How do health services engage culturally and linguistically diverse consumers? An analysis of consumer engagement frameworks in Australia

ABSTRACT Background Engagement frameworks provide the conceptual structure for consumer engagement in healthcare decision making, but the level to which these frameworks support culturally and linguistically diverse (CALD) consumer engagement is not known. Objective This study aimed to investigate how consumer engagement is conceptualised and operationalized and to determine the implications of current consumer engagement frameworks for engagement with CALD consumers. Method Altheide's document analysis approach was used to guide a systematic search, selection and analytic process. Australian Government health department websites were searched for eligible publicly available engagement frameworks. A narrative synthesis was conducted. Results Eleven engagement frameworks published between 2007 and 2019 were identified and analysed. Only four frameworks discussed engagement with CALD consumers distinctly. Organisational prerequisites to enhance engagement opportunities and approaches to enable activities of engagement were highlighted to improve CALD consumers' active participation in decision making; however, these largely focused on language, with limited exploration of culturally sensitive services. Conclusion There is limited discussion of what culturally sensitive services look like and what resources are needed to enhance CALD consumer engagement in high‐level decision making. Health services and policy makers can enhance opportunities for engagement with CALD consumers by being flexible in their approach, implementing policies for reimbursement for participation and evaluating and adapting the activities of engagement in collaboration with CALD consumers. Patient/Public Contribution This study is part of a wider ‘CanEngage’ project, which includes a consumer investigator, and is supported by a consumer advisory group. The study was conceived with inputs from the consumer advisory group, which continued to meet regularly with the project team to discuss the methodology and emerging findings.

ensuring ease of consumer-provider interaction, high levels of consumer health literacy, support and guidance regarding the engagement activities and efforts towards even power distribution between consumers and health professionals. [11][12][13] As such, effective consumer engagement for culturally and linguistically diverse (CALD) consumers is close to nonexistent. 14 CALD is primarily used as a term in the Australian context to describe those who were born overseas, have parents who were born overseas or speak languages other than the official national languages and/or have lower proficiency of native or national languages. 15 Inequities in engagement identified in these communities are further compounded by fears of intimidation, low self-confidence in their own healthcare, racism, gender inequalities, sex, disabilities, low trust in health professionals and the health care system and communication barriers. 16-18 A 2018 survey study in Australia examining activities for consumer participation as indicated by the National Safety and Quality Health Services (NSQHS) Standards found that only 50 out of 115 Australian health services reported including people of CALD background in decision-making processes. 19 There is emerging evidence identifying factors that present barriers to CALD consumer engagement, leading to variations in access to and experience of healthcare, and poorer health and healthcare quality outcomes. 14,[20][21][22] A recent systematic review concluded that safety events (events that could have or did result in harm due to care they receive) among CALD patients are dependent on the setting and the population, and that poor engagement with CALD consumers is one factor associated with their increased vulnerability to safety events. 23 Poor engagement is often associated with an inability of the health system to recognise and address the nuanced sociocultural differences that exist between and within diverse CALD groups and with a lack of responsiveness to those differences. 14,23 In multicultural Australia, where over 300 languages are spoken and almost half of the Australians are born overseas or had one or both parents born overseas, 15 it is imperative for health systems and services to provide a context that facilitates effective engagement for CALD consumers towards improved care quality and outcomes.
The importance for consumer engagement in healthcare is constructed to a large extent through health systems policies, standards and guidance for consumer engagement that have emerged over the last two decades nationally and internationally. [24][25][26][27][28][29] These documents highlight the increasing importance of consumer engagement in healthcare and provide policy directives, guidance and avenues to integrate consumer participation in decision making. Consumer engagement frameworks provide a conceptual structure for engaging consumers in decision-making processes at various levels of the healthcare system. 3 The narrative of such frameworks provides a context for consumer engagement that is relevant to the populations being served and to system responsiveness to minority and/or priority populations such as CALD communities. 3,30,31 Engagement frameworks adopted by Australian federal-and state-level government health departments provide direction and understanding of an organisation's commitment to consumer engagement to operationalise health system goals at individual, service and system levels. These frameworks also provide a reference point for accountability and promote leaders, managers and clinical teams to be more responsive to consumers, and allocate appropriate resources for engagement. 3,11,32 The extent to which these frameworks articulate engagement activities and recognise sociocultural differences for CALD consumers is unknown. This knowledge is critical to inform and ensure a health system context that considers and is responsive to the CALD population.
The aim of this document analysis of consumer engagement frameworks in Australia at federal-and state-level health departments was to examine the health system narrative regarding CALD consumer engagement and the extent to which these frameworks may promote and support nuanced approaches for engagement with the CALD population. This study aims to explore: (1) how consumer engagement is conceptualised across the Australian healthcare system; (2) how consumer engagement is operationalized; and (3) the implications of current consumer engagement frameworks for engagement with CALD consumers.

| METHODS
A document analysis utilising a systematic process for the search, selection and analysis was undertaken to address the research aims. 33,34 This widely adopted approach has been used to explore policy positioning in healthcare settings. 35,36 We used Altheide's document analysis approach to guide the research process, due to its effective application in similar work. 34,36 The Standard for Reporting Qualitative Research guideline was used for reporting this paper 37 (Supporting Information File SA).

| Document search and selection
Document selection was undertaken through an iterative search and selection process. An initial document search of government websites was conducted between June and July 2020 by two reviewers (A. C. and J. L.) using various key search words (consumer/patient engagement, consumer/patient engagement framework, consumer/ patient participation, consumer/patient involvement). This search identified an initial set of 40 documents (engagement frameworks, strategic plans, consumer engagement guidelines, consumer engagement strategies, consumer engagement toolkits and cultural diversity plans). These 40 documents were then discussed with the last reviewer (R. H.) to further refine the search strategy and to develop eligibility criteria.

| Eligibility criteria
Eligible data sources: Federal-, state-and territory-level government health departments and the associated agencies were included as they are primarily responsible for setting principles and policies for the delivery of health services in Australia. Engagement frameworks originating between January 2001 and July 2020 were included. This time period was selected because consumer engagement has increasingly been prioritised in the last 20 years.

Types of documents:
We defined consumer engagement frameworks as documents that provided a conceptual structure for engagement with consumers in the decision-making process at various levels of health systems, and that outlined levels and the spectrum of engagement, and the methods and activities of engagement.
Data sources and documents that did not fulfil the above criteria were excluded. Individual local health district-level consumer engagement frameworks were excluded as they linked up to higher-level frameworks included in the analysis. Consumer engagement toolkits, guidelines and implementation plans were excluded as these were outside of the definition. Engagement frameworks for mental health services or drug and alcohol services were also excluded as these were considered very specific areas of engagement for engaging with other minority and priority population groups and were not relevant to the study objectives.
Unit of analysis: The aspects of the framework that discussed the concept of engagement, principles of engagement, process of engagement, type of engagement and activities of engagement with consumers were analysed along with how CALD populations are represented in these documents and what special considerations were made for CALD consumer engagement.

| Document collection and data extraction
After establishing the eligibility criteria, the same reviewers (A. C. and J. L.) applied this to the initial set of 40 documents identified, along with another search conducted of the Australian Government (federal, state and territory) health department websites and associated agencies for eligible documents (see Supporting Information File SB for the full list of the website searched). This search identified 11 publicly available engagement frameworks that fulfilled the eligibility criteria. A protocol for data extraction was developed based on the research aims. Data were independently extracted by the same reviewers (A. C. and J. L.) under the following categories: federal or state level; health system or service level; organisation, document title and year of publication; purpose of the document; key messages regarding consumer engagement; and diverse populations discussed (Table 1).

| Data analysis and reporting
Arnstein's Ladder of citizen engagement 38 and Carman et al's. 3 frameworks for patient and family engagement were used to guide the narrative data synthesis. These two frameworks are well-established engagement frameworks used to differentiate between tokenistic versus meaningful engagement across the continuum of consumer involvement in the decision-making process and hence were considered relevant for this document analysis. 3,38,39 Along with the original data extraction tool (Table 1), a separate table (Supporting Information File SC) was developed drawing on the similarities and differences between the selected frameworks, focusing on elements of conceptualisation and operationalization of these frameworks.
The data extracted were then explored to identify what support structures and contextual features were proposed or adopted by health services in Australia to engage with consumers and how these were discussed in the context of CALD consumers.
A narrative synthesis was conducted. Synthesising data using a narrative synthesis approach allowed us to establish a relationship between research, policy and practice and generate key common CHAUHAN ET AL. concepts relevant to the research objectives. [40][41][42] Key information from each set of documents was extracted on a data extraction form (Table 1) to provide a narrative on common themes. AC conducted the initial analysis of the data. Data were grouped into categories resembling the research questions and common narratives across the documents examined and analysed. Following this grouping, the findings were discussed with the wider research team and the analysis was further refined. Any disagreements and differences were resolved with discussion.

| Data sources and characteristics
Using Altheide's document analysis approach (Figure 1), a total of 11 engagement frameworks, two at the federal level and nine others across the state and territory levels, were identified as eligible. [43][44][45][46][47][48][49][50][51][52][53] Of the eleven frameworks, three were identified as stakeholder engagement frameworks, while eight comprised community and/or consumer engagement. Where the term stakeholder was used, the term was described as inclusive of consumers and community. The 3.2 | Q.1) How is engagement conceptualised?
This process is consistent with the Deming management approach to continuous improvement of the Plan, Do, Study and Act Cycle. 54 The process of engagement was further conceptualised in three frameworks as an ongoing cycle supporting engagement activities via thorough planning, preparation, action and evaluation of the activities. 45,47,48 Involvement in the process was articulated as either participation in the whole process or participation in specific activities within the process. 45,47,48 A wide range of concepts were included that described the nature of activities, ranging from consultation through to participation and codesign, reflecting engagement as a continuum. The term 'participation' was also used as a synonym for engagement rather than a specific level of engagement in two documents. 46,47 Principles for engagement were explicitly mentioned in eight frameworks, 44,47-53 with the four most common principles identified consumers. There was a lack of discussion and clarity on the relationship between the activities used and intended outcomes. Table 2 presents an overview of suggested engagement methods and activities included in the various engagement frameworks along with the most common activities highlighted.
Organisational prerequisites to enhance opportunities for engagement for CALD consumers focused on three key initiatives: (1) provision of culturally sensitive services; (2) greater access to interpreters at the service level; and (3) inclusion of CALD consumers in committees. Provision of culturally sensitive services and engagement strategies was discussed in three frameworks [46][47][48] ; however, no clear definition of culturally sensitive services was provided in these documents. External tools and resources were referred to in these frameworks to develop culturally sensitive services. Cultural diversity plans, strategic plans recognising the health needs of CALD consumers and committees representing CALD consumers were identified as mediums through which culturally sensitive services can be developed to optimise opportunities for engagement for CALD consumers. 47,48 The need for adequate financial and physical resources and dedicated time was identified as a prerequisite for all consumers; however, for CALD consumers, the need for increased access to interpreters was highlighted as an additional resource requirement in one framework. 46 While identifying consumers from diverse backgrounds was discussed in the context of broader minority and priority groups overall, identifying CALD consumers was considered essential for advisory committees and governance activities. 45 However, the degree to which diversity within CALD participants needs to be included in such committees was not clear. The mechanism to involve CALD consumers in advisory panels and committees was described in one framework, 45  interpreters. 46,47 The provision of orientation and training for consumers was discussed as critical for effective engagement for all consumers; however, for CALD consumers, two frameworks emphasised providing training to staff and providers, which were designed to improve their cultural responsiveness. 46,47 This training was intended to create an environment that is culturally safe, and to ensure that language barriers are addressed when engaging with CALD consumers, thereby enhancing engagement activities. 46,47 However

| DISCUSSION
Health services in Australia and internationally recognise not only the need for consumer engagement but also the need to demonstrate meaningful partnerships rather than tokenistic actions. 31,39,55 The critical need to recognise minority and priority groups such as CALD consumers is also highlighted. 39,55 Our document analysis provides evidence of the need for this shift in the landscape of consumer engagement, and particularly the need for greater clarity regarding approaches to enhance minority representation and active participation. This analysis showed that while engagement was described as a process, conceptualisation of the process was limited. 45,47,48 While many of the activities and methods used for engagement were described, there was a limited exploration of activities against the intended outcomes, with the evaluation of these activities limited to collecting feedback and surveys from consumers. 49,52 Addressing language barriers remains a key area of focus for enhancing engagement with CALD consumers, whereby recent frameworks acknowledged the role of culturally sensitive services and health professional cross-cultural training to improve opportunities for engagement. [45][46][47][48] Our findings are similar to a recent analysis of migrant health policies in European countries, which demonstrated that policy initiatives for migrant health were largely focused on interpreter use and health professional cross-cultural education. 56 Culturally sensitive services were identified as a prerequisite to enhance CALD consumer engagement. 48,53 Cultural sensitivity refers to being aware of cultural diversity, including the influence of culture on consumers' values beliefs, and attitudes and acknowledging and respecting these differences 57 ; yet, the lack of shared understanding of what constitutes a culturally sensitive service and how this can be achieved is an ongoing challenge. 58,59 The promotion of cultural competence at the system, organisation and staff levels was recognised as a critical prerequisite for a culturally sensitive service. 22 Cultural competency in healthcare staff is described as the ability of staff to effectively deliver healthcare that meets the social, cultural and linguistic needs of patients. 22 73 Embedding flexibility for consumers that are convenient to their schedule but also recognise their health condition, caregiving and other responsibilities can promote an enduring and deeper relationship. 74,75 The need to value service user input through sufficient reimbursement is also recognised as important for all consumers but particularly those who may be from lower socioeconomic backgrounds, who live further from central city locations or who have caregiving responsibilities. 74 Modelling policies and guidelines internationally on consumer reimbursement at the national level in Australia may provide one approach to ensure that sufficient reimbursement is consistently provided. 76,77 Given the range of CALD background and diversity between and within groups, the gold-standard approach to ensuring sufficient and appropriate diversity for CALD consumer engagement activities remains elusive; 4 the documents reviewed were noteworthy for their lack of discussion about the need to consider sociocultural diversity across CALD populations and how sufficiently diverse input might be determined. International literature also supports our findings for the lack of diverse minority representation in consumer engagement literature. 39,78 Guidelines for engaging with multicultural communities encourage collaboration with established multicultural services or multicultural committees to seek participants, 45,79 which are also recognised as a way to enhance consumer participation internationally. 80 This approach may lead to disproportionate participation from some CALD groups or some individuals with the inadequate representation of new and emerging CALD groups. 56 Over time, the use of well-trained consumers in research may lead to desensitisation to the needs of their community. 81 There currently appears to be limited consideration of nuanced sociocultural differences within and between populations. 23 Consumer engagement frameworks provide a valuable opportunity to highlight some of these issues and drive thought and discussion regarding approaches to address issues of widening participation and diversity in CALD consumer engagement nationally and internationally.
Continuous improvement, as a key principle within healthcare, was prominent within the included frameworks. Evaluation of consumer involvement was discussed in many of the frameworks, but not its application for continuous improvement in the methods and activities used for consumer engagement and specifically for CALD groups. Integrating routine feedback and dissemination of lessons learned from consumer engagement activities within consumer engagement frameworks is the next step to support the dissemination of evidence-based methods and activities across healthcare systems.
Using a collaborative approach with consumers to evaluate the effectiveness of the consumer engagement methods and activities used and the adaptations or support required for CALD groups will contribute to ensuring that optimal methods and activities are used. 82 CHAUHAN ET AL.