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Introduction
Once upon a time…
Since we gathered around the fire until our days, telling stories has been and it is, in fact, a natural and universal way of communication in order to preserve stories, cultures or ideas and to transmit knowledge (teach). We hear stories every day and we tell them, in the same way, to friends, parents, children or grandchildren. In addition to their value and originality, they represent the experience and vision of the world of those who count them. When stories are told in a reflective, emotional and somewhat improvised way we become "narrators". Depending on how we disclose "our" history, we will be able to reach more or less people1,2. It must be noted that just as there are people with a natural gift to tell stories, others require learning and training. As a result, they will overcome barriers, and shared stories will be stronger3. The latter has led to the development of storytelling (ST) as a method of communication, a great tool to communicate. Solidarity, respect for others, or the development of imagination, dreams and hopes, are some of the outstanding values among those who accept the pleasure of ST2,4.
A story, a narrative, is a representation of connected events and characters that has an identifiable structure, bounded in space and time, and contains implicit or explicit messages about the topic being addressed5. People use narrative in their daily lives as they communicate and interact with others by testimonials or ST in order to exchange messages6; it is a way to share and receive information as well as a way for us to understand our own lives and those of others around us7. Contrary to this way of communication, many programs of health promotion or disease prevention are usually based on information about risks in numeric form with statistics and probabilities, and the same applies in the case of doctor-patients communication. This form of communication is not always well understood by people with low level of education 8. In order to make complicated messages easier to understand, the use of narratives in health communication is increasingly being used as a strategy to educate and promote health behavior change as well as to give more quality in the doctors-patients relationships6,9.
In this regard, Guber proposed that every storyteller should follow four rules or truths: 1. To be truthful for the narrator, thus allowing them to express their deepest and sincere values; 2. To be truthful for the audience, making the time spent worthwhile, attending their needs and catching them with the story; 3. To be truthful with the moment, adapted to the moment (that is flexible enough to allow improvisation), and 4. To be truthful with the objective, so that the story reflects the passion and effort transmitted for the storyteller 10. There is evidence that the memory of information when presented in this way is greater 11.
Highlighting this idea, some attributes, purposes and considerations in order to perform a good story have been established. In the majority of cases, four basic emotions are elicited: happiness, sadness, anger and fear. The same story can trigger different emotional responses, a mere smile could generate happiness or anger, depending on the context in which it occurs 12.
Health education is any combination of learning experiences designed to help individuals and communities to improve their health, by increasing their knowledge or influencing their attitudes. The WHO health promotion glossary describes health education as not limited to the dissemination of health-related information but also "fostering the motivation, skills and confidence (self-efficacy) necessary to take action to improve health", as well as "the communication of information concerning the underlying social, economic and environmental conditions impacting on health, as well as individual risk factors and risk behaviors, and use of the health care system". A broad purpose of health education therefore is not only to increase knowledge about personal health behavior but also to develop skills that "demonstrate the political feasibility and organizational possibilities of various forms of action to address social, economic and environmental determinants of health" 13.
In this field of health education, ST emerges as an instrument that helps us in the learning and management of the disease, by taking advantage of the teachings transmitted by other patients who have gone through the same illness: sharing experiences. It requires an interaction between the one who relates (implicit emotional and corporal language: visual, auditory and gestural) and the listener, allowing the listener to conceptualize and create more valuable ideas 14-17. There would be a mutual benefit when patients exchange experiences related to health, which may lead to discovering new information, strategies or skills. The use of ST can serve as a means, establishing a network of trust and equality among participants, allowing a way of expression that would eliminate the stigmatization of suffering from a disease. In addition, telling stories can be a vehicle that breaks resistance to the messages promoting a healthy lifestyle, or that dilutes them to face behavioral changes facilitating the incorporation of new behaviors that improve health or overcome the disease 18,19.
ST as a group activity, for example in a group of patients with a certain pathology, allows a network of reciprocal trust and equality among participants, mitigating the desorption associated with the disease and increasing relationships among the participants. For those who find it difficult to tell their experiences, it is a very facilitating instrument. In addition, it allows us to learn through dialogue in the traditional way of the American Indian tribes (Talking Circles). Speaking, asking, counting, sharing, all these tools of communication are facilitated by ST 20-23. The use of ST allows a transformation of both the storyteller and the group that listens: you would see diseases not as something abstract, but as something that affects me, my life and the lives of others I know.
In short, ST facilitates support for the disease by allowing the patient to examine their emotions and problem-solving strategies, set objectives and exchange social support, which is of great importance for the personal management of the disease and to create awareness of the importance of the patient as an active subject before its decay 24,25.
Dissemination of medical research tries to make available to the general public topics of that field in an intelligible language, devoid of, whenever possible, technique medical terms. Some authors are a clear example of this 26-28. However, stories do not provide the answer to everything, although they are important to understand the how and why of the changes that have occurred.
With this article we intended to conduct a review of empirical studies on ST and health education, considering contexts, purposes, learning, attitudes and behaviors improvements related to the use of this tool of communication.
Method
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines we systematically reviewed records that included relevant results on the use of ST in health education 29.
Search procedure
We searched MEDLINE in January 2019. Two team members (MQ & JL) independently reviewed the study titles and abstracts to remove duplicates and to design eligible studies. Confirmation of eligibility was based on reading the full texts. In addition, a hand-search was developed to include other possible relevant studies in the field.
Inclusion and exclusion criteria
We included English- and Spanish-language studies on ST that linked this communication tool with health education. In this regard, following the WHO concept of health education we focused on "learning experiences designed to help individuals and communities to improve their health, by increasing their knowledge or influencing their attitudes" 13. The review was limited to full-texts articles of empirical studies, with no-date limitations. Editorials, letters, commentaries and reviews were excluded.
Due the fact that many of studies were based on qualitative methodology, it was necessary to include those in which that methodology was used. In this regard, the process of considering PRISMA analysis was applied only for quantitative studies.
Quality assessment
Studies were evaluated by the authors following the Jadad scale 30. Apart from the items related to bias control (randomization and reasons for withdrawal/dropouts) some others were considered: objectives, outcome measurements, well-defined inclusion/exclusion criteria, clear description of intervention, and statistical analyses if appropriate. A score of 2 or above was accepted. In order to measure the results of different programs of health education based on ST, the effective training evaluation plan of the New World Kirkpatrick Model was considered 31.
Data
Once the studies were selected, some data were extracted: type of publication, objectives, design, setting, ST characteristics, outcomes, and conclusions. The above-mentioned authors resolved discrepancies trough discussion with the third author (MG). Both quantitative and qualitative data were analyzed.
Thematic analysis
In order to analyze the selected articles, a thematic analysis was used following the six-step framework of Braun and Clarke 32: becoming familiar with the data, creating initial codes, searching for themes, reviewing themes, defining and naming themes, and producing the report. Fragments of data that identify a significant feature of such data were acknowledged and grouped together into related themes. As a result, the following main different topics were obtained: ST training programs, focused on clinical education (medical and nurse education), care and self-care, medical and scientific dissemination, sex and gender related topics, ageing, children and maternal problems, specific pathologies, oncology, drugs and sexually transmitted diseases, and general prevention topics.
Results
Searching process yield a total of 222 articles. After reviewing all of them, 37 were excluded because they did not fit the inclusion criteria. This way a total of 185 articles were considered.
ST training programs focused on clinical education (nurse and medical education)
Each person is the author and narrator of his/her unique life story. Telling stories is a relevant part of our lives since our birth. Due the fact that we are prone to impose meaning and structure on all information, it is possible to produce true stories when we have an appropriate base. If we do not have it, our stories can be elaborated introducing "lies" 33. For clinical education, the usual context is the patient's story of a journey from health to illness and, hopefully, back again 34. Students might be good communicators, but still lack the ability to hear and interpret patients´ stories; it is necessary to give the patients space and time to tell their story and to actually hear what they say. In this regard, students should acquire several skills such as synthesis, analysis and reflection 34.
In this field of clinical education, several studies have been developed focused on ST as a method in clinical replacement studies 35; as a tool to communicate with empathy 36; as a way to improve education rules working with patients 37; to facilitate clinical judgement 38; in midwifery education 39-42; in mental health nursing practice 43; in order to learn from clinical placement experience analysis nursing students´ reflections 44; to develop resilience considering nurse academics´ stories 45; as a tool to teach spiritual care and pastoral education 46,47; to facilitate the reflection on medical residents prejudices toward poverty 48; to promote reasoning skills in nursing education 49; to improve medical students´ attitudes toward persons with dementia 50,51; and in the formation of novice researchers 52.
Apart from these specific topics, there are many studies based on general nurse education 40,53-63) as well as on general medical education 64-67.
Many studies have focused on the preparation of storytellers: family and patient storytellers 68, digital ST workshops 69, and digital ST as a cultural relevant health promotion tool 70-72.
Care and self-care
Recent studies have explored creative processes such as ST as a tool for professional caregivers to address their self-care needs 38,73. ST is a social process that seems to offer potential as a community approach to support nurses and other health care providers 74. Different studies have emphasized the role of ST as a tool for improve both care and self-care. In this regard, it must be noted the research such as the one of Bruce et al. 74; a study of Archibald et al. focused on asthma 75; ST to improve hypertension 76,77; ST based interventions to improve good hygiene behaviors 78; ST applied to pregnancy care 79; ST for diabetes self-management 80,81; stories created to learn about neonatal care experience 82; ST to support nurses and families in intensive care units 83; ST aimed to activate patients at risk for osteoporosis 84; ST to support people's experience of hemodialysis 85; ST to manage shame among eating disorders patients 86; self-care among patients with diabetes 87-89; ST to improve lifestyle for obese adolescents 90; incorporation of ST into a physical activity intervention 91; ST to achieve better healthy lifestyles 14,92 and better healthy decisions 93; connection of ST networks, education and chronic disease 94; ST to improve blood pressure 95; and ST to enhance children's health 96.
Medical and scientific dissemination
Traditional modes of communication within the scientific community, including presentation of data at conferences and in peer-reviewed publications, use technical jargon that limits public engagement. Alternative tools that go beyond the data are required and ST would be one of them 97. First-person narratives can help to make science personally relevant and can encourage people to invest in a topic. For this objective, different innovative ways might be used (e.g. comics, movies, plays and other art forms) 97. ST has been applied to address health communication with minority populations 98; it has been used in order to compare multi-sensory and regular ST with profound intellectual and multiple disabilities 99, to engage people with intellectual disabilities 100 and to improve communication with disabled people 101; the integration of patients stories into patient education interventions -a dissemination of lessons from theater arts-, wellness courses -e.g. for community health workers-, has been another field of ST as a tool 102; storytellers have participated as partners in developing a genetics education resource for health professionals 103; ST has also applied to access social context and advance health equity 104; the shared health-related stories on the Internet has been analyzed among young people 105; empowerment of social action through narratives of identity and culture is another topic in the field of ST and dissemination 106.
Sex and gender related topics
Källström, Peterson and Wallenberg in their study of gendered ST have conclude that to target women, storytellers should focus to create a highly emotional story that contains sentimental elements and shows the importance of family, relationships and love. If they want to target the male audience, they should focus on creating a story that includes a character that is distinctly portrayed as a hero, information is told clearly and straight away where the males easily can identify the mission and, also emphasize statistics and status 107. This gendered view of ST has been applied to differentiate the enactment of hookup scripts among emerging adults 108; to promote LGBT inclusion 109; to talk about sexuality and identity 110; in the context of occupational therapy and sexual and reproductive health promotion 111; to analyze male students´ stories about care 112; the reasons why women choose a medical practice or a women's health center for routine health screening has been also addressed by means of ST 113; to teach reproductive options 114; and to explore the oppression and resiliency of post-apartheid black gay men and lesbians in South Africa 115, among others.
Ageing
In the most developed countries, ageing population is increasing. ST has been applied to explore how are older people's lives in the context of their own personal histories and experiences, as well as to address their current experience of ageing. As a care technology, ST has been focused on continuing education for active ageing 4 as well as a proactive approach to healthy ageing 116. ST is also a tool to explore the accuracy of older people's story recall 117, to help older adults find meaning and purpose 118 and to stimulate creativity 119. Regarding the health state of older people, ST is an educational strategy to cope with chronic illnesses 120.
Children and maternal problems
Communications between children and different caregivers (mothers, fathers, nurses, doctors) is usually improved by means of ST or mutual ST. It is possible to use the language of children to probe into areas of their thinking while bypassing conscious inhibitions or fears. A simple technique consists of asking the child to relate a story about an event, such as "being in the hospital". In the case of mutual ST, it would be possible to begin by asking the child to tell a story about something, then tell another story that is similar to the child's tale but with differences that help the child in problem areas. If the child's story is about going to the hospital and never seeing his or her parents again, a nurse story might be about a child in the hospital but whose parents visit every day in the evening after work 121.
ST as an early storybook reading has been explored in the context of childhood development 122 and ST compared with creative drama methods has been studied with respect to children's awareness about personal hygiene 123 as well as to promote positive development 124. Another application of ST is the interactive play during early childhood involving children, families, and neighborhood associations 125. ST has been also applied in the context of group crisis intervention for children during ongoing war conflicts 126. Multi-sensory ST is another technique to gather knowledge about preferences and abilities of children with profound intellectual and multiple disabilities 127.
With respect to pathologies and health problems, ST has been proved as a useful tool for antenatal education for childbirth-epidural analgesia 127, for psycho-educational interventions with children and adolescents with epilepsy 128, for teaching young children about burn injury accidents 129, for the promotion of children's health and oral health 130, for the improvement of parenting practices 131, for collecting data from adolescents for the development of health interventions 132, for parents of children with crup 133 and others. Finally, ST has been used in pediatric dialysis units 134.
Specific pathologies
Stories in the consultation begin when patients present symptoms. Information is gathering from the patients´ stories (ideas, concerns, expectations, feelings, thoughts, previous experiences) and doctors´ stories (signs, symptoms, investigations, underlying pathologies, differential diagnosis, ideas of management). Along with some moral and ethical dimensions, a shared story emerges, which is comprised by two stories in order to produce a working diagnosis and shared management plan 135.
In this regard, ST communication tool has been used among patients with psoriasis 136, diabetes 137-141, obesity 142, dementia 143,144, Di George syndrome 145, syphilis 146, depression 147,148, asthma 149, myocardial infarction symptoms 150, and persons with implantable cardioverter defibrillators 151, among others.
Oncology
ST is an inexpensive psychosocial intervention with minimal patient risk that may be effective for patients with chronic illness 152,153. ST may be particularly helpful for emotionally vulnerable group participants who lack the energy or ability to analyze their current situations but feel better in the telling and retelling of the stories of their cancer experiences 154.
ST is a useful tool into communication skills teaching programs for medical oncology 155, a very good approach to analyze the impact of viewing stories of oncology patients 156, a screening tool for cervical cancer 157,158, colorectal cancer 8,159-162 and breast cancer 163-166, an interesting way to promote cancer education 5,167-169, a tool for health promotion and cancer awareness 170 and to explore de contributions of caregivers of cancer patients 171.
Drugs and sexually transmitted diseases
The use of stories as an intervention strategy, with culturally-appropriate empowering narrative, a focus on key behavior change elements (e.g., attitude/behavior change, reinforcement of targeted behaviors), and appropriate channels of dissemination, may prove to be a promising health communication tool in addressing HIV and other STD-STI health disparities 172,173. Thus, ST interventions on knowledge and risk perception of HIV/AIDS among school children have been developed in Africa 174 and among the Inuit communities 175. The antiretroviral therapy adherence has been also studied in Africa by means of ST 176,177. ST has also been applied to antismoking public service announcements 178 and to enhance smoking cessation 179,180 as well as in drug abuse among adolescents 181.
General prevention topics
Regarding the effectiveness of narratives in sharing scientific information with the public, it seems that the persuasiveness of narratives can both benefit science communication and create challenges. Stories can sway beliefs on topics, such as vaccines. This way, awareness, knowledge, social norms and vaccination intentions have been explored in some communities 182, narrative interventions have been developed for HPV vaccine behavior change among mothers and daughters 174, and digital ST seems to be a tool to teach public health advocacy 183. Another modern topic refers to the fact that ii is necessary to combat (might be through ST) anti-vaccine misinformation 184.
Other themes for application of ST have been dietetics 185, sport courses among military personnel 186 and fitness among university employees 187, or to explore social determinants of health 188.
Discussion
Communication is a basic component in patients care. Frequently the pressure in medical/nurse care makes that communication inappropriate, with the consequent worse clinical outcome. Improving this communication is not an option but a need (and a must). But an isolated communicative ability is insufficient to create and maintain a satisfactory doctor/nurse-patient relationship, which would consist of sharing perceptions and feelings in relation to the nature of the health problem, therapeutic purposes and the mandatory psychological support. The patient's satisfaction with the treatment received rests fundamentally on how such communication is fulfilled (patient-centered communication), since proper communication would help to regulate patient's emotions, facilitate the understanding of medical information and allow a better identification of their needs, perceptions and expectations 189. All these aspects help in the patients´ recovery 190. In addition, a satisfied patient also gives some advantages to his/her doctor, since it creates a greater job satisfaction, reduces stress and reduces burnout 191.
Despite most doctors/nurses usually believe they are good communicators, there is always room for improvement, modifying or even eliminating some habits, or, in the same way, accentuating positive behaviors while removing the negative ones. Bearing in mind that ST is above and beyond a communicational tool, the relationship between doctor/nurses and patients (and their families) might be optimized by using ST. Studies revised in this context, especially those referred to ST training programs for professionals, highlight some circumstances in which ST can play a relevant role: prepare the "first" encounter with a patient, acquire skills in listening (listening is not a waste of time), transmit essential facts to patients in a comprehensible way (easy to understand), avoid cowing the patient, make eye contact (a significant nonverbal form of communication), do pedagogy (educate the patient), never overestimate the patient's ability to understand, talk the language of patients (do not rely on medicine's language) and doctors, who are human beings, so they may appear to be, from time to time, harried, unhappy, confused, ill adjusted, frustrated, etc., and they should not avoid touch the patient's shoulder for example 189,192.
Once again it is necessary to mention the WHO (2012) 13 when establishes that "a broad purpose of health education is not only to increase knowledge about personal health behavior but also to develop skills that demonstrate the political feasibility and organizational possibilities of various forms of action to address social, economic and environmental determinants of health".
Regarding health education, ST has emerged as an instrument that helps us in the learning and management of the disease by sharing experiences (an interaction between the one who relates and the listener, allowing the listener to conceptualize and create more valuable ideas) 14-17. When experiences are shared, new information, better strategies and better skills usually emerge. ST is a way of expression so telling stories can be a vehicle that breaks resistance to the messages promoting a healthy lifestyle, or that dilutes them to face behavioral changes 18 facilitating the incorporation of new behaviors that improve health or overcome the disease 19 as we mentioned above.
It seems that ST facilitates support for the disease by allowing patients to examine their emotions and problem-solving strategies, set objectives and exchange social support 24,25. Areas such as ST training programs (medical and nurse education), care and self-care in different contexts, sex and gender related topics, ageing, children and maternal problems, specific pathologies, oncology, drugs and sexually transmitted diseases, and general prevention topics, along with medical and scientific dissemination are promising fields of study in the future. Nowadays it is absolutely crucial to disseminate medical research making each new advance available to the general public.
Based on ST there is a perspective, which is the narrative medicine (or medicine practiced with narrative skills). In this way to practice medicine, the stories of patients and their caretakers are considered integral to the experience of ill health and healing. Despite Avrahami and Reis published their article in 2009 193, some of their conclusions are still valid: "While becoming quite visible in the literature, it still forms islands rather than bridgeheads. Its further propagation seems to await both more empirical work demonstrating clinical benefits and the maturation of different educational and practical approaches. And yet, narrative medicine education emerges as a pragmatic method of ensuring efficient implementation of evidence-based care precisely because it is the best bridge we have to date between the generalizations of scientific knowledge and the practical requirement of constantly adapting these generalizations to clinically unique situations.
