Trust Building in Public Health Approaches: The Importance of a “People-Centered” Concept in Crisis Response

The Promise of Changing Public Health Approaches to Crisis Response

The world has undergone significant changes due to Covid-19. It has become evident that public health emergencies will continue to affect daily life, particularly syndemics, which account for the interplay among pathogens, biotic elements (ie living parts of ecosystems including humans, non-human animals, plants, and pathogens) abiotic elements (ie non-living chemical and physical factors in the atmosphere), and socio-economic determinants.^1,2 Although syndemics have long been acknowledged in academic debates, they have gained growing public and political understanding under the “One Health” ecological paradigm, which emphasizes the interconnectedness of environmental, human, and animal health.³

It is now recognized that susceptibility and vulnerability exist in all regions of the world, with high-income countries in the global north not immune to these challenges, despite differences in their intensity compared to countries in the south.⁴ Additionally, geographical asymmetries within and between countries highlight disparities in resources and attention, a concept known as “unfair geographies”.⁵ This concept remains relevant, even as we approach the United Nations’ 2030 Agenda for sustainable development.

Changes have been promised to strengthen healthcare systems, particularly in public health. The international academic and political discourse has been inundated with discussions of legislative changes, policies, and increased funding aimed at crucial areas such as national surveillance and within-country coordination.⁶ This includes intersectoral coordination in public health responses, the development of new crisis preparedness plans addressing both clinical and social dimensions, and heightened concern for vulnerable population subgroups, such as migrants, refugees, and those with low income and education levels.⁷ Additionally, there has been a focus on improving risk communication, enhancing health human resources, bolstering laboratory response capabilities, and refining logistics and storage procedures for medicines, vaccines, and other supplies.^8,9

Ultimately, the promise was that the lessons of Covid-19 had been learned to deal with new public health emergencies, but is it really so?

A Key Challenge to Public Health Approaches in Crisis Response

Despite the motivation for new approaches in public health, challenges to their implementation persist and need to be acknowledged. This does not entail adopting a negative view of the path of change. It is understood that the pace of change in responses to public health crises will always be slower than the needs and the best scientific evidence available at any given moment. Furthermore, it does not disregard the unprecedented advances that occurred during Covid-19, particularly international scientific collaboration for the diagnosis, surveillance, and treatment of SARS-CoV-2, as well as the mechanisms for centralized vaccine procurement by Covax.¹⁰

There is a structural challenge central to public health, which has persisted from the past and will continue to influence responses to future public health crises. This challenge concerns the political ambiguity at the supranational level. While countries remain the primary decision-making units for defining and implementing health policy responses, the global world requires mechanisms that bind across countries. This raises the age-old question between “soft” (advisory) and “hard” (binding) laws.¹¹ The WHO was established and continues today as an instrument of “soft” laws to enhance cooperation and respect for the unity of countries represented by governments. There is no foreseeable change to this, especially any that would involve the partial surrender of jurisdictional powers associated with the sovereignty of member states to supranational entities. This is to ensure respect for the principles of equality and democratic representation in the face of conflicting geopolitical, financial, economic, and cultural logics.¹²

Various possibilities have been considered within this framework. For example, strengthening mandatory funding from Member States to the WHO to prevent vulnerability to populist political fluctuations that threaten the continuity of its actions. Additionally, expanding its normative authority through the support of technical-scientific bodies that produce evidence, assist in its implementation, and aid in decision-making.¹³

The efforts are notable However, as Covid-19 recedes, signs of concern arise in patterns similar to what was predicted to occur after previous public health emergencies (H1N1 in 2009, Ebola in 2014 or Zika in 2016).¹⁴

Despite a growing recognition of the importance of adopting a “Health For All Policies” approach,¹⁵ those involved in preparing, managing, and recovering from emergency crises at the global, national, and local levels continue to work in silos.¹⁶ Eventually, this is a clear sign of the lack of in-depth reflections and translation on how a “Health For All Policies” approach can be implemented in the context of syndemics and through the One Health paradigm.

The challenge associated with political ambiguity at the supranational level leaves us at a crossroads, the solution to which remains unclear: we know what needs to change, but the political instruments are not sufficient to bring about that change.

The remaining question is how to drive change to enhance the response to public health emergencies?

Trust: A Pivotal Concept in Healthcare

Responding to the aforementioned question leads us to the concept of trust. Trust in healthcare represents the faith and confidence patients have in the healthcare providers and institutions responsible for their care. It is fundamental for effective healthcare delivery and patient satisfaction, encompassing both confidence and reliance. Individuals find themselves in a vulnerable and dependent position concerning practitioners, decision-makers, and institutions. Thus, trust influences people’s willingness to seek and maintain medical care, impacting health promotion, disease prevention, and mental wellbeing.¹⁷

The concept of trust is multifaceted. Philosophy, sociology, economics, psychology, and medicine interpret it differently, each offering insights into its significance for health, health policy, healthcare provision, and social cohesion. The overarching understanding is that trust in health is indispensable for effective functioning, underpinning the solidarity necessary for quality healthcare.¹⁸

In the context of public health emergencies, trust is of utmost importance. The population needs to be willing to listen to updated information, follow instructions, seek healthcare if necessary, share information, and adhere to treatment plans. Likewise, the health and care workforce must trust that they will be valued to remain in the sector, sustain motivation, and perform optimally.¹⁹ Policy-makers require trust in the health system’s capacity to deliver quality care efficiently to justify resource allocation. Furthermore, trust between policy-makers and the public is crucial during crises.²⁰

Transparency fosters trust and promotes accountability, whereas opacity regarding healthcare costs, medical errors, and conflicts of interest undermines it. Addressing disinformation and misinformation is vital as they undermine trust, particularly with misleading AI-generated content. Regulation of online resources and protection of data privacy are imperative.²¹

The complexity of trust dynamics, contextual factors, diverse actors’ experiences, expectations, and tolerances, and temporal changes must all be considered in trust-building efforts.

Trust Building as a “People-Centered” Approach in Crisis Response

The argument posits that trust-building is one solution for responding to public health crises in the face of the major challenge of political ambiguity in international health governance. This ambiguity extends to within high-, low- and middle-income countries, where people often do not adhere or adhere minimally to public health measures precisely due to policy designs that do not address the specific needs of vulnerable and/or minority groups (migrants, ethnicities, women, individuals with low income and education).^22,23 In fact, disproportionate negative health impacts from emergencies illustrate the extent to which exposure, vulnerability, and capacity vary among populations and communities.

Trust-building entails fostering engagement among individuals within the community and between communities and institutions responsible for ensuring health and well-being, hence the “people-centered” perspective. This focus on people-centeredness results in the concept of trust being seen as a binding force that unites individuals within the community, fostering a sense of belonging and participation, extending to broader institutions such as healthcare services and systems, science, and policymakers.

In these terms, trust-building allows for viewing individuals and communities as active partners (or agents) rather than just beneficiaries of policies, thereby realizing the principle of resilient communities.²⁴ Fundamentally, addressing trust in public health approaches reinforces well-established principles in the field of health promotion, whereby improving the social determinants of health is a mandatory condition for the continuous and sustainable improvement of population health outcomes and the mitigation of risks in the face of public health emergencies.²⁵

Greater trust allows for the creation of active and resilient communities that can more easily achieve the following objectives during public health emergencies:²⁶

• Preparation and readiness: from an individual perspective, it enables adherence to health promotion and disease prevention programs capable of ensuring adequate population health outcomes in the face of outbreak spread. Structurally, it involves mobilizing communities to influence the creation and/or maintenance of structures and resources for public health surveillance, ensuring the availability and motivation of human resources, and facilitating coordination with social support services.
• Response to emergent risks: for example, through consulting information from legitimate and credible sources, and adhering to pharmacological and non-pharmacological measures.
• Recovery: strengthening mobilization to support vulnerable groups in the short term and/or pressure political decision-making to swiftly return to normality.
• Risk mitigation and adaptation: strengthening mobilization to pressure political decision-making in the medium and long term for the incorporation of lessons learned and risk mitigation measures.

Pathways to Build Trust in Public Health Approaches

The remaining question is how to measure and identify the dimensions and determinants of trust so that it is possible to determine in each context and under specific circumstances if trust needs to be strengthened, if so, for which groups and for what reasons.

Multiple analyses from different disciplines and countries complicate this understanding and translation. There is consensus on the multiple dimensions of trust: individual-level (eg, interpersonal trust and trust regarding communities and institutions); community-level (eg, trust between socio-cultural groups and institutions); institutional-level (eg, trust between decision-makers and involving science, communication, and judicial and military forces).²⁷ There is also consensus on embracing key dimensions of willingness to risk vulnerability, confidence, benevolence, reliability, competence, honesty, and openness.²⁸

Nevertheless, trust can be studied either as a process or an outcome, through experimental, qualitative, or quantitative longitudinal research.²⁹ Evidence highlights the need to improve response formats, measurement tools, and comprehensive data collection to assess differences within populations over time. Centralized data sources with international coordination are enhancing comparability, while particular emphasis on minority or marginalized groups continues to be stressed as a necessity.^30,31

In sum, studies are lacking that systematize the components for measuring trust and understanding its dimensions in the context of public health responses. However, there are clues in the debate that help to understand this path.^18,32 Trust can be strengthened through:

1. Transparent and user-friendly information and communication channels, along with methods to educate users on their effective utilization, are crucial, particularly in combating misinformation and navigating the complexities of artificial intelligence.
2. Establishing robust and equitable health systems capable of swift crisis response is imperative, diverging from funding solely directed towards priority programs (eg, specific diseases or groups).
3. Strengthening “social capital”, defined as the collective value of social networks, is essential for community resilience and cohesive response efforts.
4. Engaging diverse stakeholders is vital, necessitating collaboration across sectors and inclusive participation of civil society, media, and the public. Stakeholder engagement in decision-making processes, recognition of lived experiences, and promotion of co-production of care are essential aspects to address power and information imbalances effectively.
5. Providing comprehensive initial and ongoing training to healthcare professionals is crucial to ensure they can establish supportive and empathetic relationships with patients and families, recognizing the intrinsic vulnerability inherent in caregiving.

In the context of Covid-19 and previous public health emergencies, various international agencies have developed tools for planning, implementing, and evaluating responses in Risk Communication and Community Engagement (RCCE).^33,34 The five components abovementioned as central to trust-building align with some of these tools, making them valuable contributions to fostering the measurement of trust in the context of public health responses. Components 1, 4, and 5 resonate most strongly with the RCCE literature, facilitating their application to concrete cases. Components 2 and 3, however, remain more academic in nature, requiring further implementation studies. Advancements in the concepts of health system resilience³⁵ and social capital³⁶ are likely to should be leveraged to enhance the measurement of trust-building.

Conclusion

Trust in public health approaches can be fostered through consistent delivery of quality care, a clear, shared vision and values underpinned by ethical standards, commitment to stakeholder well-being including staff, integration of reliability, integrity, and transparency into policies, strategies, and practices, exemplary leadership, openness in resource utilization, and addressing waste or corruption, and effective communication of these principles. Nevertheless, there is need for more empirical evidence on the components for measuring trust and understanding its dimensions in the context of public health responses.