From Linchpin to Lever — Part 2: Building Trust Through Reflective Action

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From Linchpin to Lever - Part 2: Building Trust Through Reflective Action

Transforming Public Health for the 21st Century: Bridging Theory to Practice is a blog series that will explore the challenges and opportunities faced by the public health sector and will introduce innovative ideas and unique voices to support transformation. Sign up here to receive these summaries and more, and also follow KHI on Facebook, X, LinkedIn, and Instagram. Learn more about the series on our blog page. Please feel free to share your feedback or suggestions with us by emailing [email protected].

In March we made the claim that local health departments (LHDs) may be the linchpin for rebuilding trust in the public health system, and in June we showed how trust in the public health system could be measured through the Behavioral Risk Factor Surveillance System (BRFSS) and community health assessments (CHAs). This would allow public health leaders to know where they stand and better understand where the leverage points may be for rebuilding trust. But a linchpin is not a lever, and measuring trust is not the same as building it.

Rebuilding trust is complex and may have too many moving parts to solve in a single stroke. What public health leaders need instead is a way to center their organization's attention on the problem, take action, learn what works and adjust along the way - a process of reflective action. Political scientist Charles Lindblom argued that when faced with a problem too complex to solve in one move, the rational course is a series of small, correctable steps.¹ Rebuilding trust is exactly that kind of problem, and the methods for taking those steps are ones already in public health's culture.

Those methods are quality improvement and action learning. The Institute for Healthcare Improvement's Model for Improvement organizes quality improvement work around three questions: what are we trying to accomplish, how will we know a change is an improvement, and what changes can we make that will result in improvement (Figure 1).² This post explores how this model could be applied to rebuilding trust in public health.

Figure 1. Institute for Healthcare Improvement's Model for Improvement

Source. Structure adapted from the Model for Improvement from the Institute for Healthcare Improvement. Accessed July 21, 2026. https://www.ihi.org/library/model-for-improvement

What Are We Trying to Accomplish?

The first question addresses the aim the team is trying to accomplish. For a health department working to rebuild trust, the aim can feel obvious - more people trusting the public health system. But the philosopher Onora O'Neill suggests that trust cannot be pursued directly.³ Trust cannot be demanded. It has to be given. To rebuild trust, institutions must consistently act trustworthy. The four dimensions introduced in Part 1 - competence, benevolence, integrity and predictability - provide a framework health departments can use to embed trustworthiness into their identity.⁴ The real aim, then, is not trust. It is trustworthiness, demonstrated consistently enough and visibly enough, to be noticed.

If trust follows trustworthiness, the practical question is whether a department's trustworthy actions are recognized. That is an empirical question, and it is the kind that can be addressed through cycles of reflective action. Applying quality improvement to trust does not mean manufacturing a feeling. It means testing, in small ways, whether specific demonstrations of trustworthiness resonate with specific audiences and adjusting course when they do not. Trust cannot be manufactured, but trustworthiness can be made visible, and organizations can test whether people recognize and respond to those efforts.⁵

How Will We Know When a Change Is an Improvement?

The second question asks how will we know we've improved trust? The survey questions discussed in Part 1 are tempting answers. However, the BRFSS survey is fielded once per year, and the results lag several months behind the survey. That measure matters over the long run but is too infrequent to support real rapid cycle quality improvement that's necessary to support transformational change. Annual surveys cannot tell teams whether the change they instilled last month helped. If the aim is trustworthiness, though, there are leading indicators that move at a faster pace and can support real-time quality improvement.

First, health departments can set and define a commitment to trustworthiness. This is an internally focused process measure. Checking to see if the health department is keeping its own commitments can provide real-time feedback on its trustworthiness. "What did we say we would do and are we doing it?" A health department that commits to engaging community members in decision making can track if it is doing this.⁶ A health department that commits to explaining how it makes recommendations - based on evidence and ethics - can measure how it has been communicating this.⁷ These are not just proxies for trust. They are the direct measures of trustworthiness and are within the institution's power to change in real time.

Second, health departments can track what stakeholders are willing to risk on their behalf. This is an externally focused leading outcome measure. Siv Vangen and Chris Huxham say that as trust grows, people's willingness to open themselves up to risk also grows.⁸ While this may be difficult to measure quantitatively, health departments can keep a log of the times external stakeholders or the public went out on a limb for them. When residents speak at a county commission meeting to defend the health department's budget, they are spending their own social capital on the department's behalf. When a partner organization offers to take lead on one of the priorities in the community health improvement plan, they are aligning their resources with the health department's goals. Both are examples of stakeholders' willingness to be vulnerable and take on risk based on positive expectations - which is how we defined trust in Part 1.

Third, health departments could also track sentiment in mass media and social media using tools such as discourse analysis. Monitoring social media or the framing of coverage in a local paper may provide insight into the public's feelings toward the health department. However, these forums tend to skew toward negative dialogue and may provide a distorted view of trust.^9,10 Sentiment in these venues could be worth watching as an early warning sign. It might give you hints on issues you need to get ahead of, but it also is unlikely to provide a true measure of the public's trust.

These measures provide real time signals to help health departments take action, reflect and iterate toward improved trust. But they do not give a quantifiable measure of the public's trust. This brings us back to the survey measures described in Part 1. Embedding trust as a question in surveillance systems such as BRFSS allows public health leaders to track long-term trends and identify how these trends vary in segments of the population. While survey measures like this cannot support rapid-cycle quality improvement, they can support the overall process and provide a more concrete measure of the public's trust over time.

What Changes Can We Make That Will Result in Improvement?

The model's third question asks what changes a department can make that will improve trust. We showed earlier that trust follows from acting in a trustworthy way and making that trustworthiness visible. The changes a department makes, then, should build its competence, benevolence, integrity and predictability, and make examples of these commitments more visible for the community to see. But those are broad categories. Public health leaders still need to identify the specific, concrete changes that will demonstrate their trustworthiness.

Several quality improvement tools can help a team move from a broad category to a specific change. The first is a cause-and-effect diagram, which sorts the plausible reasons trust is lacking into categories and drills down to specific, concrete issues within each. We suggest organizing the categories around the four dimensions of trustworthiness, plus visibility. A clear-eyed look at each category, not just the ones that are easiest to fix, gives a team the fullest set of issues to choose from.

Other tools can help a team go further. The 5 Whys presses past a general issue on the diagram to its root cause, asking why it happens, then why that happens, until the answer is specific enough to act on. A driver diagram can be used to organize the strongest root causes into a short list of testable change ideas, connecting the aim to the handful of factors that plausibly drive it.

These tools tend to produce more ideas than a department can test at once, especially for a busy health department stretched across its core services. A prioritization matrix helps a team choose where to start. Plotting each idea by its likely effect on trust and the effort it takes to try gives a team a fast way to prioritize the options for change. An idea with high likely effect and low effort is worth testing first, one with low effect and high effort should be dropped, and the rest fall somewhere in between. This is a cornerstone of reflective action. A department does not need the single best idea. It needs the next idea worth trying.

Plan-Do-Study-Act: The Disciplined Approach to Reflective Action

Plan-Do-Study-Act (PDSA) operationalizes the process of reflective action. Planning is not the hard part - starting is. Rebuilding trust in public health is a large and diffuse problem, and challenges like this are the kind teams freeze in front of. No one's job description reads "fix trust in public health." Framed at that scale the task can feel too big to begin. In these situations, teams often get stuck in the planning phase. Planning feels like progress, but it teaches a team nothing about the problem. No one can learn how a community will react to a change until the change is made.

PDSA asks for speed over polish and small tests over comprehensive ones. At a pace of roughly one change a month, each stage stays small. Planning includes naming the change, defining how it will be implemented and what the team expects to happen. Doing means implementing the change at a small enough scale to undo. Studying means comparing what happened to what the team expected, using the measures already in place. Acting means deciding to scale the change up, adjust it or set it aside for the next one.

Action learning adds something the PDSA cycle alone does not. The difference between quality improvement and action learning is that quality improvement places more focus on the goal and action learning places more emphasis on the team.¹¹ If quality improvement asks whether the change improved the goal, action learning asks what the team learned about themselves and how they improved by trying it. This is an important distinction because health departments carry assumptions about why they are or aren't trusted, what they are allowed to do and how much leadership they can enact to repair their organization's trust. Those assumptions are rarely examined and hard to do without acting. Incorporating action learning brings these assumptions into the open.

The benefit of reflective action is that it shrinks overwhelming problems into a single actionable step teams can commit to. It turns the paralysis of "rebuild trust" into an answerable question of "what's one thing we could try this month?" This isn't an argument against ambitious goals. But it recognizes that a team's confidence in itself will grow as it works through the process of reflective action. While each cycle may feel small, applied consistently over time, this process can lead to transformation through evolution.

Figure 2. A Process of Reflective Action for Increasing Trust in Public Health

Source: Model created by KHI based on a synthesis of the work cited in this blog post.

Pulling the Lever

In March we argued that LHDs may be the linchpin for rebuilding trust in public health. In June we showed how that trust could be measured. But a linchpin only holds a system in place, and a measure only tells us where we stand. Moving trust takes a lever.

Reflective action through quality improvement and action learning can be that lever, and public health is already incorporating these methods into practice. They are embedded in PHAB accreditation and becoming part of public health's culture. What has rarely been done in public health is aim these tools at trust itself. That work does not require a national strategy or a new mandate, and it builds public health's improvement capability through each step. It lets public health leaders start from where they already stand.

Trust is not only tested in a crisis. It is challenged in ordinary times, by every decision made and every commitment kept or unfulfilled. Building trust is not a campaign with an end date. It is consistent action, cycle after cycle, visible to the communities public health serves. The question is no longer whether public health is trusted. It is how trust is built.

References

1. Lindblom, C. E. (1959). The Science of "Muddling Through." Public Administration Review, 19(2), 79-88. https://doi.org/10.2307/973677
2. Institute for Healthcare Improvement. Model for Improvement. Institute for Healthcare Improvement. Accessed July 29, 2026. https://www.ihi.org/library/model-for-improvement
3. O'Neill O. Linking Trust to Trustworthiness. International journal of philosophical studies : IJPS. 2018;26(2):293-300. doi:10.1080/09672559.2018.1454637
4. Dietz G, Den Hartog DN. Measuring trust inside organisations. Sanders K, Schyns B, eds. Personnel review. 2006;35(5):557-588. doi:10.1108/00483480610682299
5. Fuoli M, Paradis C. A model of trust-repair discourse. Journal of pragmatics. 2014;74(Dec):52-69. doi:10.1016/j.pragma.2014.09.001
6. Clinical and Translational Science Awards Consortium Community Engagement Key Function Committee Task Force on the Principles of Community Engagement. Principles of Community Engagement. 2011. Accessed December 6, 2023. https://www.atsdr.cdc.gov/communityengagement/pdf/PCE_Report_508_FINAL.pdf
7. American Public Health Association. Public Health Code of Ethics issue brief. Accessed July 25, 2026. https://www.apha.org/about-apha/apha-code-of-ethics
8. Vangen S, Huxham C. Nurturing Collaborative Relations: Building Trust in Interorganizational Collaboration. The Journal of applied behavioral science. 2003;39(1):5-31. doi:10.1177/0021886303039001001
9. Watson J, van der Linden S, Watson M, Stillwell D. Negative online news articles are shared more to social media. Scientific reports. 2024;14(1):21592. doi:10.1038/s41598-024-71263-z
10. Altheide DL, Michalowski RS. Fear in the News: A Discourse of Control. Sociological quarterly. 1999;40(3):475-503. doi:10.1111/j.1533-8525.1999.tb01730.x
11. McGill I, Brockbank A, Yorke M. The action learning handbook: powerful techniques for education, professional development and training. Studies in higher education. 2005;30(2):229-231.