Measuring community engagement and trust in community health workers in Haiti, Malawi, and Rwanda: a cross-sectional...

Community health workers (CHWs) increase the accessibility of institutional health systems by building trust in communities. We assessed community members' trust in CHWs in Haiti, Malawi, and Rwanda. We explored whether potentially modifiable factors, including sex concordance between community members and CHWs and time spent by CHWs engaging with their community, are associated with increased trust in CHWs.

Between June and October 2023, we used two-stage sampling to conduct a cross-sectional survey of 1920 community members, cared for by Partners In Health. We multiplied the frequency and duration of self-reported interactions with CHWs to calculate cumulative self-engagement and cumulative perceived engagement between a CHW and others in their community over the past six months. Community members who interacted with their CHW at least once in the past six months answered the Trust-in-CHW Scale. We compared engagement levels by country using a Rao-Scott χ² test and explored the association between sex and sex concordance, CHW engagement, and trust, by country using clustering-adjusted regression models.

Many community members in Haiti (51.1%), Rwanda (47.2%), and Malawi (5.8%) reported no interaction with their CHW in the past six months (P < 0.001). Among those who had interacted at least once, the cumulative self-engagement duration (in hours) was highest in Malawi (mean (x̄) = 3.3 hours), followed by Rwanda (x̄ = 1.2) and Haiti (x̄ = 1.1). Trust in CHWs was also the highest in Malawi (x̄ = 3.6), followed by Rwanda (x̄ = 3.5) and Haiti (x̄ = 3.4). While neither sex nor sex concordance were significantly associated with self-engagement duration or trust, longer cumulative durations of self- and community-engagement were significantly associated with increased trust for all countries.

Increased duration of engagement with CHWs was associated with increased trust. However, many community members reported no meaningful engagement with their CHWs in the past six months. This finding underscores the importance of empowering CHWs to engage with community members.