Salience of Trust in Discussions and Recommendations of the United States’ COVID-19 Health Equity Task Force

Abstract

Objective:

The COVID-19 pandemic has further eroded trust in public health institutions across the United States. We examined the salience of trust in the federal government’s discussions and recommendations of the US COVID-19 Health Equity Task Force (HETF).

Methods:

We conducted a thematic analysis of publicly available HETF documents, including the executive order, 8 meeting minutes, and 2 final deliverables. Given that trust operates at multiple levels of the socioecological continuum, we used an interpretive analytic approach to our inquiry.

Results:

We found that several barriers, facilitators, and influencers to trust were discussed during HETF meetings but few were mentioned consistently across all documents. Trust was most frequently mentioned by individuals in the public comments section of HETF meetings, more so than HETF members or representatives of federal agencies. Public commenters comprised 52% of total mentions of trust. However, these mentions did not make their way into the final HETF deliverables, signaling a potential disconnect between insights from public commenters and HETF representatives.

Conclusions:

Our findings indicate that trust had limited prominence in HETF discussions and recommendations. To rebuild the public’s trust, it is imperative that the federal government, in collaboration with state and local partners, further develop actionable mechanisms to foster trust as a pillar of public health practice. By ensuring ethical principles are applied in decision-making and implementation, gaps in (mis)trust may be bridged, ultimately boosting the efficacy of public health emergency response.

The COVID-19 pandemic has challenged health and social services across the globe. In the United States, nearly 6.3 million hospitalizations and more than 1.1 million deaths have been attributed to COVID-19, with racial and ethnic minority groups disproportionately affected.^1,2 Amid rapid global communication, public health officials had the difficult task of communicating evolving health guidance, which left room for public misinterpretation and the spread of misinformation.^3,4 The pandemic intensified debates about evolving medical evidence and public policies (eg, face masking, quarantining, closing borders, public venues), prompting scrutiny of scientific experts, pharmaceutical companies, and elected officials.^5,6 Against a backdrop of increasing political polarization and a history of discriminatory public health practices,^7,8 trust in health care providers, scientific experts, and public health officials has been diminished.^9-14

Four years since the declaration of the COVID-19 pandemic, a persistent deficit in trust is evident.^4,15-17 This crisis has underscored the vulnerabilities in our public health systems and heightened the effect of systemic racism and health inequities on racial and ethnic minority groups.^2,18-22 Ethically informed practices for rebuilding and maintaining trust in public health are crucial, not only for responding to current and future health threats but also for confronting enduring inequities among people who have been historically marginalized, including those facing medical, social, or economic disadvantages. ²²

To address these challenges, Executive Order 13995 established the COVID-19 Health Equity Task Force (HETF) on January 21, 2021. ²³ The task force was part of a government-wide effort to identify and eliminate inequalities that led to disproportionately higher rates of COVID-19 among marginalized communities, including those who are Black, Latinx, Indigenous, or experiencing socioeconomic disadvantages, as compared with those who are predominantly White, have higher incomes, or live in more resourced communities. ²³ The present study explored the prominence of trust across 11 documents published by the HETF, guided by 3 research questions: (1) How was trust discussed and prioritized by the HETF? (2) How did discussions about trust evolve over time? and (3) What aspects of trust are absent from these discussions? We conclude by discussing trust-based ethical practices to enhance the effectiveness of public health emergency response.

Methods

Analytical Framework

Trust, defined as “assured reliance on the character, ability, strength, or truth of someone or something,” ²⁴ is a foundational element of public health practice. ²⁵ Strong and resilient trust connections between public health agencies and communities are essential for implementing health policies and fostering public confidence in safety measures such as vaccination and face masking.^6,9-11 Trust is dynamic and continuously influenced by social, economic, cultural, and political factors. ²⁶

Inextricably linked to trust is the principle of health equity, defined by Healthy People 2030 as “the attainment of the highest level of health for all people.” ²⁷ When there is trust, people are more likely to seek assistance, follow recommendations, and engage in preventive measures, which leads to improved health outcomes.^28,29 Therefore, trust acts as a mechanism for improving health and advancing equitable health systems.

Given that trust can operate across various levels of the socioecological model (eg, from interpersonal to institutional),^25,30 our research used an interpretive analytic approach. This approach acknowledges that policy decisions are not value free and that “dominant political values” influencing decision-making processes may be concealed from the broader public. ³¹ Analyzing mentions of trust within HETF documents helps us understand its relevance for this task force, its participating agencies, and external partners. Furthermore, we can recognize how trust dynamics intersect with socioecological factors such as community norms, institutional practices, and broader societal attitudes, providing a holistic view of how trust affects health equity initiatives within complex social systems.

Analytical Sample

Our analysis included 11 publicly available HETF policy documents, comprising 1 executive order, 8 meeting minutes, and 2 final deliverables, totaling 574 pages. These documents were published between January and October 2021 on the US Department of Health and Human Services, Office of Minority Health website. ²³ This project did not involve human data or participants; therefore, per the guidelines of the University of Massachusetts Institutional Review Board (IRB), IRB assessment was not necessary.

The HETF consisted of Chair Nunez-Smith, MD, MPH, and 12 nonfederal members who represented a “diversity of backgrounds and expertise, a range of racial and ethnic groups, and a number of important populations,” ²³ including young people, educators, health care providers, immigrants, individuals with disabilities, LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and other identities), public health experts, and rural communities. In addition, 8 federal ex-officio members, each representing a different federal agency, served on the task force and contributed their expertise to conversations. These 21 individuals (referred to hereinafter as HETF members) were assigned to at least 1 of 4 subcommittees (Communications and Collaborations; Health Care Access and Quality; Data, Analytics, and Research; Structural Drivers and Xenophobia) that met regularly to discuss and develop recommendations.

From February through October 2021, the HETF held 8 public meetings, which included the task force members, 21 subject matter experts invited by the HETF to provide context to discussions (referred to hereinafter as meeting guests), and 70 public commenters representing either themselves or an organization. These sessions covered health equity topics such as vaccine access and distribution, COVID-19 outcomes, and the influences of social drivers on pandemic vulnerability. The HETF held additional subcommittee meetings and working sessions during this time, although their minutes were not publicly released. However, key points from these discussions were incorporated into the meeting minutes. By October 2021, the HETF concluded its series of public meetings and published 2 final deliverables that outlined action steps to integrate health equity considerations into pandemic response and recovery efforts. ²³

Content Analysis

Our thematic analysis used both inductive and deductive approaches to develop and refine our codebook, supported by ongoing data interpretation and reflection. ³² We began by conducting a comprehensive review of the documents to identify trust-related terms. We then compiled a concise list of search terms derived from the root term trust, ²⁴ including trust, confidence, mistrust, distrust, trustworthy, and trust building (Supplemental Table 1). ³³ Using these terms, we identified relevant sections of text within the documents and conducted a detailed analysis of each section. Using NVivo version 14 (Lumivero), we organized the data through a systematic coding process. First, we conducted open coding of each section of text to highlight relevant concepts, followed by axial coding to categorize them into broader categories and subcategories. Finally, we applied selective coding to combine subcategories into overarching themes while also tracking the frequency and order of keywords and extracting representative quotes. Our primary data source for code generation was the 8 sets of meeting minutes, organized into 3 overarching themes: barriers, facilitators, and influencers of trust in public health. We continuously cross-referenced themes by comparing meeting minutes with coded sections of the executive order and final deliverables.

Results

Executive Order

In the Executive Order, trust was mentioned twice, particularly when calling on agencies to engage in equitable pandemic response through various strategies, including “An outreach campaign to promote vaccine trust and uptake among communities of color and other underserved populations with higher levels of vaccine mistrust due to discriminatory medical treatment and research, and engage with leaders within those communities.” ²³ This section also recognized present-day racism and discrimination, along with their historical effects on medical mistrust.

Meeting Minutes

In total, trust was directly mentioned 107 times across the 8 sets of minutes, with public commenters contributing to 52% of these mentions (eTable 2 in the Supplement). Further analysis of these documents revealed 3 recurring themes: barriers to trust, facilitators of trust, and influencers of trust in public health.

Barriers to Trust

Throughout the HETF meetings, participants mentioned barriers to trust several times (Table 1), often with a focus on historical injustices and the marginalization of populations during the COVID-19 pandemic. These barriers were frequently discussed in the context of present-day racism and discrimination, as seen in the rise in xenophobia against Asian American people. For example, the meeting minutes noted, “Inequities in vaccine rollouts have been compounded by long-standing inequitable practices in medical and public health institutions that impede access and reduce trust” (Meeting guest, meeting minutes #1). ²³

Table 1.

Mentions of barriers to trust across all COVID-19 Health Equity Task Force documents released between January and October 2021 ^a

Barriers to trust	Mentions of barriers to trust from the meeting minutes b
Accessibility	I believe that the Health Equity Task Force will build public trust without inadvertently fostering health inequities. . . . To this end, I recommend the following initiatives: limit or eliminate the need to preregister for COVID-19 testing and vaccination services. The digital divide, particularly among the at-risk aging community, is contributing to barriers with accessing services. (Public commenter, meeting minutes #1)
History	[D]eeply rooted distrust in government stems from our nation’s long history of systemic racism. (Meeting guest, meeting minutes #6)
	There are long-standing concerns in these communities, and it will take relationships and trust-building in order to bring these communities where they should be. (Public commenter, meeting minutes #6)
Medical mistrust	For many communities with mistrust of medical providers, safety-net providers and, specifically, reproductive health providers have become the most trusted source of care. (Public commenter, meeting minutes #2)
Politicization	The elevation of politics over science led to diminished trust in the health care system and willingness to comply with evidence-based measures to combat the spread of the virus. (Task force member, meeting minutes #6)
Poor infrastructure	The general lack of a timely, reliable data dashboard at the STLT [state, tribal, local, and territorial] levels as well as the absence of standardized, real-time threat information-sharing, case investigation, and contact-tracing data has hindered an effective and trusted special pathogens response. (Task force member, meeting minutes #6)
Present-day racism and discrimination	Systemic racism and a lack of trust in the criminal justice system led to fear, uncertainty, and underreporting of interpersonal violence, including hate crimes, in marginalized and minoritized communities. (Task force member, meeting minutes #6)
	[X]enophobia that has led to individuals fearing for their safety. One way to combat this safety issue is to engage trusted messengers and gatekeepers in the community in the form of community health workers and community-based organizations. (Meeting guest, meeting minutes #2)
Workforce challenges	The lack of diverse providers who reflect the communities they serve is compounded in health professional shortage areas and has led to a lack of confidence in the health care system across these communities. (Task force member, meeting minutes #6)
	Approached by a trusted physician and asked about the enrollment into these trials. (Public Comment, meeting minutes #8)

^aThe task force was part of a government-wide effort to identify and eliminate inequalities that led to disproportionately higher rates of COVID-19 among marginalized communities. The present study explored the prominence of trust across 11 documents published by the Health Equity Task Force, including 1 executive order, 8 meeting minutes, and 2 final deliverables. ²³

^bOne quote per participant (ie, task force member, meeting guest, or public commenter) is provided as appropriate. Not all respondents mentioned trust in each of the 7 domains.

Participants also voiced concerns about deficiencies in public health infrastructure that negatively affect trust, such as poor data collection and data use strategies that overlook groups marginalized by systemic inequities, including Black, Latinx, Indigenous, LGBTQIA+, and low-income populations. These deficiencies can perpetuate disparities by failing to capture accurate data on their needs and experiences, further eroding trust. They also highlighted the lack of federal guidance and partnership during the pandemic response, which resulted in disjointed messaging across federal, state, and local health agencies. One HETF member said in the meeting minutes, “Public health infrastructure often lacks the knowledge and relationships necessary to engage with marginalized communities in a culturally and linguistically responsive manner and build trust in the vaccine deployment” (HETF member, meeting minutes #2). ²³

Workforce challenges were also seen as barriers to trust, including health care provider shortages and the lack of racial and ethnic diversity among health care professionals, who often do not represent the communities they serve.

Facilitators of Trust

Participants mentioned several facilitators of trust (Table 2). Many of these facilitators extended beyond the pandemic response, emphasizing people-centered approaches to public health planning that are community based and equity focused, with particular attention to historically marginalized voices. One meeting guest noted, “center and formally structure the people and ideas of those most historically marginalized in preparedness and response systems and efforts and restore trust in public health” (meeting guest, meeting minutes #6). ²³

Table 2.

Mentions of facilitators of trust across all COVID-19 Health Equity Task Force documents released between January and October 2021 ^a

Facilitators of trust	Mentions of facilitators to trust from the meeting minutes b
Acknowledge history	Build public trust without inadvertently fostering health inequities by addressing the needs of Americans through a lens of acknowledging the hurts of COVID-19. (Public commenter, meeting minutes #1)
Address misinformation	Multipronged public–private awareness, education, and communications campaign focused on clarifying misinformation associated with vaccines and rebuilding trust in government will be strengthened and informed by stakeholders from diverse communities. (Task force member, meeting minutes #4)
Employ people-centered approaches	Incentivize equity in health care systems by encouraging data- and community-driven approaches focused on decreasing distrust in the health care system. (Task force member, meeting minutes #6)
	Asian American researchers and community groups worked closely with their local health departments and with Asian American–serving FQHCs to increase the number of vaccinations available at places that Asian Americans trusted and felt safe going to. (Public commenter, meeting minutes #6)
Enhance health care provider education	I believe that the Health Equity Task Force will build public trust without inadvertently fostering health inequities. . . . To this end, I recommend the following initiatives: [health care] provider education that equips providers with tools to engage patients in a restorative/trauma-informed approach to reduce retraumatizing patients at the point of care. [Public commenter, meeting minutes #1)
Improve accessibility (physical and/or informational)	Achieving equity will also require culturally responsive messaging that builds trust among communities disproportionately affected by COVID-19. (Task force member, meeting minutes #1)
	FQHCs and other federally funded organizations need access to on-site interpreting at testing and vaccination centers to inform patients, meet health care needs, and build trust. (Public commenter, meeting minutes #1)
Strengthen infrastructure	The federal government should coordinate with relevant associations (ASTHO, NACCHO, NGAs) to distribute information and leverage its coordinated communications campaign while also strengthening knowledge of who are trusted providers and expanding the number of community members available to distribute vaccines to marginalized communities. (Task force member, meeting minutes #2)
	Create a unified, national response that may involve directing a lead agency to work in close collaboration with trusted state [and] local leaders and trusted private sector entities. (Task force member, meeting minutes #6)

Abbreviations: ASTHO, Association of State and Territorial Health Organizations; FQHC, federally qualified health center; NACCHO, National Association of City and County Health Officials; NGA, nongovernmental agency.

^aThe task force was part of a government-wide effort to identify and eliminate inequalities that led to disproportionately higher rates of COVID-19 among marginalized communities. The present study explored the prominence of trust across 11 documents published by the Health Equity Task Force, including 1 executive order, 8 meeting minutes, and 2 final deliverables. ²³

^bOne quote per participant (ie, task force member, meeting guest, or public commenter) is provided as appropriate. Not all participants mentioned trust in each of the 6 domains.

Another frequently cited facilitator to trust was strengthening public health infrastructure through increased federal leadership, coordinated messaging strategies, and improved data practices. In addition, participants stressed the importance of fostering strong partnerships among federal agencies and community-based organizations. One meeting guest said, “More federal-level guidance supported at state and local levels will result in fewer kinks in trust and at the ground level from the public as to why changes are being made” (meeting guest, meeting minutes #6). ²³

Participants also emphasized the need for greater physical and intellectual accessibility of COVID-19 resources to ensure care that is culturally and linguistically tailored and appropriate for individuals with varying physical, sensory, or cognitive abilities. For example, participants highlighted the importance of improving digital literacy among older adult populations to enhance access to online health services and strengthen trust.

Influencers of Trust

Influencers of trust are recognized for their ability to guide others in placing trust in public health (Table 3). Participants identified community health workers, peer specialists, pharmacists, and other health care providers as the most trusted sources of guidance throughout the pandemic. At the community level, participants mentioned schools, federally qualified health centers, local health departments, and religious organizations as key institutions capable of influencing trust. At the institutional level, government entities such as safety-net agencies, the US Department of Health and Human Services, and members of the HETF were also seen as important trust influencers.

Table 3.

Mentions of influencers of trust across all COVID-19 Health Equity Task Force documents released between January and October 2021 ^a

Influencers of trust	Mentions of influencers of trust from the meeting minutes b
Health care providers	Highlighted the importance of the trusted voices such as certified peer specialists who play a key role as both messengers and individuals with lived experience serving on clinical teams. (Task force member, meeting minutes #2)
	CHWs serve as trusted messengers because they have the lived experience of the community and the experience of the health care setting, providing contextualization for other health care workers. (Meeting guest, meeting minutes #2)
	For many communities with mistrust of medical providers, safety-net providers and, specifically, reproductive health providers have become the most trusted source of care. (Public commenter, meeting minutes #2)
	Many women of reproductive age place great trust in their reproductive health providers. In fact, one study found that women rate their family planning providers as higher than general practitioners on a number of measures, including listening, cultural understanding, and shared decision-making. (Public commenter, meeting minutes #2)
	Engage trusted messengers and gatekeepers in the community in the form of community health workers and community-based organizations. (Meeting guest, meeting minutes #2)
Messengers (nonspecific)	There are valid and varied reasons for distrust of health care among people of color with disabilities. For this reason, a trusted messenger is needed to ensure that equitable health care systems gain the trust of individuals in need. (Meeting guest, meeting minutes #2)
	Continue to use trusted messengers to talk about prevention, the importance of getting a COVID-19 vaccine, and where and how to obtain one. (Public commenter, meeting minutes #1)
Community-based organizations and institutions	[A]s schools prepare for students to return to in-person learning, governments and organizations are considering engagement strategies that can rebuild trust and re-engage families with support, meals, and nutrition education; she stressed that COVID-19 infection, safety, and vaccination information could be included in these packages. (Task force member, meeting minutes #2)
	As trusted members of their communities and one of the most easily accessible health care providers, pharmacies are able to help address the specialized needs of those with limited mobility. (Public commenter, meeting minutes #2)
	[P]artnering with trusted faith and community organizations that are already providing aid to sites. (Task force member, meeting minutes #4)
	[T]he Asian American researchers and community groups worked closely with their local health departments and with Asian American–serving FQHCs to increase the number of vaccinations available at places that Asian Americans trusted and felt safe going to. Also, it’s extremely important to involve them in identifying sites. (Public commenter, meeting minutes #4)

Abbreviations: CHW, community health worker; FQHC, federally qualified health center.

^aThe task force was part of a government-wide effort to identify and eliminate inequalities that led to disproportionately higher rates of COVID-19 among marginalized communities. The present study explored the prominence of trust across 11 documents published by the Health Equity Task Force, including 1 executive order, 8 meeting minutes, and 2 final deliverables. ²³

^bOne quote per participant (ie, task force member, meeting guest, or public commenter) is provided as appropriate. Not all participants mentioned trust in each of the 3 domains.

Participants also mentioned other “trusted voices” or “trusted messengers” without specifying who they were. One participant noted, “It is critical for the task force to continue to encourage vaccine distribution models that center meeting people where they’re at and leveraging trusting messengers” (public commenter, meeting minutes #2). ²³

Final Recommendations and Implementation Plan

The HETF developed 316 recommendations, 12 of which directly mentioned trust (eTable 3 in the Supplement). Eight of the 12 recommendations were consolidated under communications and collaboration, highlighting the need to enhance access to culturally relevant information and services, improve communication campaigns, and build strong community partnerships. The remaining 4 recommendations were split among structural drivers and xenophobia, and health care access and quality, emphasizing expanded health care access and advocating for equitable data collection practices (eTable 4 in the Supplement). From the initial 316 recommendations, the HETF prioritized 55 recommendations, 5 of which directly mentioned trust. Three recommendations were categorized as communications and collaboration and 2 recommendations as health care access and quality. Two recommendations included action steps to guide future work.

In addition, the HETF recommended that public trust be considered a key performance indicator by the federal government when establishing evaluation metrics for COVID-19 interventions. However, the single-item question suggested as a metric asked about trust in the federal government overall (ie, it does not measure public trust at other levels of governance or in public health agencies specifically). ³⁴

Continuum of Trust

Improvements to public health infrastructure stood out as the only construct consistently discussed in relation to trust (Table 4). Hence, 4 key concepts were directly connected to (1) increase federal guidance and national emergency response standards, (2) implement joint messaging for effective communication across all levels of governance, (3) improve data collection and data use processes at all levels of governance, and (4) develop robust intergovernmental and community-based partnerships. These concepts highlight the critical role of trust in advancing effective public health initiatives and underscore the foundational importance of robust infrastructure in supporting these efforts. However, the HETF materials offer limited guidance on how to effectively address these needs. Detailed strategies to fund trust-building efforts were also absent from the HETF meetings and the final deliverables.

Table 4.

Mentions of barriers to, facilitators of, and influencers of trust across all COVID-19 Health Equity Task Force documents released between January and October 2021 ^a

Mentions of trust	Executive order	Meeting minutes	Final deliverables
			General recommendations	Prioritized recommendations
Barriers to trust
Accessibility		✓	✓	✓
History b		✓
Medical mistrust b	✓	✓
Politicization		✓	✓	✓
Poor infrastructure	✓	✓	✓	✓
Present-day racism and discrimination b	✓	✓
Workforce challenges		✓
Facilitators of trust
Acknowledge history		✓
Address misinformation		✓	✓	✓
Employ people-centered approaches		✓	✓	✓
Enhance health care provider education		✓
Improve accessibility		✓	✓	✓
Strengthen infrastructure	✓	✓	✓	✓
Influencers of trust
Health care providers b		✓
Community-based organizations and institutions		✓	✓	✓
Messengers (nonspecified)		✓	✓	✓

^aThe task force was part of a government-wide effort to identify and eliminate inequalities that led to disproportionately higher rates of COVID-19 among marginalized communities. The present study explored the prominence of trust across 11 documents published by the Health Equity Task Force, including 1 executive order, 8 meeting minutes, and 2 final deliverables. ²³

^bNot mentioned in reference to a recommendation but mentioned as a Spotlight story or under Case for Change in the final report and recommendations (page 11; 19-23; 54).

Discussion

This study provides a novel examination of the prominence of trust across HETF policy documents. Our findings indicate strong alignment between HETF trust-related discussions and the core values of the American Public Health Association’s (APHA’s) 2019 Public Health Code of Ethics (hereinafter, Code of Ethics), ²² particularly in promoting transparency, accountability, and respect for diverse values, all of which are essential elements for building trust. In fact, the principle of health justice and equity in the Code of Ethics ²² resonates directly with the HETF’s mission to address health inequities caused or exacerbated by the COVID-19 pandemic. ²³ Despite this apparent alignment, the HETF recommendations seem to lack operational details to effectively address these inequities. To rebuild trust, actionable tools and resources are needed to enhance preparedness for future public health crises.^35-38 The lack of detailed guidance may have important consequences for public health preparedness. Without it, public health agencies risk undermining efforts to rebuild trust, particularly among groups that have been historically marginalized because of systemic racism and socioeconomic inequities, thereby hindering effective future emergency response efforts.

Our analysis revealed how little trust-building initiatives were developed by the HETF compared with other topics (eg, funding for health care improvements). Trust-related recommendations (eg, a communication campaign to build trust) lacked detailed steps or funding plans. In contrast, the Code of Ethics provides practical actions related to transparent and timely reporting to community partners (domain 4.2.7) and the establishment of ethics committees (domain 4.11.7) to foster trust. ²² We found no reference to the Code of Ethics in the HETF documents.

Our study also found that trust was most frequently mentioned by public commenters (eTable 1 in the Supplement), but many of the trust-building mechanisms they proposed were not fully reflected in the HETF’s final deliverables. For example, key suggestions consistent with the Code of Ethics, such as transparent communication or community-led solutions (eg, engaging trusted community members for restorative criminal justice initiatives), were not incorporated into the final deliverables. This disconnect highlights the need for better integration of public input from community leaders, advocacy organizations, health care providers, and representatives from medically underserved groups (eg, racial and ethnic minority groups, families with low incomes). ²² Strong community partnerships and inclusive communication are essential for building trust, as emphasized in both the HETF documents and the Code of Ethics. To leverage these insights, federal agencies must adopt a proactive approach, develop comprehensive blueprints with clear benchmarks, and include robust funding strategies across community, institutional, and policy domains to strengthen public health systems. These efforts should go beyond infrastructure to address other essential public health services. ³⁹

Limitations

This study had several limitations. First, our analysis was constrained to the 11 documents that were publicly available at the time our study was conducted. We did not include meeting presentations or recordings (available for some, but not all, HETF meetings). Future research may benefit from including these supplementary materials. Second, our study focused on explicit mentions of trust, which may have limited our ability to capture underlying references to trust, such as the connection between trust and transparency. ⁴⁰ For example, while we identified several mentions of transparency, none were explicitly linked to trust. Future research should expand the scope of the analysis to capture implicit mentions of trust. Third, other meeting materials, such as subcommittee meeting minutes and the detailed processes for creating and refining recommendations, were not publicly available. These materials may have offered further insights into trust-related discussions. Fourth, the scope of the HETF’s authority may have been constrained to what the task force could recommend, which could explain why certain trust-related themes were absent from final deliverables. Fifth, our analysis could not shed light on HETF’s processes that led to limited community representation. Future research should explore how community inclusion in federal public health initiatives can increase trust and improve health equity. Lastly, our qualitative research was subject to potential bias, as interpretive coding of data can be influenced by our preconceptions. Our team, which consisted of 2 researchers with diverse public health experiences spanning policy, research, and practice, had no prior involvement in the HETF, neither as members nor as public commenters.

Conclusions

The COVID-19 pandemic challenged public trust in US health agencies ⁹ and shed light on a public health infrastructure that has been chronically underfunded.^36,37 An urgent need exists to reinvest and rebuild public health infrastructure, characterized by multilevel and intersectional collaboration.^41,42 Our findings highlight long-standing issues of (mis)trust that continue to affect public health preparedness today.^18-21 Although the HETF presented an opportunity to enhance trust in public health initiatives, its recommendations seem to lack sufficient depth, which may hinder progress in addressing health inequities. ²⁷

As stewards of the public’s trust, public health agencies and their partners must prioritize efforts to foster trust ³⁸ in an era increasingly challenged by uncertainty and misinformation.^9,43 Drawing on insights from HETF documents, the Code of Ethics, and additional examples of equity-centered initiatives,^22,23,28,44 we can translate intentions into actions. ² By formalizing inclusivity processes and amplifying marginalized voices, we can build trusted, resilient, responsive, and equitable health systems.