From Linchpin to Lever — Part 1: Measuring Trust in Public Health

In March, we demonstrated that local health departments (LHDs) may be the linchpin for rebuilding trust in public health. The case is simple. LHDs are now the most trusted type of public health organization, they have rebuilt trust beyond pre-pandemic levels, and their trust rests on something different.^1,2​ It is built on relational foundations such as care, hard work and presence in the community, rather than scientific prestige. We ended with a strategic move — measure trust and build it iteratively through quality improvement processes

But a linchpin only holds a system together. For LHDs to serve as a lever to build trust, public health leaders must know how much trust there is and whether what they are doing is strengthening trust. That requires measurement. But there isn’t a systematic way to do this now. However, there are decades of investment in surveillance systems like the Behavioral Risk Factor Surveillance System (BRFSS) and thousands of community health assessments (CHAs) that could help with that. This post takes up the first half of our strategic move; how can we measure trust in public health?

What Does It Mean to Trust?

Trust is one of those words that feels self-evident until you try to measure it. Because it is so familiar, we rarely stop to ask what it actually means. Researchers have examined this issue and found that trust can be defined as a psychological state in which someone is willing to be vulnerable based on positive expectations of how another party will behave.^3​​​ Other research shows that there are four common factors that impact this.​^4​

• Competence asks whether someone can actually deliver on their promise. We cannot form positive expectations about someone we believe is incapable of delivering.
• Benevolence gets at someone’s motive. Do they have good intentions for us or are they only self-interested? It is difficult to be vulnerable with someone we suspect may use that vulnerability against us.
• Integrity refers to honesty, fairness and adherence to defensible principles. We can only extend positive expectations to someone we believe will act on principle even when it is inconvenient or costly for them.
• Predictability refers to the consistency and regularity of behavior over time. It is difficult to form positive expectations about someone whose behavior shifts, especially under pressure.

These factors matter for rebuilding trust in public health because trust in one factor can erode while others hold. A health department can be seen as competent but self-interested, well-intentioned, but unpredictable. Measuring trust overall can tell us whether trust is rising or falling. It cannot tell us why, or where to focus our energy to change it. That requires measuring the dimensions separately.

How Has Trust in the Public Health System Been Measured?  

Researchers have been studying trust in the public health system for decades, with that work accelerating since the COVID-19 pandemic. The result is a growing catalogue of measurement approaches, including validated scales, national tracking polls and primary studies. To take stock of what exists, we reviewed nine sources and documented the questions they used to measure trust in the public health system (Figure 1). We captured questions focused on the overall function of the public health system, as opposed to specific actions, such as responding to the COVID-19 pandemic or providing information about vaccines.

Several features of these questions strengthen their ability to measure trust. First, most questions asked about a specific agency, such as the Centers for Disease Control and Prevention (CDC), state health departments or local health departments. Specifying the agency of interest may improve measurement since people may not understand what is included in the general public health system or may have differing views on different agencies. Second, questions took a variety of approaches to measure trust. They examined overall trust, factors influencing trust, similar to those described in the previous section, as well as concepts adjacent to trust such as value or familiarity. The questions identified in our review provide public health leaders with options for developing a system to measure trust.

However, there are some limitations with this catalogue. Some dimensions are covered infrequently or not at all. Predictability is nearly absent across the sources, and benevolence is only partially addressed. These gaps are worth closing, given that inconsistent messaging was on of the most commonly cited drivers of eroding trust during the pandemic.​

How We Can Measure Trust in the Public Health System  

So how can we build a measurement system? We need one that can provide local estimates consistently across jurisdictions, while also providing the flexibility needed to measure the distinct factors that may be driving trust in separate localities.

BRFSS is a strong vehicle for consistent measurement. BRFSS collects data in all 50 states, Washington D.C. and three U.S. territories. More than 400,000 interviews are completed each year, making it the largest continuously conducted health survey system in the world.​^5​​ That scale is what allows for BRFSS data to be aggregated down to the local level for many cities and counties across the U.S. This gives local health departments data that they can act on. Trust belongs on this platform because it shapes the behaviors BRFSS already tracks — vaccination, adherence to preventive measures and engagement with public health guidance.​⁶​

Two items from this catalogue stand out as strong candidates for measuring overall trust through BRFSS. Both focus on the full spectrum of public health functions rather than a single activity like issuing recommendations, and both name a broad health outcome without defining it too narrowly. Adapted versions are shown below.

“[State Health Department/Local Health Department] does its best to improve the health of [the population of interest].”

Adapted from Shea’s distrust scale.^7​

“[State Health Department/Local Health Department] does everything it should to protect the health of [the population of interest].”

Adapted from Holroyd’s lead item.^8​

Adding new measures to BRFSS is an involved process and not something any single state or health department can do alone. A more immediate path may be through state-added questions, which allow individual states to include supplemental items on their version of the survey. Kansas and other states could begin measuring trust this way, building a local evidence base while making the case for broader national adoption over time.

BRFSS can track whether trust is rising or falling. It cannot tell us why. That is where CHAs come in. Measures of trust could be incorporated into CHAs for this reason. CHAs are not an occasional exercise. They are required every five years for PHAB accreditation, and the IRS requires every nonprofit hospital to conduct its own community health needs assessment (CHNA) every three years. CHAs and CHNAs are being conducted on a rolling basis in nearly every community in the country, creating exactly the kind of recurring, locally rooted infrastructure needed to measure trust and rebuild it at the local level. CHAs and CHNAs could allow public health leaders to examine the specific dimensions of trust described earlier, including competence, benevolence, integrity and predictability, through both surveys and focus groups.

Moving From Linchpin to Lever

The tools exist. BRFSS can be used to establish a consistent baseline for trust across jurisdictions. CHAs can diagnose where trust is strong, where it is eroding, and why. The next step is to put the system to work so local health departments can leverage their trust advantage. But measurement alone will not rebuild trust. In part 2, we examine how quality improvement processes can turn that knowledge into action, and how local health departments can use what they learn to build trust for more ambitious goals.

Figure 1: Selected Instruments and Survey Items for Measuring Trust in Public Health

Nine instruments and surveys used to measure trust and related constructs in the public health system were reviewed. Information from each is abstracted here. Questions were reproduced verbatim from the source. Response options were captured in a separate column. If a question included multiple public health agencies, this was compacted in brackets and itemized in the notes column. Domain labels in plain text are taken from the source. If a source did not assign a domain label to a question, KHI assigned a label based on its wording. These are italicized and marked with an asterisk.  

References

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5. Behavioral Risk Factor Surveillance System. Accessed June 19, 2026. https://www.cdc.gov/brfss/index.html
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