By Kate Hawkins, Kingsley Chikaphupha, Rosalind Steege, Sushama Kanan, Aschenaki Z. Kea. Robinson Karuga, Ralalicia Limato, Nelly Muturi, Daniel Datiko, Maryse Kok
Trust: “The optimistic acceptance of a vulnerable situation in which the trustor believes the trustee will care for the trustor’s interest”(Hall et al. 2001)
The work of Dr Maryse Kok has brought to the attention that health systems are social institutions and community health worker programmes are part of this complex map. Besides the ‘hardware’ elements of health systems (often referred to as the WHO’s building blocks) we need to take account of the 1) ideas and interests, 2) relationships and power, and 3) values and norms that effect these programmes (the software elements of health systems). Looking at this ‘software’, every health worker is part of social interactions and environments, which, together with available resources, shape their performance.
Performance is a transactional social process and trust plays a part of this. Trust can be built by personal behaviours and organizational practices that provide space for engagement and open dialogue (Gilson 2006). Other factors that have been found to influence trust of health workers are: perceived organisational support, communication, procedural justice and feedback from upper levels (Albrecht and Travaglione 2003; Nyhan 2000). Understanding the factors that influence trust and CHWs interpersonal relationships with different actors in the community and health sector (such as supervisors and managers) is important in order to analyse and improve CHW performance.
In a refreshing fish bowl session at the first symposium on the Contribution of Community Health Workers (CHWs) in attainment of the Sustainable Development Goals (SDGs) we heard from colleagues from around the world about how CHWs can build trust, how we can strengthen the software components of the system and how to improve data quality and feedback loops. As well as hearing some warnings on how mistrust can negatively impact CHW programmes. We thank the participants whose interventions have helped us write this blog.
Building trust is an evolving process
Several participants pointed out that the process of building trust does not happen overnight.
We heard that trust starts with how CHWs are selected, their training, and the quality of their work. In Ethiopia, the community is part of the selection process for hiring CHWs. They choose community members that they trust to play the role of CHW and the CHW cements and builds this trust through their ongoing work. The more useful they are the more it grows. This can create demand for more services – which is evidence of their impact. From Uganda, we heard that CHWs’ integrity has at its foundation a clear terms of reference right from their first engagement with the community. One colleague pointed out that having adequate time to spend with the community can make the community feel trust in the CHW. Building rapport can be a long-term process.
Policy making and implementation to build trust
Policy making and implementation that favours CHWs can improve CHWs motivation. Suspicion from communities of CHWs’ involvement in politics also influence their trust of the CHWs.
In Ethiopia policy makers demonstrate their trust in CHWs when they construct policies, structures, and budgets (including monitoring and evaluation systems) that support and celebrate their work.
CHWs told us that whether or not the district level management is aware of them and is sensitised to their work motivates the CHWs. It is important that the health units know who the people are in the community.
We heard that policy makers need to take account of the plurality of health care providers within communities. In Bangladesh, informal for-profit providers such as pharmacists are more integrated into the community and accepted as almost family members. Because they are more trusted the community find them more credible than other health care providers and they are often the first point of call in the case of ill-health. So, good communication and rapport with informal providers helps CHWs in Bangladesh to build trust with community and refer clients to proper health facility. How can CHW programmes work with them and learn from them? In Uganda, we heard that Traditional Birth Attendants (TBAs) are part of the Village Health Teams (VHTs) and the communities trust them. However, policy makers do not trust them despite training them in the past. In Ethiopia, TBAs used to be very important in providing family health. But now they have been integrated into the CHW programme as health development army leaders working towards ensuring model household families.
From South Africa, we heard what happens when the trust breaks down. In this highly-politicised environment – which has moved from Apartheid to democracy – people may be reluctant to trust CHWs who they see as agents of the state as they think that they are visiting the home to try and canvas for votes or act as surveillance force. Fear of surveillance is heightened because of very real fears about HIV-related stigma. To counteract this there is a need to involve the communities in designing the intervention itself. Top down approaches to programme design often fail to take into accounts beliefs and norms and local context which is important to success. For example in South Africa, there is a belief in some communities that you should not allow visitors into your home 100 days after the birth of a child, which is at odds with the CHW policy. By ignoring cultural values, the relationship between the CHW and the community is at risk of further deterioration.
From Kenya, we heard how CHW programmes can be effected by political events and crises in the health system that go beyond the community sector. For example, the Kenyan doctors and nurses strikes can undermine trust in the health system which effects CHWs. However, CHWs may have an important role in re-establishing trust in systems that have been battered by instability and it would be good to understand better how this process can be supported.
CHW practices that maintain trust
To gain trust from the community, CHWs are expected to keep confidentiality and act in a responsble manner during interactions with the community, they should have a good knowledge on the health topics they deliver and be available whenever the community needs them.
A colleague from Kenya pointed out that when CHWs maintain confidentiality this supports the process of trust building. CHWs are in the unique position of not just handling sometimes stigmatising health issues but seeing vulnerabilities within the private space of the household. If they are successful communities have to believe that they will handle this information responsibly and sensitively. Commenting on Ethiopia a colleague pointed out that this becomes even more important when it comes to mhealth and new communication technologies. Communities may not fully understand who will see the information that is being entered into electronic devices and what it might be used for. So, they need to place a great deal of trust in the hands of the person that they are giving this data to. Conversely, just having access to an electronic device, like a phone or tablet, may make CHWs more trustworthy as it may make them seem more professional, or at least better equipped. The use of text messaging helps them to make prompt follow up of clients and improved adherence to care.
A colleague from Uganda felt that when CHWs treat themselves as professions for example, they don’t turn up to the household visits drunk, this can increase the respect and therefore trust that their clients have for them. However, another VHT colleague argued that you need to ‘live the professionalism’. A corporate manner when speaking with bad boys does not work. If you have a little drink with the alcoholics as it gains their trust. In addition, speaking the language of the community helps you to relate. You need to put yourself in the shoes of the people you are talking to – CHWs need to advise not supervise.
Colleagues from TASO in Uganda related that being experts in the subject that you are talking about, in this case HIV, helps build trust. This expert knowledge may mean you are living with HIV or have relatives or friends affected by HIV. In this way clients know that you are coming with a knowledge of the issues that are relevant to them.
We heard that trust is linked to availability. When the community knows the CHW is there for them they can trust then and in Zambia this has been shown to increase health service delivery. Availability isn’t just about the amount of time spent with the community. Particularly in emergency care settings it is about being there when a crisis occurs.
Data handling and trust
Trust between CHWs and the community can affect data collection and handling in terms of the aim of data collection, the existence of community dialogue/participation, and the availability of quality tools.
From Kenya, a participant felt that data quality was part of the process of trust building – in terms of what is collected and what is relayed to the community. Relationships effect the quality of data. If communities don’t trust that household visits are authentic and if they think the CHW got paid for collecting data it can affect the quality of the data provided and this is particularly true for vertical programmes. The reasons for collecting data need to be transparent. In addition, if CHWs are expected to ask the same questions of the same households month after month then households can fail to see the importance of answering them correctly. This effects the reliability of the information we are working with. A colleague pointed out that falsification of data sometimes occurs because of pressure to perform. To overcome this all CHWs need to meet together and frankly discuss the challenges that they have in data collection. From a disability organisation in Uganda we heard that an app for diagnosis and prescription improved the quality of the data collected by CHWs as they knew there were ramifications of not filing information correctly.
In Kenya, the governance of community health programmes can effect trust. CHWs collect data and submit it upwards but if they don’t know what happens to it they can stop feeling incentivised. In this case why not make it up – after all they do not know what they are contributing to. We heard that in Cote D’Ivoire the Ministry of Health wanted data accountability. To facilitate this data was made available at the clinic and CHWs and community members could talk directly to the nurses about it. In this way they could verify that they were being heard and that the community and the health system were connected. In Kenya, community dialogue days enable people to view the data collected by CHWs on a chalk boards and prioritise community action days. However, for these to be successful more support from development partners is required. A colleague in Uganda suggested that parallel systems of data collection for CHW data are being created and this can erode trust.
A participant from Uganda pointed out that to get quality data CHWs need quality tools. Whilst in Kenya it was argued that there are too many tools, as NGO working with specific community units and programmes often introduce their own tools creating parallel reporting systems with the standard Ministry of Health system thus leaving CHWs over-burdened and as a result cannot clearly see the impact of their work. In addition, we heard from South Africa that tools tend to measure how much work a CHW has done but whether or not this work was appropriate is not captured. This calls for a focus on quality not just coverage. In Malawi, We learnt that conducting regular and supportive supervision was key to getting quality data. Irregular supervision or lack of it led to CHWs testing the system in search of being supervised by submitting poor data that led to serious effects on decision making and interventions.
Other health system practices to build trust
Feedback to the community, approaches from CHWs’ supervisors, and financial incentives also can influence trust between CHWs and the health system.
We heard that in Malawi feedback loops for information help to build trust. For example, being able to tell communities what has happened to the information that has been collected is helpful for the relationship with the CHW.
Another participant felt that it was important that CHWs provide correct and accurate information in their messages, but also that they accept when they are defeated and don’t know. They pointed out that if community members suspect a CHW is pretending to know something that they don’t their clients may provoke them to see how much they know, with potentially negative results.
We heard that in terms of the supervision of CHWs trust is important. The approach and aim of supervision affect the relationship between supervisor and the CHWs. Fault finding can cause mistrust in the CHW relationships with their supervisors which can have knock on effects in the service that they provide. We heard from Ethiopia that the language of supervision is important. CHWs feel sense of belongingness and freely share their ideas when the supervisors able to speak local languages spoken by the CHWs. Using phrases like, ‘Let’s do this together’ and ‘We both want to achieve this’, can be motivating. From Uganda, we heard that the delegation of responsibility to CHWs – as long as it is manageable – can build trust, and it boosts confidence.
From Malawi, we heard that financial incentives can be motivating and build trust between the health system and CHWs. However, they can also have a negative effect. They can move CHWs to the programmes that pay the most, cause attrition, particularly allowances linked to training and workshops. This can affect trust across a range of other stakeholders, and the community. In many cases, community members expect basic care from CHWs. When the CHW supply kits are not sufficiently stocked over prolonged periods of time, apathy develops towards CHWs and this affects the trust that community members have in CHWs.
Gendered elements of trust
We heard that in Kenya the sex of the CHW matters as young men coming to visit the house is seen as a security concern by many. In addition, women do not want to have personal conversations with male CHWs about family planning as they fear that confidential information may be relayed to their husbands or others. Conversely, the trust built between a CHW and the community can also help women to overcome harmful gender norms. In Bangladesh, female CHWs are more able to freely move around the community and are less at risk from provocation by local thugs as they have earnt a position of respect within the community. In Ethiopia, all CHWs are women and are better positioned to make household visits and address maternal and child health issues.
From the above experiences and literature it is evident that most challenges affecting health systems are behaviour and relationships related. Trust has a lot to offer in health care delivery and policy analysis and by exploring it further, we are able to capture its relevance to health systems and the need to harness it. Trust plays a very important role for both health care providers and institutions and is a fundamental human norm. As such, it demands consideration as a key ‘software’ element of the health system. Further, the implications of ‘hardware’ interventions on trust, and how these play out in the community provide important lessons for CHW programmes across contexts.