; experienced increase in supportive relationships and friendships
Increase community understanding and control of usage of mine royalties to facilitate community development
Increased community understanding and perceived and actual community control; increase perceived benefits of project and increase in projects that support the whole community.
Use aboriginal royalties to support education and training initiatives
Perceived improvements in school performance and increase youth employment; growing capacity and ability of committee. Observed increase in school attendance because of school excursions.
Increase awareness of nutritional need of children and improve early childhood health.
Observed increased awareness nutritional needs, decrease failure to thrive kids and increase in fruits and vegetables in store. Increase confidence in buying healthy food; increase of healthier kids in community. Establishment of community garden.
Address youth substance misuse and crime and develop youth activities
No changes in school attendance (2003: 55.9 %; 2005: 51.3 %), or youth apprehension (2003: 68; 2005: 75); decline in cannabis use (2001: 80 %; 2004: 74 %, p = .003), statistically significant for females (13–36 years, p = .008) and older males (>16 years, p = .007).
Improve knowledge about and management of diabetes
Increase in visits to health professionals; improved adherence to diabetes management protocol; 65 % decrease in sugar purchases; increase in fruit (81 %) and vegetable (11 %) purchases; no change in biochemical control.
Strengthen and empower families to help children succeed in life
Non-significant increase in school attendance (48.4 to 53 %; p > .1); improvements in family environment; no improvements in parental involvement in education; children show more respect towards teachers and other children.
Improve relationship between communities and government and build community capacity.
Reduction Indigenous students in lowest literacy bands (2005: 16 %; 2006: 6 %); increase in TAFE enrolments (2001: 1480; 2006: 1718); 32 % increase year 11 and 12 completions; 71 % increase of students finishing certificates and 50 % increase in diplomas; 45 % drop alcohol related hospitalisations, 13 % drop in diabetes-related hospitalisations; decrease in thefts (21.6 %) and breaks (15.8 %) from dwellings.
Significant reduction in frequency of injuries before (96; SE = 4.8) and after (65; SE = 3.08) start of the project (Student’s t = 5.07, df = 21, p < 0.001).
Discussion
This study systematically reviewed the peer-reviewed and grey literature on community development projects in Australian Indigenous communities. One hundred and twelve relevant and available publications were identified, 31(28 %) studies were evaluations, 21of these evaluation studies (68 %) were published in grey literature. There were no marked differences observed between evaluations published in the grey and peer-reviewed literature in terms of the detailed descriptions of the qualitative methods used, the quality of the quantitative methods or the reported levels of community participation. This high comparability reflects the generally low quality of all the evaluations published in both the peer-review and the grey literature. It would be an asset to the community development field to increase the publication rate of higher-quality evaluation studies in the peer reviewed literature, especially in open access journals, to utilise peer review as a quality assurance mechanism and to optimise the transparency of study results.
Community participation in community development projects
Community participation was assessed as moderate in most of the studies evaluating Indigenous community development projects (87 %). The wide variation in community participation between projects and project phases, and within project phases, in these Australian Indigenous studies is reflected in the international literature [32, 36]. For half of the studies included in this review, the intent for community participation was clearly described, but the actual level of participation was not reported for at least one of the phases of project development. Documenting the community participation strategies and processes used, including details about how the community was engaged and who in the community participated, would allow the more successful community participation strategies to be identified and replicated in subsequent projects [36].
Although the unique characteristics of each community will lead to variation in their capacity to participate in each phase of a project [36, 71], the extent and nature of community participation can be optimised by careful planning and the utilisation of appropriate frameworks to guide the development, implementation and evaluation of community-based projects. An approach like participatory action research provides practical guidelines to achieve this [72, 73].
Quality of evaluation methodology
In line with previous research [4–12], the methodological quality of the studies identified in this review are poor, or they are difficult to assess because their methods are inadequately described. It is acknowledged that issues specific to Indigenous community-based research can impact on the research quality, including time needed to engage with the community, difficulties with recruiting enough participants, high staff turn-over at service providers and culturally-specific delays (e.g. ceremonies or celebrations) [14]. Careful and flexible planning is therefore needed in community development projects to address these issues to reduce their impact on the quality of the research. The complex interventions framework, for example, provides one mechanism to carefully plan projects to maintain methodological rigour [74, 75]. The methodological quality of qualitative studies could also be improved by using appropriate analysis methods, multiple coders, and describing the extent of potential bias attributable to the researcher [37].
The methodological rigour of both the qualitative and the quantitative studies could further be improved by using measures with demonstrated reliability and validity: only two studies identified by this review reported that they had used such measures [45, 58]. Using reliable and valid measures increases confidence in the accuracy of the study outcomes [76]. Such measures should be validated specifically for the Indigenous population, because of their holistic concept of health and wellbeing [77]. Existing studies show that it is possible to develop reliable and valid measures that are culturally appropriate and acceptable to Indigenous Australians [78–83], but the lack of measurement studies specifically related to community projects identified in this review (one study, see Fig. 1) clearly indicates that more of this measurement research is urgently needed [80].
Only three studies (10 %) reported on intervention integrity, which includes the level of exposure to the project, and the consistency and frequency with which project components were delivered in practice. Studies evaluating community development projects would be improved by routinely including process measures, to allow an examination of the extent to which outcomes are a consequence of the project components, as opposed to reflecting the extent to which the project components were implemented [74].
Eight studies (26 %) evaluated a community development project using a mixed methods design. Increasing the use of mixed methods is likely to optimally improve the effectiveness of future community-based evaluations because they provide a greater range of relevant data [11, 84]: quantitative analysis can provide rigorous methods to evaluate the effectiveness and costs of projects, while qualitative data can capture community members’ experiences [85] and help identify the project elements that are most acceptable to community members [11].
The critical appraisal also identified a lack of detailed reporting of the methodologies used, especially in relation to the qualitative evaluations. Only 41 % of the qualitative studies reported on their data collection process, for example, and only 24 % reported the data analysis methods that were used. Future Indigenous community development evaluations would benefit from more detailed reporting using established guidelines, such as the COREQ criteria for qualitative research [86] or the guidelines recommended by the Equator Network [87]. In addition to improving reporting standards, using these guidelines in the development, implementation and evaluation phases of community development projects would most likely improve the quality of the interventions and their evaluation [37, 38].
Outcomes of indigenous community development projects
There is currently insufficient evidence about the impact of community development projects on health and wellbeing outcomes for Indigenous Australians. Although all reviewed studies reported positive outcomes for the communities, they are not methodologically rigorous enough to support clear conclusions about their cost-effectiveness, and no studies have undertaken an economic analysis to weigh the benefits of community development against its costs. This finding is highly consistent with the conclusions of similar reviews of international Indigenous community development studies, where generally positive outcomes are difficult to interpret because of the relatively poor quality of their evaluation designs and reporting [9, 19, 88]. Published results of community-based evaluations with greater methodological quality are required to provide evidence of cost-effective community development projects [9, 74]. Ideally, future studies would use rigorous evaluation designs, reliable, valid and culturally appropriate measures, economic analysis and a complex intervention framework to balance standardisation and tailoring.
Strengths and limitations
To ensure that qualitative and quantitative study components were assessed against appropriate criteria the Dictionary for Effective Public Health Practice Project Quality Assessment tool [38] was used to assess the methodological quality of quantitative components and an adaptation of the qualitative study appraisal tool, developed by Long and Godfrey [37] was used for the qualitative study components. The methodological quality of the studies and extent of community participation may have been misclassified, however the high level of agreement between blinded coders suggest not. Of the 231 full-text articles sought for detailed review, 40 (17 %) were excluded because the full text version of these papers were unable to be accessed. Excluding these 40 papers is unlikely to have compromised the comprehensiveness of this review for three reasons: 1) they only represent 17 % of the full-text articles; 2) the majority were older studies or reports that were not publically available; and 3) the references lists of identified publications were hand searched and researchers in the field were consulted to identify publications not found by the electronic database search.
Conclusion
This systematic review identified that levels of community participation fluctuate across community development project phases: moderate in the Diagnosis and Development phases, high in the Implementation phase, but low in the Evaluation phase. It also identified that the methodological quality of studies evaluating Australian Indigenous community development projects is too weak to confidently determine the cost-effectiveness of these projects in improving the health and wellbeing of Indigenous Australians. Studies of greater methodological quality are required to accurately assess the impact of community development projects. Partnerships combining researchers’ expertise and community members’ skills and knowledge have great potential to improve methodological quality and community participation in Indigenous community development projects [9, 11, 89].
Declarations
Acknowledgements
The authors gratefully acknowledge the NDARC Education Trustees for funding the PhD candidature of MS. We thank New South Wales Health for funding the Maldahnalanga project, of which this review is a part. We also gratefully acknowledge the Post-Doctoral Research funding from the Northern Research Futures Collaborative Research Network of ASt. We also gratefully acknowledge the input from the Aboriginal community-based partners who are part of the Maldahnalanga project.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Authors’ Affiliations
(1)
National Drug and Alcohol Research Centre (NDARC), UNSW
(2)
Public Health and Society, Department of Social Sciences, Wageningen University and Research Centre (WUR)
(3)
The Northern Research Futures Collaborative Research Network, The Cairns Institute, James Cook University (JCU)
(4)
National Centre for Epidemiology and Population Health, Research School of Population Health, College of Medicine, Biology and Environment, Australian National University
References
Vos T, Barker B, Begg S, Stanley L, Lopez A. Burden of disease and injury in Aboriginal and Torres Strait Islander Peoples: the Indigenous health gap. Int J Epidemiol. 2009;38(2):470–7.View ArticlePubMedGoogle Scholar
Steering Committee for the Review of Government Service Provision. Overcoming indigenous disadvantage. Key indicators. Melbourne: Commonwealth of Australia; 2011.Google Scholar
ABS (Australian Bureau of Statistics). The health and welfare of Australia’s Aboriginal and Torres Strait Islander peoples, 2010, in cat. no. 4704.0. Canberra: ABS; 2010.Google Scholar
Calabria B, Clifford A, Shakeshaft AP, Doran CM. A systematic review of family-based interventions targeting alcohol misuse and their potential to reduce alcohol-related harm in indigenous communities. J Stud Alcohol Drugs. 2012;73(3):477–88.View ArticlePubMedGoogle Scholar
Clifford A, Pulver LJ, Richmond R, Shakeshaft A, Ivers R. Smoking, nutrition, alcohol and physical activity interventions targeting Indigenous australians: Rigorous evaluations and new directions needed. Aust N Z J Public Health. 2011;35(1):38–46.View ArticlePubMedGoogle Scholar
Power J, Grealy C, Rintoul D. Tobacco interventions for Indigenous Australians: a review of current evidence. Health Promot J Austr. 2009;20(3):186–94.PubMedGoogle Scholar
McCalman J, Tsey K, Clifford A, Earles W, Shakeshaft A, Brainbridge R. Applying what works: a systematic search of the transfer and implementation of promising Indigenous Australian health services and programs. BMC Public Health. 2012;12:600–7.View ArticlePubMedPubMed CentralGoogle Scholar
Paul C, Sanson-Fisher R, Stewart J, Anderson A. Being sorry is Not enough. The sorry state of the evidence base for improving the health of indigenous populations. Am J Prev Med. 2010;38:556–8.Google Scholar
Campbell D, Pyett P, McCarthy L. Community development interventions to improve aboriginal health: building an evidence base. Health Sociol Rev. 2007;16(3–4):304–14.View ArticleGoogle Scholar
Clifford A, Doran C, Tsey K. A systematic review of suicide prevention interventions targeting indigenous peoples in Australia, United States, Canada and New Zealand. BMC Public Health. 2013;13(1):463.View ArticlePubMedPubMed CentralGoogle Scholar
Mikhailovich K, Morrison P, Arabena K. Evaluating Australian Indigenous community health promotion initiatives: a selective review. Rural Remote Health. 2007;7(2):746.PubMedGoogle Scholar
Morris PS. Randomised controlled trials addressing Australian Aboriginal health needs: A systematic review of the literature. J Paediatr Child Health. 1999;35(2):130–5.PubMedGoogle Scholar
National Health & Medical Research Council. Values and ethics: guidelines for ethical conduct in Aboriginal and Torres Strait Islander health research.Google Scholar
Jamieson LM, Paradies YC, Eades S, Chong A, Maple-Brown L, Morris P, et al. Ten principles relevant to health research among Indigenous Australian populations. Med J Aust. 2012;197(1):16.View ArticlePubMedGoogle Scholar
Aboriginal Health and Medical Research Council Ethics Committee. AH&MRC Guidelines for Research into Aboriginal Health: Key principles. Sydney: Aboriginal Health and Medical Research Council of New South Wales; 2013.Google Scholar
WHO. Preamble to the Constitution of the World Health Organization, in International Health Conference. 1948: New York: World Health Organisation.Google Scholar
WHO. Ottawa Charter for Health Promotion. in First International Conference on Health Promotion. 1986. Ottawa: World Health Organisation.Google Scholar
World Health Organization. Evaluation in Health Promotion: Principles and Perspectives. WHO Regional Publications European Series, vol. 92. Denmark: World Health Organisation; 2001.Google Scholar
O’Mara-Eves A, Brunton G, McDaid S, Oliver S, Kavanagh J, Jamal F, et al. The effectiveness of community engagement in public health interventions for disadvantaged groups: a meta-analysis. BMC Public Health. 2015;15(1):129.View ArticlePubMedPubMed CentralGoogle Scholar
Haswell-Elkins M, Lyndon R, Fagan R, Ypinazar V, Hunter E, Tsey K, et al. Listening, sharing understanding and facilitating consumer, family and community empowerment through a priority driven partnership in Far North Queensland. Australas Psychiatry. 2009;17 Suppl 1:S54–8.View ArticlePubMedGoogle Scholar
Hunt J, Smith D, Garling S, Sanders W. Contested governance: culture, power and institutions in Indigenous Australia. in CAEPR research monograph. Canberra: ANU E Press; 2008.Google Scholar
Schnarch B. Ownership, control, access, and possession (OCAP) or self-determination applied to research. J Aborig Health. 2004;1(1):80–95.Google Scholar
Hunt J. Engagement with Indigenous Australia - exploring conditions for effective relationships with Aboriginal and Torres Strait Islander communities. In: Clearinghouse CTG, editor. Issues paper. Canberra: Australian Institute for Health and Welfare; Australian Institute for Family Studies; 2013.Google Scholar
Burchill M, Higgins D, Ramsamy L, Taylor S. ‘Workin’ together’: Indigenous perspectives on community development/Marlene Burchill, Daryl Higgins, et. al., D.J. Higgins, Editor. 2006.Google Scholar
Sherwood J. What is community development/by Jaunita Sherwood. 1999.Google Scholar
Lea DAM, Wolfe JS. Community development planning and Aboriginal community control. Casuarina: Australian National University, North Australia Research Unit; 1993.Google Scholar
Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gøtzsche PC, Ioannidis JPA, et al. The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration. PLoS Med. 2009;6(7):e1000100.View ArticlePubMedPubMed CentralGoogle Scholar
Ife J. Community Development: community-based alternatives in an age of globalisation. French Forest NSW: Pearson Education Australia Pty Limited; 2002.Google Scholar
Hunt J. Strengthening indigenous community governance for sustainability: Using indigenous principles in a community development approach, in community development and ecology: Engaging ecological sustainability through community development. Melbourne: Deakin University; 2008.Google Scholar
Sanson-Fisher RW, Campbell EM, Perkins JJ, Blunde, SV, Davis BB. Indigenous health research: A critical review of outputs over time. Med J Aust. 2006;184(8):502.PubMedGoogle Scholar
Wagemakers A, Corstjens R, Koelen M, Vaandrager L, van't Riet H, Dijkshoorn H. Participatory approaches to promote healthy lifestyles among Turkish and Moroccan women in Amsterdam. Promot Educ. 2008;15(4):17–23.View ArticlePubMedGoogle Scholar
Wagemakers A, van Husen G, Barrett JB, Koelen MA. Amsterdam’s STI/HIV programme: An innovative strategy to achieve and enhance the participation of migrant community-based organisations. Health Education Journal. 2014; 74(4): p. 0017896914542665.Google Scholar
Pretty JN. Participatory learning for sustrainable agriculture. World Dev. 1995;23(8):1247–63.View ArticleGoogle Scholar
Butterfoss FD. Process evaluation for community participation. Annu Rev Public Health. 2006;27:323–40.View ArticlePubMedGoogle Scholar
Nitsch M, Waldherr K, Denk E, Griebler U, Marent B, and Forster R. Participation by different stakeholders in participatory evaluation of health promotion: A literature review. Eval Program Plann. 2013;40:42–54.View ArticlePubMedGoogle Scholar
Long AF, Godfrey M. An evaluation tool to assess the quality of qualitative research studies. Int J Soc Res Methodol. 2004;7(2):181–96.View ArticleGoogle Scholar
Effective Public Health Practice Project. Quality Assessment Tool for Quantitative Studies Dictionary. 2009. Available from: http://www.ephpp.ca/PDF/QADictionary_dec2009.pdf. accessed: 21/11/2015.
Tsey K, Wenitong M, McCalman J, Whiteside M, Baird L, Patterson D, et al. A participatory action research process with a rural Indigenous men’s group: monitoring and reinforcing change. Aust J Prim Health. 2004;10(3):130–6.View ArticleGoogle Scholar
Gauld S, Smith S, Kendall MB. Using participatory action research in community-based rehabilitation for people with acquired brain injury: from service provision to partnership with Aboriginal communities. Disabil Rehabil. 2011;33(19–20):1901–11.View ArticlePubMedGoogle Scholar
Murphy L, Kordyl P, Thorne M. Appreciative inquiry: a method for measuring the impact of a project on the well-being of an Indigenous community. Health Promot J Austr. 2004;15(3):211–4.Google Scholar
Lee KS, Conigrave KM, Clough AR, Wallace C, Silins E, Rawles J. Evaluation of a community-driven preventive youth initative in Arnhem Land, Northern Territory. Australia Drug and Alcohol Review. 2008;27(1):75–82.View ArticlePubMedGoogle Scholar
Tyrrell M, Grundy J, Lynch P, Wakerman J. Laramba Diabetes Project: an evaluation of a participatory project in a remote Northern Territory community. 2003. p. 48–53.Google Scholar
Salisbury C. A health service and community partnership utilising action research for the development of Aboriginal and Torres Strait Islander services. 1997.Google Scholar
Moran MF. An evaluation of participatory planning at Mapoon aboriginal community: Opportunities for inclusive local governance. Aust Aborig Stud. 2003;2:72–84.Google Scholar
Jarvie W. Working differently to make a difference to Indigenous communities. Public Administration Today. 2008;14:5–13.Google Scholar
Shannon C, Canuto C, Young E, Craig D, Schluter P, Kenny G, et al. Injury prevention in indigenous communities: results of a two-year community development project. Health Promot J Austr. 2001;12(3):233–7.Google Scholar
Parker E, Meiklejohn B, Patterson C, Edwards K, Preece C, Shuter P, et al. Our games our health: a cultural asset for promoting health in Indigenous communities. Health Promot J Austr. 2006;17(2):103–8.PubMedGoogle Scholar
McMurray L. The Women’s Development Project: Indigenous Australia Program: evaluation report. 2012: p. 109.Google Scholar
Hunt J. Casestudy 1: The partners - Oxfam Australia and Yorgum Aboriginal Operation. In: Hunt J, editor. Partnerships for indigenous development: Internation development NGOs, aboriginal organisations and communities. Canberra: Centre for Aboriginal Economic Policy Research; 2010.Google Scholar
Central Land Council. The warlpiri education and training trust (WETT). In: Kelly L, editor. 2011 report on the central land council community development program. Alice Springs: Central Land Council; 2012.Google Scholar
Higgins D. Jarjum youth group. In: Higgins D, editor. Early learnings Telstra foundation research report volume 2: Indigenous community development projects and early learnings. Melbourne: Telstra Foundation; 2005.Google Scholar
Smith D. Community action to promote child growth in Gapuwiyak: final report on a participatory action research project/Danielle Smith. Casuarina: Cooperative Research Centre for Aboriginal Health; 2004.Google Scholar
McCalman J, Tsey K, Wenitong M, Patterson D, Baird B, Warta D, et al. “No more bandaid solution”: Yaba bimbie indigenous Men’s support group evaluation report: January 2004-june 2005. Cairns: James Cook University; 2005.Google Scholar
Bromfield L, Burchill M. Soaring: Kurruru indigenous youth performing arts. In: Higgins D, editor. Early learnings Telstra foundation research report volume 2: Indigenous community development projects and early learnings. Melbourne: Telstra Foundation; 2005.Google Scholar
Taylor S. Torres strait paediatric asthma education. In: Higgins D, editor. Early learnings Telstra foundation research report volume 2: Indigenous community development projects and early learnings. Melbourne: Telstra Foundation; 2005.Google Scholar
Ramsay L. Keeping kids health makes a better world. In: Higgins D, editor. Early learnings Telstra fondation rsearch report volume 2: Indigenous community development projects and early learnings. Melbourne: Telstra Foundation; 2005.Google Scholar
Guenther J. Evaluation of FAST Galiwin’ku program. Ulverstone: Cat Conatus; 2011.Google Scholar
Hunt J. Casestudy 2: ThePartners - caritas Australia and centacare WIlcannia-forbes. In: Hunt J, editor. Partnerships for indigenous development: Internation development NGOs, ABoriginal organisations and communities. Canberra: Centre for ABoriginal Economic Policy Research; 2010.Google Scholar
Central Land Council. The granites mine affected areas aboriginal corporation project (GMAAAC). In: Kelly L, editor. Report on the central land council community development program. Alice Springs: Central Land Council; 2012.Google Scholar
Central Land Council. The Tanami dialysis project. In: Kelly L, editor. 2011 report on the central land council community development program. Alice Springs: Central Land Council; 2012.Google Scholar
Central Land Council. The Uluru-Kata Tjuta Rent Money Project (URM). In: Kelly L, editor. 2011 report on the central land council community development program. Alice Springs: Central Land Council; 2012.Google Scholar
Central Land Council. Northern territory parks rent money project. In: Kelly L, editor. 2011 report on the central land council community development program. Alice Springs: Central Land Council; 2012.Google Scholar
Taylor S. Traditional indigenous games. In: Higgins D, editor. Early learnings Telstra foundation research report volume 2: Indigenous community development projects and early learnings. Melbourne: Telstra Foundation; 2005.Google Scholar
Burchill M, Bromfield L, Higgins D. Ara Irititja Archival Project: knowing the past to strengthen our future. In: Higgins D, editor. Early learnings Telstra foundation research report volume 2: Indigenous community development projects and early learnings. Melbourne: Telstra Foundation; 2005.Google Scholar
Ramsay L. Cape york youth network. In: Higgins D, editor. Early learnings Telstra foundation research report volume 2: Indigenous community development projects and early learnings. Melbourne: Telstra Foundation; 2005.Google Scholar
Green MJ, Sonn C. In: Sonn CC, editor. Drawing out community empowerment through arts and cultural practice: final report. Perth: Community Arts Network WA; 2009.Google Scholar
Ramsay L. Children’s picture dictionairies. In: Higgins D, editor. Early learnings Telstra foundation research report volume 2: Indigenous community development projects and early learnings. Melbourne: Telstra Foundation; 2005.Google Scholar
Tsey K, Deemal A, Whiteside M, Gibson T. “It’s an eye-opener for people to see you can change things”: an evaluation of a ‘family wellbeing’ personal and community development pilot project in two Cape York communities. 2003.Google Scholar
Wang C, Burris MA. Photovoice: Concept, methodology, and use for participatory needs assessment. Health Educ Behav. 1997;24(3):369–87.View ArticlePubMedGoogle Scholar
Israel BA, Schultz AJ, Parker EA, Becker AA, Allen AJ, Guzman JR. Critical issues in developing and following CPBR Principles, in Community-Based Participatory Research for Health 2nd edition, M. Minkler and N. Wallerstein, Editors., Jossey-Bass: San Fransisco: 2008.Google Scholar
Esler DM. Participatory action research in indigenous health. Aust Fam Physician. 2008;37(6):457–9.PubMedGoogle Scholar
Craig P, Dieppe P, Macintyre S, Michie S, Nazareth I, Petticrew M. Developing and evaluating complex interventions: The new medical research council guidance. BMJ. 2008;337:a1665.Google Scholar
Bonell CP, Hargreaves J, Cousens S, Ross D, Hayes R, Petticrew M, et al. Alternatives to randomisation in the evaluation of public health interventions: design challenges and solutions. J Epidemiol Community Health. 2011;65(7):582–7.View ArticlePubMedGoogle Scholar
Bowling A, Ebrahim S. Handbook of research methods in health: Investigation, measurement and analysis. Milton Keynes: Open University Press; 2005.Google Scholar
Lock M. Aboriginal holistic health: A critical review, in cooperative research centre for aboriginal health discussion paper series. Casuarina: Cooperative Research Centre for Aboriginal Health; 2007.Google Scholar
Deady M. A review of screening, assessment and outcome measures for drug and alcohol settings. Sydney: Network of Alcohol and other Drug Agencies (NADA); 2009.Google Scholar
Calabria BCA, Shakeshaft A, Conigrave KM, Simpson L, Bliss D, Allan J. Identifying Aboriginal-specific AUDIT-C and AUDIT-3 cut off scores for at risk, high risk and likely dependent drinkers using measures of agreement with the 10-item AUDIT. Addict Sci Clin Pract. 2014;9:17.View ArticlePubMedPubMed CentralGoogle Scholar
Stephens A, Graham D, Clough AR. Screening and assessment instruments for use in Indigenous-specific alcohol and drug treatment rehabilitation. Journal of Tropical Psychology. 2013;3:e2.View ArticleGoogle Scholar
Haswell MR, Kavanagh D, Tsey K, Reilly L, Cadet-James Y, Laliberte A, et al. Psychometric validation of the Growth and Empowerment Measure (GEM) applied with Indigenous Australians. Aust N Z J Psychiatry. 2010;44(9):791–9.View ArticlePubMedGoogle Scholar
Schlesinger CM, Ober C, McCarthy MM, Watson JD, Seinen A. The development and validation of the Indigenous Risk Impact Screen (IRIS): A 13-item screening instrument for alcohol and drug and mental health risk. Drug Alcohol Rev. 2007;26:109–17.View ArticlePubMedGoogle Scholar
Thomas A, Cairney S, Gunthorpe W, Paradies Y, Sayers S. Strong Souls: development and validation of a culturally appropriate tool for assessment of social and emotional well-being in Indigenous youth. Aust N Z J Psychiatry. 2010;44(1):40–8.View ArticlePubMedGoogle Scholar
Campbell M, Fitzpatrick R, Haines A, Kinmonth AL, Sandercock P, Spiegelhalter D, et al. Framework for design and evaluation of complex interventions to improve health. 321. 2000. 694–696.Google Scholar
Davies H, Nutley SM. Healthcare: Evidence to the fore. In: Daves H, Nutley SM, Smith PC, editors. What works? Bristol: Policy Press; 2004.Google Scholar
Tong A, Sainsbury P, Craig J. Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups. Int J Qual Health Care. 2007;19(6):349–57.View ArticlePubMedGoogle Scholar
The EQUATOR network. Enhancing the QUAlity and Transparency Of Health Research. 2015 [cited 2015 23 October]; Available from: http://www.equator-network.org/. accessed 21/11/2015.
Milton B, Attree P, French B, Povall S, Whitehead M, Popay J. The impact of community engagement on health and social outcomes: a systematic review. Community Development Journal. 2012;47(3):316–34.View ArticleGoogle Scholar
Roussos ST, Fawcett SB. A review of collaborative partnerships as a strategy for improving communit health. Annu Rev Public Health. 2000;21:369–402.View ArticlePubMedGoogle Scholar
