Building trust through collaboration: a mixed-methods evaluation of San Francisco’s Pregnancy Village model of cross-sector care delivery

Historical injustices, systemic racism, unequal healthcare access, and provider bias have fostered mistrust in healthcare institutions. Cross-sector collaborations between healthcare institutions and community-based organizations (CBOs), such as San Francisco’s Pregnancy Village (PV) model, could potentially build institutional trust within minoritized communities. This study primarily aimed to examine trust in PV, with secondary aims exploring participant perceptions of trust in the health system and CBOs, including their views on the health system’s involvement in PV. Between July 2021 and June 2022, we conducted a convergent, mixed-methods study involving 116 survey participants (57 pregnant/postpartum individuals and 59 family members) and 18 semi-structured interviews (13 pregnant/postpartum people and five family members). Trust was assessed quantitatively using a seven-item scale (scores standardized to 0-100) adapted from the Public Healthcare System Trust Scale and qualitatively with open-ended questions. We performed univariate, bivariate, and multivariate analyses of the quantitative data and thematic analyses of the qualitative data. The mean trust in PV score was 85.9/100 (SD = 18.9), with lower trust among Latine participants (β = -12.2, 95% CI: -21.6, -2.9), those with prior preterm birth (β = -11.0, 95% CI: -20.5, -1.4), and those experiencing food insecurity (β = -12.4, 95% CI: -21.0, -3.8). Qualitative findings revealed that trust in both the health system and CBOs was shaped by receipt of person-centered care. Trust in CBOs was attributed to their focus on holistic care, relatability, and responsiveness to community needs. Distrust in the health system was shaped by experiences of racism and neglect. Participants held mixed views on the health system’s role in PV; some highlighted its ability to meet community needs, while others voiced skepticism due to ongoing structural racism and inequities in care. Participants perceived PV as trustworthy, with mixed views of the health system, generally positive perceptions of CBOs, and overall support for the health system’s involvement in PV despite lingering concerns regarding structural racism. These findings underscore PV’s unique role in bridging sectors and highlight that sustained, community-guided collaboration is essential to building trust and advancing more equitable cross-sector care.