A systematic review of studies evaluating Australian indigenous community development projects: the extent of community participation, their methodological quality and their outcomes

Background 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.

Community participation has long been argued as being an essential factor in successful health promotion initiatives [16][17][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][21][22][23][24][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.

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].
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 2the community was only informed about the project); participation by information (score 3information was collected from the community without their participation and without providing feedback); participation by consultation (score 4information was collected from the community, feedback was given and further inclusion of community was sought); functional participation (score 5community collaboration, but on outsiders' terms); interactive participation (score 6collaboration on mutually defined terms); and self-mobilisation (score 7outsider'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.

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. 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. Community works together with outsiders to develop projects decided upon by the outsiders.

Participation by information
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.

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)
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.

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. 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 %) Possible 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] b Participation varied within the phase c Participation was somewhere in between these levels 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].

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 peerreviewed 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]. 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]

Position of researcher discussed
Generalised to other communities, implications for project described

Quality of evaluation methodology
In line with previous research [4][5][6][7][8][9][10][11][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][79][80][81][82][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 Table 4 Critical appraisal of qualitative components of studies evaluating Indigenous community development projects (n = 29) (Continued) Lee et al. (2008) [42] Detailed description Described Not described Generalised to communities with similar problems.      [47] Reduce injuries in the community 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).
reviewed studies reported positive outcomes for the communities, they are not methodologically rigorous enough to support clear conclusions about their costeffectiveness, 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].