Relational trust in outreach with women experiencing street-involvement in British Columbia, Canada: a qualitative study

Women who experience street-involvement are severely underserved in health care. Outreach can address this service gap, but little is known about what constitutes gender-appropriate and effective outreach worker-client relationships in this context. To explore the relational attributes of outreach, qualitative interviews were conducted with women (n = 19) enrolled in a pilot study (2017–2020) aimed at designing a gender-specific outreach program in British Columbia and with outreach staff (n = 8). Data analysis focused on women’s experiences, supplemented by outreach staffs’ perspectives. Reflexive thematic analysis informed by central tenets of feminist relational theory and harm reduction was used. Trust was the overarching theme, conceptualized as a relational, dynamic, and iterative process co-constructed over time. Eight interrelated domains of trust were identified: commitment; consistency; professional boundaries; privacy and confidentiality; empathy; non-judgement; expert knowledge; and “doing with not for”. Relational trust integrated understandings of the impact of gender-based violence, poverty, and drug-related criminalization. When enacted, trust facilitated participants’ engagement with outreach workers, improved care access, and advanced women’s capacities to navigate their general and substance use health care more independently. Trust is a critical element of health and social service delivery and distrust remains a major barrier. These findings advance new conceptualizations of trust that consider the interplay between interpersonal and structural features of care delivery such as stigma, discrimination, colonization, ableism, and classism. Outreach programs emphasizing trust-building as a dynamic and socio-structurally embedded process hold significant potential for improving care engagement among women who are chronically underserved. Retrospectively registered on February 25, 2025 (NCT06854770) with ClinicalTrials.gov.