Exploring the relationships between heritage tourism, sustainable community development and host communities’ health and wellbeing: A systematic review

Previous studies examining the impact of heritage tourism have focused on specific ecological, economic, political, or cultural impacts. Research focused on the extent to which heritage tourism fosters host communities’ participation and enhances their capacity to flourish and support long-term health and wellbeing is lacking. This systematic review assessed the impact of heritage tourism on sustainable community development, as well as the health and wellbeing of local communities. Studies were included if they: (i) were conducted in English; (ii) were published between January 2000 and March 2021; (iii) used qualitative and/or quantitative methods; (iv) analysed the impact of heritage tourism on sustainable community development and/or the health and wellbeing of local host communities; and (v) had a full-text copy available. The search identified 5292 articles, of which 102 articles met the inclusion criteria. The included studies covering six WHO regions (Western Pacific, African, Americas, South-East Asia, European, Eastern Mediterranean, and multiple regions). These studies show that heritage tourism had positive and negative impacts on social determinants of health. Positive impacts included economic gains, rejuvenation of culture, infrastructure development, and improved social services. However, heritage tourism also had deleterious effects on health, such as restrictions placed on local community participation and access to land, loss of livelihood, relocation and/or fragmentation of communities, increased outmigration, increases in crime, and erosion of culture. Thus, while heritage tourism may be a poverty-reducing strategy, its success depends on the inclusion of host communities in heritage tourism governance, decision-making processes, and access to resources and programs. Future policymakers are encouraged to adopt a holistic view of benefits along with detriments to sustainable heritage tourism development. Additional research should consider the health and wellbeing of local community groups engaged in heritage tourism. Protocol PROSPERO registration number: CRD42018114681.


Introduction
Tourism, heritage, and sustainable development go hand in hand. Socio-economically, tourism is considered a vital means of sustainable human development worldwide, and remains one of the world's top creators of employment and a lead income-generator, particularly for Global South countries [1]. For most low-and middle-income countries (LMICs), tourism is a key component of export earnings and export diversification, and a major source of foreigncurrency income [1]. In 2019, prior to the international travel restrictions implemented to contain the spread of coronavirus disease (COVID- 19), export revenues from international tourism were estimated at USD 1.7 trillion, the world's third largest export category after fuels and chemicals with great economic impacts. Tourism remains a major part of gross domestic product, generating millions of direct and indirect jobs, and helping LMICs reduce trade deficits [1]. It accounts for 28 per cent of the world's trade in services, 7 per cent of overall exports of goods and services and 1 out of 10 jobs in the world [1]. Given this, it is anticipated that tourism will play a strong role in achieving all of the Sustainable Development Goals (SDGs), but particularly Goals 1 (No poverty), 8 (Decent work and economic growth), 12 (Responsible consumption and production), 13 (Climate action) and 14 (Life below water).
To ensure tourism's continued contribution to sustainable development efforts, the World Tourism Organisation (UNWTO) has established the T4SDG platform in order to "to make tourism matter on the journey to 2030" [2]. Likewise, in recognition of the relationship between heritage, tourism, and sustainable development, UNESCO launched the World Heritage and Sustainable Tourism Programme, which was adopted by the World Heritage Committee in 2012. This Programme encapsulates a framework that builds on dialogue and stakeholder cooperation to promote an integrated approach to planning for tourism and heritage management in host countries, to protect and value natural and cultural assets, and develop appropriate and sustainable tourism pathways [3].
The addition of 'heritage' creates an important sub-category within the tourism industry: heritage tourism. This study adopts a broad definition of 'heritage', which encompasses the intersecting forms of tangible heritage, such as buildings, monuments, and works of art, intangible or living heritage, including folklore, cultural memories, celebrations and traditions, and natural heritage, or culturally infused landscapes and places of significant biodiversity [4]. This encompassing definition captures 'heritage' as it is understood at the international level, as evidenced by two key UNESCO conventions: the 1972 Convention Concerning the Protection of the World Cultural and Natural Heritage, which protects cultural, natural, and mixed heritage; and the 2003 Convention for the Safeguarding of the Intangible Cultural Heritage, which protects intangible heritage. Although the identification, conservation and management of heritage has traditionally been driven by national aspirations to preserve connections with history, ancestry, and national identity, the social and economic benefits of heritage tourism at community levels have also been documented [5].
Heritage tourism, as one of the oldest practices of travelling for leisure, is a significant sector of the tourism industry. It refers to the practice of visiting places because of their connections to cultural, natural, and intangible heritage and is oriented towards showcasing notable relationships to a shared past at a given tourism destination [4]. It contributes to global interchange and inter-cultural understanding [4]. Heritage tourism places economic and political value on recognised heritage resources and assets, providing additional reasons to conserve heritage further to the cultural imperatives for its maintenance [5]. By drawing on the cultural and historical capital of a community, heritage tourism can contribute to the flourishing of local communities and their positive sustainable development. However, as this systematic review will demonstrate, when applied uncritically and without meaningful engagement with

Study rationale
For many years, the impact of heritage tourism has predominantly been viewed through ecological [8,9], economic and cultural [10,11] or political [12] lenses. For example, it has often been assumed that the conservation of historic, cultural, and natural resources, in combination with tourism, will naturally lead to sustainable local economies through increases in employment opportunities, provisioning of a platform for profitable new business opportunities, investment in infrastructure, improving public utilities and transport infrastructures, supporting the protection of natural resources, and, more recently, improving quality of life for local residents [13][14][15].
Similarly, the impact of heritage tourism on health and wellbeing has tended to focus on visitors' wellbeing, including their health education and possible health trends, medical aspects of travel preparation, and health problems in returning tourists [16][17][18]. It has only been more recently that host communities' health needs and wellbeing have been recognised as an intrinsic part of cultural heritage management and sustainable community development [19]. In this literature, it has been hypothesised that potential health implications of heritage tourism are either indirect or direct. Indirect effects are predominantly associated with health gains from heritage tourism-related economic, environmental, socio-cultural, and political impacts [20]. In contrast, health implications associated with direct impacts are closely associated with immediate encounters between tourism and people [20]. Yet, little is known of the overall generative effects of heritage tourism on sustainable community development, or the long-term health and wellbeing of local communities. For the first time, this systematic review identified and evaluated 102 published and unpublished studies in order to assess the extent to which heritage tourism fosters host communities' participation and, consequently, their capacity to flourish, with emphasis placed on the long-term health impacts of this. The primary objective of the review was to determine: (1) what the impacts of heritage tourism are on sustainable community development; as well as (2) on the health and wellbeing of local host communities. Understanding the relationship between heritage tourism, 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.

Methods
This systematic review adhered to the guidelines and criteria set out in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement [21]. A protocol for this review was registered with PROSPERO (CRD42018114681) and has been published [22].

Search strategy
In order to avoid replicating an already existing study on this topic, Cochrane library, Google Scholar and Scopus were searched to ensure there were no previous systematic reviews or meta-analyses on the impact of heritage tourism on sustainable community development and the health of local host communities. No such reviews or analyses were found. The search then sought to use a list of relevant text words and sub-headings of keywords and/or MeSH vocabulary according to each searched database. Derived from the above research question, the key search words were related to heritage tourism, sustainable community development, and health and wellbeing of local host communities. A trial search of our selected databases (see below) found that there are no MeSH words for heritage and tourism. Therefore, multiple keywords were included to identify relevant articles.
To obtain more focused and productive results, the keywords were linked using "AND" and "OR" and other relevant Boolean operators, where permitted by the databases. Subject heading truncations (*) were applied where appropriate. The search query was developed and tested in ProQuest Central on 22 November 2018. Following this search trial, the following combination of search terms and keywords, slightly modified to suit each database, was subsequently used: ("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) AND ("sustainable development" [MeSH] OR sustainab* or "community development" or "local development" or "local community" or "indigenous community") The search covered the following bibliographic databases and electronic collections: Where the full texts of included articles could not be accessed, corresponding authors were contacted via e-mail or other means of communication (e.g., ResearchGate) to obtain a copy. A further search of the bibliographical references of all retrieved articles and articles' citation tracking using Google Scholar was conducted to capture relevant articles that might have been missed during the initial search but that meet the inclusion criteria. For the purposes of transparency and accountability, a search log was kept and constantly updated to ensure that newly published articles were captured. To maximise the accuracy of the search, two researchers with extensive knowledge of heritage tourism literature (EW and HS) and two research assistants with backgrounds in public health and social sciences implemented independently the search syntax across the databases and organisations' websites to ensure no article was missed.

Inclusion and exclusion criteria
Criteria used in this systematic review focused on the types of beneficiaries of heritage tourism, outcomes of interest, as well as the intervention designs. The outcomes of interest were sustainable community development and evidence for the overall health and wellbeing of local host communities. In this systematic review, sustainable community development was defined in terms of its two components: 'community sustainability' and 'development'. Community sustainability was conceptualised 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" (pp. 21, 24) [23].
In contrast, development was conceptualised 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" (p. 44) [7]. To this, we added the question of whether the development was positive or negative. Thus, going beyond the Brundtland definition introduced earlier and once again borrowing from the work of Paul James, positive sustainable development was 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 [23].
Health was defined, using the World Health Organisation (WHO) definition, as "overall well-being" and as including both physical, mental and social health [24]. 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 [25]. Therefore, wellbeing in this systematic review was 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 [26].
In terms of intervention and design, this systematic review included peer-reviewed and grey literature sources of evidence [27, 28] from quantitative, qualitative, and mixed methods studies. Intervention designs of interest were observational studies (e.g. longitudinal studies, case control and cross-sectional studies) as well as qualitative and mixed-methods studies. The following additional restrictions were used to ensure texts were included only if they were: (i) written in English; (ii) analysed the impact of heritage tourism on sustainable community development and health and/or wellbeing of local host communities; (iii) research papers, dissertations, books, book chapters, working papers, technical reports including project documents and evaluation reports, discussion papers, and conference papers; and (iv) published between January 2000 and March 2021. Studies were excluded if they were descriptive in nature and did not have community development or health and wellbeing indicators as outcome measures.
The year 2000 was selected as the baseline date due to the signing of the United Nations Millennium Development Goals (MDGs) by Member States in September of that year. With the introduction of the MDGs, now superseded by the Sustainable Development Goals (SDGs), there was an increase in commitment from government and non-governmental organizations to promote the development of responsible, sustainable and universally accessible tourism [29,30]. Editorials, reviews, letter to editors, commentaries and opinion pieces were not considered. Where full text articles were not able to be retrieved despite exhausting all available methods (including contacting corresponding author/s), such studies were excluded from the review. Non-human studies were also excluded.

Study selection and screening
Data retrieved from the various database searches were imported into an EndNote X9 library. A three-stage screening process was followed to assess each study's eligibility for inclusion. In the EndNote library, stage one involved screening studies by titles to remove duplicates. In stage two, titles and abstracts were manually screened for eligibility and relevance. In the third and final screening stage, full texts of selected abstracts were further reviewed for eligibility. The full study selection process according to PRISMA is summarised in Fig 1. A total of 5292 articles from 10 databases and multiple sources of grey literature were screened. After removal of duplicates, 4293 articles were retained.
Titles and abstracts were further screened for indications that articles contain empirical research on the relationship between heritage tourism, sustainable community development and the health and wellbeing of local host communities. This element of the screening process resulted in the exclusion of 2892 articles. The remaining 1401 articles were screened for eligibility: 1299 articles were further excluded, resulting in 102 articles that met our inclusion criteria and were retained for analysis. Study selection was led by two researchers (EW and HS) and one research assistant, who independently double-checked 40% of randomly selected articles (n = 53). Interrater agreement was calculated using a 3-point ordinal scale, with the scoring being 'yes, definitely in' = 1, '?' for unsure = 2, and 'no, definitely out' = 3. Weighted Kappa coefficients were calculated using quadratic weights. Kappa statistics and percentage of agreement were 0.76 (95%CI: 0.63, 0.90) and 0.90 (95%CI: 0.85, 0.96) respectively, suggesting excellent agreement.

Data extraction
Data extraction was completed using a piloted form and was performed and subsequently reviewed independently by three researchers (AR, EW and HS), all of whom are authors. The extracted data included: study details (author, year of publication, country of research), study aims and objectives, study characteristics and methodological approach (study design, sample size, outcome measures, intervention), major findings, and limitations.

Quality assessment
To account for the diversity in design and dissemination strategies (peer-reviewed vs nonpeer-reviewed) of included studies, the (JBI) Joanna Briggs Institute's Critical Review Tool for qualitative and quantitative studies [31], mixed methods appraisal Tool (MMAT) for mixed

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Heritage tourism, sustainable community development and host communities' health and wellbeing methods [32], and the AACODS (Authority, Accuracy, Coverage, Objectivity, Date, Significance) checklist for grey literature [33] were used to assess the quality of included studies. The quality assessment of included studies was led by one researcher (CB), but 40% of the studies were randomly selected and scored by three senior researchers (AR, EM, and HS) to check the accuracy of the scoring. Cohen's kappa statistic was used to assess the agreement between quality assessment scorers. Kappa statistics and percentage of agreement were 0.80 (95%CI: 0.64, 0.96) and 0.96 (95%CI: 0.93, 0.99) respectively, suggesting excellent interrater agreement. The quality assessment scales used different numbers of questions and different ranges, hence they were all rescaled/normalised to a 100 point scale, from 0 (poor quality) to 100 (high quality) using the min-max scaling approach. Scores were stratified by tertiles, being high quality (>75), moderate quality , or poor quality (<50).

Data synthesis
Due to the heterogeneity and variation of the studies reviewed (study methods, measurements, and outcomes), a meta-analysis was not possible. Campbell and colleagues (2020) [34] recognise that not all data extracted for a systematic review are amenable to meta-analysis, but highlight a serious gap in the literature: the authors' lack of or poor description of alternative synthesis methods. The authors described an array of alternative methods to meta-analysis. In our study we used a meta-ethnography approach to articulate the complex but diverse outcomes reported in included studies [35]. Increasingly common and influential [36], meta-ethnography is an explicitly interpretative approach to the synthesis of evidence [36, 37] that aims to develop new explanatory theories or conceptualisations of a given body of work on the basis of reviewer interpretation [37]. It draws out similarities and differences at the conceptual level between the findings of included studies [37], with the foundational premise being the juxtaposition and relative examination of ideas between study findings [37]. Resulting novel interpretations are then considered to transcend individual study findings [36].
Originating with sociologists Noblit and Hare [36,38], and adopted and expanded upon by other researchers [36, 37], meta-ethnography involves a 7-stage process of evidence synthesis and concludes with the translation and synthesis of studies [38]. The approach centres around the emergence of concepts and themes from included studies that are examined in relation to each other and used to synthesise and communicate primary research findings. In meta-ethnography, the diversity of studies such as the heterogeneity and variation of included studies in the present review, is considered an asset opposed to an issue in synthesis or translation of research findings [37].
Common threads, themes and trends were identified and extracted from both qualitative and quantitative narratives to generate insight on the impact of heritage tourism on sustainable community development and health. In order to increase reproducibility and transparency of our methods and the conclusions drawn from the studies, the narrative synthesis adhered to the "Improving Conduct and Reporting of Narrative Synthesis of Quantitative Data" protocol for mixed methods studies [39]. One of the primary researchers (CB) summarised the study findings and narrated the emerging themes and subthemes. The emerging themes were discussed with all authors for appropriateness of the content as well as for consistency. All studies were included in the synthesis of evidence and emergence of themes. The meta-ethnographic approach involved the following processes: Identifying metaphors and themes. Included studies were read and reviewed multiple times to gain familiarity and understanding with the data and identify themes and patterns in each study. As noted above, data was extracted from each study using a piloted template to remain consistent across all studies. The aims and/or objectives of each study was revisited regularly to validate any extracted data and remain familiar with the purpose of the study. Themes and, where relevant, sub-themes were identified, usually in the results and discussion section of included studies.
Determining how the studies were related. Studies were grouped according to WHO regions (see Table 1). Thematic analysis was compared across all included studies regardless of region to identify common themes and/or sub-themes to determine how studies were related to one another. Although this review included a widely varied and large number of studies (n = 102), the findings of each study nonetheless had a common underpinning theme of heritage-based tourism. This enabled the identification of communal categories across the studies indicating their relatedness. For example, there were common themes of socio-cultural, socioeconomic, community health, wellbeing, and empowerment factors and so on.
Translation and synthesis of studies. Themes and, where relevant, sub-themes within each study were considered and compared to the next study in a process repeated for all included studies. Such translation of studies compares and matches themes across a corpus of material, and usually involves one or more of three main types of synthesis: reciprocal translation, refutational translation, and line of argument [37]. Themes were condensed and streamlined into main thematic areas, in addition to outlining common topics within those thematic areas. The primary researcher (CB) undertook this process with discussion, validation and confirmation of themes and topics from three other researchers (EW, HS and AR). Translation between studies and the resulting synthesis of research findings followed the process of the emergence of new interpretations and conceptualisation of research themes. A line of argument was also developed, and a conceptual model produced to describe the research findings, which is shown in Fig 2. Both the line of argument and conceptual model were agreed upon by all authors.

Results
A total of 102 studies were included in the analysis. Of these, 25 studies were conducted in the Western Pacific region, 23 in the African region, 20 in the Region of the Americas, 17 in the South-East Asia region, 12 in the European region, and 1 in the Eastern Mediterranean region. The remaining 4 studies reported on multiple regions. This may at first seem surprising given the prominence of European cultural heritage on registers such as the World Heritage List, which includes 469 cultural sites located Europe (equivalent to 47.19% of all World Heritage Properties that are recognised for their cultural values). However, any studies focusing on Europe that did not also examine sustainable community development and the overall health and wellbeing of local host communities were screened out of this systematic review in accordance with the abovementioned inclusion and exclusion criteria. Results of the data extraction and quality assessment across all included studies are presented in Table 1. Of the included studies, 24 used a mixed methods design, 22 studies were qualitative, 36 were quantitative and 20 were grey literature (see Table 1 for more detail regarding the type of methods employed). Of these, 48 studies were assessed as high quality (>75), 32 as moderate quality (50-74) and 22 as poor quality (<50).
The major health and wellbeing determinant themes emerging from the included studies were grouped according to social, cultural, economic, and ecological health determinants. Fig  3 presents the proportion of included studies that investigated each of the four health determinants when assessed by WHO region. A large proportion of economic studies was shown across all regions, although this focus was surpassed by the social health determinant in the South-East Asia region (Fig 3). Studies on the social health determinant also yielded a strong proportion of studies across most other regions, although notably not in the African region. This was closely followed by an ecological focus among the Americas, South-East Asia and Western Pacific regions. The Americas had the highest proportion of cultural studies, with the European region being the lowest proportionally (Fig 3).
More specifically, for studies focused on Africa, 100% of the publications included in this review explicitly investigated the economic benefits of tourism on wellbeing (74% of them exclusively), with European-focused studies reflecting a similarly high interest in economic

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wellbeing (91% of publications). Across the Americas, economic determinants of wellbeing were investigated in 86% of publications and in the Western Pacific, methods to investigate this variable were built into 80% of included studies. By comparison, this research demonstrates that only just over two thirds of articles reporting on the South-East Asia region shared this focus on economic determinants (65% of publications). Instead, social determinants of wellbeing form a stronger component of the research agenda in this region, with 76% of publications investigating this theme in studies that also tended to consider multiple drivers of health. For example, in 47% of publications reporting on the South-East Asia context, at least three themes were integrated into each study, with particular synergies emerging between social, economic and ecological drivers of wellbeing and their complex relationships.
Similarly, 47% of publication reporting on the Americas also included at least three health determinants. Research outputs from these two regions demonstrated the most consistently holistic approach to understanding wellbeing compared to other regions. In Africa, only 13% of the papers reviewed incorporated three or more themes; in the Western Pacific, this figure is 32% and in Europe only 8% of research outputs attempted to incorporate three or more themes. It seems unlikely that the multidimensional relationship between socio-economic and ecological sustainability that is always in tension could be adequately explored given the trend towards one-dimensional research in Africa, the Western Pacific and particularly Europe.
The associated positive and negative impacts of heritage tourism on each of the health and wellbeing determinants are then presented in Table 2, along with the considered policy implications. Some of the identified positive impacts included improved access to education and social services, greater opportunities for skill development and employment prospects, preservation of culture and traditions, increased community livelihood and greater awareness of environmental conservation efforts. Negative impacts of tourism on host communities included forced displacement from homes, environmental degradation and over-usage of natural resources, barriers to tourism employment and reliance on tourism industry for income generation and economic stability, dilution and loss of cultural values and practices, civil unrest and loss of social stability, increased rates of crime and disease and lack of direct benefit to local communities. Both positive and negative impacts across each health and wellbeing determinant had acknowledged implications on policy development, many of which revolved around governance and ownership of tourist activities, participation of the local community in tourism sectors and active management of environmental protection programs. Such themes are shown in Table 2.
Recent thematic trends can be observed in Table 3, whereby the percentage of research outputs that investigate economic drivers of health and wellbeing produced since 2019 are shown. In Africa, Europe and the Americas, the proportion of outputs investigating economic health determinants since 2019 is the smallest (Table 3), being 17% in Africa and the Americas, and 36% in Europe, respectively. On the contrary, 50% of Western Pacific region studies since 2019 had research focused on the economic drivers of wellbeing in relation to heritage tourism. Moreover, 65% of studies included economy-focused research in South-East Asia, with more than half of those outputs produced in the last two years (Table 3). The proportion of research outputs where local community members were asked to give their opinions as participants is presented in Table 4, where they were invited to co-lead the research but were excluded from data production. In the Western Pacific region, there was a relative lack of participation (either as researchers or stakeholders) by local communities in the studies included in this review. Meaningful modes of community participation in the South-East Asian region can be calculated to 65%, more closely in line with Africa, Europe and the Americas (Table 4).

Discussion
This systematic review is the first of its kind to explicitly consider the relationships between heritage tourism and host communities; specifically, the impact of tourism on host communities' capacity to flourish and support long-term health and wellbeing. Such impacts were found to be both positive and negative, with either direct or indirect consequences on the development of local governance policies. Our synthesis revealed that there are important regional variations in the way that determinants of health-social, cultural, economic or ecological-drive tourism research agendas. They commonly included considerations of social dynamics, access and health of the local community, empowerment and participation of host communities in tourism-based activities and governance, employment opportunities, preservation or erosion of culture, and environmental influences due to tourism promotion or activity.
Economic impacts represented the strongest focus of the studies include in this review, often to the detriment of other cultural or environmental considerations. With the exception of South-East Asia, studies focused on all other WHO regions (Africa, Europe, the Americas and the Western Pacific) were overwhelmingly built around attempts to understand economic variables as determinants of health and wellbeing, and in some instances were likely to focus on economic variables in lieu of any other theme. Given the steady growth of an interest in economic variables in South-East Asia since 2019, it is plausible that this will soon represent the largest concentration of studies in that region, too. This trend towards emphasis on economic influences is problematic given that some of the emerging impacts from tourism-related practices identified in this review were found to be common across multiple determinants of health and thus not limited to economic health alone. For example, the limitation placed on access to prime grazing land for cattle belonging to local residents was perceived to be a negative impact both ecologically and economically [60,141]. This may be considered detrimental from an environmental standpoint due to the alteration of the local ecosystem and destruction of natural resources and wildlife habitat, such as the building of infrastructure to support the development of tourist accommodation, transport, and experiences.
Economically, the loss of grazing land results in reduced food sources for cattle and consequently a potential reliance on alternative food sources (which may or may not be accessible or affordable), or in the worst-case scenario death of cattle [92]. In turn, this loss of cattle has an adverse impact on the financial livelihood of host communities, who may rely on their cattle as a sole or combined source of income. Considered in isolation or combination, this single negative impact of tourism-reduced grazing access-has flow-on effects to multiple health determinants. Therefore, it is important to consider the possible multifactorial impacts of tourism, heritage or otherwise, on the host communities involved (or at least affected) given they may have a profound and lasting impact, whether favourable or not.
The potential interrelationships and multifactorial nature of heritage tourism on the health and wellbeing of host communities were also identified among a number of other studies included in this review. For example, a study from the Western Pacific Region explored connections between the analysis of tourism impacts, wellbeing of the host community and the 'mobilities' approach, acknowledging the three areas were different in essence but converging areas in relation to tourism sustainability [125]. That said, the cross-over between social determinants was not always observed or presented as many studies primarily focused on a single health domain [43-51, 53, 55-57, 59, 61, 71, 74, 86-90, 103, 104, 108-110, 118, 130, 134-136, 138-140]. Some studies, for instance, focused on poverty reduction and/or alleviation [134,135], while others focused solely on cultural sustainability or sociocultural factors [109,110,118], and others delved only into the ecological or environmental impacts of tourism [86,89]. As noted above, the majority of studies that focused on a single health determinant considered economic factors.
A common theme that spanned multiple health domains was the threat of relocation. Here, local communities represented in the reviewed studies were often at risk of being forced to relocate from their ancestral lands for tourism and/or nature conservation purposes [41, 60,80,131]. This risk not only threatens their way of life and livelihood from an economic perspective, but will also have social implications, jeopardising the sustainability and longevity of their cultural traditions and practices on the land to which they belong [41,60,80,131]. Moreover, it may have ongoing implications for the displacement of family structures and segregation of local communities.
Importantly, this systematic review revealed that cultural determinants of health and wellbeing were the least explored in every region and were in many instances entirely omitted. This is at odds with the increasingly prevalent advice found in wider heritage and tourism academic debates, where it is argued that cultural institutions such as museums and their objects, for example, may contribute to health and wellbeing in the following ways: promoting relaxation; providing interventions that affect positive changes in physiology and/or emotions; supporting introspection; encouraging public health advocacy; and enhancing healthcare environments [142][143][144]. Likewise, Riordan and Schofield have considered the cultural significance of traditional medicine, citing its profound importance to the health and wellbeing of the communities who practice it as well as positioning it as a core element of both local and national economies [145].
Of greater concern is the finding of this review that of the relatively small number of papers investigating cultural health determinants, many recorded profoundly negative and traumatising outcomes of tourism development, such as a rise of ethnoreligious conflict, loss of ancestral land, a dilution of cultural practices to meet tourist demands, and a loss of cultural authenticity [41]. Consequently, comparative studies that focus on cultural determinants, in addition to economic and environmental determinants, are currently lacking and should therefore be prioritised in future research. In fact, only one fifth of those papers included in this review adopted the qualitative approach needed to probe the socio-cultural dimensions of health. Novel qualitative research methods to investigate community health are therefore a major research lacuna.
Just as solely equating community health and wellbeing with economic flourishing is problematic, so too is assuming that health is reducible only to clinical care and disease [146], given that "[i]deas about health . . . are cultural" [146]. Early indications of an acceptance that culture and heritage might be central to community health and wellbeing can be found in UNESCO's 1995 report, Our Creative Diversity: Report of the World Commission on Culture and Development [147]. More recently, this notion is evidenced in the 2019 Operational Guidelines for the Implementation of the World Heritage Convention [148] and the 2020 Operational Directives for UNESCO's Convention for the Safeguarding of Intangible Cultural Heritage [149], both of which indicate the need for a major shift in research foci towards cultural determinants of health and wellbeing if research is to keep pace with assumptions now operating within international policy [148,149].
Although Africa, Europe and the Americas are the three regions with the highest proportion of papers investigating the economic benefits of tourism on health and wellbeing, these regions are also the most responsive to the above recommended changes in policy and debate (see Table 3). In these three regions, the proportion of outputs investigating economic health determinants since 2019 is the smallest, demonstrating a recent decline in research that is persuaded by the a priori assumption that economic wellbeing automatically equates to cultural wellbeing. Despite demonstrating the most holistic approach to understanding health and wellbeing across all the themes, an upwards trend in economy-focused research was identified in South-East Asia, since more than half of the economic outputs were produced in the last two years. Such a trend is potentially problematic for this region because it may reinforce the notion that the main benefits of tourism are direct and financial, rather than refocusing on the tension created by indirect effects of tourism on quality of life and community wellbeing.
Conversely, this review demonstrates that the Western Pacific region has persisted with research focused on the economic drivers of wellbeing in relation to heritage tourism (see Table 3). This persistence may be explained by the relative lack of participation (either as researchers or stakeholders) by local communities in any of the studies included in this review (see Table 4). Indeed, the Western Pacific had the lowest occurrence of community participation and/or consultation in establishing indicators of wellbeing and health and/or opinions about the role of tourism in promoting these.
On the contrary, while seemingly demonstrating the second highest proportion of exclusionary research methods as discussed above, South-East Asia remains the only region where any attempts were made to ensure community members were invited to design and co-lead research (see Table 4). Nonetheless, meaningful modes of participation in this region were found to be more closely in line with the deficits found in Africa, Europe, and the Americas. This lack of approaches aimed at including affected communities as researchers in all but one instance in South-East Asia is an important research gap in tourism studies' engagement with health and wellbeing debates.
Importantly, this failure to adequately engage with affected communities is at odds with the depth of research emanating from a range of health disciplines, such as disability studies, occupational therapy, public health, and midwifery, where the slogan 'nothing about us without us', which emerged in the 1980s, remains prominent. Coupled with a lack of focus on cultural determinants of health, this lack of participation and community direction strongly indicates that research studies are being approached with an a priori notion about what 'wellbeing' means to local communities, and risks limiting the relevance and accuracy of the research that is being undertaken. Problematically, therefore, there is a tendency to envisage a 'package' of wellbeing and health benefits that tourism can potentially bring to a community (regardless of cultural background), with research focusing on identifying the presence or absence of elements of this assumed, overarching 'package'.
Interestingly, along with the paucity of full and meaningful collaboration with local community hosts in tourism research, there were no instances across the systematic review where a longitudinal approach was adopted. This observation reinforces the point that long-term, collaborative explorations of culturally specific concepts including such things as 'welfare', 'benefit', 'healthfulness' and 'flourishing', or combinations of these, are lacking across all regions. To bring tourism research more in line with broader debates and international policy directions about wellbeing, it is important for future research that the qualities of health and wellbeing in a particular cultural setting are investigated as a starting point, and culturally suitable approaches are designed (with local researchers) to best examine the effects of tourism on these contingent notions of wellbeing.
Importantly, a lack of longitudinal research will lead to a gap in our understanding about whether the negative impacts of tourism increase or compound over time. Adopting these ethnographies of health and wellbeing hinges upon long-term community partnerships that will serve to redress a research gap into the longevity of heritage tourism impacts. Furthermore, of those papers that asked local community members about their perceptions of heritage tourism across all regions, a common finding was the desire for greater decision-making and management of the enterprises as stakeholders. It seems ironic, therefore, that research into heritage tourism perceptions itself commonly invites the bare minimum of collaboration to establish the parameters of that research.
In a small number of papers that invited community opinions, local stakeholders considered that the tourism 'benefits package' myth should be dispelled, and that responsible tourism development should only happen as part of a wider suite of livelihood options, such as agriculture, so that economic diversity is maintained. Such a multi-livelihood framework would also promote the accessibility of benefits for more of the community, and this poses a significant new direction for tourism research. For example, an outcome of the review was the observation that infrastructure development is often directed towards privileged tourism livelihood options [150], but a more holistic framework would distribute these sorts of benefits to also co-develop other livelihoods.
Although there is a clear interest in understanding the relationship between heritage, tourism, health and wellbeing, future research that explores the intersections of heritage tourism with multiple health domains, in particular social and cultural domains, is critical. Indeed, the frequency with which the negative impacts of heritage tourism were reported in the small number of studies that engaged local community participants suggests that studies co-designed with community participants are a necessary future direction in order for academics, policymakers and professionals working in the field of heritage tourism to more adequately address the scarce knowledge about its socio-cultural impacts. The accepted importance of community researchers in cognate fields underscores that the knowledge, presence and skills of affected communities are vital and points to the need for similar studies in heritage tourism.

Conclusions
There are five main findings of this systematic review, each of which is a critical gap in research that should be addressed to support the health and wellbeing in local communities at tourism destinations. Firstly, whilst one of the primary findings of this systematic review was the increase in employment opportunities resulting from tourism, this disclosure arose because of a strong-in many cases, exclusive-methodological focus on economic indicators of health and wellbeing. Such research reveals that heritage tourism may significantly reduce poverty and may be used as a poverty-reducing strategy in low-income countries. However, the assumption underlying this focus on the economic benefits of tourism for health and wellbeing is that economic benefits are a proxy for other determinants of health, e.g., cultural, social, environmental, etc., which are otherwise less systematically explored. In particular, the ways in which combinations of environmental, social, cultural, and economic determinants on wellbeing interact is an area requires considerable future research.
Secondly, whilst economic drivers of wellbeing were the most common area of research across all regions, the impacts of tourism on cultural wellbeing were the least explored. Moreover, in many publications culture was entirely omitted. This is perhaps one of the most troubling outcomes of this systematic review, because in the relatively small number of papers that did investigate the cultural impacts of tourism, many reported traumatising consequences for local communities, the documentation of which would not be recorded in the majority of papers where cultural wellbeing was absent. Tourism's profoundly damaging consequences included reports of a rise in ethnoreligious violence, loss of ancestral land and the threat of forced relocation, not to mentioned extensive reports of cultural atrophy.
Linked to this lack of understanding about the cultural impacts of tourism on wellbeing, the third finding of this review is that there are far fewer studies that incorporate qualitative data, more suited to document intangible cultural changes, whether positive or negative. Furthermore, more longitudinal research is also needed to address the subtle impacts of tourism acting over longer timescales. The systematic review revealed a lack of understanding about how both the negative and positive outcomes of heritage tourism change over time, whether by increasing, ameliorating, or compounding.
The fourth finding of this research is that, to a degree and in certain regions of the world, research is responding to international policy. This review has illustrated that, historically, Africa, Europe and the Americas prioritised research that measured the economic effects of tourism on health and wellbeing. However, after 2019 a shift occurred towards a growing but still under-represented interest in social-cultural wellbeing. We propose that this shift aligns with recommendations from UNESCO's 2019 Operational Guidelines for the Implementation of the World Heritage Convention [148] and the 2020 Operational Directives for UNESCO's Convention for the Safeguarding of Intangible Cultural Heritage [149]. The exception to this shift is the Western Pacific region, where the economic impacts of tourism are increasingly prioritised as the main indicator of wellbeing. Given the overall efficacy of policy for steering towards ethical and culturally-grounded evaluations of the impacts of tourism, we would urge heritage policymakers to take account of our recommendations ( Table 2).
The policy implications emerging from this review are the fifth finding and can be distilled into a few key propositions. There is a need for meaningful decolonising approaches to heritage tourism. More than half of the negative consequences of heritage tourism for health and wellbeing could be mitigated with policy guidance, contingent cultural protocols and anti-colonial methods that foreground the rights of local (including Indigenous) communities to design, govern, lead, and establish the terms of tourism in their local area. Although 'participation' has become a popular term that invokes an idea of power symmetries in tourism enterprises, it is clear from this systematic review that the term leaves too much latitude for the creep of poor-practice [151] that ultimately erodes community autonomy and self-determination. Participation is not enough if it means that there is scope for governments and foreign investors to superficially engage with community wellbeing needs and concerns.
Furthermore, calls for 'capacity-building' that effectively re-engineer the knowledges of local communities are fundamentally problematic because they presuppose a missing competency or knowledge. This is at odds with impassioned anti-colonial advocacy [152] which recognises that communities hold a range of knowledges and cultural assets that they may, and should be legally protected to, deploy (or not) as a culturally-suitable foundation that steers the design of locally-governed tourism enterprises. In short, to maximise and extend the benefits of heritage tourism and address major social determinants of health, host communities' presence in heritage tourism governance, decision making processes, and control of and access to the resultant community resources and programs must be a priority. Future policymakers are encouraged to make guidance more explicit, enforceable and provision avenues for feedback from local communities that offers the protections of transparency. It is also imperative that researchers involve and empower local community groups as part of studies conducted in relation to their health and wellbeing. If current practices remain unchanged, the primary benefit of tourism could easily be rendered inaccessible through lack of education and/or appropriate training which was frequently identified as a barrier to community participation.