https://ojs.wpro.who.int/ 1WPSAR Vol 13, No 2, 2022 | doi: 10.5365/wpsar.2022.13.2.915 Brief Report I n Australia, as in other developed nations, the coronavirus disease 2019 (COVID-19) pandemic has disproportionately affected culturally and linguistically diverse (CALD) communities. In many countries, immigrant communities have experienced higher rates of COVID-19 infection, hospitalization, severity of disease and death.1–3 We know that, in Australia, the risk of transmission and serious illness from COVID-19 is not equal across the population – one vulnerable population disproportionately impacted by COVID-19 is people from CALD backgrounds.4 The discrepancies in outcomes between CALD and non-CALD populations evident through the COVID-19 pandemic were also seen during the 2009 H1N1 pan- demic.5,6 It has long been argued that the principles of social justice and corrective justice must be applied in pandemic planning, to enable risk reduction in popula- tions where the need is greatest.7 Families and communities are the ultimate recipi- ents of the effects of pandemic plans, and thus need to be involved in their development. Any pandemic health policy or plan must address the public’s real concerns and needs, especially among groups who are at higher risk, because this will lead to a reduction in risk for the whole population.8,9 Not engaging with vulnerable communities when developing health policies or plans is not only unfair but also endangers the health of the broader population.9 This article presents a rapid assessment of COVID-19 pandemic plans applicable to the region of the public health unit (PHU) conducting the study. It ex- plores whether the needs, expectations and challenges of CALD communities are represented in these plans. The terms “immigrant” and “CALD communities” are used interchangeably here. The study did not include a review of all relevant literature or research papers; a Multicultural Health Service, Hunter New England Health, Wallsend, New South Wales, Australia. b The University of Newcastle, Callaghan, New South Wales, Australia. c College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia. Published: 2 May 2022 doi: 10.5365/wpsar.2022.13.2.915 Objective: This paper presents a rapid assessment of coronavirus disease 2019 (COVID-19) pandemic plans and explores the representation of culturally and linguistically diverse (CALD) communities in such plans. Four levels of pandemic plans were reviewed: regional, state, national and international. Methods: Discussions with representatives from four CALD communities informed the development of search and selection criteria for the COVID-19 plans, which were gathered and assessed using a CALD lens. Six COVID-19 pandemic plans that met the inclusion criteria were critically assessed. Results: The reviewed plans did not report any CALD community voices, views or consultations with community groups in the development phase, nor did they acknowledge the diversity of CALD populations. A few plans noted the vulnerability of CALD communities, but none discussed the challenges CALD communities face in accessing health information or health services during the pandemic, or other structural barriers (social determinants of health). Discussion: Our analysis revealed major gaps in all pandemic plans in terms of engaging with immigrant or CALD communities. Policies and plans that address and consider the complex needs and challenges of CALD communities are essential. Collaboration between public health services, multicultural services and policy-makers is vital for the inclusion of this higher-risk population. Culturally and linguistically diverse voices and views in COVID-19 pandemic plans and policies Nafiseh Ghafournia,a,b Peter D Massey,c Sunita J Rebecca Healeya,b and Bhavi Ravindranb Correspondence to Nafiseh Ghafournia (email: Nafiseh.Ghafournia@health.nsw.gov.au or Nafi.Ghafournia@newcastle.edu.au) WPSAR Vol 13, No 2, 2022 | doi: 10.5365/wpsar.2022.13.2.915 https://ojs.wpro.who.int/2 Ghafournia et alCALD voices ties and addressing real health needs and challenges. None of the reviewed plans reported any voices, views or consultations with CALD community groups in the development phase. There was some mention of the significance of community engagement in the process of policy-making, but there were no details on which communities or how to engage with them. The assessed plans included no acknowledgement of the diversity of CALD populations. When immigrant or CALD communities were named, they were presented incorrectly as generalized and homogeneous communi- ties. The vulnerability of immigrant and refugee or CALD communities was noted in three plans (the two WHO plans and the COVID-19 Pandemic Plan for the Victorian Health Sector). However, none of the documents discussed CALD community challenges in accessing health information or health services dur- ing the pandemic or other structural barriers such as social determinants of health. Also, the documents did not mention factors such as unemployment, crowded housing, visa status, low health literacy, racism and cultural beliefs. A few references were made to chal- lenges in communication between health organizations and immigrant communities, but the plans tended to fall short of addressing solutions for overcoming barriers to reduce risk. Only two plans (the NSW Health Influenza Pandemic Plan and the COVID-19 Pandemic Plan for the Victorian Health Sector) talked about the necessity of providing translated information. DISCUSSION In general, Australian policies and plans do not engage with CALD communities, and there is little data regard- ing the needs of these communities and the challenges they face in accessing health-care systems. This may be an indication of structural racism in the system.10 Poli- cies and plans that address and consider the complex needs of and challenges faced by CALD communities are essential,8,9 and their development must include the knowledge and expertise of diverse groups from CALD communities and multicultural service providers. We call for health plans and policies to be redeveloped to be inclusive, culturally responsive and based on consultation with CALD communities. There must be a clear process of engagement, respectful and meaningful rather, the focus was on pandemic plans and policies at multiple settings and levels (from regional to inter- national). METHODS Pandemic plans at regional, state, national and interna- tional levels were selected, accessed and then critically assessed through a “CALD lens”. The selection criteria included plans that were: • available online at the time of assessment; • updated or published within the past 5 years; and • applicable to the region or state of the PHU un- dertaking the review, to a neighbouring state or to international plans published by the World Health Organization (WHO). As part of using a CALD lens, discussions with rep- resentatives from four CALD communities informed the development of the search and selection criteria. These key informants were emailed a series of questions. Four consumer representatives of local multicultural health services then discussed the emailed questions with the informants to finalize the assessment questions. The final questions were as follows: 1. Does the plan describe a governance structure that includes CALD community representatives? 2. Does the plan describe any consultation with CALD communities before or during the develop- ment of the plan? 3. Does the plan outline how it reflects and embraces the diversity of CALD communities? 4. Does the plan reference the challenges CALD communities encounter in accessing health sys- tems? 5. Does the plan describe how CALD communities would be involved in the oversight, implementa- tion or review of the plan when it is operational- ized? RESULTS Six plans met the inclusion criteria and were critically reviewed (Table 1). All were found to have major gaps in terms of engaging with immigrant or CALD communi- WPSAR Vol 13, No 2, 2022 | doi: 10.5365/wpsar.2022.13.2.915https://ojs.wpro.who.int/ 3 CALD voices Ghafournia et al Table 1. Pandemic plans reviewed by setting 2. Khunti K, Singh AK, Pareek M, Hanif W. Is ethnicity linked to in- cidence or outcomes of COVID-19? BMJ. 2020;369:m1548. doi:10.1136/bmj.m1548 pmid:32312785 3. Clark A, Jit M, Warren-Gash C, Guthrie B, Wang HHX, Mercer SW, et al. Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study. Lancet Glob Health. 2020;8(8):e1003–17. doi:10.1016/S2214-109X(20)30264-3 pmid:32553130 4. Smith JA, Judd J. COVID-19: vulnerability and the power of privi- lege in a pandemic. Health Promot J Austr. 2020;31(2):158–60. doi:10.1002/hpja.333 pmid:32197274 5. Zhao H, Harris RJ, Ellis J, Pebody RG. Ethnicity, deprivation and mortality due to 2009 pandemic influenza A(H1N1) in England during the 2009/2010 pandemic and the first post-pandemic season. Epidemiol Infect. 2015;143(16):3375–83. doi:10.1017/ S0950268815000576 pmid:25850904 6. Tricco AC, Lillie E, Soobiah C, Perrier L, Straus SE. Impact of H1N1 on socially disadvantaged populations: summary of a systematic review. Influenza Other Respir Viruses. 2013;7(Suppl 2):54–8. doi:10.1111/irv.12082 pmid:24034485 7. Kayman H, Ablorh-Odjidja A. Revisiting public health prepared- ness: incorporating social justice principles into pandemic pre- paredness planning for influenza. J Public Health Manag Pract. 2006;12(4):373–80. doi:10.1097/00124784-200607000- 00011 pmid:16775535 8. Oxman AD, Lavis JN, Lewin S, Fretheim A. SUPPORT tools for evi- dence-informed health policymaking (STP) 1: What is evidence-in- formed policymaking? Health Res Policy Syst. 2009;7(Suppl 1):S1. doi:10.1186/1478-4505-7-S1-S1 pmid:20018099 9. Wild A, Kunstler B, Goodwin D, Onyala S, Zhang L, Kufi M, et al. Communicating COVID-19 health information to culturally and lin- guistically diverse communities: insights from a participatory re- search collaboration. Public Health Res Pract. 2021;31(1):3112105. doi:10.17061/phrp3112105 pmid:33690789 10. Elias A, Paradies Y. The costs of institutional racism and its ethi- cal implications for healthcare. J Bioeth Inq. 2021;18(1):45–58. doi:10.1007/s11673-020-10073-0 pmid:33387263 two-way communication between policy-makers and CALD communities to identify culturally appropriate and effective public health control strategies. CONCLUSION Despite the health inequities faced by people from CALD communities, their voices and needs were not reflected in the pandemic plans assessed in this study. The plans failed to address embedded inequities, which are particu- larly important in health emergencies. It is recommended that CALD communities be included in the development and implementation of pandemic plans. Further research should be undertaken with diverse communities to en- able effective public health actions for COVID-19 and future pandemics. Conflicts of interest The authors declare no conflicts of interest. Funding No funding was given for this activity. References 1. Mude W, Meru C, Njue C, Fanany R. A cross-sectional study of COVID-19 impacts in culturally and linguistically diverse com- munities in greater Western Sydney, Australia. BMC Public Health. 2021;21(1):2081. doi:10.1186/s12889-021-12172-y pmid:34774039 Plan Setting Website Hunter New England Pandemic Plan for Influenza and Other Respiratory Infections Regional https://www.hnehealth.nsw.gov.au, accessed 31 August 2020 NSW Health Influenza Pandemic Plan State https://www1.health.nsw.gov.au/pds/ActivePDSDocu- ments/PD2016_016.pdf, accessed 31 August 2020 COVID-19 Pandemic Plan for the Victorian Health Sector State Link is no longer active; available from the correspond- ing author upon request Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19) National https://www.health.gov.au/resources/publications/aus- tralian-health-sector-emergency-response-plan-for-novel- coronavirus-covid-19, accessed 31 August 2020 COVID-19 strategy update, World Health Organization International https://www.who.int/publications/m/item/covid-19-strat- egy-update, accessed 31 August 2020 Operational planning guidelines to support country preparedness and response, COVID-19 strategic preparedness and response plan, World Health Organization International https://www.who.int/publications/i/item/draft-operation- al-planning-guidance-for-un-country-teams, accessed 31 August 2020