The role of trust in health-seeking for non-communicable disease services in fragile contexts: A cross-country comparative study

Abstract

Non-communicable diseases (NCDs) disproportionately affect people living in fragile contexts marked by poor governance and health systems struggling to deliver quality services for the benefit of all. This combination can lead to the erosion of trust in the health system, affecting health-seeking behaviours and the ability of individuals to sustain their health. In this cross-country multiple-case study, we analyse the role of trust in health-seeking for NCD services in fragile contexts. Our analysis triangulates multiple data sources, including semi-structured interviews (n = 102) and Group Model Building workshops (n = 8) with individuals affected by NCDs and health providers delivering NCD services. Data were collected in Freetown and Makeni (Sierra Leone), Beirut and Beqaa (Lebanon), and Morazán, Chalatenango and Bajo Lempa (El Salvador) between April 2018 and April 2019. We present a conceptual model depicting key dynamics and feedback loops between contextual factors, institutional, interpersonal and social trust and health-seeking pathways. Our findings signal that firstly, the way health services are delivered and experienced shapes institutional trust in health systems, interpersonal trust in health providers and future health-seeking pathways. Secondly, historical narratives about public institutions and state authorities’ responses to contextual fragility drivers impact institutional trust and utilisation of services from public health institutions. Thirdly, social trust mediates health-seeking behaviour through social bonds and links between health systems and individuals affected by NCDs. Given the repeated and sustained utilisation of health services required with these chronic diseases, (re)building and maintaining trust in public health institutions and providers is a crucial task in fragile contexts. This requires interventions at community, district and national levels, with a key focus on promoting links and mutual accountability between health systems and communities affected by NCDs.

Restricted family presence for hospitalized surgical patients during the COVID-19 pandemic: How hospital care providers and families navigated ethical tensions and experiences of institutional betrayal

“…Trust is a multifaceted and complex construct that is a foundational ethical value in healthcare. In public health, trust in healthcare systems and organizations is instilled through the establishment of accessible, safe, evidence-based quality care which contributes to building one dimension of trust: institutional trust ( Arakelyan et al, 2021 ). Institutional trust relies to some extent on an organization's reputation vis-à-vis transparent performance indicators and health outcomes.…”

“…On the ground, in hospitals and other medical settings, it is another dimension of trust – interpersonal trust – that is developed. Interpersonal trust between patients-families and providers is not necessarily linked to health outcomes the way institutional trust is; rather, it is a relational type of trust affected more by perceived motivations and intentions usually conveyed through communication practices and behaviours, and perceptions of reliability and technical competence ( Arakelyan et al, 2021 ; Blödt, Müller-Nordhorn, Seifert, & Holmberg, 2021 ; Hall, Dugan, Zheng, & Mishra, 2001 ). Healthcare encounters are characterized by many different types of interrelated trust, which may be established, broken, and re-established continuously over time ( Smith, 2017 ).…”

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“…Where such care models are absent or ill-implemented, as they are in many situations of fragility, the trust of communities and service users in the health system may be affected. 14 Fragility can also arise at the interface between community and health systems and manifest in this loss of trust. 6 For example, trust in the health system could affect access to and use of medical care as well as affect a persons' relationship with providers.…”

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“…Increasingly, however, fragility is also being used to describe performance of the health system (or wider ‘systems for health’)6 7 and the way such systems connect with communities. The latter are also frequently recognised as fragile themselves, with discussions on vulnerable populations abounding 8. These trends chime with the OECD’s multidimensional understanding of fragility.…”

“…A large part of care for common chronic conditions such as diabetes and hypertension, therefore, occurs beyond formal facilities. Informal local stakeholders—ranging from teachers, through faith leaders to traditional healers—play an important role in health-seeking journeys 8 15. Deep-seated spiritual and cultural beliefs, but also the relative convenience and perceived affordability of obtaining care from local traditional healers or medicine sellers, influence who communities seek care from.…”