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

Non-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.

Help-seeking, trust and intimate partner violence: social connections amongst displaced and non-displaced Yezidi women and men in the Kurdistan region of northern Iraq.

BACKGROUND: Conflict and displacement impact the social fabric of communities through the disruption of social connections and the erosion of trust. Effective humanitarian assistance requires understanding the social capital that shapes patterns of help-seeking in these circumstances - especially with stigmatised issues such as violence against women (VAW) and intimate partner violence (IPV). METHODS: A novel social mapping methodology was adopted amongst a Yezidi population displaced by ISIS (ISIS: Islamic State of Iraq and Syria, locally known as Da'esh) occupation and a neighbouring settled Yezidi population in the Kurdistan region of northern Iraq in late 2016. Six participatory workshops were conducted to identify available resources with respect to: meeting basic needs, dispute resolution and VAW. Subsequently, 51 individual interviews were conducted (segmented by gender and settlement status) to identify connectedness to, and trust in, the resources identified, with a focus on IPV against women. RESULTS: 90% of participants reported God as a key source of help in the previous 6 months, representing the most widely cited resource. Following God, the most accessed and trusted resources were family and community, with NGO (non-governmental organisation) provision being the least. Women drew more strongly upon familial resources than men (Χ 2 = 5.73, df = 1, p = 0.017). There was reduced trust in resources in relation to seeking help with IPV. A distinction between trust to provide emotional support and trust to resolve issues was identified. Settled women were 1.6 times more likely to trust community members and government services and 3.7 times more likely to trust NGOs than displaced women. CONCLUSIONS: Mapping social connections and trust provides valuable insight into the social capital available to support help-seeking in populations of humanitarian concern. For these Yezidi populations, family, religious and community resources were the most widely utilised and trusted. Trust was mostly reserved for family and their main religious leader regarding IPV against women. Lack of trust appeared to be a major barrier to stronger engagement with available NGO provision, particularly amongst displaced women. The role of faith and religious resources for this population is clearly significant, and warrants an explicitly faith-sensitive approach to humanitarian assistance.