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

Stella Arakelyan - ORCID: 0000-0003-0326-707X https://orcid.org/0000-0003-0326-707XArek Dakessian - ORCID: 0000-0001-7792-6862 https://orcid.org/0000-0001-7792-6862Karin Diaconu - ORCID: 0000-0002-5810-9725 https://orcid.org/0000-0002-5810-9725Lizzie Caperon - ORCID: 0000-0001-5204-170X https://orcid.org/0000-0001-5204-170XAlison Strang - ORCID: 0000-0003-3064-5283 https://orcid.org/0000-0003-3064-5283Sophie Witter - ORCID: 0000-0002-7656-6188 https://orcid.org/0000-0002-7656-6188Alastair Ager - ORCID: 0000-0002-9474-3563 https://orcid.org/0000-0002-9474-3563Replaced AM with VoR 2021-10-21Non-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.This research was funded by the National Institute for Health Research (NIHR) Global Health Research programme 16/136/100.https://doi.org/10.1016/j.socscimed.2021.114473291pubpu