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1. REFLECTIONS
A research-based narrative assignment for global health
education
Raphael Lencucha
Received: 27 September 2012 / Accepted: 23 January 2013 / Published online: 2 February 2013
Springer Science+Business Media Dordrecht 2013
Abstract There is a paucity of research on novel approaches to classroom-based global
health education despite the growing popularity of this topic in health professional curricula.
The purpose of the following paper is to (1) describe the rationale underlying the use of a
research-based narrative assignment for global health education, and (2) describe the results
from an evaluation of this assignment with undergraduate public health students, including
its strengths and limitations. The research-based narrative assignment was implemented during
an introductory global health course for third and fourth year undergraduate public health
students. The students(n = 20)completedthe assignment and thenwrotea two-page reflection
about their experience. The author analyzed these student reflections using open coding and
thematic analysis. Four salient themes were identified from the written reflections including (1)
the challenge of representing persons, (2) the opportunity to develop an engaged understanding
of the chosen issue, (3) seeing the bigger picture or integrating the various determinants into a
coherence story, and finally (4) the struggle to create a compelling story that was based on
accurate information. The analysis of the students’ reflections provides important insights into
their experience conducting this assignment, particularly in highlighting key strengths and
challenges of this approach. These strengths and challenges are discussed.
Keywords Curriculum development Curriculum evaluation Global health education
Narrative
Narrative writing is an art form, much like music or the visual arts. Stories touch into
the humanity of the author and resonate with the humanity of the reader. A narrative
research paper is written in the form of a story, describing the sequence of fictional or
non-fictional events incorporated with scientific evidence. (Participant 12)
In 2010, my aunt recommended a book called ‘‘What is the what?’’ by Dave Eggers. This
gripping account of one boy’s heart-breaking journey from the turmoil of Southern Sudan
to the United States of America invigorated a renewed craving to ‘‘live’’ alongside my
R. Lencucha ()
Faculty of Health Sciences, University of Lethbridge, 4401 University Drive, Lethbridge, AB, Canada
e-mail: raphael.lencucha@uleth.ca
123
Adv in Health Sci Educ (2014) 19:129–142
DOI 10.1007/s10459-013-9446-8

2. fellow global citizens. After completing this novel I read a sequence of fictionalized
accounts of life in other countries from Iran to Ethiopia, Spain to Columbia. I became
convinced of the power of literature to transport the mind to new contexts while engaging
the emotional and intellectual faculties. I now begin my introductory global health course
with a discussion of the students’ favorite books. My desire is to instill in these students an
appreciation for the power of literature as a tool for global health education. In the winter
of 2012 I developed what I call a ‘‘research-based narrative assignment’’ which serves as
the major assignment in my introduction to global health course. This assignment was
prompted not only by my belief in the power of literature as a learning tool for global
health education but also my desire for the students to engage in an assignment that is both
comprehensive and emotionally impactful.
I have been teaching global health courses for over 3 years and have assigned traditional
research papers until 2012. These papers are no doubt useful learning tools for the students
to delve into the evidence surrounding a particular global health issue. My students have
chosen a wide variety of issues to research including HIV/AIDS in Africa, post-disaster
relief and cross-border infectious disease transmission and control. What I felt was missing
from these ‘‘standard’’ research papers was (1) an empathetic account of the lived expe-
rience of a ‘‘global health issue’’ and (2) an analysis and presentation of the complexity of
such an issue. This feeling is perhaps similar to the motivation underlying the emergence
of narrative ethics in the health professions. This ethical approach brings to the forefront
the storyteller while exploring an ethics of inquiry, where the story is ‘‘challenged and
modified in the process of … ‘‘narrative reflective equilibrium’’’’ (McCarthy 2003). The
purpose of the following paper is to (1) describe the rationale underlying the use of a
research-based narrative assignment for global health education, and (2) describe the
results from an evaluation of this assignment with undergraduate public health students,
including its strengths and limitations.
Global health education
Health professionals continue to call for more global health content during their training
and education (Drain et al. 2007). Numerous health professional schools have heeded this
call and have developed global health electives, majors and/or credited international
clinical opportunities. The desire for more global health training along with the greater
salience of global health issues has prompted Drain and colleagues to ‘‘recommend that all
medical students receive training in global health and that an international clinical rotation
become more routinely available to medical students’’ (Drain et al. 2009). A group of
Canadian scholars have suggested that not only should global health be included in the
training of public health professionals but that core competencies should be developed to
ensure that all students are exposed to a base-line set of knowledge and skills across
academic institutions (Cole et al. 2011). However, how to integrate an understanding and
appreciation of global health in the health professional curricula is left grossly unspecified.
The breadth and depth of content covered by global health curriculum varies widely
across institutions (Izadnegahdar et al. 2008). Much of the literature on global health
education within medical curricula assesses the value of international clinical placements
(Duvivier et al. 2010; Edwards et al. 2004, 2001; Harden 2006; Shah and Wu 2008). One
can presume that international clinical experience is the ideal form of exposure to ‘‘global
health issues’’ because of the visceral experiential learning that takes place. This visceral or
‘‘hands-on’’ approach to global health is no-doubt an important pedagogical tool for global
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3. health. However, many students will never have the opportunity to engage in international
clinical experience due to financial and/or programmatic constraints. This reality points to
the importance of bringing global health issues to the classroom.
Classroom content can differ greatly depending on the professional program and the
topic of the course. It is as likely to find global health content pertaining to infectious
disease control or the treatment of neglected tropical diseases as it is to find content
pertaining to the health impacts of globalization. Houpt et al. (2007) call for three cate-
gories of content to be covered in medical education, namely the burden of global diseases,
travel medicine, and immigrant health. It is sensible that global health content delivered in
a medical program will differ, in part, than that delivered in a public health or rehabilitation
science program. However, the technical content of say, disease diagnosis, treatment and
control can be complemented by a common commitment to engaging students in an in-
depth exploration of the context of global health issues. This context includes cultural
diversity (and universality), health system diversity (and similarity), the ‘‘lived experi-
ence’’ of health, and the intersection of international and local economic, political and
social practices. The premise underlying this paper is that students benefit from exposure to
the technical as well as the emotive and systemic features of global health. This premise
informed the establishment of a research-based narrative assignment for global health
education in the health professions.
Although the narrative form is situated as an aesthetic, non-instrumental form and
process, it can serve to connect ones ‘‘heart’’ with ones social environment and as such is
an important tool in the educational process. However, unlike Jerome Bruner’s (1991)
characterization of narrative as a form that is not governed by ‘‘empirical verification and
logical requiredness’’, this assignment requires the students to conduct research and then
construct a story that integrates this factual information. The integration of factual
information in the narrative does not mean that the story is merely a vehicle to deliver
technical information, but is a form of communication that engages the different faculties
of the creator (e.g. intellectual, linguistic, and emotional).
In the following section ‘‘Global health education’’ I provide a rationale for the
research-based narrative assignment as a tool for classroom-based global health education.
I argue that this tool can serve to move students beyond the facts and figures of global
health to engage them in a self-reflective process of learning that emphasizes (1) trans-
national competence, (2) empathy and (3) a critical analysis and integration of the deter-
minants of health. This method of global health education facilitates learning of the
substantive content of global health issues, whether it is neglected tropical diseases or
men’s violence against women, while providing a framework to engage in the process of
‘‘engaged’’ learning.
Global health education and the research-based narrative assignment
Transnational competence
Koehn and Swik (2006) provide an in depth discussion of the need to move away from the
delivery of Cultural Competency in medical education to Transnational Competency. The
thrust of their discussion addresses the lack of consensus on the concept of culture and the
risk of ‘‘othering’’ in the process delivering a cultural competency-based education. They
note that typical cultural competency education focuses on cultural groups and is not
sensitive to issues such as intra-group differences. Transnational competence involves the
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4. ability to address individual diversity in dealing with health issues as well as the ability to
assess the different factors that contribute to the health of individuals (e.g. experience of
war and violent conflict, health care system resources and social supports). Although the
research-based narrative assignment does not emphasize practical skill development it does
contribute to the development of transnational competence by facilitating ‘‘lateral think-
ing’’ (Koehn and Swick 2006). This type of thinking requires the students to examine and
construct a complete story about the characters of their choosing. For example, one student
chose to tell two parallel stories of the experiences of two women from conception to birth
in two different countries (Ethiopia and Canada). This story not only discussed the typical
aspects of prenatal care in the two countries, but also integrated aspects of custom and
social norms. For example, the student found that traditional Ethiopian society values large
families and encourages marriage and childbirth at ages that would be considered ‘‘too
young’’ in Canada. These cultural norms contribute to how the woman experiences the
pregnancy and birthing process. In addition to the differences between the experiences of
the two women, the student created a narrative that integrated the similarities between the
experience of the two women and how they shared similar emotional experiences and
social and other challenges. Narrative has the potential to bring to the forefront common
human experiences and challenges the students to articulate the subtleties of these expe-
riences without ‘‘othering’’ based on objective indicators such as income or access to
health professional resources (Williams et al. 2003).
Empathy
Empathy is often neglected in global health education. This neglect can take the form of an
overemphasis on information about global health without addressing the ‘‘lived experi-
ence’’. For example, the understanding of the prevalence of malaria in a given country is
quite different than an understanding of what it is like to try to protect one’s children from
contracting the disease, experiencing the symptoms of malaria, or caring for those left
behind after a loved-ones death from malaria. Both the information and sensitivity to the
lives of persons are important components of global health education. This need for
empathy in global health education aligns well with narrative ethics, which explores the
importance of the stories told by others and meaning they attribute to life situations (Jones
1997, 1999). Benatar and colleagues state the need for the emotional connection to issues
of global health most pointedly when they note that, ‘‘solidarity is not discovered by
reflection and reasoning, but rather by increasing our sensitivity (empathy) and adequate
responses to the pain, suffering, and humiliation of others’’ (Benatar et al. 2005).
However, I also think that an overemphasis on suffering can skew ones perception of
others and can be a form of ‘‘othering’’. This idea stems from the notion that individuals
have complex identities and if we reduce these identities to one element or experience, then
we risk ‘‘othering’’ or creating distance from and relationship between one’s own expe-
rience and the experience of others. With this consideration in mind, I encouraged the
students to celebrate the joy, happiness and meaning of the lives of their characters. This
encouragement is intended to strengthen the narrative and enhance empathy or sensitivity
not only to the suffering of others but also to a celebration of their strengths and victories.
It is this effort to expand the scope of the students’ empathy that aligns with the notion that
‘‘state of mind … is perhaps the most crucial element in the development of an ethic of
global health’’ (Benatar et al. 2005).
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5. Determinants of health
Global health issues tend to shirk simple linear causal explanations. The nature of global
health issues suggests that they transcend geographic or political boundaries and are
influenced at multiple levels (Koplan et al. 2009). For example, in order to understand the
health system in Haiti one benefits from an understanding of seemly disparate factors such
as colonial history, international trade, diverse cultural perspectives on health, and global
financial systems. While it is necessary to understand these factors it is not sufficient to
draw a line from any one particular factor to the operation of the health system. It is
important for students of global health, particularly in an introductory course, to grasp the
complex host of factors that contributes to a singular global health issue. Bateman and
colleagues note ‘‘globalization is accelerating and is forcing us all to realize that we cannot
isolate ourselves from international issues’’ (Bateman et al. 2001). One of the benefits of
integrating global health into health professional curricula, even if the majority of students
choose to work ‘‘locally’’, is to facilitate an enhanced appreciation of how the determinants
of health are not bound by geography or political boundaries. Most directly, the students
will presumably be better able to understand the health needs of recent immigrants and
more astutely consider the context that these individuals are coming from (Houpt et al.
2007). More indirectly, these students will gain a better appreciation for the interaction of
international and local determinants of health. For example, it is now widely accepted that
international economic arrangements impact the health of local populations through the
movement of health harming products such as tobacco and unhealthy food, or global
governance of medication (Hawkes 2006; Labonte et al. 2011; Smith 2006).
The intention of the research-based narrative assignment is to encourage the students to
investigate the different factors that contribute to a particular health issue and then inte-
grate these factors into a coherent story. The research-based narrative may facilitate
research into the various levels of contributing factors or determinants (i.e. local, national,
regional, global) of health issue. The predicted strength of this type of assignment is that
the students will be better able to integrate the global with the local while also integrating
the ‘‘lateral’’ factors such as the local social context including the various norms that
operate in this environment.
Methods
At the beginning of the semester the third and fourth year undergraduate public health
students were provided the following description of the research-based narrative
assignment:
The research/narrative paper (10 pages max.) will provide you the opportunity to be
creative. You will conduct research into a particular region (e.g. City, town, village,
geographic area, etc.) and a particular health issue that the individuals in this region
face. You will take this research and create a story about a particular individual or
family. This story will be written in the narrative form. This story will allow some
creative license to provide an emotional account of this individual or family, while
tying in factual information about their health situation within the context of the
region (e.g. you can collect disease statistics for this region, research that examines
the causes of disease in this region, or other factors that contribute to the health of the
people in the region). This story should be believable and should ensure that the
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6. culture and practices of the family/individual are respected. In addition to the above
criteria, the story must connect to the broader global context (i.e. how does the local
situation of the family/individual relate to the global environment, such as economic,
trade/investment, transportation, etc. contexts). For example, obesity in some countries
may be linked to the import of processed foods from the United States and Europe.
Following the completion of the research-based narrative assignment the students (n = 20)
were asked to submit a two-page reflection on their experience preparing for and completing
the assignment. The students were asked to reflect on the strengths, limitations and what they
felt they gained by completing the assignment. The two-page reflections were analyzed using
qualitative thematic analysis (Charmaz 2007). I coded the two-page reflections and then
organized the codes under common themes. The written reflection has limitations as a source
of data because it does not allow the researcher to follow-up with the students’ comments or
probe to better understand the meaning of the comments. Despite this limitation the principal
strength of the written reflection is the ability of the student to reflect on the questions posed
without having to provide an immediate response, as a face-to-face interview requires. The
students’ names have been replaced with numbers (e.g. Participant 1) in order to ensure
anonymity. I have included excerpts from the student reflections in order to provide a thick
description of the themes (Geertz 1973). Four themes were identified from the analysis of the
student reflections. These themes express both the challenges and benefits of the research-
based narrative assignment. Forexample, some students saw thetheme of‘‘representation’’ as
both a strength and a challenge by facilitating reflection on whether one can fully represent the
experience of another when not having living this experience directly. Both the strengths and
challenges identified by the students provide important insights into the value of the research-
based narrative assignment.
Results
Representation
One of the prominent themes that I identified from the students reflections was that of
representation. The students expressed the struggle and opportunity that they had to
‘‘represent’’ another individual or group of characters. This challenge aligned with the
objective of the assignment by encouraging the students to reflect on what it is like to live
in a different context. The desire to represent the character in the particular context seemed
to facilitate a different way of knowing and learning about global health:
I found myself having to rewrite the paper a few times because my character was
sounding too robotic … When I re-wrote the paper, I took a step back and pictured
myself being in the position of a Burmese refugee in Thailand. Imagining that life
made the information I researched become knowledge at a whole new level. (Par-
ticipant 1)
The thing I struggled the most with was the decision to write it in the first person or
the third. A silly problem to some maybe, but in the end I believe it was the factor
that brought much of the depth and emotion into my telling of the story. I so often
found myself wanting to simply write down the facts and leaving it at that and my
background section is essentially a replica of that idea but with a bit of storytelling
involved. It is easy enough to assume from an outsider’s point of view (in the case of
my character’s story) the implications and effects immigration might have on
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7. individuals but it was extremely difficult to figure out how to understand and explain
these implications from the point of view of someone facing them. (Participant 2)
Cultural sensitivity was another challenge in writing about Haiti as a distinct ethnic
entity. It was difficult to avoid feeding into mainstream stereotypical assumptions
especially writing about people’s behavior. Many writers have done narratives on
Haiti that cover issues of voodoo, poverty and ethnicity and fail to give voice to the
people. It was challenging trying to maintain a storyline as well as give agency to
characters in the story. (Participant 7)
To write about a place different than my own required me to try to see the whole life
through a different lens than my own experience, to consider what life is like for
others. From my observations, there are both universal experiences and emotions we
have as human and families, and differences because of where and how we live.
(Participant 9)
I struggled with how I would actually start my story and feared my ability in
accurately depicting what it would be like to really face the hardships faced by many
of these young girls. (Participant 18)
These passages suggest that the students were compelled to explore the ‘‘lived experience’’
of the characters and to move beyond the objective facts of the chosen global health issue.
The challenge of representation seemed to be the decisive factor in choosing the global
health issue and the story to tell. It is interesting that three of the students felt that they
could not accurately represent their characters because they did not feel that they had the
knowledge of or comfort with the context.
Though I was very interested in the relationship between social determinants and
disease transmission, I felt as though I could not properly describe the setting when I
had never travelled to Africa myself, or personally met anyone affected by HIV/AIDS.
My attempt at grasping the entirety of the issue felt fraudulent as I was basing my story
on observations from the journals and documentaries of others. (Participant 4)
I started out wanting to write on HIV/AIDS in Africa but changed my focus close to
home as I was more comfortable wit the material and I had a better understanding of
my surroundings with the topic. (Participant 8)
I realized that I didn’t know how to write a narrative set in a place I’ve never been. It
don’t know what it’s like to live in Somalia. How could I write a convincing nar-
rative? (Participant 15)
Unlike a typical research paper, the students were encouraged to face the challenge of
representation. Some may see the fact that the three students were unable to write about the
issue that they had initially chosen as a weakness of the assignment. However, there seems
to be merit in the idea that it is beneficial that the students reflected so deeply about the
similarities and differences between their own life and the life of persons in other contexts.
As mentioned in the previous section, one of the objectives of the assignment was to
facilitate both transnational competence and empathy for the ‘‘lived experience’’ of others.
This objective is encapsulated in the depth of the following student reflection:
When one writes a traditional paper, there is a sense that it contains, or approximates,
the truth as we know it to date. A narrative is a different experience leaving me with
questions like: Can I give genuine voice to others lived experiences? Can we tell
stories from other places and socio-economic circumstances and get it right? Is what
I have written an expression of reality? Is there scientific merit in this paper?
(Participant 9)
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8. Engaged understanding
The second theme that was identified from the student reflections is ‘‘engaged under-
standing’’. This theme encapsulated the reflection that the narrative feature of the
assignment allowed the students to move beyond statistics and facts to explore how these
statistics and facts express one’s daily life. This theme aligned with the intention to
facilitate empathy in the students for those that they have not met.
Most importantly, by creating characters for a narrative I learned how to make
personal connection with the research. … Diseases are often discussed as statistics,
physiological effects, or are defined by risk factors and can lack humanistic
attachment. I liked that this assignment stressed that these statistics apply to real
people … (Participant 4)
… I was able to make the characters speak, I gave them their own voice, and they were
able to express what they wanted, and they were able to tell the reader what changes
they wanted, and tell their own stories … and that made me fell like my characters were
more than just characters, they came to life and they seemed like real people and that
was a great experience, it made me have this connection with my characters, and made
me feel like they were part of my life all along.’’ (Participant 19)
Through the writing of the narrative the students seemed to connect with the chosen issue
on a more ‘‘human’’ level. For example, one student noted, ‘‘being able to write as if you
were a spectator or a person in the story, you were able to have a better perspective and
understanding of just how realistic these issues are’’ (Participant 5). Others students
thought that this type of learning contrasted with their experience of other assignments in
the public health program:
Writing in narrative voice allowed me to take a different point of view on individual
experience in a global health issue. That is, in public health we focus on population
health issues and seldomlook at theparticular experiences ofindividuals.(Participant 7)
Everyone has a story that needs to be told. Many times information in public health
and other sectors is given in the form of statistics and complex journal articles. And
yet, if we can understand the story behind many of the statistics the information can
become more real and relevant. (Participant 16)
Another student noted that this engagement with the ‘‘human level’’ facilitated the learning
process:
I found the main strength of the narrative form for me was that all the research I did
came together to create a more unified picture, which to me is more memorable than
disjointed facts and statistics. (Participant 15)
The same student expressed how they explored the similarities and differences between
two characters in two different countries and how this prompted further reflection on the
chosen issue:
I hoped to show similarities in some experiences, such as the excitement of being
pregnant with your first child, or the uncertainty about childbirth. I also hope to show
the differences in health services, culture, and the ways in which common global
issues affect women in different parts of the world. … I found that comparing two
women’s experiences really helped me drive my research. If I pictured the Canadian
woman finding out she was pregnant by taking a pregnancy test, I then wondered
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9. how the experience of learning you are pregnant was different and/or similar for the
Ethiopian women. This led to research about pregnancy and pre-natal care in Ethi-
opia. (Participant 15)
In addition to connecting to the story on an emotional level this assignment also seems to
uncover the implicit assumptions of the students to the topic of global health. It is
understandable that engaging with writing a narrative exposes such assumptions and
possible prejudices by having to tell someone else’s story. One student noted that:
Generally speaking – whether it is a good thing or a bad thing – when given the
words ‘‘Global Health Issue(s)’’ I immediately steer towards Africa and their issues
such as: poverty, HIV/AIDS, famine, child soldiers, etc. Don’t ask me why but for
some reason it’s where my brain goes. (Participant 12)
Seeing the bigger picture/determinants of health
Similar to the theme of engaged understanding, the theme ‘‘seeing the bigger picture’’
involved moving beyond the statistics of the chosen issue to see how different factors
intersected. Part of this theme reflected the students expressed need to explore the cultural
practices, social norms and customs of a region.
In short, I had to familiarize myself with the local practices, customs and to some
extent even the language of the region; in addition to researching the existing
‘official’ policies, legislation and organizational frameworks that exist to support the
health of a population. (Participant 17)
Another student noted that they ‘‘went much broader in (his/her) reading’’, reading about
‘‘India, public health issues at large, environmental concerns, and how society was
structured … the growth of the cities, the industry and a wonderfully insightful travel blog
by a young English couple who had spent a month there’’ (Participant 9). This investigation
and presentation of the ‘‘bigger picture’’ seems unique to the narrative research approach
where the students move beyond typical health statistics and indicators to fill in the story.
One student expressed that generating the story helped to gain an appreciation of the
different factors that contribute to a health issue:
This realization helped me understand the vast complexity of international health
issues; even though I can learn about contributing factors, statistical evidence alone
is not sufficient to comprehend how individual persons are affected by disease.
Knowing this is useful for me in the future; if I should ever be so lucky to contribute
to global health policies and prevention strategies, I want to strive to learn and
experience the cultural, social, political, and economic factors of disease from per-
sonal accounts. (Participant 4)
Another student noted that they gained a greater appreciation for the determinants that
contributed to their chosen global health issue:
The problems and the solutions are inextricable from the economic, political, social
and cultural milieu of the world. It seems that greater understanding of the condition
of mankind comes from being able to put as many of the pieces of the global puzzle
together as possible while still maintaining the humanity of it all. Enter the narrative
assignment, which as a learning experience made me think more comprehensively
than a traditional research paper. (Participant 1)
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10. This type of pedagogy seems to encourage the student to move beyond a description of the
determinants of health to maintain a focus on the ‘‘humanity of it all’’.
Inexperience and novelty
The final theme represents the many challenges that the students identified while engaging
in this type of assignment. The research-based narrative assignment was new, not only to
me as the professor, but also to the students. This novelty created challenges when iden-
tifying what was expected of the students:
I have never written a research-based narrative paper before, so at first I did not
understand how the paper was going to turn out … but after a few days I realized that
this was a great way for me to show my creative side and I was able to pick a subject
that I hold dear to my heart. (Participant 19)
All of the students noted that they were apprehensive to write a ‘‘story’’ having not worked
on one for many years. Below is a sample of the students’ reflections on this challenge.
My first challenge was writing a paper in narrative style as I have become so used to
writing more traditional papers. (Participant 1)
Writing a research-based narrative was definitely a new experience for me – I hadn’t
written a narrative story since I was in the ninth grade – so I had a lot of anxieties
about writing this research narrative. (Participant 2)
I thought writing a narrative research paper was going to be a piece of cake … When
it actually came down to writing the paper I then realized it wasn’t as easy as I
thought it would be. I haven’t written a story since junior high or high school.
(Participant 11)
Initially, I thought the assignment would be easy and fun to do. After all, it involved
storytelling and it wasn’t as rigid as an academic research paper, which is usually
more difficult. However, the process of actually writing the paper made me change
my mind about how easy the process was. (Participant 16)
Initially, I was freaking out, I didn’t know what or how I was going to ‘‘narrate’’ a
story, let alone know what I was going to write about. (Participant 18)
Discussion
One of the prominent challenges for global health education is to engender a strong sense
of caring for persons beyond one’s immediate environment. The emphasis on technical
solutions to global health problems is now widely recognized as necessary but insufficient.
Despite this recognition there is also reluctance or perhaps lack of vision to guide ‘‘par-
adigm shifts in the ethical discourse and in human cooperation worldwide’’ (Benatar et al.
2003). The research-based narrative assignment will not produce grand changes in global
health’s persistent challenges. However, this assignment is an attempt to engender a deeper
understanding of transnational competence, heightened empathy for the humanity under-
lying all global health issues, and a greater appreciation for the complexity of the deter-
minants of global health issues in health professional students. The analysis of the students’
reflections provides important insights into their experience conducting this assignment,
particularly in highlighting key strengths and challenges of this approach.
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11. The narrative form seems to direct students towards the challenge of representing the
life of another while not having experienced the various aspects of that life. This challenge
seemed to also provide an opportunity for the students to reflect on what the characters life
is like, not just in the surface-level health indicators but in the living of a social life
embedded in a particular historical, political, economic and cultural context. The challenge
of representation seems to straddle the line between ‘‘othering’’ and romanticizing the life
of the character. As one student had noted, they made a conscious effort to move beyond
the stereotypes and monolithic descriptions of Haitians to provide a more nuanced view of
the characters’ lives. A number of students noted that the challenge of representation
steered them away from the topic that they initially chosen, which provides an interesting
insight into the process that many of the students went through. This process can be viewed
as a strength of this particular assignment in that it demonstrates the self-reflective process
of the students and their efforts to consider the power of ‘‘giving voice’’ to another human
being. From this perspective the students engaged in an empathic reflection, trying to
understand what it means to tell the story of another person and what is required to tell this
story with accuracy and nuance, a type of education in humility (Benatar et al. 2003).
Many of the students expanded the research process to include an exploration of the social
and cultural features of the chosen region. This theme of engaged understanding also
included a prominent emotional element. The students described the power of having to
tell the story of someone’s life and the emotional experience of this person while facing
disease, death, resilience, support, love, care etcetera. The emotive power of narrative is
embedded in the idea that ‘‘narrative practice is relational’’ (Jones 1999), even if the
relationships are being worked out in one’s mind in the development of a fictional account.
This finding provides important insight into the process of developing a sense within the
students that they are part of a ‘‘moral community’’ (Benatar et al. 2003) and that the
notion of interdependence does not simply mean that statistics can change. The strength of
the narrative genre can be derived from White’s following pointed explanation, ‘‘Far from
being a problem, then, narrative might well be considered a solution to a problem of
general human concern … the problem of fashioning human experience into a form
assimilable to structures of meaning that are generally human rather than culture-specific’’
(White 1980).
The assignment described in this paper serves a two-fold function. On the one hand, the
assignment is a way to foster and develop the ability to communicate complexity and
humanity. On the other hand, it is a way to ‘‘expose’’ and explore the students vision of
‘‘the other’’. Both functions are based on the premise that ‘‘When somebody tells you his
life (or the life of another) … it is always a cognitive achievement rather than a through-
the-clear-crystal recital of something univocally given’’ (Bruner 1987). This statement is
particularly true in the case of fictional accounts. This premise suggests that narrative is a
starting point for exploration, an uncovering of assumptions, perspectives and affective
associations. McCarthy (2003) states that the use of narrative as a tool for ethical practice
is premised on the notion that it does not ‘‘necessarily unify moral beliefs and commit-
ments, but is opens up dialogue, challenges received views and norms and explores ten-
sions between individual and shared meaning’’.
The two-fold function of the research-based narrative assignment requires not just the
preparation and writing of the story, but also reflection following its completion. How this
reflection occurs and in what form is something that will need to be explored further. For
example, would collective reflection contribute to a student-to-student dialogue that would
then contribute to greater exposure of the student’s assumption, perspectives and affective
association? Would reflection in the form of journal writing be a safer space for the
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12. students to look back on their work and what it means about their own viewpoint? The
importance of reflection may also provide important considerations for how the story is
developed and told. I asked the students to write a research-based narrative paper. How-
ever, does this requirement privilege the written word over oral or other artistic forms of
storytelling? Did I exclude voices by insisting on this form of presentation? Thomas King
has written extensively about the subtle implications of narrative form in the context of
Aboriginal histories (King 2008). It is in light of this type of critical-historical analysis that
should prompt further reflection on how this and other narrative assignments can be
delivered in the classroom setting. In the case of this research-based narrative assignment,
the oral form of storytelling may have actually engaged the other students and me in a
more dialogic form of audience-storyteller reflection.
The factors that contribute to the health of human beings are inherently complex and
intersecting. The research program that strives to link the features of globalization to
human health provides many examples of this. For example, something as obscure as trade
and investment regulation can contribute to the rise or fall of chronic disease prevalence
(Beaglehole and Yach 2003; Labonte et al. 2011; Magnusson 2010). The movement of
health professionals from resource-poor regions to stronger economic contexts can create
service gaps that can greatly affect the care of ill persons (Dussault and Dubois 2003;
Wibulpolprasert et al. 2004). A challenge for educators is to provide a (somewhat) com-
plete picture of how these determinants of health intersect and operate from the global to
the local level (Cole et al. 2011). Having the students develop a story may contribute to this
objective by encouraging them to integrate the determinants into the lives of persons. For
example, how does colonization contribute to the real lives of persons and how do the
structural features of this legacy operate to support or detract from a health-promoting
environment? Many of the students described how they strove to examine and integrate the
different determinants into their story. In the absence of international clinical experience
whereby students may see the determinants of health operating in the particular context,
the research-based narrative assignment may contribute to the cognitive orienting of these
determinants around particular characters. This cognitive process of identifying the
determinants and then ‘‘storying’’ their operation can serve to provide something like a
‘‘global state of mind’’ (Benatar et al. 2003). The research-based narrative assignment was
not without obstacles. The key obstacle that the students identified was the lack of
experience writing a research-based narrative. All of the students noted that they were
unsure how to tell a compelling story and it was true that some of the stories did lack depth
and nuance that is characteristic of a great narrative. There may be merit in working with
literature faculties to develop ways to enhance both the education of how to write a
compelling story, and ways that these stories can be evaluated. However the output was not
of ultimate importance. The process of conducting research for and reflecting on how to
incorporate the information into a coherent story was one of the main learning objectives of
this assignment. Learning how to conduct research about a particular issue was as
important as learning how to empathize with persons in a way that examined differences
between oneself and the characters and perhaps more importantly similarities. Because this
was the first time that I delivered this type of assignment there was no examples of what a
research-based narrative for the students to access. I think that having exceptional stories
written by students in past semesters to use as examples may have made it easier for the
students to know what was expected of them. As many students noted, they felt anxiety
about conducting this assignment because they were not familiar with a paper that drew
from research but did not cite the research directly in the text but rather was recognized in a
reference list at the end of story.
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13. Conclusion
Faculties and departments are only beginning to systematize efforts to engage health
professionals in an understanding of the broad field of global health. The breadth of the
field makes it difficult to know what content to cover in global health curricula and various
social, cultural, economic, political and other differences only compound this challenge.
However, there are many opportunities for creative pedagological approaches to global
health education for the health professions. This paper described one novel approach to
global health education that focuses on fostering transnational competence, empathy and
an appreciation for the many determinants of global health. This assignment was evaluated
by analyzing written reflections completed by the students. Four themes were prominent in
the student reflections, including the challenge of representing persons, the opportunity to
develop an engaged understanding of the chosen issue, seeing the bigger picture and
integrating the various determinants into a coherence story, and finally the struggle to
create a compelling story that was based on accurate information. This assignment is one
strategy among a growing field of scholarship that is exploring how global health can be
best included in health professional education. It is hoped that the description of this
assignment and the lessons learned from its implementation can contribute to this
important field.
Conflict of interest None.
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