Leveraging Trust in Primary Care to Promote Behavior Change During COVID-19

During the COVID-19 pandemic, population-level health behavior modification has been the key to curbing viral transmission. But behavior change is complex and occurs only when combined forces overcome the inertia of ambivalence. Communities have faced a serious question: how to influence the forces that can bring about behavior change across an entire population.

Each of these forces — cognitive, affective, sociocultural, and functional — are activated by trust. Most individuals act because they trust information (cognitive), trust feelings or intuition (affective), trust in other individuals or the community (sociocultural), and/or trust individual efficacy (functional). Because trust is like the cofactor to an enzyme catalyzing a reaction, health leaders should leverage trust to optimize population health.

Where does trust in the health system lie for many people? With their primary care clinicians. The heart of primary care is the enduring relationship between the interdisciplinary team and the patient and family receiving care. By exhibiting beneficence, compassion and prudence, team members build a vast cache of trust with individuals and society. The depth and enduring nature of primary care trust leads communities to look to primary care when widespread health crises such as a pandemic occur. Given the high stakes in vaccination uptake, now is a vital time to capitalize on community trust in primary care.

For the past 11 months, our federally qualified health center (FQHC) in Waco, Texas has worked to leverage our community’s trust in us to inform pandemic-related thoughts, attitudes, cultural norms, and self-efficacy. While I am admittedly aware of our shortcomings, we have nevertheless seen broad endorsement of our guidance and shift in attitudes brought about by our engagement. For example, our clinical leaders have been regularly cited in local media coverage. We’ve also seen signs of improved community understanding of COVID-19 containment, including more testing for mild symptoms and perceived risk of exposure.

As early cases of COVID-19 emerged, our primary care leadership examined key issues in our community: low health literacy, lack of knowledge about modes of viral transmission, variable feelings of fear and indifference about the looming threat, regional cultural values privileging individual liberties over collective good, and low self-efficacy to change the impact of the pandemic.

Using simple two-minute informative videos, primary care clinicians from our clinic provided the community “Corona 101” education in English and Spanish on a host of topics related to the pandemic. Each video was created to be accessible to individuals with very low health literacy. Videos were distributed via social media through patient networks in our community.

Similarly, primary care clinicians spoke directly to the community via “Facebook Live” question and answer sessions held weekly. Questions were submitted in English and Spanish and answered in both languages in a manner accessible to those with low health-literacy. In addition, since March, organization and clinical primary care leadership has joined the Waco mayor and the county judge (the top elected official within Texas counties) on weekly press conferences that have helped frame local news stories.

Our FQHC invited local elected officials and race equity advocates to join a COVID-19 race equity committee that has been meeting with the aim to limit the impact of systemic racism within health care and the broader community on COVID-19 outcomes. The work of this committee changed policy, instituted new programs, and promoted a culture of equity within the community. Early disparities in testing were discovered by the group, so testing policy was changed to remove criteria contributing to inequities such as travel and objective fever criteria. Language and cultural barriers for Latinx populations were examined by the committee, leading to town hall meetings in Spanish and printed and online materials targeting Spanish speakers. The committee offered city and county policymakers and local health care leadership information and advice about COVID-19, public health, and race equity.

Now the health center is considering how to optimally use primary care trust to maximize vaccine uptake. This question is complicated by the dearth of vaccines distributed directly to primary care within the United States. For example, last year alone, our health center saw 20% of people residing in our county; but since vaccine distribution began in December, we have received less than 5% of the county’s total vaccine allotment from the state.

While local mass vaccination strategies are critically important, they should work hand-in-hand with primary care delivery strategies. Our nursing teams calling phase 1B patients report that patients indicate strong preference to wait until the vaccine is available from their primary care team over signing up for the health district mass vaccination program. In our experience, only one-third of patients called by primary care nursing staff accept the opportunity for vaccination through a public program; but over half of patients accept a vaccine appointment through primary care.

For FQHCs that serve those disproportionately harmed by the pandemic, there is some hope. On February 9, the White House described an initiative to supply more vaccines to FQHCs. With ample vaccines, the 1,400 community health centers offering primary care to 1 in 11 Americans can use their social trust to increase vaccination rates for vulnerable communities. This measure will be key for vaccine distribution equity in the United States, a feat unattainable without the trust cultivated through primary care relationships.

With many institutions experiencing historic lows in social trust, primary care stands out as a key institution able to use its place of strong trust within communities to influence knowledge, attitudes, cultural norms, and self-efficacy to bring about healthy behavior change. The trust engendered between primary care practitioners and their patients remains a precious asset. All of primary care should use it — and their place in the community — to advance vaccine uptake and equity.