Promoting inclusivity and partnership with recipients of health services: Short report on redesigning Engaging All Voices (previously Consumer Voice)

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Woodward, Irenia A. Ball, JoAnn E. Kirchner, Sara J. Landes, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9224470/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Researchers identified “preparing patients to be active in innovations” as one of the top five most effective implementation strategies; this included educating patients to be engaged in their care. If engaging patients in their own care enhances adoption of innovations, engaging patients and service users across any setting (e.g., healthcare, education, carceral) in implementation activities may also enhance adoption. To provide guidance on this topic, we developed Consumer Voice: a free, online platform for community engagement in implementation efforts. In July 2023, we disseminated the tools and received feedback that “consumer” had a negative connotation for some. This feedback mimicked discontent with terminology for the “service user” in the broader implementation field. Our study goal was to identify inclusive, acceptable terminology for the “service user” in implementation practice or research. Methods We collected quantitative data then qualitative data from service users, implementers, and implementation researchers in two phases: 1) Brainstorming and prioritizing terminology for service users through Nominal Group Technique, then 2) Contextualizing implications of different terms through focus groups. Between phases, we used quantitative counts to inform sampling and inductive qualitative analysis. Results Participants represented a range of demographic groups; over 40% identified primarily as individuals receiving health services, 30% as implementers, and 26% as implementation researchers. There was consensus to rename our engagement tools “Engaging All Voices.” Our data indicated there was no universally acceptable term for “service user.” Even within similar communities, some terms were controversial e.g., “patient,” “peer.” Two terms felt off-limits to most: “stakeholder” and “user.” Participants thought any engagement language should convey a sense of action and partnership to move beyond performative, superficial “engagement.” Conclusions We sampled people from multiple service settings and thus, findings may generalize in healthcare, education, carceral, and other systems. Our experience redesigning Engaging All Voices revealed that how recipients of innovations are referred to can shape receptiveness to engagement approaches. There is no single “right” term to refer to service users across settings. Engaging All Voices now guides learners in an early exercise to determine terminology preferred by service users throughout an implementation effort. service users consumer patient engagement3 patient and public involvement community engagement implementation science quality improvement Contributions to the Literature There is not one “correct” word to refer to people who receive health services, so when working with them to launch or sustain a service, discuss with them terms they would prefer to be called. Avoid “stakeholder” or “user” to refer to people who receive health services (service users). Former Consumer Voice tools to teach workforce staff how to engage service users in implementation have been renamed Engaging All Voices and now include a learning objective about selecting acceptable terms for people receiving health services. Introduction Researchers have identified “preparing patients to be active in innovations” as one of the top five most effective implementation strategies to date. 1 – 3 Preparing patients to be active includes educating them to be engaged in their care by asking questions about care guidelines and rationale for clinical decisions. These data 1 – 3 provide a scientific signal that engaging patients in the organizational “inner workings” to design and deploy health services, versus only engaging them in their care, could improve adoption of effective treatments. 1 , 4 There has been little guidance on what preparing service users of an innovation entails or how to co-develop and deploy strategies with the service user, who we define as the intended recipients of an innovation—those expected to receive and benefit from a service. Service user engagement can range in level of intensity from one-time interactions to ongoing efforts. Roles for service users who receive health services in any setting (e.g., schools, clinics) in implementation activities may include guiding cultural adaptation of a treatment before launch in a new setting, advising on implementation strategy selection, or serving as an implementation practitioner. 4 In 2018, we conducted an environmental scan documenting the need for guidance to engage service users in implementing services that are meant for them. 5 Following Kwan et al.'s Fit-to-Context framework for dissemination, 6 we attempted to fill this need by creating tools for implementers to engage service users in implementation efforts. We involved patients in a health system and professionals from multiple systems (e.g., hospital, criminal justice, community clinics, schools) in co-designing and user-testing these tools. 7 The result was Consumer Voice: a free, online platform offering tools for community engagement in implementation efforts. In July 2023, we disseminated Consumer Voice tools publicly for implementers. We received feedback from potential users that the word “consumer” had a negative connotation in social sciences and public health because it drew from business and for-profit fields, and that some service users did not want to be referred to as consumers in healthcare settings. We needed to enhance the “product to context fit” of the engagement tools. 6 This feedback also mimicked lack of consensus with terminology for the “service user” in the broader implementation research and practice field. 8 , 9 Our study goal was to identify inclusive, acceptable terminology referring to the “service user” and its potential consequences to a broad variety of social positions we encounter in implementation practice and research. This study was also a next step to enhance product-context fit to a variety of cultural norms in which our engagement tools may be used, consistent with Kwan et al’s framework. 6 Methods Study Design Using an exploratory sequential design, 11 we collected data from people involved in implementation processes in two phases: 1) brainstorming and prioritizing terminology when referring to service users through Nominal Group Technique, and 2) contextualizing implications of applying different terms through focus groups (Table 1 ). Study activities were deemed human subjects research by the Central Arkansas Veterans Healthcare System Institutional Review Board. We conducted a verbal and written informed consent process. Table 1 Study matrix showcasing multiple methods Procedures Sample (n = individual participants) Goal Analysis or interpretation Phase 1: Nominal Group Technique (n = 6 sessions) Service users (n = 47) Implementers (n = 5) Researchers (n = 6) Generate ideas and vote on terminology priorities for “service users.” Compile quantitative voting sums and descriptive statistics of participant demographics. Connect data to inform qualitative focus group questions and determine participant sampling strategy. Panel of community engagement and implementation researchers (n = 4, co-authors) Align the list of top preferred terms from Nominal Group Technique sessions to open-ended questions to contextualize terms in focus groups. Vote to narrow the potential list to the top three choices and identify participant groups that need representation in the next phase. Phase 2: Focus groups (n = 4 groups) New sample of service users (n = 7), implementers (n = 12), Researchers (n = 2) Conduct member checking to contextualize and understand the implications of adopting terms Perform rapid qualitative analysis using a template approach. Make meta-inferences Same panel of community engagement and implementation researchers (n = 4, co-authors) Determine consensus on top-rated terms and their contextual implications. Clarify the new name for Consumer Voice tools upon refinement of results. Participants in Nominal Group Technique and Focus Groups We recruited from multiple service settings including educational, healthcare, and other places where health services are delivered. From April 2024 to September 2025, we sent e-mails to recruit participants from our team’s North American networks in implementation science, practice, and community organizations (e.g., patient/family advisory councils for health systems, national learning collaborative for practice facilitators). Due to funding regulations, we offered service users of the U.S. Veterans Health Administration received a $ 50 check; other participants received a $ 50 Amazon gift card. Service users. These were people over 18 years old receiving health services (e.g., patients) because we wanted their perspectives reflected in the nomenclature. Implementers. Implementers were professionals responsible for navigating the launch / quality of a health service in any setting. Our purpose was to ensure that our engagement tools were attractive to them. Researchers. These researchers were participants, not our research team. They were recruited based on implementation science or community engagement experience to learn their perspectives. Data Collection and Analysis between Phases Phase 1: Brainstorming and prioritizing. We hosted 50-minute virtual meetings using Nominal Group Technique 13 to brainstorm then prioritize preferred names for service users and our engagement tools across different settings. Each group consisted of either service users, implementers, or researchers and 1–2 people from the contact organization who co-facilitated the meeting. Thus, most groups consisted of participants on the same “level” regarding power in decision making about implementing a health service. Each person was sampled only once. Our goal was to synthesize a set of preferred terms for “service user” across settings. We asked these questions with five minutes to silently brainstorm: “What are potential names for the person receiving services besides ‘consumer?’” and “What would you suggest we rename ‘Consumer Voice?’” We asked each participant to share all their responses verbally and visually posted all ideas on a virtual whiteboard all could see. Next, we prompted participants to discuss rationales for their ideas for 5–10 minutes. Finally, each participant was given a specific number of votes based on the list of brainstormed choices; the longer the list, the more votes were allowed ( Range = 3–10). 14 Participants could spread those votes across one or more terms they preferred. We repeated this process with six different groups until we heard the same set of options. One researcher facilitated while another took notes and transcribed video recordings (see reflexivity statement). Phase 1 data analysis: We summed votes across Phase 1 meetings to rank the top five preferred names for the “service user” and top three alternate names for the engagement tools. We shared these results alongside ideas that were mentioned more than once during participants’ discussions with our entire research team to interpret findings. We analyzed participants' demographics after Phase 1. For Phase 2, we recruited populations underrepresented in Phase 1 to maximize participant variation. 12 Phase 2: Contextualizing. We recruited a new sample for four focus groups to develop consensus on a new name for our engagement tools and discuss unintended or intended consequences of preferred terms for “service users.” This is a form of member checking to enhance validity by allowing participants to broaden, clarify, or generate new information based on Phase 1 data. 15 We shared a low-fidelity prototype advertisement for the engagement tools and elicited participants’ reactions to it, including proposed names of the tools. Sample focus group questions were: “For the name of tools on the advertisement, what does this word make you think about?” and “What pros or cons do you see to using this word?” By the last focus group, we did not hear any new information, and ceased sampling. 16 Phase 2 qualitative analysis: Both researchers (ENW and IAB) completed a verbal and written debriefing process using memos, checked video recordings for unclear areas, and completed a summary of written data from each focus group. They organized written data into a single matrix, with questions posed during focus groups as column headers and participant's primary role (service user, implementer, researcher) in each row. They added to the cells all repeating ideas from participant discussions during Phase 1 sessions and Phase 2 focus groups. The goal of our inductive qualitative analysis was to generate major findings regarding: “ What are recommendations for language for the ‘service users’ in implementation efforts?” and “What is an ideal name for the engagement tools?” Each analyst independently reviewed the matrix, combining concepts described more than once into repeating ideas, then synthesizing them into higher-level concepts. Analysts met and compared initial analyses, referring to the data to verify, clarify, and expand. They came to consensus on a potential name for engagement tools—Engaging All Voices. Final Data Validation. We sent a one-question e-mail survey to all participants comparing an older advertisement for Consumer Voice to a new advertisement for Engaging All Voices. We asked, “W hich flyer resonates more with you?” The Engaging All Voices flyer was chosen by 87.5% of participants (21 out of 24). Results Demographics Table 2 reflects a diverse and knowledgeable sample, grounding results in relevance and inclusiveness. Over 40% identified as individuals receiving health services. Many participants (36%) reported some familiarity with community engagement, enhancing depth of their feedback. Table 2 Participant Demographics Demographic Characteristic N (%) * Age Mean = 49.7 years, Range = 26–78 Roles (check all that apply) Veteran of the US military* 20 (27%) Service user of healthcare 31 (42%) Facilitator, quality improvement person, clinic manager 22 (30%) Implementation researcher 19 (26%) Caregiver and other 13 (12%) Gender Identity* Man 21 (29%) Woman 50 (68%) Education Level College degree or greater 28 (58%) No college degree 20 (42%) Racial Identity American Indian or Alaska Native 10 (13%) Black or African American 28 (38%) White 26 (35%) Ethnicity Non-Hispanic, Latino, or of Spanish origin 60 (82%) Hispanic, Latino, or of Spanish origin 11 (20%) Ancestors from Puerto Rico 10 (14%) Sexual Identity Straight, that is, not gay or lesbian, etc. 56 (76%) Geographic Location based on zip code* Urban 34 (65%) Rural 14 (26%) *Note: Counts < 10 participants are not depicted to prevent re-identifying them. We asked about U.S. military Veteran status as this is our health system. Not all percentages = 100 because some participants endorsed “prefer not to answer” to some questions. Gender identity: some participants identified as non-binary. Racial identity: Some participants identified also as Asian (e.g., Chinese, Thai) or “another race.” Ethnicity: Some had as ancestors from another place of Hispanic, Latino, or Spanish origin. Sexual identity: Some identified as bisexual, lesbian, gay, or another identity. Zip code translated to Rural Urban Commuting Area code: 1–3 = urban, 4–9 = rural, 10 = highly rural. Some participants were outside the U.S. Quantitative Findings from Nominal Group Technique The terms participants prioritized are in Table 3 . During analysis interpreting Phase 1 results, our team noted that many of these words would not fit every implementation setting (e.g., 'client' not suitable in schools). Also listed were participants’ top names for our engagement tools. The majority voted for suggestions that were either very specific or for a format substituting the original “consumer” for another noun referring to service users (e.g., Community Voice). Table 3 Terms and Engagement Tool Names Prioritized by Participants Top Five Terms Prioritized for the Service User Count a Client 45 Participant 32 Constituent 21 Patient 19 Survivor 19 Top Three Names for Engagement Tools Count b Specific Option (e.g., Guiding Light, Raising the Bar) 15 [Placeholder Noun] Voice (e.g., Client Voice) 13 [Placeholder Verb] Voices (e.g., Empower Voices) 4 Grand Total of Choices 32 Note. A. Votes will exceed the number of participants. B. Votes do not reflect all participants, as 50% of the Nominal Group Technique participants did not have time to vote on their brainstormed terms. Qualitative Findings from Focus Groups Participants in the last two focus groups found unanimous consensus to rename our engagement tools “Engaging All Voices.” Our qualitative data indicated there was no universally accepted term for a service's end user. Four findings are presented with repeating ideas below. “Engaging All Voices” may not be completely clear on its own, but it does have appeal, accurately applies to a broad audience, and evokes inclusivity. One implementer said, “ With a [more generic name], you have to do a little work to think about ‘am I included in this’?” The broad name was acceptable if accompanied by clear, compelling messages that elaborated on the tools' concept, functions, and intended audience (e.g., tagline). Also, more specific names did not accurately represent the tools’ generalizability across populations (e.g., Student Voice). Some implementers wanted more workforce-centered language in the tools, including one who said, “‘Workforce voices’ don’t seem to be included in [the ads for the tools] even though the ultimate service users are people in the workforce, so that omission could be confusing.” A second finding was that some terms were controversial even within communities with shared demographic characteristics, such as “patient,” “peers,” “people in need,” and “consumer.” Within a focus group of people who access mental healthcare at the same clinic, two participants with a business/finance background felt comfortable with “consumer” while two other participants rejected the term because it implied a false sense of choice in seeking health services. Some participants did not like “patient” because it felt disempowering. Two terms felt off-limits to most: “stakeholder” and “user.” Although “stakeholder” was familiar to implementers, it made them think about executive leaders, or as one implementer shared, “ People who have power, money, make decisions and not all people we serve…would be that.” The word “user” connoted negativity, as one implementer said it implied people are “ substance users, potentially, or “users” of a health system in a negative way. ” A sense of action and partnership should be conveyed through the words used in engagement to evoke a motivated and committed group of personnel ready to move beyond performative, superficial “engagement.” Specifically, language about "voices" was appealing in the tools. Service users expressed that, “ advocacy is important, so ‘voice’ is important” because they wanted to be empowered through having their voices heard and respected. Implementers and service users preferred active verbs to describe service users’ engagement. One service user said, “ I like to think of ‘engage’ as it is more active than ‘including;’ We are supposed to be working together.” This highlighted the concept of collaboration. Participants responded positively to the tools' purpose to promote inclusivity and liked that the tools offered workforce personnel actions to move toward inclusivity. Most participants perceived that the tools would teach them something new. Meaningful partnerships were important to participants, and they felt tools that help personnel do that are needed. As one implementer stated, “ It would help me do my job better – means that efforts we are implementing, improvement efforts, that are not just top-down mandates, but they can be two-way streets, working in partnership together to be the best it can be.” Discussion There was no consensus on acceptable terms for the service user in the context of implementation efforts across any setting. Language that promoted inclusivity and implied partnership was more important than selecting a single label for service users. The lack of consensus across diverse participants from several social positions validates that we, as implementers and researchers, also struggle with these terms. As a result, we added a learning objective to Engaging All Voices to co-develop terminology that is culturally responsive to people meant to receive the service. Specifically, there is a module in the toolbox entitled “Prepare to Work with Everyone” which highlights tasks to be accomplished early in an implementation partnership, such as identify why it is important to engage others in a particular effort and plan ways to compensate others for their contributions. We do not recommend any certain terminology. We propose activities to determine preferred terms defined with the community in question. One issue in implementation science is that we may not critically examine how people involved in implementation efforts respond to terms used “about” them rather than “by” them. One result of our study was that common terms in implementation science and practice, such as “patient,” “peer,” “people in need,” and “consumers,” elicited mixed reactions. Even among similar groups, participants disagreed on terms, with some suggesting their use because they were clear and others recommending against their use because they implied a state of disempowerment or inaccuracy. A common word in our field, “stakeholder,” 17–19 was perceived negatively by service users and implementers. We might avoid using “stakeholder” unless it is the most accurate and acceptable term. Because implementation science and practice rely on significant interpersonal collaboration, 20–22 it behooves us to be thoughtful about our language about people we collaborate with. In future implementation efforts, we may need to conduct an assessment to determine acceptable terminology for service users. Implementation science paradigms, influenced by context, often stress urgency, efficiency, and rapid knowledge production. yet, our rapid knowledge translation can sacrifice relatability, relationship-building, and trust among our collaborators. Processes to “design for dissemination” that harness community-engaged implementation, as in our study, can explore this tension. 6 Establishing trust among all people involved in an implementation effort is increasingly seen as vital to an innovation’s success. 21 Conclusion We identified a new name for our engagement tools: Engaging All Voices. This compendium includes free tools to help implementers engage service users in launching and sustaining health services. It is hosted on two platforms: one within the Veterans Health Administration server, 23 and one for individuals outside the Veterans Health Administration. 24 Engaging people who will receive health services is a potentially powerful but underutilized implementation strategy. Redesigning Engaging All Voices revealed that how recipients of innovations are referred to can shape receptiveness to engagement. Our study suggests there is no “right” term for service users across any setting and provides a process by which implementers can thoughtfully engage service users to determine suitable terminology. Future work should evaluate Engaging All Voices feasibility and outcomes. Declarations 1 Ethics approval and consent to participate: The study was reviewed and approved by the Institutional Review Board of the Central Arkansas Veterans Healthcare System (IRBNet #157782). The IRB approved the use of verbal informed consent for all study participants. This consent process was explained to each participant before the interview, and all individuals agreed to provide verbal consent. Because consent was obtained verbally, no written consent forms were collected. Consent for publication: Not applicable. Conflict of Interest The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. Author Contributions ENW conceptualized the study design and led all data collection and analysis. IAB collected and analysed data. CW helped conceptualize this study and provided training on its methods. SJL helped conceptualize the study and guide methods. LRMH helped conceptualize the study and guide methods. JEK helped conceptualize the study and guided methods. All authors contributed to interpreting data and writing or editing this manuscript. Funding This work was supported by Dr. Woodward’s Career Development Award Number IK2 HX003065 and “Small aWard Initiative For impacT (SWIFT)” grant from the United States (U.S.) Department of Veterans Affairs Health Systems Research Service (Woodward & Ball) and the CBPR Scholars Pilot Grant by the University of Arkansas for Medical Science Translational Research Institute, grant UL1TR003 07 through the National Institutes of Health. Partial funding support: VA Center for Mental Healthcare and Outcomes Research, North Little Rock, AR, and VA Behavioral Health Quality Enhancement Research Initiative (QUERI): Advancing 21st Century Mental Health Care for Veterans (QUE 20-026; PIs: Landes & Miller). Acknowledgments Thank you to participants in this study for their knowledge and thoughts that shaped this work. The online platform for these tools has been supported by Brenda Salgado at the VA Center for Innovations, Quality, Effectiveness, and Safety, Houston, TX, and the VA Center for Integrated Healthcare. Through initial development of these tools, Dr. Woodward was a fellow with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (5R25MH08091607). Authors’ Information: Reflexivity Statement The two researchers who conducted research activities and analyzed data (ENW and IAB) held multiple relevant lived experiences. One was a PhD clinical psychologist conducting implementation science and community engaged research focused on improving health equity, Eva Woodward. She writes, “ I identify as a White woman, not Hispanic or Latina, who grew up in the rural U.S. without health insurance and other socioeconomic disadvantages and difficulty getting adequate healthcare. I have been an implementer for many innovations in healthcare and community settings .” Irenia Ball was a research assistant with six years of experience in implementation science and qualitative research. She states, “ I recognize the influence of my positionality. I am a college‑educated Black woman from a middle‑class urban background and a Hurricane Katrina survivor who has used mental health services. My prior work as a youth mental health case manager and lack of implementation‑innovation experience inform my perspective when engaging veterans and other health service users. ” Data Availability Statement The datasets generated and analyzed for this study are not listed in a public repository. Please contact the first author to discuss use of de-identified datasets. 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Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 04 May, 2026 Reviewers agreed at journal 30 Apr, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviewers invited by journal 15 Apr, 2026 Editor assigned by journal 15 Apr, 2026 Submission checks completed at journal 02 Apr, 2026 First submitted to journal 25 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9224470","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Short Report","associatedPublications":[],"authors":[{"id":626439670,"identity":"b9cf5708-9b35-4d1d-94fa-e7f4042543ed","order_by":0,"name":"Eva N. Woodward","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5UlEQVRIiWNgGAWjYBAC+wYGBmYeBgZGIM0g8aGCCC0GDEhaJGecIVWLNG8bMVokkh8w81TYyG44fvbhDd55h+UZ+Bcfk8CnxV4izYA550ya8YYz6cYWktsOGzZIPEvDq8WA54ABc27b4cRtB9LYJAy3pTE2SJwxNsCv5fgHiJbzz9gkEuek2RPWwt5jwPwXpOUG0JaDDTaJDfw9hg8IaCk4PAfol/03njFbNhyzSW6TYEvEq8W+mX3jY1CIzexPY7z9p0bCtp//8IED+LSAAKoCNokEQhowAD9BO0bBKBgFo2CEAQA8GEu0VwjHWwAAAABJRU5ErkJggg==","orcid":"","institution":"University of Arkansas for Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Eva","middleName":"N.","lastName":"Woodward","suffix":""},{"id":626439671,"identity":"59d4d7b6-1940-4d6e-975e-fd0883723aca","order_by":1,"name":"Irenia A. Ball","email":"","orcid":"","institution":"Central Arkansas Veterans Healthcare System","correspondingAuthor":false,"prefix":"","firstName":"Irenia","middleName":"A.","lastName":"Ball","suffix":""},{"id":626439672,"identity":"7516c15c-c08e-42b1-bcd7-abb84affcc9c","order_by":2,"name":"JoAnn E. Kirchner","email":"","orcid":"","institution":"University of Arkansas for Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"JoAnn","middleName":"E.","lastName":"Kirchner","suffix":""},{"id":626439673,"identity":"e375628f-d426-4c59-9f7b-cda19c8ee2c5","order_by":3,"name":"Sara J. Landes","email":"","orcid":"","institution":"University of Arkansas for Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Sara","middleName":"J.","lastName":"Landes","suffix":""},{"id":626439674,"identity":"ec294abf-924b-4691-aaf0-a7828c6cc809","order_by":4,"name":"Leslie R. M. Hausmann","email":"","orcid":"","institution":"VA Pittsburgh Healthcare System","correspondingAuthor":false,"prefix":"","firstName":"Leslie","middleName":"R. M.","lastName":"Hausmann","suffix":""},{"id":626439675,"identity":"5e70be45-34e2-4747-9e01-92dd19954b69","order_by":5,"name":"Cathleen Willging","email":"","orcid":"","institution":"Pacific Institute for Research and Evaluation","correspondingAuthor":false,"prefix":"","firstName":"Cathleen","middleName":"","lastName":"Willging","suffix":""}],"badges":[],"createdAt":"2026-03-25 14:38:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9224470/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9224470/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107707082,"identity":"da734040-9467-446a-acbd-5b3400dfc07f","added_by":"auto","created_at":"2026-04-24 09:19:28","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":279639,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9224470/v1/43abf6ef-19dd-40ac-ac8e-dba4370a6bfe.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Promoting inclusivity and partnership with recipients of health services: Short report on redesigning Engaging All Voices (previously Consumer Voice)","fulltext":[{"header":"Contributions to the Literature ","content":"\u003cul\u003e\n \u003cli\u003eThere is not one “correct” word to refer to people who receive health services, so when working with them to launch or sustain a service, discuss with them terms they would prefer to be called.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eAvoid “stakeholder” or “user” to refer to people who receive health services (service users).\u003c/li\u003e\n \u003cli\u003eFormer Consumer Voice tools to teach workforce staff how to engage service users in implementation have been renamed Engaging All Voices and now include a learning objective about selecting acceptable terms for people receiving health services.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Introduction","content":"\u003cp\u003e\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eResearchers have identified \u0026ldquo;preparing patients to be active in innovations\u0026rdquo; as one of the top five most effective implementation strategies to date.\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Preparing patients to be active includes educating them to be engaged in their care by asking questions about care guidelines and rationale for clinical decisions. These data\u003csup\u003e\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e provide a scientific signal that engaging patients in the organizational \u0026ldquo;inner workings\u0026rdquo; to design and deploy health services, versus only engaging them in their care, could improve adoption of effective treatments.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003cp\u003eThere has been little guidance on what preparing service users of an innovation entails or how to co-develop and deploy strategies with the service user, who we define as the intended recipients of an innovation\u0026mdash;those expected to receive and benefit from a service. Service user engagement can range in level of intensity from one-time interactions to ongoing efforts. Roles for service users who receive health services in any setting (e.g., schools, clinics) in implementation activities may include guiding cultural adaptation of a treatment before launch in a new setting, advising on implementation strategy selection, or serving as an implementation practitioner.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn 2018, we conducted an environmental scan documenting the need for guidance to engage service users in implementing services that are meant for them.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Following Kwan et al.'s Fit-to-Context framework for dissemination,\u003csup\u003e6\u003c/sup\u003e we attempted to fill this need by creating tools for implementers to engage service users in implementation efforts. We involved patients in a health system \u003cem\u003eand\u003c/em\u003e professionals from multiple systems (e.g., hospital, criminal justice, community clinics, schools) in co-designing and user-testing these tools.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The result was Consumer Voice: a free, online platform offering tools for community engagement in implementation efforts.\u003c/p\u003e \u003cp\u003eIn July 2023, we disseminated Consumer Voice tools publicly for implementers. We received feedback from potential users that the word \u0026ldquo;consumer\u0026rdquo; had a negative connotation in social sciences and public health because it drew from business and for-profit fields, and that some service users did not want to be referred to as consumers in healthcare settings. We needed to enhance the \u0026ldquo;product to context fit\u0026rdquo; of the engagement tools.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e This feedback also mimicked lack of consensus with terminology for the \u0026ldquo;service user\u0026rdquo; in the broader implementation research and practice field.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e Our study goal was to identify inclusive, acceptable terminology referring to the \u0026ldquo;service user\u0026rdquo; and its potential consequences to a broad variety of social positions we encounter in implementation practice and research. This study was also a next step to enhance product-context fit to a variety of cultural norms in which our engagement tools may be used, consistent with Kwan et al\u0026rsquo;s framework.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eUsing an exploratory sequential design,\u003csup\u003e11\u003c/sup\u003e we collected data from people involved in implementation processes in two phases: 1) brainstorming and prioritizing terminology when referring to service users through Nominal Group Technique, and 2) contextualizing implications of applying different terms through focus groups (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Study activities were deemed human subjects research by the Central Arkansas Veterans Healthcare System Institutional Review Board. We conducted a verbal and written informed consent process.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eStudy matrix showcasing multiple methods\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedures\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;individual participants)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGoal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAnalysis or interpretation\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase 1: Nominal Group Technique (n\u0026thinsp;=\u0026thinsp;6 sessions)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eService users (n\u0026thinsp;=\u0026thinsp;47)\u003c/p\u003e \u003cp\u003eImplementers (n\u0026thinsp;=\u0026thinsp;5)\u003c/p\u003e \u003cp\u003eResearchers (n\u0026thinsp;=\u0026thinsp;6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eGenerate ideas and vote on terminology priorities for \u0026ldquo;service users.\u0026rdquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eCompile quantitative voting sums and descriptive statistics of participant demographics.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConnect data to inform qualitative focus group questions and determine participant sampling strategy.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePanel of community engagement and implementation researchers (n\u0026thinsp;=\u0026thinsp;4, co-authors)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAlign the list of top preferred terms from Nominal Group Technique sessions to open-ended questions to contextualize terms in focus groups.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eVote to narrow the potential list to the top three choices and identify participant groups that need representation in the next phase.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePhase 2: Focus groups (n\u0026thinsp;=\u0026thinsp;4 groups)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNew sample of service users (n\u0026thinsp;=\u0026thinsp;7), implementers (n\u0026thinsp;=\u0026thinsp;12), Researchers (n\u0026thinsp;=\u0026thinsp;2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConduct member checking to contextualize and understand the implications of adopting terms\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePerform rapid qualitative analysis using a template approach.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMake meta-inferences\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSame panel of community engagement and implementation researchers (n\u0026thinsp;=\u0026thinsp;4, co-authors)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDetermine consensus on top-rated terms and their contextual implications.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eClarify the new name for Consumer Voice tools upon refinement of results.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants in Nominal Group Technique and Focus Groups\u003c/h3\u003e\n\u003cp\u003eWe recruited from multiple service settings including educational, healthcare, and other places where health services are delivered. From April 2024 to September 2025, we sent e-mails to recruit participants from our team\u0026rsquo;s North American networks in implementation science, practice, and community organizations (e.g., patient/family advisory councils for health systems, national learning collaborative for practice facilitators). Due to funding regulations, we offered service users of the U.S. Veterans Health Administration received a \u003cspan\u003e$\u003c/span\u003e50 check; other participants received a \u003cspan\u003e$\u003c/span\u003e50 Amazon gift card.\u003c/p\u003e \u003cp\u003eService users. These were people over 18 years old receiving health services (e.g., patients) because we wanted their perspectives reflected in the nomenclature.\u003c/p\u003e \u003cp\u003eImplementers. Implementers were professionals responsible for navigating the launch / quality of a health service in any setting. Our purpose was to ensure that our engagement tools were attractive to them.\u003c/p\u003e \u003cp\u003eResearchers. These researchers were participants, not our research team. They were recruited based on implementation science or community engagement experience to learn their perspectives.\u003c/p\u003e\n\u003ch3\u003eData Collection and Analysis between Phases\u003c/h3\u003e\n\u003cp\u003ePhase 1: Brainstorming and prioritizing. We hosted 50-minute virtual meetings using Nominal Group Technique\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e to brainstorm then prioritize preferred names for service users and our engagement tools across different settings. Each group consisted of either service users, implementers, or researchers and 1\u0026ndash;2 people from the contact organization who co-facilitated the meeting. Thus, most groups consisted of participants on the same \u0026ldquo;level\u0026rdquo; regarding power in decision making about implementing a health service. Each person was sampled only once.\u003c/p\u003e \u003cp\u003eOur goal was to synthesize a set of preferred terms for \u0026ldquo;service user\u0026rdquo; across settings. We asked these questions with five minutes to silently brainstorm: \u0026ldquo;What are potential names for the person receiving services besides \u0026lsquo;consumer?\u0026rsquo;\u0026rdquo; and \u0026ldquo;What would you suggest we rename \u0026lsquo;Consumer Voice?\u0026rsquo;\u0026rdquo; We asked each participant to share all their responses verbally and visually posted all ideas on a virtual whiteboard all could see. Next, we prompted participants to discuss rationales for their ideas for 5\u0026ndash;10 minutes. Finally, each participant was given a specific number of votes based on the list of brainstormed choices; the longer the list, the more votes were allowed (\u003cem\u003eRange\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3\u0026ndash;10).\u003csup\u003e14\u003c/sup\u003e Participants could spread those votes across one or more terms they preferred. We repeated this process with six different groups until we heard the same set of options. One researcher facilitated while another took notes and transcribed video recordings (see reflexivity statement).\u003c/p\u003e \u003cp\u003ePhase 1 data analysis: We summed votes across Phase 1 meetings to rank the top five preferred names for the \u0026ldquo;service user\u0026rdquo; and top three alternate names for the engagement tools. We shared these results alongside ideas that were mentioned more than once during participants\u0026rsquo; discussions with our entire research team to interpret findings. We analyzed participants' demographics after Phase 1. For Phase 2, we recruited populations underrepresented in Phase 1 to maximize participant variation.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003ePhase 2: Contextualizing. We recruited a new sample for four focus groups to develop consensus on a new name for our engagement tools and discuss unintended or intended consequences of preferred terms for \u0026ldquo;service users.\u0026rdquo; This is a form of member checking to enhance validity by allowing participants to broaden, clarify, or generate new information based on Phase 1 data.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e We shared a low-fidelity prototype advertisement for the engagement tools and elicited participants\u0026rsquo; reactions to it, including proposed names of the tools. Sample focus group questions were: \u0026ldquo;For the name of tools on the advertisement, what does this word make you think about?\u0026rdquo; and \u0026ldquo;What pros or cons do you see to using this word?\u0026rdquo; By the last focus group, we did not hear any new information, and ceased sampling.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e Phase 2 qualitative analysis: Both researchers (ENW and IAB) completed a verbal and written debriefing process using memos, checked video recordings for unclear areas, and completed a summary of written data from each focus group. They organized written data into a single matrix, with questions posed during focus groups as column headers and participant's primary role (service user, implementer, researcher) in each row. They added to the cells all repeating ideas from participant discussions during Phase 1 sessions and Phase 2 focus groups.\u003c/p\u003e \u003cp\u003eThe goal of our inductive qualitative analysis was to generate major findings regarding: \u0026ldquo;\u003cem\u003eWhat are recommendations for language for the \u0026lsquo;service users\u0026rsquo; in implementation efforts?\u0026rdquo;\u003c/em\u003e and \u003cem\u003e\u0026ldquo;What is an ideal name for the engagement tools?\u0026rdquo;\u003c/em\u003e Each analyst independently reviewed the matrix, combining concepts described more than once into repeating ideas, then synthesizing them into higher-level concepts. Analysts met and compared initial analyses, referring to the data to verify, clarify, and expand. They came to consensus on a potential name for engagement tools\u0026mdash;Engaging All Voices.\u003c/p\u003e \u003cp\u003eFinal Data Validation. We sent a one-question e-mail survey to all participants comparing an older advertisement for Consumer Voice to a new advertisement for Engaging All Voices. We asked, \u0026ldquo;W\u003cem\u003ehich flyer resonates more with you?\u0026rdquo;\u003c/em\u003e The Engaging All Voices flyer was chosen by 87.5% of participants (21 out of 24).\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eDemographics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e reflects a diverse and knowledgeable sample, grounding results in relevance and inclusiveness. Over 40% identified as individuals receiving health services. Many participants (36%) reported some familiarity with community engagement, enhancing depth of their feedback.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipant Demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDemographic Characteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN (%) *\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eMean\u003c/em\u003e\u0026thinsp;=\u0026thinsp;49.7 years, \u003cem\u003eRange\u003c/em\u003e\u0026thinsp;=\u0026thinsp;26\u0026ndash;78\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRoles (check all that apply)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVeteran of the US military*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (27%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eService user of healthcare\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFacilitator, quality improvement person, clinic manager\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22 (30%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImplementation researcher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCaregiver and other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (12%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGender Identity*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMan\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21 (29%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWoman\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e50 (68%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation Level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCollege degree or greater\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (58%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo college degree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (42%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRacial Identity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmerican Indian or Alaska Native\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (13%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack or African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (38%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (35%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEthnicity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-Hispanic, Latino, or of Spanish origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60 (82%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic, Latino, or of Spanish origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (20%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAncestors from Puerto Rico\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (14%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSexual Identity\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStraight, that is, not gay or lesbian, etc.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56 (76%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGeographic Location based on zip code*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (65%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14 (26%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003e*Note: Counts\u0026thinsp;\u0026lt;\u0026thinsp;10 participants are not depicted to prevent re-identifying them. We asked about U.S. military Veteran status as this is our health system. Not all percentages\u0026thinsp;=\u0026thinsp;100 because some participants endorsed \u0026ldquo;prefer not to answer\u0026rdquo; to some questions. Gender identity: some participants identified as non-binary. Racial identity: Some participants identified also as Asian (e.g., Chinese, Thai) or \u0026ldquo;another race.\u0026rdquo; Ethnicity: Some had as ancestors from another place of Hispanic, Latino, or Spanish origin. Sexual identity: Some identified as bisexual, lesbian, gay, or another identity. Zip code translated to Rural Urban Commuting Area code: 1\u0026ndash;3\u0026thinsp;=\u0026thinsp;urban, 4\u0026ndash;9\u0026thinsp;=\u0026thinsp;rural, 10\u0026thinsp;=\u0026thinsp;highly rural. Some participants were outside the U.S.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuantitative Findings from Nominal Group Technique\u003c/h2\u003e \u003cp\u003eThe terms participants prioritized are in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. During analysis interpreting Phase 1 results, our team noted that many of these words would not fit every implementation setting (e.g., 'client' not suitable in schools). Also listed were participants\u0026rsquo; top names for our engagement tools. The majority voted for suggestions that were either very specific or for a format substituting the original \u0026ldquo;consumer\u0026rdquo; for another noun referring to service users (e.g., Community Voice).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eTerms and Engagement Tool Names Prioritized by Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTop Five Terms Prioritized for the Service User\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCount\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParticipant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstituent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePatient\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurvivor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTop Three Names for Engagement Tools\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eCount\u003c/b\u003e\u003csup\u003e\u003cb\u003eb\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSpecific Option (e.g., Guiding Light, Raising the Bar)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[Placeholder Noun] Voice (e.g., Client Voice)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e[Placeholder Verb] Voices (e.g., Empower Voices)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGrand Total of Choices\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eNote. A. Votes will exceed the number of participants. B. Votes do not reflect all participants, as 50% of the Nominal Group Technique participants did not have time to vote on their brainstormed terms.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Findings from Focus Groups\u003c/h3\u003e\n\u003cp\u003e Participants in the last two focus groups found unanimous consensus to rename our engagement tools \u0026ldquo;Engaging All Voices.\u0026rdquo; Our qualitative data indicated there was no universally accepted term for a service's end user. Four findings are presented with repeating ideas below.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Engaging All Voices\u0026rdquo; may not be completely clear on its own, but it does have appeal, accurately applies to a broad audience, and evokes inclusivity. One implementer said, \u0026ldquo;\u003cem\u003eWith a [more generic name], you have to do a little work to think about \u0026lsquo;am I included in this\u0026rsquo;?\u0026rdquo;\u003c/em\u003e The broad name was acceptable if accompanied by clear, compelling messages that elaborated on the tools' concept, functions, and intended audience (e.g., tagline). Also, more specific names did not accurately represent the tools\u0026rsquo; generalizability across populations (e.g., Student Voice). Some implementers wanted more workforce-centered language in the tools, including one who said, \u003cem\u003e\u0026ldquo;\u0026lsquo;Workforce voices\u0026rsquo; don\u0026rsquo;t seem to be included in [the ads for the tools] even though the ultimate service users are people in the workforce, so that omission could be confusing.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e \u003cp\u003e A second finding was that some terms were controversial even within communities with shared demographic characteristics, such as \u0026ldquo;patient,\u0026rdquo; \u0026ldquo;peers,\u0026rdquo; \u0026ldquo;people in need,\u0026rdquo; and \u0026ldquo;consumer.\u0026rdquo; Within a focus group of people who access mental healthcare at the same clinic, two participants with a business/finance background felt comfortable with \u0026ldquo;consumer\u0026rdquo; while two other participants rejected the term because it implied a false sense of choice in seeking health services. Some participants did not like \u0026ldquo;patient\u0026rdquo; because it felt disempowering. Two terms felt off-limits to most: \u0026ldquo;stakeholder\u0026rdquo; and \u0026ldquo;user.\u0026rdquo; Although \u0026ldquo;stakeholder\u0026rdquo; was familiar to implementers, it made them think about executive leaders, or as one implementer shared, \u0026ldquo;\u003cem\u003ePeople who have power, money, make decisions and not all people we serve\u0026hellip;would be that.\u0026rdquo;\u003c/em\u003e The word \u0026ldquo;user\u0026rdquo; connoted negativity, as one implementer said it implied people are \u0026ldquo;\u003cem\u003esubstance users, potentially, or \u0026ldquo;users\u0026rdquo; of a health system in a negative way.\u003c/em\u003e\u0026rdquo;\u003c/p\u003e \u003cp\u003eA sense of action and partnership should be conveyed through the words used in engagement to evoke a motivated and committed group of personnel ready to move beyond performative, superficial \u0026ldquo;engagement.\u0026rdquo; Specifically, language about \"voices\" was appealing in the tools. Service users expressed that, \u0026ldquo;\u003cem\u003eadvocacy is important, so \u0026lsquo;voice\u0026rsquo; is important\u0026rdquo;\u003c/em\u003e because they wanted to be empowered through having their voices heard and respected. Implementers and service users preferred active verbs to describe service users\u0026rsquo; engagement. One service user said, \u0026ldquo;\u003cem\u003eI like to think of \u0026lsquo;engage\u0026rsquo; as it is more active than \u0026lsquo;including;\u0026rsquo; We are supposed to be working together.\u0026rdquo;\u003c/em\u003e This highlighted the concept of collaboration.\u003c/p\u003e \u003cp\u003eParticipants responded positively to the tools' purpose to promote inclusivity and liked that the tools offered workforce personnel actions to move toward inclusivity. Most participants perceived that the tools would teach them something new. Meaningful partnerships were important to participants, and they felt tools that help personnel do that are needed. As one implementer stated, \u0026ldquo;\u003cem\u003eIt would help me do my job better \u0026ndash; means that efforts we are implementing, improvement efforts, that are not just top-down mandates, but they can be two-way streets, working in partnership together to be the best it can be.\u0026rdquo;\u003c/em\u003e\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThere was no consensus on acceptable terms for the service user in the context of implementation efforts across any setting. Language that promoted inclusivity and implied partnership was more important than selecting a single label for service users. The lack of consensus across diverse participants from several social positions validates that we, as implementers and researchers, also struggle with these terms.\u003c/p\u003e \u003cp\u003eAs a result, we added a learning objective to Engaging All Voices to co-develop terminology that is culturally responsive to people meant to receive the service. Specifically, there is a module in the toolbox entitled \u0026ldquo;Prepare to Work with Everyone\u0026rdquo; which highlights tasks to be accomplished early in an implementation partnership, such as identify why it is important to engage others in a particular effort and plan ways to compensate others for their contributions. We do not recommend any certain terminology. We propose activities to determine preferred terms defined with the community in question.\u003c/p\u003e \u003cp\u003eOne issue in implementation science is that we may not critically examine how people involved in implementation efforts respond to terms used \u0026ldquo;about\u0026rdquo; them rather than \u0026ldquo;by\u0026rdquo; them. One result of our study was that common terms in implementation science and practice, such as \u0026ldquo;patient,\u0026rdquo; \u0026ldquo;peer,\u0026rdquo; \u0026ldquo;people in need,\u0026rdquo; and \u0026ldquo;consumers,\u0026rdquo; elicited mixed reactions. Even among similar groups, participants disagreed on terms, with some suggesting their use because they were clear and others recommending against their use because they implied a state of disempowerment or inaccuracy. A common word in our field, \u0026ldquo;stakeholder,\u0026rdquo;\u003csup\u003e17\u0026ndash;19\u003c/sup\u003e was perceived negatively by service users and implementers. We might avoid using \u0026ldquo;stakeholder\u0026rdquo; unless it is the most accurate \u003cem\u003eand acceptable\u003c/em\u003e term. Because implementation science and practice rely on significant interpersonal collaboration,\u003csup\u003e20\u0026ndash;22\u003c/sup\u003e it behooves us to be thoughtful about our language about people we collaborate with. In future implementation efforts, we may need to conduct an assessment to determine acceptable terminology for service users.\u003c/p\u003e \u003cp\u003eImplementation science paradigms, influenced by context, often stress urgency, efficiency, and rapid knowledge production. yet, our rapid knowledge translation can sacrifice relatability, relationship-building, and trust among our collaborators. Processes to \u0026ldquo;design for dissemination\u0026rdquo; that harness community-engaged implementation, as in our study, can explore this tension.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e Establishing trust among all people involved in an implementation effort is increasingly seen as vital to an innovation\u0026rsquo;s success.\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eWe identified a new name for our engagement tools: Engaging All Voices. This compendium includes free tools to help implementers engage service users in launching and sustaining health services. It is hosted on two platforms: one within the Veterans Health Administration server,\u003csup\u003e23\u003c/sup\u003e and one for individuals outside the Veterans Health Administration.\u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEngaging people who will receive health services is a potentially powerful but underutilized implementation strategy. Redesigning Engaging All Voices revealed that how recipients of innovations are referred to can shape receptiveness to engagement. Our study suggests there is no \u0026ldquo;right\u0026rdquo; term for service users across any setting and provides a process by which implementers can thoughtfully engage service users to determine suitable terminology. Future work should evaluate Engaging All Voices feasibility and outcomes.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e1\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;\u0026nbsp;Ethics approval and consent to participate: The study was reviewed and approved by the Institutional Review Board of the Central Arkansas Veterans Healthcare System (IRBNet #157782). The IRB approved the use of verbal informed consent for all study participants. This consent process was explained to each participant before the interview, and all individuals agreed to provide verbal consent. Because consent was obtained verbally, no written consent forms were collected.\u003c/p\u003e\n\u003col start=\"2\"\u003e\n \u003cli\u003eConsent for publication: Not applicable.\u003c/li\u003e\n \u003cli\u003eConflict of Interest\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.\u003c/p\u003e\n\u003col start=\"4\"\u003e\n \u003cli\u003eAuthor Contributions\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eENW conceptualized the study design and led all data collection and analysis. IAB collected and analysed data. CW helped conceptualize this study and provided training on its methods. SJL helped conceptualize the study and guide methods. LRMH helped conceptualize the study and guide methods. JEK helped conceptualize the study and guided methods. All authors contributed to interpreting data and writing or editing this manuscript.\u003c/p\u003e\n\u003col start=\"5\"\u003e\n \u003cli\u003eFunding\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThis work was supported by Dr. Woodward’s Career Development Award Number IK2 HX003065 and “Small aWard Initiative For impacT (SWIFT)” grant from the United States (U.S.) Department of Veterans Affairs Health Systems Research Service (Woodward \u0026amp; Ball) and the CBPR Scholars Pilot Grant by the University of Arkansas for Medical Science Translational Research Institute, grant UL1TR003 07 through the National Institutes of Health.\u003c/p\u003e\n\u003cp\u003ePartial funding support: VA Center for Mental Healthcare and Outcomes Research, North Little Rock, AR, and VA Behavioral Health Quality Enhancement Research Initiative (QUERI): Advancing 21st Century Mental Health Care for Veterans (QUE 20-026; PIs: Landes \u0026amp; Miller).\u003c/p\u003e\n\u003col start=\"6\"\u003e\n \u003cli\u003eAcknowledgments\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThank you to participants in this study for their knowledge and thoughts that shaped this work. The online platform for these tools has been supported by Brenda Salgado at the VA Center for Innovations, Quality, Effectiveness, and Safety, Houston, TX, and the VA Center for Integrated Healthcare. Through initial development of these tools, Dr. Woodward was a fellow with the Implementation Research Institute (IRI), at the George Warren Brown School of Social Work, Washington University in St. Louis; through an award from the National Institute of Mental Health (5R25MH08091607).\u003c/p\u003e\n\u003col start=\"7\"\u003e\n \u003cli\u003eAuthors’ Information: Reflexivity Statement\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe two researchers who conducted research activities and analyzed data (ENW and IAB) held multiple relevant lived experiences. One was a PhD clinical psychologist conducting implementation science and community engaged research focused on improving health equity, Eva Woodward. She writes, “\u003cem\u003eI identify as a White woman, not Hispanic or Latina, who grew up in the rural U.S. without health insurance and other socioeconomic disadvantages and difficulty getting adequate healthcare. I have been an implementer for many innovations in healthcare and community settings\u003c/em\u003e.”\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIrenia Ball was\u0026nbsp;a research assistant with six years of experience in implementation science and qualitative research. She states, “\u003cem\u003eI recognize the influence of my positionality. I am a college‑educated Black woman from a middle‑class urban background and a Hurricane Katrina survivor who has used mental health services. My prior work as a youth mental health case manager and lack of implementation‑innovation experience inform my perspective when engaging veterans and other health service users.\u003c/em\u003e”\u003c/p\u003e\n\u003col start=\"8\"\u003e\n \u003cli\u003eData Availability Statement\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe datasets generated and analyzed for this study are not listed in a public repository. Please contact the first author to discuss use of de-identified datasets. \u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHero JO, Goodrich DE, Ernecoff NC, et al. Implementation Strategies for Evidence Based Practice in Health and Health Care: A Review of the Evidence of Strategy Effectiveness and Use Patterns. Published online June 2023. https://www.pcori.org/sites/default/files/PCORI-Implementation-Strategies-for-Evidence-Based-Practice-in-Health-and-Health-Care-A-Review-of-the-Evidence-Full-Report.pdf\u003c/li\u003e\n \u003cli\u003eBolen SD, Chandar A, Falck-Ytter C, et al. Effectiveness and Safety of Patient Activation Interventions for Adults with Type 2 Diabetes: Systematic Review, Meta-Analysis, and Meta-regression. \u003cem\u003eJ Gen Intern Med\u003c/em\u003e. 2014;29(8):1166-1176. doi:10.1007/s11606-014-2855-4\u003c/li\u003e\n \u003cli\u003eLin MY, Weng WS, Apriliyasari RW, Van Truong P, Tsai PS. Effects of Patient Activation Intervention on Chronic Diseases: A Meta-Analysis. \u003cem\u003eJ Nurs Res\u003c/em\u003e. 2020;28(5):e116. doi:10.1097/jnr.0000000000000387\u003c/li\u003e\n \u003cli\u003eHolt CL, Chambers DA. Opportunities and challenges in conducting community-engaged dissemination/implementation research. \u003cem\u003eTransl Behav Med\u003c/em\u003e. 2017;7(3):389-392. doi:10.1007/s13142-017-0520-2\u003c/li\u003e\n \u003cli\u003eWoodward EN, Castillo AIM, True G, Willging C, Kirchner JE. Challenges and promising solutions to engaging patients in healthcare implementation in the United States: an environmental scan. \u003cem\u003eBMC Health Serv Res\u003c/em\u003e. 2024;24(1):29. doi:10.1186/s12913-023-10315-y\u003c/li\u003e\n \u003cli\u003eKwan BM, Luke DA, Adsul P, Koorts H, Morrato EH, Glasgow, R. E. Designing for Dissemination and Sustainability: Principles, Methods, and Frameworks for Ensuring Fit to Context. In: \u003cem\u003eDissemination and Implementation Research in Health\u003c/em\u003e. 3rd ed. Oxford University Press; 2023.\u003c/li\u003e\n \u003cli\u003eWoodward EN, Ball IA, Willging C, et al. Increasing consumer engagement: tools to engage service users in quality improvement or implementation efforts. \u003cem\u003eFront Health Serv\u003c/em\u003e. 2023;3:1124290. doi:10.3389/frhs.2023.1124290\u003c/li\u003e\n \u003cli\u003eCrane ME, Purtle J, Becker SJ. Amplifying consumers as partners in dissemination and implementation science and practice. \u003cem\u003eImplement Res Pract\u003c/em\u003e. 2023;4:26334895231205894. doi:10.1177/26334895231205894\u003c/li\u003e\n \u003cli\u003eSharfstein JM. Banishing \u0026ldquo;Stakeholders.\u0026rdquo; \u003cem\u003eMilbank Q\u003c/em\u003e. 2016;94(3):476-479. doi:10.1111/1468-0009.12208\u003c/li\u003e\n \u003cli\u003eSwindle T, Baloh J, Landes SJ, et al. Evidence-Based Quality Improvement (EBQI) in the pre-implementation phase: key steps and activities. \u003cem\u003eFront Health Serv\u003c/em\u003e. 2023;3:1155693. doi:10.3389/frhs.2023.1155693\u003c/li\u003e\n \u003cli\u003eCreswell JW, Klassen AC, Plano Clark VL, Smith KC. \u003cem\u003eBest Practices for Mixed Methods Research in the Health Sciences. August 2011. National Institutes of Health.\u003c/em\u003e Office of Behavioral and Social Sciences Research of the National Institutes of Health; 2011. https://obssr.od.nih.gov/training/online-training-resources/mixed-methods-research/\u003c/li\u003e\n \u003cli\u003ePalinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K. Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research. \u003cem\u003eAdm Policy Ment Health Ment Health Serv Res\u003c/em\u003e. 2015;42(5):533-544. doi:10.1007/s10488-013-0528-y\u003c/li\u003e\n \u003cli\u003eLago PP, Beruvides MG, Jian JY, Canto AM, Sandoval A, Taraban R. Structuring group decision making in a web-based environment by using the nominal group technique. \u003cem\u003eComput Ind Eng\u003c/em\u003e. 2007;52(2):277-295. doi:10.1016/j.cie.2006.11.003\u003c/li\u003e\n \u003cli\u003eAmerican Society for Quality. What is Multivoting? Published online 2023. https://asq.org/quality-resources/multivoting\u003c/li\u003e\n \u003cli\u003eMorse JM. Critical Analysis of Strategies for Determining Rigor in Qualitative Inquiry. \u003cem\u003eQual Health Res\u003c/em\u003e. 2015;25(9):1212-1222. doi:10.1177/1049732315588501\u003c/li\u003e\n \u003cli\u003eHennink M, Kaiser BN. Sample sizes for saturation in qualitative research: A systematic review of empirical tests. \u003cem\u003eSoc Sci Med\u003c/em\u003e. 2022;292:114523. doi:10.1016/j.socscimed.2021.114523\u003c/li\u003e\n \u003cli\u003eArwal SH, Aulakh BK, Bumba A, Siddula A. Learning by doing in practice: a roundtable discussion about stakeholder engagement in implementation research. \u003cem\u003eHealth Res Policy Syst\u003c/em\u003e. 2017;15(S2):105. doi:10.1186/s12961-017-0275-8\u003c/li\u003e\n \u003cli\u003eKirchner JE, Parker LE, Bonner LM, Fickel JJ, Yano EM, Ritchie MJ. Roles of managers, frontline staff and local champions, in implementing quality improvement: stakeholders\u0026rsquo; perspectives: Stakeholder perspectives on implementing QI. \u003cem\u003eJ Eval Clin Pract\u003c/em\u003e. 2012;18(1):63-69. doi:10.1111/j.1365-2753.2010.01518.x\u003c/li\u003e\n \u003cli\u003ePeters DH, Bhuiya A, Ghaffar A. Engaging stakeholders in implementation research: lessons from the Future Health Systems Research Programme experience. \u003cem\u003eHealth Res Policy Syst\u003c/em\u003e. 2017;15(S2). doi:10.1186/s12961-017-0269-6\u003c/li\u003e\n \u003cli\u003eMeza RD, Triplett NS, Woodard GS, et al. The relationship between first-level leadership and inner-context and implementation outcomes in behavioral health: a scoping review. \u003cem\u003eImplement Sci\u003c/em\u003e. 2021;16(1):69. doi:10.1186/s13012-021-01104-4\u003c/li\u003e\n \u003cli\u003eMetz A, Jensen T, Farley A, Boaz A, Bartley L, Villodas M. Building trusting relationships to support implementation: A proposed theoretical model. \u003cem\u003eFront Health Serv\u003c/em\u003e. 2022;2:894599. doi:10.3389/frhs.2022.894599\u003c/li\u003e\n \u003cli\u003eKirchner JE, Kearney LK, Ritchie MJ, Dollar KM, Swensen AB, Schohn M. Research \u0026amp; Services Partnerships: Lessons Learned Through a National Partnership Between Clinical Leaders and Researchers. \u003cem\u003ePsychiatr Serv\u003c/em\u003e. 2014;65(5):577-579. doi:10.1176/appi.ps.201400054\u003c/li\u003e\n \u003cli\u003eWoodward, E. N., Ball IA, Willging CE, et al. Engaging All Voices. Consumer Voice tools within VHA. January 2026. https://dvagov.sharepoint.com/sites/ConsumerVoice\u003c/li\u003e\n \u003cli\u003eWoodward EN, Ball IA, Willging CE, et al. Engaging All Voices. Consumer Voice tools on Google Drive. January 2026. https://drive.google.com/drive/folders/1VlANfyhwM_wzOT3DSLV094lBETLnkm3o?usp=sharing\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"service users, consumer, patient engagement3, patient and public involvement, community engagement, implementation science, quality improvement","lastPublishedDoi":"10.21203/rs.3.rs-9224470/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9224470/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eResearchers identified \u0026ldquo;preparing patients to be active in innovations\u0026rdquo; as one of the top five most effective implementation strategies; this included educating patients to be engaged in their care. If engaging patients in their own care enhances adoption of innovations, engaging patients and service users across any setting (e.g., healthcare, education, carceral) in implementation activities may also enhance adoption. To provide guidance on this topic, we developed Consumer Voice: a free, online platform for community engagement in implementation efforts. In July 2023, we disseminated the tools and received feedback that \u0026ldquo;consumer\u0026rdquo; had a negative connotation for some. This feedback mimicked discontent with terminology for the \u0026ldquo;service user\u0026rdquo; in the broader implementation field. Our study goal was to identify inclusive, acceptable terminology for the \u0026ldquo;service user\u0026rdquo; in implementation practice or research.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe collected quantitative data then qualitative data from service users, implementers, and implementation researchers in two phases: 1) Brainstorming and prioritizing terminology for service users through Nominal Group Technique, then 2) Contextualizing implications of different terms through focus groups. Between phases, we used quantitative counts to inform sampling and inductive qualitative analysis.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003e Participants represented a range of demographic groups; over 40% identified primarily as individuals receiving health services, 30% as implementers, and 26% as implementation researchers. There was consensus to rename our engagement tools \u0026ldquo;Engaging All Voices.\u0026rdquo; Our data indicated there was no universally acceptable term for \u0026ldquo;service user.\u0026rdquo; Even within similar communities, some terms were controversial e.g., \u0026ldquo;patient,\u0026rdquo; \u0026ldquo;peer.\u0026rdquo; Two terms felt off-limits to most: \u0026ldquo;stakeholder\u0026rdquo; and \u0026ldquo;user.\u0026rdquo; Participants thought any engagement language should convey a sense of action and partnership to move beyond performative, superficial \u0026ldquo;engagement.\u0026rdquo;\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eWe sampled people from multiple service settings and thus, findings may generalize in healthcare, education, carceral, and other systems. Our experience redesigning Engaging All Voices revealed that how recipients of innovations are referred to can shape receptiveness to engagement approaches. There is no single \u0026ldquo;right\u0026rdquo; term to refer to service users across settings. Engaging All Voices now guides learners in an early exercise to determine terminology preferred by service users throughout an implementation effort.\u003c/p\u003e","manuscriptTitle":"Promoting inclusivity and partnership with recipients of health services: Short report on redesigning Engaging All Voices (previously Consumer Voice)","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-23 07:21:15","doi":"10.21203/rs.3.rs-9224470/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-04T18:02:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300711269250754659720328018128069068455","date":"2026-04-30T20:44:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"177227140641960818137142693505685244850","date":"2026-04-18T10:00:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-15T14:53:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-15T14:33:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-02T06:57:19+00:00","index":"","fulltext":""},{"type":"submitted","content":"Implementation Science Communications","date":"2026-03-25T14:29:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"implementation-science-communications","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"iscm","sideBox":"Learn more about [Implementation Science Communications](https://implementationsciencecomms.biomedcentral.com)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/ISCM/default.aspx","title":"Implementation Science Communications","twitterHandle":"@ImplementSci","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"36495130-1318-4cf5-9bcd-330fccb12d23","owner":[],"postedDate":"April 23rd, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-04T18:02:33+00:00","index":25,"fulltext":""},{"type":"reviewerAgreed","content":"300711269250754659720328018128069068455","date":"2026-04-30T20:44:24+00:00","index":24,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-23T07:21:15+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-23 07:21:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9224470","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9224470","identity":"rs-9224470","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}