Many challenges are associated with communicating health messages to promote healthy behaviors and prevent cancer including limited health literacy levels, varied life experiences, and different learning styles. In this issue of Cancer Prevention Research, Chen and colleagues codeveloped personal, audiovisual digital stories using community-engaged, Digital Storytelling. Their goal was to improve the attitudes of and vaccination intention for human papillomavirus among Vietnamese American mothers of unvaccinated children ages 11–14. This spotlight discusses the implications of their results and further the broader use of stories as tools to promote health and prevent cancer—particularly in underserved minority and immigrant populations.

See related article, p. 465

The problem of human papillomavirus and human papillomavirus vaccination

In the United States, human papillomavirus (HPV) is a common virus that infects more than 42 million Americans (1) and can lead to cancers of the cervix, vulva, vagina, penis, anus, and oropharynx. The HPV vaccine protects against the types of HPV that most commonly cause these cancers. The Centers for Disease Control indicates that an estimated 92% of cancers caused by HPV could be prevented by getting the HPV vaccine; therefore, they recommend that all 11 or 12 year olds get the HPV vaccine before they are ever exposed to the virus. Vietnamese American (VA) females have one of the highest rates of cervical cancer mortality (18.9/100,000) compared with White American females (7.1/100,000) (2, 3). Unfortunately, only 9% of VA females have received the HPV vaccination (4). Therefore, effective interventions are needed to encourage parents to get their children vaccinated to prevent them from developing HPV-related cancers later in life.

In this issue of Cancer Prevention Research, Chen and colleagues (5) invite two immigrant VA mothers to cocreate personal digital stories as their primary approach to encourage VA children's vaccination. The resulting brief (3-minute long), first-person, audiovisual narratives include these mothers’ explanations of their own decision processes to vaccinate their children for HPV and incorporate digital images, audio recordings, music, and other text. The stories were created in both English and Vietnamese during a 2-day workshop. Importantly, following their creation, the stories were evaluated via anonymous pre/post surveys in a community sample of 114 VA mothers of unvaccinated children. This commentary will discuss the implications of this work as well as explore why stories and storytelling are useful tools that can be more broadly used to better promote health and prevent cancer and chronic diseases—particularly in populations that experience greater health inequities.

The challenge of health promotion

As the fields of health promotion and cancer prevention focus on keeping people healthy, high-quality tools that clearly communicate health messages are invaluable to engage and empower individuals and communities to choose healthier lifestyles and make positive behavior changes. Ultimately the hope is that these changes will lead to a reduced risk of developing cancer as well as other chronic diseases and comorbidities. While a plethora of health information is available to inform people's choices, much too often people have trouble accessing and processing this information. Indeed, the ability to understand the complexities of many health issues requires not only the ability to read and write, but also the capacity to meaningfully discuss and clarify confusing issues (a.k.a critical skills in health literacy). Approximately one-third of adults in the United States have limited health literacy (6), and limited health literacy is more common among racial and ethnic minorities, older adults, people with limited English skills, and those with less education and economic stability (7).

In addition to issues related to health literacy, people's capacity to understand health information may be further limited by the complexity of the health care system and/or the difficulty of the health issues themselves. Moreover, peoples’ abilities to understand complex information are influenced by many factors, including psychologic/emotional, educational, and sociocultural characteristics; age-related challenges; and life experiences (8). Differences in learning style also impact the most appropriate way to present health information.

In the educational literature, one model for describing learners’ strengths and preferences identifies learners as either linear or global. Linear learners are believed to have a sequential learning process and appreciate clearly explained and defined activities, schedules with deadlines, and “how to” pictures and/or examples (9). These learners might prefer health messaging with information about risk in numeric form presented using statistics and probability (10). In contrast, global learners commonly have a more holistic learning process and are more likely to benefit from learning through experience and reflection. Importantly, they are motivated by discovering new knowledge and understanding “why” a phenomenon exists so they can consider how they might personally apply the information (11). Numeric personal risk information is often more challenging for global learners (12).

Resources for health learning frequently favor linear learners because linear forms of information are often the default approach of the science and health professionals creating them. Stories such as those used by Chen and colleagues (5) naturally offer a more experiential learning experience that can benefit global learners and consequently heightens their health literacy (8).

Stories for health promotion

Stories are recognized but underutilized strategies in health promotion and prevention programming (13). Whether a factual telling of personal experiences, a recounting of a historical or community event, or a fictional tale, all stories are narratives: “a representation of connected events and characters that has an identifiable structure, is bounded in space and time, and contains implicit or explicit messages about the topic being addressed” (14).

The versatility of stories makes them valuable in a wide variety of settings. Health promotion stories can be read quietly, read aloud with others, listened to, or viewed. They can be shared in written or verbal formats and/or on digital platforms. They can be accompanied by images or presented in graphic or comic style formats. Importantly, while use of stories can benefit all learners, stories are especially useful in working with experiential and global learners, those with limited health literacy, and those typically underserved by traditional health communication approaches.

Furthermore, storytelling comes natural to most of us. Indeed, storytelling is one of the most ancient forms of human expression. Throughout history, the telling and sharing of stories has enabled reflection and healing across diverse cultural groups (15). In religious practice, academics, poetry, songwriting, and many other forms, stories are employed to teach and to help others remember hardships so that future generations may struggle less. Personal narratives are shared in our daily lives to communicate and engage with one another (16). We commonly use stories to share and accept information as well as to understand our own lives as well as the lives of those around us (17).

Story codesign

Stories can have the greatest impact when they are codesigned with representatives of the target population. Codesign is the active collaboration between researchers, designers, developers, and users as “experts of their experiences” (18) as they jointly explore and articulate needs and collectively explore and make solutions (19). Codesign of health promotion stories with representatives of the target community empower storytellers to use their significant experiences to promote and advocate for health and health equity in their own communities and communities like their own. Cocreating stories with community members across the lifespan can also encourage intergenerational interactions between participating members leading to more impact at the community level. These codesigned stories can focus on the varied experiences of people living, learning, working, playing, and praying in specific communities or neighborhoods. The codesign process ensures their relevance and meaning. Ultimately, users of the stories learn from the shared experiences of other community members “like me.” Importantly, the telling and sharing of stories not only benefits those receiving the stories, but also benefits storytellers. For example, creating a narrative around a personal experience with cancer can give storytellers an opportunity to think differently about those events which can lead to healing and greater insight into their health journeys (20).

Why stories work

Indeed, the use of stories in various forms, including storytelling and story sharing, have an ability to quicken perceptive insight and response and can support health literacy where other approaches fail (8). Stories help make complicated messages easier to understand. Research in neuroscience and psychology supports the use of stories as a powerful way to create engagement, improve learning, and influence behavior (21). Brain studies using functional MRI have shown similar activity when we hear a story as when we recall the story about ourselves (22). Others have shown that by listening to stories, our brains are activated in a manner that makes us believe that the ideas and experiences in the story are our own (22). After listening to character-driven stories, researchers have observed increases in oxytocin synthesis. Oxytocin is a chemical that enhances both empathy and motivates cooperation with others. Stories also augment the release of dopamine which keeps those receiving the stories engaged and regulates their emotional responses (23). Zak and colleagues explain that attentive listeners/readers/viewers “will come to share the emotions of the (story's) characters, and after it ends, (are more) likely to continue mimicking the feelings and behaviors of those characters.” (24) Thus, stories help people create greater personal meaning from what is shared and ultimately improve their understanding of critical points so that they can better recall these points over time.

Chen and colleagues’ Digital Storytelling approach

Chen and colleagues (5) used a Digital Storytelling (DST) approach to promote VA mothers’ intentions to vaccinate their children against HPV by the telling and sharing of their personal narratives. DST uniquely leverages technology to share the personal narratives of members of vulnerable, often underrepresented populations. The nature of the DST creation process has previously been show to result in digital stories that have greater linguistic and cultural significance, thereby better addressing health inequities that these groups’ experience (25).

Several theories have been suggested to explain how and why storytelling and specifically DST contributes to changes in health behaviors. Transportation theory is defined by Green (2006) as “an integrative melding of attention, imagery, and feelings focused on story events” (26). In DST, storytellers model how they have lived through an experience with the goal of helping others learn. On the other side, viewers focus on the digital story thus allowing them to become “carried away” by the story thus eliciting their own relevant feelings or responses (12).

According to a recent systematic review by Housten and colleagues (2021), even though people with limited health literacy often have difficultly navigating care across the cancer continuum (e.g., prevention, screening, diagnosis, treatment), evidence-based programming to support people with limited health literacy in the context of cancer is woefully inadequate (27). Using DST, Chen and colleagues (5) are helping VA mothers overcome challenges with health literacy related to HPV vaccination. Indeed, Chen and colleagues observed significant attitude changes among the community of VA mothers after viewing their representatives’ digital stories; and 74% of them indicated that they intended to vaccinate their children against HPV afterintervention compared with 53% prior to the intervention. The difference was large (OR = 9.12; Cohen g = 0.40) and statistically significant (P < 0.001). The observed increase in mothers’ intention to vaccinate provides support for the potential effectiveness of using digital stories (and other story-based interventions) as a method to promote HPV vaccination. Importantly, the study's findings open the door for future broader testing of the approach to determine whether vaccination rates will significantly improve after intervention.

Conclusions and future implications

The success of Chen and colleagues’ (5) community codesigned Digital Storytelling approach has broad applicability for health promotion and cancer prevention efforts. The codesign of health outreach stories tends to build trust therefore the collective effort can result in stronger partnerships between communities, cancer-focused and public health practitioners, and researchers alike, particularly when partnering with communities experiencing substantial cancer inequities such as minorities and immigrant populations. While Chen and colleagues used stories to promote intention to vaccinate, others have used stories for health outreach in areas such as colorectal cancer screening (10) and breast cancer survivor support (13, 28). Stories might also be useful in supporting cancer survivors in other ways including encouraging them to regularly interact with their primary care physicians, better comply with physician recommendations, seek recommended screens for second primary cancers, and assist with understanding of discharge instructions. Importantly, stories can also be used to support cancer research. For example, they can be used to improve research advocacy efforts by helping community advocates to explain the research process more easily to would-be research participants, enable new research participants to better understand the study they are consenting to and remind participants of longitudinal studies of the reasons why they need to return for follow-up visits (thus increasing study retention). Moreover, inclusion of explanations of medical and scientific information using accompanying images can further improve people's understanding of the complex materials they encounter. Future research is needed to purposely develop and thereafter evaluate these kinds of efforts so that others too can see stories’ potential value to the field of health promotion and cancer prevention.

No disclosures were reported.

M. Butsch Kovacic: Conceptualization, resources, writing–original draft, writing–review and editing. S.E. Gertz: Conceptualization, writing–review and editing.

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