The Salience of Trust to the Client-Provider Relationship in Post-Ebola Guinea: Findings From a Qualitative Study

"The study findings underscore the importance of identifying the key leverage points for trust in health systems and providers to rebuild trust and restore health care service utilization."

Trust is particularly relevant within the healthcare context, as there is an inherent power imbalance between providers and clients. Lack of trust in the healthcare system can serve as a barrier to service utilisation, especially in pandemic and postemergency settings. Trust is a composite of various underlying domains, and rebuilding trust depends on understanding and addressing the domains that are salient to clients. This analysis provides a case study of how a global health programme used qualitative research to explore salient domains of trust within the client-provider relationship in post-Ebola Guinea and developed interventions to address those domains.

The West African Ebola epidemic began in rural Guinea in December 2013. Before 2013, the Guinean health system faced understaffed and underresourced facilities, significant health disparities, and almost no systematic infectious disease surveillance or control. International experts and local leaders alike identified a lack of engagement with communities and a lack of trust in the health system as key drivers of the epidemic.

This study served as formative research for the Health Communication Capacity Collaborative (HC3) project, which worked in post-Ebola Guinea to increase the demand for and use of quality reproductive, maternal, neonatal, and child health (RMNCH) services. In June 2016, local researchers conducted (i) in-depth interviews (IDIs) with health workers (n=15) and mothers of young children (n=29) and (ii) focus group discussions (FGDs), 12 with grandmothers of young children and 12 with male heads of household in Basse Guinée and Guinée Forestière, 2 of the areas most affected by Ebola.

In FGDs and IDIs, trust in health systems and with the client-provider relationship emerged as a central element of care-seeking decisions. Comments from participants in the study confirmed that mistrust in providers was directly related to the Ebola crisis, particularly the fear of being diagnosed with Ebola and the persistent belief that providers were deliberately or through negligence spreading Ebola. However, as a male head of household who participated in an FGD said, "With the end of Ebola, trust between health providers and patients is beginning to return little by little."

As participants reflected on the client-provider relationship during and after the epidemic, there was a clear expectation that providers have an intrinsic duty or obligation to treat clients well. From there, perceived provider competence, the hospitality at the facility, provider empathy, honesty/transparency about costs, and commitment to confidentiality emerged as relevant influences on participant trust in providers. Both health workers and community members identified open communication and community mobilisation as key to rebuilding trust and ultimately restoring health facility utilisation.

The researchers note that, although participants did describe a variety of access issues - the cost and availability of medications, the presence of personnel at the clinics, and the distance to the facility - they rarely linked these issues to trust.

HC3 incorporated the study findings into Gold Star campaign messages and programme strategies in Guinea, particularly the development of interpersonal communication trainings for health providers. Study findings also informed the development of community dialogues between community leaders and health workers to encourage mutual understanding of the challenges faced by each group and to develop shared solutions to address those challenges. For example, people were invited to attend "open-door days" at their local health facilities, where they could visit with providers to learn about the services offered and the associated costs to build trust in the competence and financial honesty of the clinic.

Since HC3 ended, a new iteration, Breakthrough ACTION, began. In 2020, the project began efforts in COVID-19 response and then in 2021 around Ebola. The team is working to identify ways to apply insights around trust from this study into both programmatic areas.

In conclusion, this study offers insight into some underlying components of trust that can provide leverage points to rebuild trust and promote care seeking in postemergency settings. Referencing the work being undertaken by Breakthrough ACTION, the researchers assert that these lessons could be useful in other crises, such as the COVID-19 pandemic.