###### Abstract  
(1) Background: Community health workers (CHWs) are an essential public health workforce defined by their trustful relationships with vulnerable citizens. However, how trustful relationships are built remains unclear. This study aimed to understand how and under which circumstances CHWs are likely to build trust with their vulnerable clients during the COVID-19 pandemic. (2) Methods: We developed a program theory using a realist research design. Data were collected through focus groups and in-depth interviews with CHWs and their clients. Using a grounded theory approach, we aimed to unravel mechanisms and contextual factors that determine the trust in a CHW program offering psychosocial support to vulnerable citizens during the COVID-19 pandemic. (3) Results: The trustful relationship between CHWs and their clients is rooted in three mental models: recognition, equality, and reciprocity. Five contextual factors (adopting a client-centered attitude, coordination, temporariness, and link with primary care practice (PCP)) enable the program mechanisms to work. (4) Conclusions: CHWs are a crucial public health outreach strategy for PCP and complement and enhance trust-building by primary care professionals. In the process of building trustful relationships between CHWs and clients, different mechanisms and contextual factors play a role in the trustful relationship between primary care professionals and patients. Future research should assess whether these findings also apply to a non-covid context, to the involvement of CHWs in other facets of primary healthcare (e.g., prevention campaigns, etc. ), and to a low- and middle-income country (LMIC) setting. Furthermore, implementation research should elaborate on the integration of CHWs in PCP to support CHWs in developing the mental models leading to build trust with vulnerable citizens and to establish the required conditions. community health workers; primary healthcare; vulnerable populations; trust; COVID-19; realist evaluation; grounded theory +
Footnote †: journal: Journal of  
_Article_  
Understanding Trustful Relationships between Community Health Workers and Vulnerability Citizens during the COVID-19 Pandemic: A Realist Evaluation  
[1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] [33] [34] [35]  
Considerable evidence confirms that CHWs' role in enabling vulnerable communities to access care is underpinned by the trustful relationships with their clients [17; 18]. In addition, existing literature states that CHWs perceive 'building trust with the community' (beyond trust in health services) as a critical component of their practice [19; 20; 21; 22; 23; 24]. However, it remains unclear how these trustful relationships are built, or in other words, which mechanisms lead to the building of this trust. Trust, a complex, multifaceted notion, 'influences individuals' willingness to act based on others' words, motives, intentions, actions and decisions under conditions of uncertainty, risk or vulnerability' [25]. Social relations of trust are accepted as a core contributor to health systems' performance; a trust-based health system is grounded in cooperation, communication, and empathy, enabling the successful functioning of the health service [26]. Trust is a complex construct, of which the specific elements vary between settings and relationships. The conceptual framework by [PERSON] et al. [27] describes the interaction between workplace and patient-provider trust (see Figure 1). Workplace trust, defined as respectful and fair treatment in the workplace, is rooted in trust in the employing organization, the supervisor, and colleagues. Patient-provider trust is rooted first in interpersonal trust, in this case between a patient and CHW. Patient-provider trust is also rooted in institutional trust, the extent to which the CHW and patient can trust that the health system will support the CHWs to act in the patient's best interests.