Narrative change for health equity in grassroots community organizing: A study of initiatives in Michigan and Ohio.

To achieve health equity, there is a need to act on the social determinants of health. This reality is now understood more widely, and in greater detail, than ever. Amid this movement toward health equity, there has been a natural gravitation to community organizing, which has long worked to produce more equitable systems and policies. Community organizing builds power through cycles of listening, participatory research, collective action, and reflection. One manifestation of this power is that organizing initiatives can often influence which issues are up for public debate, and the terms of those debates. This dimension of community power is often described by practitioners as narrative change work, and involves intervening on, complicating, and resisting dominant societal narratives that hinder action on the systems that perpetuate inequity. This article reports results from a study of organizing initiatives in Detroit, MI and Cincinnati, OH which both engaged in intentional narrative change work around health and health equity. We analyzed data from interviews with 35 key leaders across both cities. Results describe the organizational processes and activities taking place in both sites, with an emphasis on one issue in each city: educational equity in Cincinnati and water equity in Detroit. We then use coded interview data to examine how narrative change work took place in organizing around these issues during the COVID-19 pandemic, a challenging time for organizing initiatives. Results provide insights into adaptations taking place in community organizing during this time, as well as various approaches to narrative change work as part of holistic efforts to build and exercise community power to alter social determinants of health.

Stories of self, us, and now: narrative and power for health equity in grassroots community organizing.

Introduction: Community organizing initiatives, which build power through cycles of listening, participatory research, collective action, and reflection, have demonstrated the capacity to intervene on, complicate, and resist dominant societal narratives while promoting alternative public narratives focused on shared values and hope for a better future. Methods: To explore processes of public narrative change and their relationship to community and organizational empowerment, we interviewed 35 key leaders in community organizing initiatives in Detroit, MI and Cincinnati, OH about how narrative change takes place within community organizing practices. Results: Leaders' perspectives revealed crucial roles for narrative and storytelling in guiding individual and collective behavior, supporting the development of relationships of trust and accountability, and linking personal and collective experiences to pressing social issues. Discussion: Findings from this study indicate that systemic change is a labor-intensive process and one that requires the development of leaders (stories of self) and the cultivation of collective structures (stories of us) capable of enacting power to effect change with urgency (stories of now). We conclude by discussing implications of these findings for public narrative interventions and related health equity promotion efforts.

Stories for Change: The impact of Public Narrative on the co-production process.

INTRODUCTION: Involving service users in health service design and delivery is considered important to improve the quality of healthcare because it ensures that the delivery of healthcare is adapted to the needs of the users. Co-production is a process used to involve service users, but multiple papers have highlighted the need for the mechanisms and values guiding co-production to be more clearly stated. The aim of this paper was to evaluate the mechanisms and values that guided the co-production approach of the Stories for Change project, which used Public Narrative as part of the co-design process to create change in National Health Service maternity services. METHODS: This study was conducted using a rapid feedback evaluation approach. Semistructured interviews (n = 16) were the main source of data, six of which were maternity service users, with observations (5 h) and documentary analysis also carried out in parallel. RREAL sheets were used for data analysis to organize data based on key topics of interest. RESULTS: This study identified three broad mechanisms and values underpinning the co-production approach: creating an open and safe space to share ideas, learning how to tell stories using Public Narrative and having service providers who play a key role in strengthening the health system listen to stories compelling them to action. This study identified the main areas for improvement of the Stories for Change project related to recruitment, the inclusion of participants, the co-design process, the Skills Session and the Learning Event. CONCLUSION: Our study provided a deeper understanding of the co-production approach that addresses the need to uncover the mechanism and values underlying co-production and co-design approaches. This study expands on the literature pertaining to the influence of storytelling in creating meaningful change in health care. We propose a co-design methodology that uses Public Narrative as a model for service user engagement to help inform future healthcare development processes. PATIENT OR PUBLIC CONTRIBUTION: The experiences and perceptions of maternity service users and health professionals informed this evaluation. The project organizers were involved in the manuscript preparation stage by providing feedback, and service users wrote a commentary on the project from the lived experience perspective.

A case study on the use of Public Narrative as a leadership development approach for Patient Leaders in the English National Health Service.

Background: In 2016 the National Health Service (NHS) England embraced the commitment to work for maternity services to become safer, more personalized, kinder, professional and more family-friendly. Achieving this involves including a service users' organizations to co-lead and deliver the services. This article explores how Public Narrative, a framework for leadership development used across geographical and cultural settings worldwide, can enhance the confidence, capability and skills of service-user representatives (or Patient Leaders) in the National Health Service (NHS) in England. Specifically, we analyse a pilot initiative conducted with one cohort of Patient Leaders, the Chairs of local Maternity Voices Partnerships (MVPs), and how they have used Public Narrative to enhance their effectiveness in leading transformation in maternity services as part of the NHS Maternity Transformation Programme. Methods: Qualitative two-phase case study of a pilot training and coaching initiative using Public Narrative with a cohort of MVP Chairs. Phase 1 consisted of a 6-month period, during which the standard framework was adapted in co-design with the MVP Chairs. A core MVP Chair Co-Design Group underwent initial training and follow-up coaching in Public Narrative. Phase 2 consisted of qualitative data collection and data analysis. Results: The study of this pilot initiative suggests two main ways in which Public Narrative can enhance the effectiveness of Patient Leaders in service improvement in general and maternity services in specific. First, training and coaching in the Public Narrative framework enables Patient Leaders to gain insight into, articulate and then craft their lived experience of healthcare services in a way that connects with and activates the underlying values of others ("shared purpose"), such that those experiences become an emotional resource on which Patient Leaders can draw to influence future service design and decision-making processes. Second, Public Narrative provides a simple and compelling structure through which Patient Leaders can enhance their skills, confidence and capability as "healthcare leaders," both individually and collectively. Conclusions: The Public Narrative framework can significantly enhance the confidence, capability and skills of Patient Leaders, both to identify and coalesce around shared purpose and to advance genuine co-production in the design and improvement of healthcare services in general and maternity services in specific.

Preparing Doctors in Training for Health Activist Roles: A Cross-Institutional Community Organizing Workshop for Incoming Medical Residents.

INTRODUCTION: Physicians are increasingly being called on to address inequities created by social and structural determinants of health, yet few receive training in specific leadership skills that allow them to do so effectively. METHODS: We developed a workshop to introduce incoming medical interns from all specialties at Boston-area residency programs to community organizing as a framework for effective physician advocacy. We utilized didactic sessions, video examples, and small-group practice led by trained coaches to familiarize participants with one community organizing leadership skill-public narrative-as a means of creating the relationships that underlie collective action. We offered this 3-hour, cross-institutional workshop just prior to intern orientation and evaluated it through a postworkshop survey. RESULTS: In June 2019, 51 residents from 13 programs at seven academic medical centers attended this workshop. In the postworkshop survey, participants agreed with positive evaluative statements about the workshop's value and impact on their knowledge, with a mean score on all items of over 4 (5-point Likert scale, 1 = strongly disagree, 5 = strongly agree; response rate: 34 of 51). Free-text comments emphasized the workshop's effectiveness in evoking positive feelings of solidarity, community, and professional identity. DISCUSSION: The workshop effectively introduced participants to community organizing and public narrative, allowed them to apply the principles of public narrative by developing their own stories of self, and demonstrated how these practices can be utilized in physician advocacy. The workshop also connected participants to their motivations for pursuing medicine and stimulated interest in more community organizing training.