Abstract
BACKGROUND: Trust remains a critical concept in healthcare provision, but little is known about the ability of health policy and interventions to stimulate more trusting relationships between communities and the health system. The CONNECT (Community Network Engagement for Essential Healthcare and COVID-19 Responses Through Trust) Initiative in Lao PDR provided an opportunity to assess the community-level impact of a trust-building community engagement approach. METHODS: A mixed-method process evaluation was implemented from 10/2022-12/2023 among 14 diverse case study communities in four provinces across Lao PDR. Data collection involved two rounds of census surveys (3161 observations incl. panel data from 618 individuals) including an 8-item trust scale, 50 semi-structured interviews with villagers, and 50 contextualizing key informant interviews. The two data collection rounds were implemented before and three months after village-based CONNECT activities and helped discern impacts among activity participants, indirectly exposed villagers, and unexposed villagers in a difference-in-difference analysis. RESULTS: Stakeholders attested strong support for the CONNECT Initiative although community-level retention of trust-related themes from the activities was limited. Quantitative data nevertheless showed that, at endline, the 8-item trust index (from [-8 to +8]) increased by 0.95 points from 4.44 to 5.39 and all trust indicators were universally higher. Difference-in-difference analysis showed that villagers exposed to the CONNECT activities had a 1.02-index-point higher trust index compared to unexposed villagers. Trust impacts improved gradually over time and were relatively more pronounced among men and ethnic minority groups. CONCLUSIONS: The CONNECT Initiative had considerable direct and systemic effects on community members' trust in their local health centers in the short term, which arose from strong stakeholder mobilization and gradual institutional learning. Relational community engagement approaches have the potential to create important synergies in health policy and broader cross-sectorial strategies, but also require contextual grounding to identify locally relevant dimensions of trust.