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Narrative Practices Among Global Health Fellows: A Needs Assessment for Future Curriculum Development


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Narrative Practices Among Global Health Fellows:

A Needs Assessment for Future Curriculum Development

Zachary G. Jacobs, MD1, Robin Tittle, MD, MS2, Joseph Scarpelli, MPH2, Karen Cortez2, Samuel Aptekar2, Sriram Shamasunder, MD, DTM&H1,2

1Division of Hospital Medicine, 2HEAL (Health, Equity, Action, Leadership) Initiative, University of California, San Francisco, CA



•Delivering healthcare in resource-limited settings can be isolating and challenging.
•Teaching narrative skills to healthcare providers can promote resiliency; global health is a potential niche for narrative training that has not been explored.1
•The HEAL Initiative (Health, Equity, Action, Leadership) is a two-year, inter-professional global health fellowship wherein healthcare providers engage in immersive clinical experiences at underserved sites, both domestically and internationally.
•At present, HEAL fellows are encouraged to blog about their experiences, but have limited formal training in reflective writing.
•To conduct a needs assessment for the development of a reflective writing curriculum via 1) survey and 2) qualitative assessment of written reflections.



•We surveyed first- and second-year HEAL fellows (N=61) electronically on the following:
1.Interest in additional narrative training;
2.Current reflective practices;
3.Perceived barriers to reflection;
4.Attitudes toward global health
•Surveys were administered mid-way through the academic year.

Blog Analysis

•We conducted a deductive content analysis of historical blog posts written by current and former fellows between 2013 and 2017.
•Blogs were coded independently by three reviewers (Z.G.J., K.C., S.A.) for the following:
1.One major theme;
2.One or more minor themes;
3.Degree of emotional disclosure (none, low, high)
•Each blog was assigned 1 major theme and ≥1 minor themes deductively from a codebook of 11 themes common to healthcare and global health (table 1).
•The codebook was adapted from a previously published study2 based on the core competencies of the HEAL curriculum.
•Discrepancies between reviewers were discussed until consensus was reached.

Table 1: themes used in deductive analysis of global health fellows’ blog posts, with RED text indicating those especially relevant to global health practice


Table 2: global health fellows’ survey responses to needs assessment on reflective writing practices (N= 47/61; response rate 77%)

Figure 1: fellows’ attitudes toward global health rated on a 5-point Likert scale

Figure 2: frequency of major and minor themes among global health fellows’ 31 blog posts



•Our study demonstrates that the majority of current global health fellows do not regularly practice reflective writing and are interested in receiving formal training.
•Common barriers were lack of time, lack of skill, and difficulty identifying a topic.
•Fellows recognized challenges such as isolation, frustration, and emotional exhaustion.
•Analysis of historical blog posts demonstrated that disparities, caregiving, ethics, and humanism accounted for the majority of thematic content, and that explicit emotional disclosure was rare.
•Future curricula should focus on overcoming barriers, broadening thematic content of reflections, and emboldening emotional disclosure/introspection.


1.Charon R et al. The Principles and Practice of Narrative Medicine. Oxford University Press, 2017.
2.Fischer MA et al. Comparison of blogged and written reflections in two medicine clerkships. Med Educ. 2011; 45: 166–175.
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