Interview to Trisha Greenhalgh, author of the WHO document on narrative research for health sector

tgreenhalgh1-1Q. What is the importance of the document Cultural contexts of health: the use of narrative research in the health sector in your opinion?

TG. The document represents an important shift in the WHO’s thinking about evidence. Many of the issues the WHO seeks to address are what might be called “grand challenges”. Whilst the results of randomized trials, meta-analyses and large routinely collected quantitative datasets are crucial in addressing some aspects of these grand challenges, there is growing recognition that there are also different kinds of question for which we need a broader range of research methodologies. This was expressed very well recently in the introduction to a book on qualitative research methods in public health:

Over the last several decades, there has been increasing recognition of complex forces that contribute to the public’s health—factors that interact at individual, family, community, population, and policy levels. Social, economic, political, ethnic, environmental, and genetic factors all are associated with today’s public health concerns. Public health problems are complex, not only because of their multi-causality but also as a result of new and emerging domestic and international health problems. Consequently, public health practitioners and researchers recognize the need for multiple approaches to understanding problems and developing effective interventions that address contemporary public health issues. – Ulin PR, Robinson ET, Tolley EE. Qualitative methods in public health: a field guide for applied research. John Wiley & Sons; 2012, p. xiii.

Q. Why this attention to the research for narrative methods?

TG. As I explain in the monograph, “narrative truth” is a very different kind of truth from the logico-deductive truth of scientific evidence. A narrative (story) is a subjective version of events; it also has an intersubjective dimension – the storyteller’s dialogic (teller-listener or writer-reader) relationship with a real or imagined audience. Narrative is about making sense of what happens in our lives; conveying meaning and highlighting (or questioning the lack of) moral order. Let me give you an example. Hundreds of randomized trials have been undertaken of patient education in the management of type 2 diabetes. Educators emphasise the importance of “healthy behaviours” (taking exercise and restricting diet to certain healthy foods and small portions). We know that diabetes education works a little for some people but has limited efficacy in changing the behaviour of some people – especially those from certain cultural and social groups. Through narrative, we can find out what the suggested “healthy behaviours” actually MEAN to the target population. Sometimes, we find we are asking them to undertake social practices that have very negative cultural meaning (e.g. rejecting a gift, arguing with one’s mother-in-law, acting in an immodest way). Of course people resist pressure to follow such recommendations! Systematic attention to the cultural storylines that shape and constrain people’s actions will allow us to design better public health programmes with greater chance of success.

Q. Which are the main points of attention of this document?

TG. I think three key points. First, the point I made above about narrative being an important form of evidence that can complement and extend traditional forms of health evidence. Second, that narrative research is a broad church. A wide range of approaches can be used to capture cultural contexts through stories. They include the traditional clinical case study (especially when closely analysed from a scholarly perspective); sociological studies of the ‘illness narrative’ (usually captured through narrative interviews); more contemporary sociological studies of the multi-vocal narratives of online communities (typically captured by narrative analysis of website text); anthropologically-informed studies of cultural practices (using techniques such as ethnography and photo-elicitation); the construction of organisational or community case studies; and the study of the ‘storylines’ or meta-narratives that frame policy (using discourse analysis).  Key quality criteria for such research include measures to assure trustworthiness, plausibility and criticality. And third, that like all research, narrative research can be done well or badly.  People need to be trained in the methodology and quality standards of narrative research, because otherwise the research findings will not be valid. If WHO is going to use narrative research successfully to enrich its written reports and inform its future strategies, systematic attention must be given to capacity-building and researcher development.

We need to be wary of the mis-use of narrative research. Only last week, a group of homeopathic practitioners cited my work on narrative to claim that homeopathy “works”. Their line of reasoning was that if narrative research is a legitimate approach, then we don’t need randomized trials to evaluate the efficacy of a drug – we can just take individual patient stories. Of course, this is nonsense. To evaluate the efficacy of a drug you need a randomized controlled trial! This example illustrates why we need to pay careful attention to quality standards and to the need to match the research question to the appropriate methodology. If the research question is of the format “what is the meaning of….?”, narrative is likely to inform the answer. But if the question is a QUANTITATIVE one (“what is the effect size…?”), narrative is not the way to go.

Maria Giulia Marini

Epidemiologist and counselor in transactional analysis, thirty years of professional life in health care. I have a classic humanistic background, including the knowledge of Ancient Greek and Latin, which opened me to study languages and arts, becoming an Art Coach. I followed afterward scientific academic studies, in clinical pharmacology with an academic specialization in Epidemiology (University of Milan and Pavia). Past international experiences at the Harvard Medical School and in a pharma company at Mainz in Germany. Currently Director of Innovation in the Health Care Area of Fondazione ISTUD a center for educational and social and health care research. I'm serving as president of EUNAMES- European Narrative Medicine Society, on the board of Italian Society of Narrative Medicine, a tenured professor of Narrative Medicine at La Sapienza, Roma, and teaching narrative medicine in other universities and institutions at a national and international level. In 2016 I was a referee for the World Health Organization- Europen for “Narrative Method of Research in Public Health.” Writer of the books; “Narrative medicine: Bridging the gap between Evidence-Based care and Medical Humanities,” and "Languages of care in Narrative Medicine" edited with Springer, and since 2021 main editor for Springer of the new series "New Paradigms in Health Care."

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