“Build Trust” isn’t a strategy. It’s a signal that something deeper needs repair

We hear it everywhere in health and public policy:

“We need to build trust.”

It’s the go-to response for everything from vaccine hesitancy to gaps in service uptake. But for a phrase that’s so widely used, it’s surprisingly vague. It's the kind of statement you can’t really disagree with. Yet it rarely leads to meaningful action.

That’s because “building trust” is often framed as a goal when in fact it should be understood as an outcome. Trust is the result of systems, structures, and communications that are actually worthy of it.

That shift in framing matters more than most people realize.

Trust isn’t one thing, and it doesn’t flow in one direction

When we say “trust,” are we talking about trust in the health system? In science? In individual health workers? In a specific intervention?

Each of these forms of trust requires different conditions to emerge. Each is influenced by more than community engagement or good messaging.

Trust is contextual, directional, and most importantly, relational. It is not a static trait or belief. It forms between people, communities, institutions, and the information systems that connect them. You cannot build or restore trust without understanding what that relationship requires from both sides.

And trust is not fixed. It evolves over time. It is shaped by performance, consistency, and memory: how past promises were kept (or not), whether values were violated (or not), and whether current behavior affirms or contradicts those experiences. This means that trust isn’t something you “build” once and retain forever. It must be actively sustained through action and accountability.

Trust is built, or broken, long before the message

Public health efforts often focus on communication. Find the right trusted messenger. Craft the right narrative. Fight misinformation. And build trust.

But these efforts often assume that the underlying system is already worthy of trust. Or worse, that trust can be restored without addressing why it was lost.

A trustworthy message in an untrustworthy system is not persuasive. It is disorienting.

As I’ve written elsewhere, trust is not an emotion. It is a judgment in relationship to something or someone, and one that people make by evaluating motive, competence, reliability, and respect. These judgments are shaped not just by individual experience, but by the broader information environment and the system’s track record.

No message, no matter how well designed, can overcome systems that routinely fall short on those four dimensions.

What about social cohesion and social capital?

One of the major gaps in the way “building trust” is often discussed is the lack of attention to social cohesion and social capital. These are real, measurable conditions that shape the success or failure of health systems and public health interventions.

Social capital refers to the networks of relationships and shared norms that enable people to act collectively. Social cohesion reflects the strength of those bonds and the sense of belonging within a community. Both influence who people trust, how information flows, and whether public goods are seen as legitimate.

Ignoring these concepts leads to narrow, individual-focused trust-building efforts that overlook the broader societal fabric that holds trust together, or reveals its absence.

In polarized or inequitable environments, people’s ability to trust institutions is deeply affected by whether they trust one another. And yet, very few health strategies recognize this. We can’t build trust in systems without also investing in the conditions that allow communities to trust themselves and one another.

“Being trustworthy” is necessary, but still not enough

There is a growing call for institutions to “be trustworthy”, especially in science and health. That is a step forward, but it still misses the mark if we treat it as a moral imperative rather than a complex systems challenge.

Being trustworthy is the baseline. But in a polluted or fragmented information environment, even genuinely well-intentioned systems will struggle to earn trust unless they also:

• Deliver care or products consistently, not just competently

• Address structural asymmetries in information and access

• Protect the safety and dignity of health workers, not just their productivity

• Create feedback loops that acknowledge and repair trust violations

Trust does not come from engagement alone. It comes from alignment between what is promised, what is delivered, and how that is communicated.

Trust is the output of design

Trust is not a trait. It is an outcome. A well-designed system, embedded in a coherent information environment, produces trust naturally.

This reframing leads to better questions:

• What would make people feel safe to trust us again?

• Where are we placing the burden of adaptation—on the public, or on the system?

• Are we delivering care consistently, competently, and respectfully across contexts?

Time to let go of comfortable language

If shifting from “build trust” to “be trustworthy” helps leaders think more clearly, that’s progress. But we cannot stop there.

As long as “trust” remains a placeholder for everything we cannot explain about health behavior, we will keep investing in symptoms rather than causes.

And as long as we treat "building trust" in a kind of moral or purist way, while ignoring the complex systems, power dynamics, and environmental design that shape whether trust can exist, we will keep failing. We’ll remain stuck in abstract language and frameworks that sound good on paper but are impossible to translate into practice.

What needs to change is not just how we talk about trust, but how we hold public health systems, institutions, and organizations accountable for it.

That means defining what trustworthy performance looks like and building systems that are measured, evaluated, and resourced based on how well they earn and sustain trust in real-world conditions.

The real challenge is not how to build trust. It is how to design systems and environments where trust emerges and makes sense and where institutions are accountable for delivering on it.

PS: And if trust is an outcome, not a goal, then we can remind ourselves that the goal of public health is not to be trusted for its own sake. The goal is to protect and promote health, equitably and effectively. Trust is what emerges when systems deliver on that promise, over time, in ways that are transparent, respectful, and responsive. It’s not the mission. It’s the signal we’re doing the mission well.