The Impact of Heritage Tourism on Sustainable Community Development , Health and Wellbeing : A Systematic Review Protocol

This systematic review aims to understand the impact of heritage tourism on sustainable community development, including the health and wellbeing of local host communities. The protocol is guided by the Preferred Reporting Items for Systematic Reviews and MetaAnalyses Protocols (PRISMA-P) guidelines. It highlights the scope and methodology for the systematic review to be conducted. Studies will be included if they: (i) were conducted in English; (ii) were published between January 2000 and December 2018; (iii) used quantitative and/or qualitative methods; and (iv) analysed the impact of heritage tourism on sustainable community development and/or the health of local host communities. Data extraction will be informed by Cochrane Collaboration. The quality of evidence of the studies included will be assessed using validated tools. Findings will be summarised into themes and narrated. The systematic review will establish the impact of heritage tourism on sustainable community development including health and well-being. It also aims provide a theoretical framework which will inform recommendations to improve the life-worlds of local host communities and moderate any tensions between the expanding heritage reach of states and the maintenance of customary and traditional value systems, community governance structures, and associated community development and health benefits. Systematic review registration: This protocol is registered with the international prospective register of systematic reviews and meta-analysis (PROSPERO) with the registration reference


Background 1.1 Heritage, Tourism and Sustainable Development
Tourism has become a vital means of sustainable human development in many regions and countries.Tourism is one of the world's top creators of employment and a lead incomegenerator, especially for Global South countries (UNWTO, 2012).It generates significant revenue for local economies in payment for goods and services rendered to tourists, as well as employment opportunities in the service-sector of the economy (UNWTO, 2012).In 2011, tourism accounted for 30 per cent of the world's trade in services and 6 per cent of overall exports of goods and services (UNWTO, 2017).
Heritage tourism, as a significant sector of the tourism industry, is oriented towards showcasing the heritage of a tourism destination and contributes to global interchange and inter-cultural understanding.Here, the concept of 'heritage' refers to the intersecting forms of tangible heritage, such as buildings, monuments, and works of art; intangible heritage, including folklore, language, music, celebrations and traditions; and natural heritage, or culturally condensed landscapes and places of significant biodiversity (Ahmad, 2006).Heritage tourism places economic, political and cultural value on heritage resources and assets, providing additional reasons to conserve heritage in addition to the cultural imperatives for its maintenance (Leaver, 2012).By drawing upon the cultural and historical capital of a community, heritage tourism has the potential to contribute to the flourishing of local communities and their positive sustainable development.
The classic report Our Common Future, more commonly known as the Brundtland Report, defined sustainable development as 'development that meets the needs of the present without compromising the ability of future generations to meet their own needs' (Brundtland, 1987).This definition still works for many purposes.However, its meaning turns on the undefined implications of the word 'needs'.It leaves open the importance task of specifying cultural, political, economic and ecological needs -with health needs crossing all of those four domains.Drawing upon the Circles of Sustainability method (see Appendix 1), which is part of a broader approach to sustainability referred to as Circles of Social Life, we define 'positive sustainable development' as practices and meanings of human engagement that make for life-worlds that project the ongoing probability of natural and social flourishing, taking into account questions of vitality, relationality, productivity and sustainability (James, 2017).In considering broader questions of natural and social flourishing, all four domains are taken to be important, and thus, by the logic of the method, all four domains of social life are important for systematically understanding the impact of heritage tourism

Heritage Tourism and Health and its Significance
Most studies examining the impact of heritage tourism have predominantly focused on particular ecological impacts (Paul-Andrews, 2017), economic and cultural impacts (Jaganathan and Mohanraj, 2016;Kumar and Kumar, 2014) or political impacts (Montgomery, 2013).For example, such studies often illustrate that the preservation and conservation of historic, cultural, and natural resources combine with tourism to sustain local economies via increases in employment opportunities; the provision of a platform for profitable new business opportunities, investment in infrastructure, improving public utilities and transport infrastructures; and the protection of natural resources and the improvement of the quality of life for residents (Gnanapala and Sandaruwani, 2016).Thus, in a circle of social impact, heritage tourism has an impact upon vitality, relationality, productivity and sustainability of the locale across all four domains of social practice: ecology, economics, politics and culture.Akin to this, while studies of the impact of heritage tourism on health and wellbeing tend to focus on the travellers' wellbeing, including the travellers' health education and possible health treats, medical aspects of travel preparation, and health problems in returning tourists (Bauer, 1999), the range of considerations needs to go much further.It is now increasingly being recognised that host communities' health needs and wellbeing are also an intrinsic part of cultural heritage management and sustainable community development.
It has been hypothesised that the potential health implications of heritage tourism are either indirect or direct.Indirect effects are predominantly associated with health gains from heritage tourism-related economic, ecological, political, and cultural impacts.By contrast, health implications associated with direct impacts are closely associated with immediate encounters between tourism and people (Bauer, 2008).Yet, little is known of the overall generative effects of heritage tourism on sustainable community development, and the longterm health and wellbeing of local communities.Hence, this review will assess the impact of heritage tourism in these areas and aims to develop a framework that will inform future intervention geared towards maximising the benefits from heritage tourism for local communities while conserving cultural values.Understanding the relationship between heritage tourism and sustainable community development and health is essential in influencing policies aimed at improving overall livelihood in local host communities, as well as informing intervention strategies and knowledge advancement.This systematic review is necessary to summarise, synthesise and appraise existing literature on the impact of heritage tourism on sustainable community development of local host communities.

Review question
The systematic review will be guided by the following question: what are the impacts of heritage tourism on sustainable community development and the health and wellbeing of local host communities?

Study design
This review protocol is informed by the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) reporting guidelines (Moher et al., 2015) and will be performed following the PRISMA flowchart.In order to avoid duplication, Cochrane library and Google Scholar were initially searched to ensure there were no previous systematic reviews or meta-analyses on the impact of heritage tourism on sustainable community development and health of local host communities.This review will look at both quantitative and qualitative evidence including peer reviewed quantitative, qualitative and mixed methods studies and grey literature.The following criteria will be applied for inclusion:

Participants
Local populations residing within close proximity, or with strong connections (i.e.diaspora populations), to heritage sites will be considered in this review.However, any tourist populations visiting the same area will be excluded.

Intervention focus and design
Both published and unpublished literature will be considered for inclusion in this review.Intervention designs of interest will be intervention studies (both randomised controlled trials (RCTs) and quasi-experimental studies), observational studies (e.g., longitudinal studies, case-control and cross-sectional studies) as well as qualitative and mixed-methods studies.
The following criteria will be used for inclusion: (i) written in English; (ii) analysed the impact of heritage tourism on sustainable community development and health and wellbeing of local host communities; (iii) crossing the four content domains of economics, ecology, politics, and culture; and (iv) including research articles, dissertations, books, books chapters, working papers, technical reports including project documents and evaluation reports, discussion papers, and conference papers however editorials, reviews, letters to editors, commentaries and opinion pieces will be excluded (v) published between January 2000 and December 2018.The year 2000 has been selected as the baseline date due to the commencement of the Millennium Development Goals (MDGs), which form part of the United Nations Millennium Declaration, signed in September 2000.With the introduction of the MDGs, there was an increase in commitment from government and non-governmental organizations to support the aims of the MDGs by promoting the development of responsible, sustainable and universally accessible tourism (UNWTO, 2010).Studies will be excluded if they do not meet the above criteria.

Outcome of interest
The outcomes of interest of this review relate to the themes of sustainable community development and the overall health and wellbeing of local host communities.In this systematic review, sustainable community development is defined in terms of its two components: 'community sustainability' and 'development': Community sustainability is defined as the "long-term durability of a community as it negotiates changing practices and meanings across all the domains of culture, politics, economics and ecology" (James, Magee, Scerri, & Steger, 2015, pp. 21, 24).Development is defined as "social change -with all its intended or unintended outcomes, good and bad -that brings about a significant and patterned shift in the technologies, techniques, infrastructure, and/or associated life-forms of a place or people" (James, 2017, p. 44).To this, we add the question of whether the development is positive or negative.Thus, going beyond the Brundtland definition introduced earlier, positive sustainable development can be defined as practices and meanings of human engagement that make for lifeworlds that project the ongoing probability of natural and social flourishing, including good health.Health is defined as per the World Health Organisation as "overall well-being", and includes both physical and mental health (World Health Organisation, 2002).While there is no consensus on what wellbeing actually means, there is a general agreement that wellbeing encompasses positive emotions and moods (e.g., contentment, happiness), the absence of negative emotions (e.g., depression, anxiety) as well as satisfaction with life and positive functioning (CDC, 2019).Therefore, wellbeing in this systematic review is conceptualised according to Ryff's multidimensional model of psychological wellbeing, which includes six factors: autonomy; self-acceptance, environmental mastery, positive relationships with others; purpose in life, and personal growth (Ryff and Keyes, 1995).

Search strategy
The review search will involve the use of relevant search terms and sub-headings of keywords relating to the impact of heritage tourism on sustainable community development and the health and wellbeing of local host communities.A trial search of our selected databases found that there are no MeSH words for heritage and tourism.Therefore, multiple keywords will be performed to identify relevant articles.These keywords will be linked using "AND" and "OR" Boolean operators and subject heading truncations (*) will be applied where appropriate.The search terms have been developed and tested in ProQuest Central on Social Science Protocols, August 2019, 1-10.http://dx.doi.org/10.7565/ssp.2019.2655 5 22 November 2018.The following combination of search terms and keywords was used in the search.Search terms were slightly modified to suit each database.
("Heritage tourism" OR tourism OR "world heritage site" OR ecotourism OR "heritage based tourism" OR "cultural tourism" OR "diaspora tourism" OR "cultural heritage tourism" OR "cultural resource management" OR "cultural heritage management" OR "historic site") AND ("Health status" [MeSH] OR "health equity" OR health OR community health OR welfare OR wellbeing OR autonomy OR "self acceptance" OR "environmental mastery" OR "positive relationship" OR "purpose in life" OR "personal growth") AND ("sustainable development" [MeSH] OR sustainab* or "community development" or "local development" or "local community" or "Indigenous community") A comprehensive search of the following ten computerized bibliographic databases will be conducted: Where the full-texts of included articles cannot be accessed, corresponding authors will be contacted via mail or other means of communication (e.g., Research Gate) to obtain a copy.A further search of the bibliographical references of all retrieved articles will be conducted to capture relevant articles that might have been missed during the search but met the inclusion criteria.The search will also be complemented by citation tracking using Google Scholar.For the purpose of transparency and accountability, a search log will be kept and constantly updated to ensure that newly published articles are captured.

Data collection
Data retrieved from the various databases will be imported into an EndNote library and duplicates removed.A three-stage screening process will be followed during data extraction.Stage One involves removing duplicates.In Stage Two, the titles and abstracts will be screened for eligibility and relevance.In the final screening stage, full texts of selected abstracts from the second screening stage will be further reviewed for eligibility.Data collection will be independently carried out by two authors (NW and AY) and any discrepancy will be resolved by consultation with the third author (HS).

Data Extraction
Data to be extracted from eligible studies will include author, country of study, year of publication, study objective, design and setting, sampling and data collection method, community development outcome and health outcome, and which of the domains of social life -economics, ecology, politics and culture (and their subdomains) -the studies cover.This data extraction form is adapted from the Cochrane Collaboration (The Cochrane Public Health Group, 2011).

Quality Assessment
To account for the diversity in design and dissemination strategies (peer-reviewed vs nonpeer-reviewed) of included studies, the Cochrane Collaboration form will be complemented by the McMaster Critical Review Tool for quantitative and qualitative studies (McMaster University et al., 1998;McMaster University et al., 2007), mixed methods appraisal Tool for mixed methods (Pluye et al., 2011), and the AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) checklist for grey literature (Tyndall, 2010) to assess the risk bias and quality of included studies.Quality assessment will focus on the appropriateness of the study methodology in addressing research questions and objectives including the study design; recruitment, participant selection, and attrition rate; data collection and analysis methods; consideration of confounders, reporting of the findings, and the exploration of study limitations.The quality assessment will be carried out independently by two researchers (NW and AY) and any probable discrepancy between them will be resolved based on third expert opinion (AR and EW).Agreement will be assessed using Cohen's kappa statistics (McHugh, 2012).

Data Analysis
Due to the heterogeneity and variation of the studies to be reviewed -especially the study methods, measurements and outcomes -it might not be possible to determine the data synthesis methods prior.However, a narrative synthesis based on tables of ratings and frequencies will be appropriate.Common threads, subthemes and trends will be identified and extracted from both qualitative and quantitative narratives to generate insight on the relationship between heritage tourism sustainable community development and health.The narrative synthesis will adhere to the "Improving Conduct and Reporting of Narrative Synthesis of Quantitative Data" protocol for mixed methods studies (Campbell, Sowden, McKenzie, & Thomson, 2018) to increase reproducibility and transparency of our methods and the conclusions drawn from the studies.The primary author will summarise the study findings and narrate the emerging themes.The emerging themes will then be discussed with all authors for appropriateness of the content as well as for consistency.Should variables in the included studies be similarly defined, a meta-analysis will be possible with random effect models to account for variations and substantial heterogeneity (I2 > 50%) between studies (Borenstein, Hedges, & Rothstein, 2007).

Discussion
Heritage tourism has profound objectives within the context of sustainable development.These objectives include the conservation and management of heritage resources, accurate interpretation and showcasing of those resources, authentic visitor experiences, and proper use of revenues earned from heritage resources.However, heritage tourism should not only focus on the identification, management and protection of heritage resources but must also take into consideration the health impact of tourism on local communities and regions.With the rise in global heritage tourism, there is a need for government and non-government organizations to mitigate the negative impacts of heritage tourism on local host communities by exploring evidence-based research.This review will apply validated tools to synthesise evidence from the large body of knowledge on heritage tourism, to identify gaps, and create a theoretical framework that will improve our understanding of the impact of heritage tourism on sustainable community development and the health of local host communities.The findings of the systematic review will inform policies and strategies to improve the benefits of heritage tourism in local communities.
This review may be limited due to the exclusion of non-English studies and this might result in an omission of literature published by non-English-speaking researchers.Despite this limitation, the review will explore a wide range of peer-reviewed and grey literature to capture and include as many relevant studies as possible to overcome the limitation.
And Geography Education 10.Tourism, Hospitality and Leisure In addition, grey literature will also be sourced from key organisations' websites such as International Union for Conservation of Nature (IUCN), International Council on Monuments and Sites (ICOMOS), International Centre for the Study of the Preservation and Restoration of Cultural Property (ICCROM), International Centre for Integrated Mountain Development (ICIMOD), International Council of Museums (ICOM), United Nations Educational Scientific and Cultural Organization (UNESCO), United Nations World Tourism Organisation (UNWTO) and the Smithsonian Institution.