Confirming—and testing—bonds of trust: A mixed methods study exploring community health workers’ experiences during the COVID-19 pandemic in Bangladesh, Haiti and Kenya

Abstract

Amidst the COVID-19 pandemic and national responses, trust (one’s belief that a system acts in one’s best interest) is important to consider. In community health systems, trust is embedded in relationships between clients, CHWs, and health system stakeholders. This mixed-methods study explores trust through the evolving COVID-19 crisis in Bangladesh, Haiti, and Kenya, where multi-country community health research was underway. We investigate the extent and ways trust between communities, community health workers (CHWs), and health system actors shift, including its relation to community fear and hostility, through self-reported positive and negative experiences of CHWs and policy/program stakeholders on a phone-based survey with 2,025 CHWs and 72 key informant interviews, including CHWs, in late 2020. On surveys, CHWs reported high levels of community trust (8/10 in Bangladesh and Kenya; 6/10 in Haiti) with over 60% reporting client relief in seeing their CHWs. About one-third of CHWs across countries reported experiencing instances of hostility from community members during the pandemic in the form of refused home-entry, ignored advice, or being shouted at. Multivariate analyses revealed that CHWs reporting more positive and fewer negative experiences is consistently associated with continuing routine work, doing COVID-19-related work, and greater community trust. Qualitative interviews showed that existing pre-pandemic trusting relationships withstood the early phase of COVID-19, mitigating negative community reactions toward CHWs and stigma towards COVID-positive individuals, maintaining routine health services, and sustaining appreciation for CHW-provided prevention information and emotional support. CHW-community and CHW-health system actor trust is strengthened when CHWs are well-resourced; CHW-community trust is strained by public frustration at the pandemic, associated restrictions, and sociopolitical stressors. Our study suggests that with adequate institutional support, bonds of trust can promote resilient community health systems during extended public health crises, through CHWs’ commitment to mitigating misinformation, reducing stigma, maintaining routine service provision, and promoting COVID-19 prevention.

Community health workers’ barriers and facilitators to use a novel mHealth tool for motivational interviewing to improve adherence to care among youth living with HIV in rural Nepal

“…When working with populations that face stigma and discrimination, such as YLWH, confidentiality concerns are expected, even after they have consented for participation. It is likely that CHWs were able to build rapport with the clients and their families given their strong presence in the community and being seen as trusted members of the healthcare team [ 44 ]. Our experiences have also shown the need to engage with the family members of YLWH, especially in the South Asian context, where parents are the primary caregivers and decision makers and their voices become important for young people to participate in studies [ 45 , 46 ].…”

A scoping review of the roles, challenges, and strategies for enhancing the performance of community health workers in the response against COVID-19 in low- and middle-income countries

“…Indeed, health promotion was integrated into the national Community Health Worker (CHW) guidelines in India and Thailand [18]. While, in Bangladesh, CHWs acted as a bridge between refugee communities and health facilities thereby addressing fears and rumours [23].…”

“…CHWs arranged transport and lodging for vaccinators and identi ed outreach locations that were likely to reach vulnerable populations. Using trusted networks, CHWs in Bangladesh, Haiti and Kenya, supported COVID-19-related and unrelated health services tasks such supporting referrals for maternal health services [20,23]. In Malawi, the CHWs conducted social mobilization to promote HPV vaccines when schools closed during the COVID-19 pandemic [15,24].…”

“…And as noted earlier, prioritized for regular training in keeping with the evolving nature of pandemics such COVID-19. In addition, providing adequate institutional support could enhance bonds of trust between CHWs and the community and also promote resilient community health systems during public health crises [23].…”

Self-perception and COVID-19 vaccination self-efficacy among Chinese adults: A moderated mediation model of mental health and trust

“…People's response to public health policies may be influenced by the degree to which the population trusts information sources as well as organizations ( Fridman et al, 2020 ; Vinck et al, 2019 ). As indicated by Sripad et al (2022) , trust is fragile and highly reactive to some unfavorable facts. When terrible cases are publicized, they can provoke public concern and anxiety, undermining patients' trust in doctors and the health systems at large.…”