Stories like Tara’s: advocating the value of public health through narrative and reflection

Abstract

As public health professionals, our duty as advocates extends beyond public policy development into advocating for why public health matters. This duty is an imperative given the documented challenges currently faced by our public health system. Storytelling is a deliberate means by which we can exercise our professional agency and present the diverse contributions that public and population health professionals are making to the health of communities and families. Storytelling may serve a critical role in professional reflection to enable transformative change within this challenging public health landscape. We highlight the value of storytelling by presenting the lived experience of a frontline service provider reflecting on her work with Tara—a resilient, young woman facing multiple challenges throughout her life that impacted her health and that of her family. Tara’s story represents but one of countless examples from across the country that public health professionals can use to advance work on addressing health inequities. Professionals should be encouraged to build their competency in reflective practice and storytelling and to continue to use stories like Tara’s in the unification of their practice and in their advocacy efforts for why public health matters to Canadians.

Rural Nova Scotia; 30 minutes to the nearest store, bus route, gas station, health centre, and school. In the spring, summer, and fall—there’s always a beautiful array of colours as you drive through the windy roads. I reflect on our last visit—focused on my next interaction with this family. Driving down the dirt road, swerving potholes, I remind myself ‘don’t miss the driveway’. It’s more like a beaten down path. I look for the bus—where they used to keep their rabbits, thinking ‘I’m here, take a deep breath.’

In Canada and across the globe, public health (PH) practice is guided by an upstream focus with the goal of addressing population health through reducing health inequities. A robust PH infrastructure is vital not only to the health of Canadians but for health system sustainability. Nonetheless, in recent years, PH infrastructure has been notably “eroded” through its downgraded position within neo-liberalist ideology amid competing political agendas (Guyon et al. 2017; Potvin 2014; Hancock 2017). Existing alongside the demoted PH infrastructure, communities, our partners, and our clients misunderstand the vital work and role of PH in supporting the health of populations and broader health system goals. This lack of understanding further limits the potential for political engagement and broad public pressure for investment in, and protection of, PH infrastructure and for the work that unifies our practice.

Central to the competence of PH professionals is to engage in advocacy efforts and to communicate effectively across diverse audiences through multiple forms (Hancock 2017). Our duty for advocacy and communication must be in the interest of public policies that reduce health inequities and improve population health, but must also extend to advocate for PH as a vital system protecting Canadians’ health (Hancock 2015, 2017). Calling for a collective PH voice, Hancock states (2015, p.e88): “public health professionals and the organizations that represent them—have to stand up and speak out in favour of their right to stand up and speak out.” But how do we ensure the value of PH work is relevant, understandable, and accessible to the broader citizenship and decision-makers with whom we engage? In the interest of grounding our PH practice and unifying our voice to advocate for investment in and protection of PH, storytelling can provide a transformative and strengths-based approach.

As a frontline PH professional, it is a privilege to work with families such as Tara’s; too frequently, these families experience systemic challenges that influence their opportunities for well-being. For example, struggling daily with insufficient financial resources to meet their needs or experiencing violence or trauma. Hearing stories like Tara’s are a daily occurrence in this line of work, yet each subsequent interaction with another family facing inequities leaves a lasting impression that encourages me to give voice to these issues. Sharing this story at a PH team meeting was intended both as a personal reflection but also to facilitate our team’s collective understanding of PH’s vital role in addressing health inequities.

Throughout history, stories and storytelling reveal insight and meaning into the human experience. Stories foster the development of professional empathy and facilitate the exploration of ethical issues within professional practice (Fairbairn 2002, 2005). Stories enable us to reflect on both our shared values and beliefs but also taken-for-granted assumptions guiding our practice and provide a catalyst for our connectedness and professional agency (Dughill et al. 2009). Stories may also augment other persuasive evidence that we commonly use to ground and connect us with our work (e.g., statistics, economic data such as returns on investment or other quantitative forms) (Brownson et al. 2009) and, where a historical and unjust absence of primary evidence exists, reveal experiences from those persons underrepresented within the research literature (Bonveski et al. 2014). As such, storytelling is recognized as a powerful social change practice and pedagogical tool in the health field (Chen 2008).

Sweet little Annie would always meet me at the door—“what’s in your bag?” She is so excited for the interaction we would have, waiting for an activity, or “Simon Says” developmental check-ins. She would lead me down the narrow hall of the family trailer, the smell of a slow cooker meal was inviting, as the wind shook the home—plastic covering the windows attempted to keep the cold air out. Making our way to the living room, Tara, Annie’s mother, apologized for the mess: “Don’t worry, the laundry is clean, we had to take our clothes to the Laundromat, and we haven’t had a chance to put them away.” Annie was bright and Tara was motivated, but life was far from easy for either of them. Annie had no idea the challenges their family has and continues to face.

Through this small glimpse into Tara’s life, we experience a connection to both Tara and the narrator. We identify with Tara’s experience parenting a small child and the PH professional’s experience playing familiar games as a form of building trust and establishing rapport. We envision the setting—a rural trailer that Tara calls home and the smells, noises, and feelings within that environment. These aspects of Tara’s story create space for a reflective PH practice and discourse about how Tara’s life is situated within a greater structural and political existence. Experiencing Tara’s story facilitates our collective understanding of how our work connects to a broader social action and public policy levers.

Tara and her partner were in their first year of community college and found out they were expecting; she was 19. Six months later, Tara woke up to find her partner, “cold, blue, pulseless.” Unfortunately, addictions had been a struggle for Annie’s dad, and although he was accessing treatment programs, a combination of street drugs and alcohol ended his young life. By now, I have known this family for 3 years; 2-year-old Annie smiles and looks at a picture of her “Dada”. Talking about Dada happens at every visit—often with tears and always with smiles. Every holiday, or often just because, Annie and her mom visit Dada’s gravesite. Only recently did that site have a tombstone, after the family finally saved enough money to purchase one. Annie would never feel her Dada’s arms wrap around her, she would never experience her dad throwing her in the air and catching her, nor would he feel her soft hands cover his eyes as they play peek-a-boo.

A story such as Tara’s provides a rich flavour of the challenges impacting this family and Annie’s healthy child development—notably the challenge of living with limited resources. Although frontline support enhances self-efficacy and promotes agency, a caution would be to interpret Tara’s story solely as one of her resilience and resolve. The road to wellness is about much more than personal capacities; Tara needs a broad community of support to enable the necessary public policies and structural shifts that will ultimately reduce inequities in health. Tara’s story enables us to interrogate the existence of these inequities but also critically reflect on our professional privilege and position within Tara’s and similar stories, and through this tension, reveal possibilities for change.

Our role [as frontline PH professionals] is to help families set goals for themselves within their context, including helping families navigate community resources; this is an ongoing challenge as we know it is a band-aid approach for addressing complex social issues. What stood out for me was Tara saying: “I want to make sure I do everything I can to make sure Annie is ready for school and ready for this world.” In spite of Tara’s motivation and resilience, the absence of broader policy shifts will limit her opportunities to overcome challenges. Tara further stated: “I want Annie to have the best life”, pausing, “not materialistic things—I want her to have the opportunities that every child SHOULD have.” Without stating the same, Tara recognized that addressing inequities are at the heart of her family’s well-being.

Every day we bear witness to those navigating and experiencing the unjust social and societal conditions impacting their opportunities for health. While Tara is exercising her own agency in caring for herself and family, it is our duty as PH professionals to share our experiences through stories like Tara’s to explore strategies at all levels of the health impact pyramid (Frieden 2010) and work across differences in position or perspective that help give rise to envisioning possibilities for change (Saltmarshe 2018). As part of reflective public health practice, stories like Tara’s enable us to strengthen our professionalism (Charon 2000) to ensure that we, as PH professionals, operate in a collective and unified capacity (Tsui and Starecheski 2018) to advocate for a supported, resourced, and protected PH infrastructure. Through this, stories like Tara’s support us in practicing cohesively and enable us to articulate to our partners, decision makers, and the broader public why public health matters and the important role that PH professionals play in working both with families and communities and also at a systems level to redress health inequities.