Open Access Research article

Integrating an ecological approach into an Aboriginal community-based chronic disease prevention program: a longitudinal process evaluation

Margaret Cargo1, Elisabeth Marks2, Julie Brimblecombe3, Maria Scarlett3, Elaine Maypilama4, Joanne Garnggulkpuy Dhurrkay4 and Mark Daniel12*

Author Affiliations

1 Social Epidemiology and Evaluation Research Group, Sansom Institute for Health Research, University of South Australia, City East Campus, Adelaide, 5001, Australia

2 Centre Hospitalier de l'Université de Montréal, Université de Montréal, 3875 Rue St. Urbain, Montréal, H2W 1V1, Canada

3 Menzies School of Health Research, Charles Darwin University, John Matthews Building, Royal Darwin Hospital, Rocklands Drive, Casuarina, 0810, Australia

4 Yalu'Marnggithinyaraw, Galiwin'ku, Elcho Island, 0822, Australia

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BMC Public Health 2011, 11:299  doi:10.1186/1471-2458-11-299

Published: 11 May 2011



Public health promotes an ecological approach to chronic disease prevention, however, little research has been conducted to assess the integration of an ecological approach in community-based prevention programs. This study sought to contribute to the evidence base by assessing the extent to which an ecological approach was integrated into an Aboriginal community-based cardiovascular disease (CVD) and type 2 diabetes prevention program, across three-intervention years.


Activity implementation forms were completed by interview with implementers and participant observation across three intervention years. A standardised ecological coding procedure was applied to assess participant recruitment settings, intervention targets, intervention strategy types, extent of ecologicalness and organisational partnering. Inter-rater reliability for two coders was assessed at Kappa = 0.76 (p < .0.001), 95% CI (0.58, 0.94).


215 activities were implemented across three intervention years by the health program (HP) with some activities implemented in multiple years. Participants were recruited most frequently through organisational settings in years 1 and 2, and organisational and community settings in year 3. The most commonly utilised intervention targets were the individual (IND) as a direct target, and interpersonal (INT) and organisational (ORG) environments as indirect targets; policy (POL), and community (COM) were targeted least. Direct (HP→ IND) and indirect intervention strategies (i.e., HP→ INT→ IND, HP→ POL → IND) were used most often; networking strategies, which link at least two targets (i.e., HP→[ORG-ORG]→IND), were used the least. The program did not become more ecological over time.


The quantity of activities with IND, INT and ORG targets and the proportion of participants recruited through informal cultural networking demonstrate community commitment to prevention. Integration of an ecological approach would have been facilitated by greater inter-organisational collaboration and centralised planning. The upfront time required for community stakeholders to develop their capacity to mobilise around chronic disease is at odds with short-term funding cycles that emphasise organisational accountability.