Using Narrative Research As a Tool for Understanding Health Disparities

Background and Purpose: African-American women have a 41% greater chance of dying from breast cancer than white women, even though White women have a higher incidence of breast cancer than African American women. Racial and ethnic disparities in the initiation of recommended breast cancer treatments are well documented and likely contribute to the inferior mortality outcomes observed between African American and White women. The purpose of this paper is to discuss the strengths of narrative research as a tool for understanding health disparities, and to provide an example of its use in social work research with a population of African American breast cancer survivors.

Methods:Riessman (2008) describes narrative research as interpreting text from a story the participant wants to tell, paying particular attention to the chronological order of the information. The approach chosen for the present study is to interview and gather the personal experiences of a set of participants and retell their story based on narrative features, such as the five elements of plot: characters, setting, problem, actions, and resolutions. Next, the narrative researcher rewrites the stories into chronological sequence, paying careful attention to incorporating the context or environment of the participant. For the present study, an adaptation of the life history grid by Elliott (2005), a treatment history timeline, was developed by the study authors to provide a framework to analyze the stories participants relayed in interviews.

The sample included African American breast cancer survivors from the eight zip codes in a large midwestern metropolitan area with the highest breast cancer mortality. In-home semi-structured interviews were completed with 96 women. Interview questions were designed to collect treatment history in the survivors’ own voice. Key domains included determining the course of breast cancer treatment, identifying key points at which women dropped out of treatment, and identifying unmet needs. The results were analyzed in a chronological order in order to convey breast cancer treatment patterns and points where women discontinue or delay treatment.

Findings: Through the use of a treatment history timeline, the authors were able to map the system of treatment pathways experienced by breast cancer patients through a complex healthcare system that includes community hospitals, federally qualified health clinics and a comprehensive cancer center. The analysis of the treatment history timelines also identified areas in the system of healthcare delivery that posed challenges to timely initiation of treatment from the perspective of the patient. Specifically, while women may complete surgery, the number of women who reported undergoing radiation, reconstructive surgery or taking adjuvant chemotherapeutic therapies was low. Women reported economic, social and cultural barriers to access for these prescribed treatments.

Conclusions and Implications. Narrative research produces a different type of knowledge than other approaches to qualitative research that is useful in informing changes at multiple levels. Collected and analyzed carefully, a narrative approach can provide a link between individual experiences, social and economic context, and insight into the social influences on health disparities.