Reflections and key learnings on the Science of Trust

Trust has been defined as ‘the glue of a healthy society [1]’ and influences social, political, and economic well-being [1] as well as health outcomes [2, 3]. It is also foundational to decision-making processes, including people’s trust in science and in clinical and public health recommendations [4]. As previously published in the Journal, trust is key ‘to the adoption and maintenance of health-related behaviors, social norms, and policies [4].’

This special issue of the Journal on the ‘science of trust’ is perhaps the first-of-its-kind in exploring this timely topic across clinical, community, and population settings. The issue reflects the growing concern over the public trust crisis in health information – including traditional sources of information (e.g., government, medical experts, academia) – as highlighted by the COVID-19 pandemic [5]. Surveys have shown public trust in science declined in the United States [5] and other global settings as a consequence of the pandemic [6]. However, the erosion of trust long preceded the COVID-19 pandemic. In part fueled by the spread of misinformation and polarization not only online but also in community and population settings, the trust crisis previously manifested across a variety of health and social issues, including vaccine hesitancy, mental health stigma, and social discrimination (e.g., racism, xenophobia) [7].

Trust is shaped by multiple factors, including biology [8] and, most importantly, many structural factors (e.g., social, political, economic, and information systems) [8–10]. Consequently, in order to advance our understanding of the precursors and consequences of trust or mistrust, concerted and multidisciplinary efforts are needed.

Recognizing the necessity of addressing trust as a complex, yet key determinant of health and well-being, this special issue reflects the Journal’s commitment to the topic and serves as a core resource in its broader Science of Trust Initiative [11]. Launched in 2021, the Initiative has already made many contributions to advancing research and understanding of issues related to trust and mistrust and builds upon the Journal’s long-term legacy on publishing on this topic. Among other efforts, a multidisciplinary expert roundtable [4] convened by the Journal in 2022, spotlighted the following areas for future research and practice [4, 12]: 1) the importance of analyzing trust across social and organizational dimensions, contributing factors, and specific aspects of a health intervention; 2) the relationship between ‘trust’ and ‘trustworthiness’ in interpersonal, community, and organizational settings; 3) the need for further understanding the impact of misinformation and disinformation (i.e., the deliberate spread of falsehoods, conspiracy theories, rumors and myths) on trust in health and science information [13]; 4) the central role of communities, patients, and peer groups, and community and patient engagement; 5) the focus on behaviors that may predict or elicit trust; 6) how trust may be sustained over time; and 7) how trust- and relationship-based approaches, including person- or community centered strategies, may help address health, racial, and social inequities. This work informed the call for papers published in December of 2022 [12], with the goals of advancing promising strategies, building a robust evidence base, and identifying future research questions in science and health information. We also solicited new resources and ideas from the field to ensure that practitioners’ experiences and voices inform our understanding of the science of trust.

The contributions featured in this special issue went through several rounds of peer review and were selected for their rigor and disciplinary, topical, and geographical diversity. Perhaps not surprisingly, several articles focus on the role of trust in the context of the COVID-19 pandemic, including trusted sources for COVID-19 testing and vaccination information [14], associations between false beliefs in COVID-19 cures and media use in India [15], the use of the socio-ecological model to explore important dimensions of trust in COVID-19 information in Black and Latinx communities [16], how trust in science moderates the effects of communication characteristics on reactions to COVID-19 public health messages [17], and how trust in public institutions may affect social media-based interventions to promote COVID-19 vaccination [18]. The remaining articles focus on diverse topics such as the influence of trust on patient-provider communication and other health-related outcomes [19], how trust and distrust for online health information impacts e-health literacy [20], and the significance of generative artificial intelligence (AI) for trust in health communication [21]. These articles also represent a variety of communities and international settings, including the United States, Norway, and India.

To complement the peer-reviewed articles, we solicited several opinion pieces focusing on perspectives and lessons learned from existing programs and strategies to foster trust or address mistrust. First, our Community Voices article [22] is a compilation of short reflections from representatives of community-based organizations and experienced community leaders. These on-the-ground reflections affirm the Journal’s commitment to highlighting community perspectives and giving voice to the needs, values, and priorities of local communities to inform research and practice. The issue also features several Commentaries and Letters. Chou and Gaysynsky discussed the importance of a relationship-centered approach to addressing mistrust and highlighted practical opportunities to focus on social relationships in health communication efforts [23]. Schiavo and Boston-Fisher offered a working model for measuring different dimensions of trust in research and practice [24]. Navqi and Saikia reflected on lessons learned regarding community-driven and multisectoral strategies to build trust in COVID-19 vaccines and other mitigation measures in communities around the world that historically experienced marginalization or vulnerability [25]. Hemberg, Wickliffe, and Ramaswamy provided a critical examination of researcher-participant relationships in health interventions with women involved with the criminal justice system, highlighting the importance of centering the participant, creating a space where participants feel safe, and demonstrating trustworthiness on the part of the researchers [26]. Zarndt, Guo, and Benoza discussed how online influencers were engaged as trusted voices in tobacco control media campaigns, thereby leveraging pre-established trust for health message delivery [27]. Finally, Sichel and Elkington offered a systems-based approach to improving behavioral health care and addressing mistrust when working with youth on probation [28].

Collectively, the articles in this issue offer readers several learnings regarding the science of trust and point to important directions, which we hope will inspire future research efforts and provide practical guidance for intervention and policy design. Major themes that advance the understanding of trust include:

• The importance of creating strong community ties, engaging local communities, and leveraging existing trusted sources of health information. Health interventions that go beyond information provision to foster personal and community connections [14, 22, 23, 25, 26], listen to people and their genuine concerns [23, 25, 28], and are culturally and linguistically sensitive [16] not only serve to build trust, but allow for the impact of the intervention to be more sustainable and lasting in addressing health inequities and promoting behavioral and social change, such as the adoption of preventative measures [14, 25, 27]. Moreover, trust building often requires identifying existing trusted sources of information and leveraging these sources for health communication. Examples of trusted voices highlighted across peer-reviewed articles and opinion pieces include physician groups, schools, pharmacies, church representatives, friends, relatives, outdoor guides, LGBTQI + influencers, and women and youth groups [14, 16, 25, 27] Indeed, across several articles, the relationship-centered approach to addressing mistrust is emphasized, which connects trust and trustworthiness through engaging communities that have been historically marginalized in community-based research efforts and intervention design.

• The need for a system-driven approach to address trust by identifying the interaction between drivers of trust/mistrust across different levels, dimensions, and groups. System thinking is about making sense of the complexity of any given issue by exploring the interactions between different elements of health and social systems, including the people, interventions, and policies that are part of such systems, and recognizing that observed outcomes are the result of a system and its interactions with determinants of health and well-being [29]. This also applies to the process of building trust in evidence-based health information. For example, one study used the socio-ecological model to identify trusted sources of information pertaining to different intervention levels and dimensions of trust [16], thereby supporting a system-thinking approach to addressing trust/mistrust, which is also reflected in the working model for measuring trust [24] proposed in one of the commentaries. Moreover, lessons learned and strategies from a participatory approach to social and behavior change in global and country-specific health settings, and in the context of building trust during a pandemic [25], also support the need for multisectoral engagement across intervention levels, groups, professions, and disciplines that contribute to health and social systems.

• The centrality of rigorous scholarship on understanding and addressing misinformation, which undermines trust in evidence-based health information and experts. The articles included in this special issue highlight ongoing research efforts to address the impact of misinformation/disinformation, including increasing digital media literacy, implementing content moderation policies and practices, or directly countering or correcting misinformation and promoting evidence-based information [15, 22, 23, 27]. Another example includes using rhetorical devices and e-health literacy strategies for improving provider-patient communication and discerning health information quality [20]. Understanding the current health information ecosystem, including why and how misinformation spreads, is a critical part of tackling mistrust and fostering effective communication.

• The importance of community- and group-specific interventions. Several articles highlight the need for interventions that are attuned to the unique characteristics of the groups being engaged. This includes segmenting audiences and developing targeted and tailored strategies ‘around trust views [18]’ of intended groups and populations (for example, different messaging for those trust versus those who do not trust public health institutions), as message effectiveness and related behavioral intentions vary for these groups [18]. As another example, strategies that may help minimize anger and negative emotions among skeptics of health recommendations [17] serve to illustrate the utility of a tailored, value-concordant, and group-specific approach that considers trust levels.

• Several emerging themes for future inquiry were also identified. These include exploring ‘how communication establishes, maintains, increases, or diminishes trust between individuals and between individual citizens and systems [20]’ through a mechanistic approach to document the establishment of trust in patient-provider communication and its impact on patient outcomes [20]. One article considered trust in the context of generative artificial intelligence (AI) in health communication and proposes that future research addresses critical challenges for trust in AI settings, including focusing on ‘standard cues for judging credibility’ and ‘the ability for models to transparently explain what information was used to inform a response,’ as well as exploring strategies to minimize ‘the potential to generate new information that appears trustworthy but is entirely wrong [21]’. In addition, at the community and interpersonal levels, areas and methods for research inquiry may include strengthening social network analysis to identify information pathways [14, 23–25], identifying multi-level and group-specific drivers to promote public health goals [14, 24, 28], assessing multi-level barriers associated with mistrust [28], grounding research efforts in community- and equity-centered approaches [22, 24, 25, 27], and using narrative and arts-based communication methods and entertainment education to understand ‘pro-social behaviors [14],’ such as those that express empathy and concern for others, and their association with trust. At the organizational level, research on the perceived motivation and competence of different information sources (e.g., government agencies, private industry, medical establishment) [18] among specific communities and the public, as well as the influence of these perceptions on trust, may provide useful evidence for communication interventions and policies. Finally, several articles [16, 23, 24, 28] highlighted the necessity of measuring trust and recognizing its evolving nature (e.g., changes in trusted voices of health information [16]) and group-specific factors (e.g., differential access to media channels, health literacy levels, community history, the intersection of health, racial and social inequities with trust/mistrust, cultural and contextual factors [16, 20, 24, 25]), which points to the importance of a systematic approach to comprehensively assess and monitor trust over time.

In summary, this issue contributes to our collective knowledge on the science of trust and provides valuable insights on promising strategies for intervention design and future research directions. It also includes lessons learned and perspectives from professionals across multiple sectors and disciplines, and most importantly, from community settings. As our knowledge on how to build or restore trust continues to grow, it is important to highlight that the factors influencing trust or mistrust are community- or group-specific, suggesting a need to identify unique factors and better listen to the communities, patients, and groups being served. Moreover, since trust is built over multiple interactions and intervention levels, it is essential to continue leveraging the expertise of diverse academic disciplines and multiple sectors, so we can effectively account for the varying definitions, measurement methods, goals and objectives. Finally, it’s important to remember that relationships are at the core of trust as much as trust is foundational to long-term healthy relationships. As other authors have suggested, ‘fostering and facilitating trust and trusting relationships [30],’ and ultimately creating a culture of trust [30] in community, clinical, educational, and organizational settings is key to many of our efforts in health communication, and is essential to advancing diversity, equity, inclusion, and social/racial justice. The pandemic has unequivocally demonstrated that building trust is one of the core issues and priorities of our time, and that the global trust crisis in health and science information can no longer be ignored.

Disclaimer

The opinions expressed here are only those of the authors and do not necessarily represent the opinions of the Journal, its publisher, or its editorial team, or any of the organizations with which the authors are affiliated including the U.S. Department of Health and Human Services. No funds supported the development of this article.

Acknowledgements

The authors wish to thank Nikita Boston-Fisher, MPH, who serves as the Senior Editorial Assistant at the Journal, and Anna Gaysynsky, MPH, who is with the Health Communication and Informatics Research Branch, Behavioral Research Program, National Cancer Institute, for their hard work, dedication, and scientific and editorial contributions to this special issue. Their strategic input, editing skills, and support were critical to seeing this issue in press.

Additional information

Notes on contributors

Renata Schiavo

Renata Schiavo, PhD, MA, CCL is the Editor-in-Chief of the Journal of Communication in Healthcare: Strategies, Media, and Engagement in Global Health. A passionate advocate for health, racial, and social equity, she is a Senior Lecturer at Columbia University Mailman School of Public Health, Department of Sociomedical Sciences, and serves as the Founder and Board President on the Board of Directors of Health Equity Initiative, a nonprofit membership organization, and a Principal at Strategies for Equity and Communication Impact, a global consultancy. Her areas of expertise include epidemics, emerging disease outbreaks and other public health emergencies, health inequities, maternal and child health, immunization, vaccine hesitancy, and building trust in science. She has published extensively on health and risk communication, global health, community-based interventions, and health equity. She conceptualized and leads The Science of Trust Initiative at the Journal and is the co-editor of this theme issue on the topic.

Wen-Ying Sylvia Chou

Wen-Ying Sylvia Chou, PhD, MPH is a Program Director in the Health Communication and Informatics Research Branch at the National Cancer Institute. A prolific health communication scholar with over 100 peer-reviewed publications, she has led a number of NIH initiatives on the impact of the evolving communication landscape on public health and cancer control and prevention. Her areas of expertise include patient-provider communication, social media, end-of-life communication, and use of mixed methods in health research. Her current research centers on understanding and addressing the spread of health misinformation and fostering relationship-centered communication. She has served as an editor for American Journal of Public Health special issue on misinformation and is the guest co-editor for this theme issue on the science of trust for the Journal of Communication in Healthcare: Strategies, Media, and Engagement in Global Health.