Risky alcohol and other drug (AOD) use is of significant concern to Indigenous populations worldwide.1 In Australia, recent surveys indicate that the proportions of Aboriginal and Torres Strait Islander (herein: Indigenous Australians) and non-Indigenous Australians drinking alcohol at levels that pose a lifetime risk of harm are similar.2 However, the available evidence indicates that the frequency of risky single-session consumption, posing a risk of both short- and long-term harm, is greater amongst Indigenous Australians.3 According to the most recent burden of disease data, mental and substance use disorders contribute the largest proportion (19%) of all chronic disease groups to the overall burden of disease.4 The harm associated with problematic AOD use is preventable, and thus effective community-based prevention and treatment programs can play a significant role in reducing the overall burden of disease for Indigenous peoples.
Factors that contribute to problematic AOD consumption in Indigenous populations internationally include economic marginalization, discrimination, cultural dispossession, cultural assimilation, family conflict and violence, and a family history of alcohol abuse.2,5 In a comprehensive examination of alcohol use in Indigenous communities in Australia, New Zealand and Canada, Saggers and Gray5 concluded that Indigenous alcohol use cannot be extricated from the comparable experiences of European colonization and the associated political and economic outcomes. All three countries were part of a British Empire in which indigenous people were economically and politically marginalized. Indigenous people of Australia, New Zealand and Canada have comparable discrepancies with non-Indigenous communities in rates of incarceration, high school completion and life expectancy.5 In a study that provided an Indigenous Australian adaptation of the World Health Organization's Alcohol Use Disorders Identification Test, Conigrave et al.6 succinctly summarized the risk factors for risky drinking behaviors as being associated with recurrent trauma, loss and disempowerment, coupled with high rates of unemployment and social disconnection.
It is estimated that illicit drug use alone is responsible for 3.4% of the overall burden of disease for Indigenous Australians. Cannabis use has been linked to poor mental health outcomes including anxiety, depression and psychosis, and illicit drug use has been identified as a major risk factor for suicide.7 High risk injecting practices lead to increases in and increased risk of developing hepatitis C and human immunodeficiency virus (HIV) within Indigenous communities in Australia.8 The social impacts of alcohol and drug use by Indigenous Australians are of significant concern, with AOD use considered a major factor for harms to children and family. Indigenous Australians who engage in illicit drug use are twice as likely to be victims of violence than those who do not engage in use. A significant proportion of Indigenous Australians entering the prison system in 2010 reported illicit drug use in the previous 12 months, which is of concern, as problematic drug and alcohol use is considered a risk factor for re-offending.7
In 2008, Jiwa et al.9 synthesized findings on 34 community-based programs in Indigenous communities in Canada, New Zealand, USA and Australia. While the authors acknowledged a paucity of outcome data available for evaluation, they did identify four components of an intervention that were drivers of success. The components of success included strong leadership, strong community member engagement, program development and organization by a paid staff member, and an ability to develop infrastructure for long term program sustainability. More recently, a systematic review of community-based interventions designed to reduce substance use in young Indigenous Australians aged eight to 25 years identified that two out of four of the evaluated programs that demonstrated reductions in use had components that included cultural activities and strong community support.10 The researchers acknowledged that further systematic evaluation of prevention and treatment programs for young Indigenous Australians is needed. This review will focus on community-based interventions which is a demonstrated factor associated with success in previous studies. It will aim to increase the pool of available research evidence by considering all age groups and examining the international evidence.
This review sits within a larger research project that has been developed in response to deep concerns about the use of methamphetamine in Aboriginal and Torres Strait Islander communities in Australia, entitled “Novel Interventions to Address Methamphetamine in Aboriginal and Torres Strait Islander Communities”. The findings of this systematic review will inform the development of culturally acceptable and appropriate community-led interventions to address methamphetamine use within Indigenous communities in Australia. The inclusion of Indigenous participants from New Zealand and Canada for this review will broaden the understanding of community-based interventions and use international evidence for the practical application of knowledge translation and program development.
A preliminary search conducted in PubMed, Cochrane Library and EPISTEMONIKOS indicated that there is no existing systematic review protocols or published reviews on this topic.
The review will consider studies that include Indigenous participants from Australia, New Zealand and Canada. All ages and genders will be included. Studies that include non-Indigenous participants will also be included as long as the majority of participants are Indigenous, or results for Indigenous participants are reported separately.
This review will consider studies that evaluate the effectiveness of community-based interventions developed to reduce harmful AOD use in Indigenous populations in Australia, New Zealand and Canada. For the purpose of this review, a community-based intervention is defined as any intervention that targets prevention, treatment or aftercare that takes place in one's home community. It may be delivered by anybody and there are no limits to frequency or duration of intervention. This definition is consistent with a prior review of community-based alcohol substance abuse programs.9 Studies that evaluate medically led interventions or that occur in an inpatient facility in which participants are required to leave their community will be excluded from the review.
All health care programs or broader model alternatives will be considered, including comparisons with no intervention, non-Indigenous people or all ethnicities in Australia, New Zealand and Canada.
This review will consider studies that report outcome measures relevant to social, physical, psychological or cultural health and wellbeing. The primary outcomes will be: change rate of harmful alcohol use and change in the rate of illicit drug use, as measured by evaluation surveys in the target communities. Secondary outcomes will include, but not be limited to: change in help-seeking behaviors, motivation to change, social functioning, cultural wellbeing and/or physical or mental health status as measured by valid survey measures or psychometric instruments. All measures for the range of included outcomes will be considered and where relevant, limitations of the measures used will be reported, for example, where an instrument has not been validated for use in Indigenous populations.
Types of studies
This review will consider both experimental and quasi-experimental study designs including randomized controlled trials, non-randomized controlled trials, before and after studies and interrupted time-series studies. In addition, analytical observational studies including prospective and retrospective cohort studies, case-control studies and analytical cross-sectional studies will be considered for inclusion. This review will also consider descriptive observational study designs including case series, individual case reports and descriptive cross-sectional studies for inclusion. Studies published in English since 2006 will be included. This timeframe covers the decade following the review by Jiwa et al.9 on a similar topic.
The search strategy will aim to find both published and unpublished studies. An initial limited search of PubMed, JBI Database of Systematic Reviews and Implementation Reports (JBISRIR), Cochrane Library, Epistemonikos and CINAHL has been undertaken followed by analysis of the text words contained in the title and abstract, and of the index terms used to describe each relevant article. This informed the development of a search strategy which will be tailored for each information source. A full search strategy for PubMed is detailed in Appendix I. The reference list of all studies selected for critical appraisal will be screened for additional studies. Databases to be searched will include: PubMed, PsycINFO, CINAHL, Scopus and Embase. The search for unpublished studies will include: Health Informit, Google Scholar and Native Web. The search strategy was developed in collaboration with a research librarian from the University of Adelaide to ensure all relevant studies will be captured for review.
Following the search, all identified citations will be collated and uploaded into Endnote (Clarivate Analytics, PA, USA) and duplicates removed. Titles and abstracts will then be screened by two independent reviewers for assessment against the inclusion criteria for the review. Studies that meet or could potentially meet the inclusion criteria will be retrieved in full and their details imported into the Joanna Briggs Institute System for the Unified Management Assessment and Review of Information (JBI SUMARI).11 The full text of selected studies will be retrieved and assessed in detail against the inclusion criteria. Full text studies that do not meet the inclusion criteria will be excluded and reasons for exclusion will be provided in an appendix in the final systematic review report. Included studies will undergo a process of critical appraisal. The results of the search will be reported in full in the final report and presented in a PRISMA flow diagram. Any disagreements that arise between the reviewers will be resolved through discussion, or with a third reviewer.
Assessment of methodological quality
Selected studies will be critically appraised by two independent reviewers for methodological quality using the standardized critical appraisal instruments from the Joanna Briggs Institute for experimental and quasi-experimental studies.11 Studies will also be appraised for ethical engagement with Indigenous communities using the Guidelines for Ethical Research in Australian Indigenous Studies.12 Any disagreements that arise will be resolved through discussion, or with a third reviewer. All studies, regardless of their methodological quality, will undergo data extraction and synthesis (where possible). Studies with methodological limitations will be included to recognize that community-based researchers may not have the resources or knowledge to develop rigorous methodologies and that these studies may still deliver meaningful and important data for inclusion in the review.
Data will be extracted from papers included in the review using the standardized data extraction tool available in JBI SUMARI by two independent reviewers (TS, RR). The data extracted will include specific details about the interventions, populations, study methods including both impact and process evaluation methods, and outcomes of significance to the review objectives. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer (JW). Authors of papers will be contacted to request missing or additional data where required.
Papers will, where possible, be pooled in statistical meta-analysis using JBI SUMARI. Effect sizes will be expressed as either odds ratios (for dichotomous data) or weighted (or standardized) mean differences (for continuous data), and their 95% confidence intervals will be calculated for analysis. Heterogeneity will be assessed statistically using the standard chi-squared and I squared tests. The choice of model (random or fixed effects) and method for meta-analysis will be based on the guidance by Tufanaru et al.13 Subgroup analyses will be conducted where there is sufficient data to investigate variation between groups based on gender, age-group or geographical location, for example. Sensitivity analyses will be conducted to test the impact of decisions made during the review process.14 Where statistical pooling is not possible, the findings will be presented in narrative form including tables and figures to aid in data presentation where appropriate.
A Summary of Findings will be created using GRADEPro GDT software. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach for grading the quality of evidence will be followed. The Summary of Findings will present the following information where appropriate: absolute risks for treatment and control, estimates of relative risk, and a ranking of the quality of the evidence based on study limitations (risk of bias), indirectness, inconsistency, imprecision, and publication bias. Primary and secondary outcomes will be included in the Summary of Findings.
We thank Professor Anna Chur Hansen for her support and encouragement, Ms. Maureen Bell for her patient assistance with the search strategy and Ms. Kathleen Brodie for her practical assistance.
This project is supported by a National Health and Medical Research Council (NHMRC) Project Grant (#1100696).
Appendix I: Initial search strategy
- 1. Community-based participatory research[mh] OR communit∗[tiab] OR consumer driven[tiab] OR participatory[tiab] OR Program development[mh] OR harm reduction[tiab] OR prevention[tiab] OR health promotion[tiab] OR strengths-based[tiab] OR service delivery[tiab] OR rehab∗[tiab] OR psycholog∗[tiab] OR counselling[tiab] OR support∗[tiab] OR aftercare[tiab] OR treatment∗[tiab] OR Program Evaluation[mh]
- 2. Substance-related disorders[mh] OR methamphetamine∗[tiab] OR alcohol∗[tiab] OR drug∗[tiab] OR ice[tiab] OR meth[tiab] OR grog[tiab] OR amphetamine∗[tiab] OR heroin[tiab] OR inhalant∗[tiab] OR marijuana[tiab] OR morphine[tiab] OR buprenorphine[tiab] OR methadone[tiab] OR speed[tiab] OR crystal[tiab] OR LSD[tiab] OR ecstacy[tiab] OR cocaine[tiab] OR GHB[tiab] OR MDMA[tiab] OR ketamine[tiab] OR solvent∗[tiab] OR cannabis[tiab] OR opiod[tiab] OR opiate∗[tiab] OR narcotic∗[tiab] OR illicit[tiab] OR binge drink∗[tiab] OR addict∗[tiab] OR risky behaviour∗[tiab] OR (drug[tiab] OR abuse[tiab]) OR injecting[tiab] OR overdose[tiab] OR Needle Sharing[mh] OR intoxicat∗[tiab] OR (drug[tiab] OR dependence[tiab]) OR withdrawal[tiab]
- 3. (Oceanic Ancestry Group[mh] OR (Aborig[tw] OR Indigen[tw] OR (Torres Strait[tw] AND Islander[tw]) OR health services, indigenous[mh] OR koori[tw] OR tiwi[tw])) AND (.au[ad] OR australia[ad] OR Australia[mh] OR Australia[tiab] OR Northern Territory[tiab] OR Northern Territory[ad] OR Tasmania[tiab] OR Tasmania[ad] OR New South Wales[tiab] OR New South Wales[ad] OR Victoria[tiab] OR Victoria[ad] OR Queensland[tiab] OR Queensland[ad]) OR Native American[tiab] OR aborig[tiab] OR Maori[tiab] OR (indigenous[tiab] AND new zealand[tiab]) OR Indians, North American[mh] OR Inuits[mh] OR Inuit[tiab] OR first nation[tiab] OR metis[tiab]
- 4. S1 + S2 + S3
1. Munro A, Allan J. Can family-focussed interventions improve problematic substance use in Aboriginal communities? A role for social work. Aust Social Work
2011; 64 2:169–182.
2. Australian Institute of Health and Welfare. Substance use among Aboriginal and Torres Strait Islander People. Canberra: AIHW; 2011.
3. Australian Institute of Health and Welfare. The health and welfare of Australia's Aboriginal and Torres Strait Islander peoples. Canberrra: AIHW; 2015.
4. Australian Institute of Health and Welfare. Impact and cause of illness and death in Australia 2011. Canberra: AIHW; 2011.
5. Saggers S, Gray D. Dealing with Alcohol: Indigenous usage in Australia, New Zealand and Canada. New York: Cambridge University Press; 1998.
6. Conigrave K, Freeman B, Caroll T, et al. The Alcohol Awareness project: community education and brief intervention in an urban Aboriginal setting. Health Prom J Aus
7. Australian Indigenous HealthInfoNet, MacRae A, Hoareau J. Review of illicit drug use among Aboriginal and Torres Strait Islander people. 2016.
8. Bryant J, Ward J, Wand H, et al. Illicit injecting drug use among Indigenous young people in urban, regional and remote Australia. Drug Alc Rev
2016; 35 4:447–455.
9. Jiwa A, Kelly L, St Pierre-Hansen N. Healing the community to heal the individual: literature review of aboriginal community-based alcohol and substance abuse programs. Canad Fam Phys
2008; 54 1000:21–27.
10. Lee K, Jagtenberg M, Ellis CM, et al. Pressing need for more evidence to guide efforts to address substance use among young Indigenous Australians. Health Prom J Aus
2013; 24 2:87–97.
11. The Joanna Briggs Institute. Joanna Briggs Institute Reviewers’ Manual: 2017 Edition. Adelaide: The Joanna Briggs Institute; 2017.
12. Australian Institute of Aboriginal and Torres Strait Islander Studies. Guidelines for Ethical Reserach In Australian Indigenous Studies. Canberra: AIATSIS; 2012.
13. Tufanaru C, Munn Z, Stephenson M, et al. Fixed or random effects meta-analysis? Common methodological issues in systematic reviews of effectiveness. Int J Evidence Based Healthcare
2015; 13 3:196–207.
14. Higgins PT, Green SE. Cochrane Handbook for Systematic Reviews of Interventions. Collaboration TC, editor. Great Britain: Wiley-Blackwell; 2011.