Building trust in humanitarian epidemic response: a scoping review

When a deadly virus spreads through a region already fractured by conflict or poverty, the most powerful tool available to health workers is not a vaccine or a medicine, but trust. In the chaotic landscape of a humanitarian crisis, where people are displaced, scared, and often have good reason to fear outsiders, the success of any medical intervention depends entirely on whether the community believes the helpers are there to protect them. If people do not trust the people arriving with aid, they will hide their sick family members, refuse vaccinations, and even attack treatment centers. This dynamic has become a central lesson for global health organizations over the last decade, particularly following the devastating Ebola outbreak in West Africa. The idea is simple: without trust, the best medical plans fail. But while everyone agrees that trust is essential, there is a profound confusion about what it actually is, how to build it, and how to know if it has been built.

A team of researchers from the London School of Hygiene & Tropical Medicine and Médecins Sans Frontières set out to untangle this confusion. They conducted a broad review of fifty published studies and reports from around the world, looking at how humanitarian organizations have tried to earn the confidence of communities during epidemics since 2014. Their goal was not just to list what people say about trust, but to see what actually happens on the ground. They examined how organizations define trust, what specific activities they use to create it, and whether there is any solid proof that these activities work. The researchers found that while the humanitarian sector has loudly declared that trust is the key to saving lives, it has not yet figured out how to construct it. The literature is filled with descriptions of why people do not trust aid workers—citing histories of colonialism, political neglect, and past failures—but it offers very little clarity on how to fix those deep wounds.

The review revealed a striking gap between the urgency of the problem and the precision of the solution. In the fifty documents analyzed, trust was mentioned constantly as a prerequisite for success. It was described as the foundation needed for people to report illnesses, accept vaccines, and follow safety rules. Yet, almost none of the studies actually defined what trust means in a practical sense. The authors of the review noted that trust is rarely measured or tested. Instead, it is often assumed. For example, a report might state that hiring local health workers or holding community meetings has "built trust," without providing any evidence to show that the community's feelings have actually changed. The researchers found that trust is often treated as a tool to get people to do something else, like take a vaccine, rather than being seen as a valuable outcome in its own right.

The most common strategy identified in the literature is community engagement. This is a broad term that covers everything from handing out flyers to holding long discussions with local leaders. The review found that forty-two of the fifty documents highlighted this approach. The idea is that by involving local people in the design and delivery of health programs, organizations can become more acceptable. This often involves working with "local intermediaries," such as religious leaders, village chiefs, or community health workers who are already known and respected. The logic is that these figures can translate messages and lend their own credibility to the medical response. However, the review also pointed out a significant flaw in this thinking: it often assumes that because someone is a leader, they are automatically trusted by everyone. The researchers found that power dynamics within communities can sometimes make this approach backfire, as certain leaders may be distrusted by specific groups, or their selection may favor the powerful over the vulnerable.

Communication is another pillar of these efforts, but the review showed that the old way of doing things—telling people what to do—is no longer effective. The successful examples described in the literature moved toward two-way dialogue. This means listening to what people are afraid of, acknowledging what is not yet known, and adapting messages to fit local cultures and languages. For instance, if a health campaign tells people to wash their hands, but the community does not have clean water, the message will fail. The review highlighted that transparency is crucial; admitting when scientists do not have all the answers can sometimes build more trust than pretending to have all the facts. Feedback mechanisms, where communities can report problems and see those problems addressed, were also identified as a promising way to show that organizations are listening. Yet, even here, the evidence is thin. While organizations claim these systems work, few studies have actually tracked whether the act of listening leads to a measurable increase in trust.

Perhaps the most important finding of the review is the realization that the focus has been on the wrong side of the equation. For years, the effort has been on how to get communities to trust the aid workers. The researchers argue that this perspective is incomplete. The literature suggests that the real work lies in making the humanitarian organizations themselves more trustworthy. This means changing how they operate, not just how they speak. It involves addressing the root causes of suspicion, such as historical injustices and political marginalization, and being willing to change their own behavior based on what the community tells them. The review found that while the sector has learned that trust matters, it has not yet developed a clear framework for how to build it. The path forward, the authors suggest, requires moving beyond simple checklists of activities and toward a deeper understanding of power, representation, and the long-term relationships between aid workers and the people they serve. Until the humanitarian sector can define trust clearly and measure it honestly, it will remain difficult to know if their efforts are truly saving lives or just making people feel better for a moment.