Actor–doctor partnership for theatre-based public health education

Abstract

Background:

Limited evidence exists on the effectiveness of using an entertainment-education methodology to address multiple public health issues and of using participatory street theatre to improve public understanding related to public health.

Objective:

To assess the feasibility, acceptability and impact of the Actor–Doctor project, an intervention involving theatre professionals and medical specialists to jointly deliver street-theatre-based public health education.

Design:

A real-world, mixed-methods post-intervention study evaluated the Actor–Doctor project among 486 participants in Ahmedabad, India, in 2017.

Setting and method:

Focus group discussions with actors and semi-structured interviews with doctors and implementers assessed project feasibility, acceptability and perceived impact. Post-intervention surveys among actors, audience and a control group assessed impact on knowledge and attitudes related to select public health issues. Quantitative data were analysed using multivariable regression, and qualitative data were analysed using an inductive thematic analysis.

Results:

The Actor–Doctor project was feasible to implement, as 20 street theatre performances on five public health themes were developed and staged. Members of the audience showed higher knowledge of environmental health, anaemia and openness to discussing sexual health issues, compared to a control group (omega squared 0.03–0.24; p < .001). Actors and doctors collaborating to create theatre-based public health education derived satisfaction from the project. Balancing scientific accuracy and entertainment, especially humour was challenging.

Conclusion:

The Actor–Doctor project was instrumental in improving public-health-related engagement between actors, doctors and the public.

Keywords

Community outreach entertainment-education health literacy public engagement street theatre

Background

Researchers have an ethical imperative to disseminate information to the public, who are unlikely to be able to access scientific publications (Chen et al., 2010). Entertainment-education involves purposively designing and implementing communication that entertains and educates people in order to enable pro-social behaviour change (Bouman, 1999). Globally, entertainment-education is a communication strategy that has been used to attract and engage the public on individual health issues such as blood pressure, smoking, vaccine promotion, family planning and HIV prevention among other issues (Daykin et al., 2008; Joronen et al., 2008; Tufte, 2005). However, there is limited evidence concerning the effectiveness of a common entertainment-education methodology to address multiple health issues that we explore in this study through the Actor–Doctor project.

The use of community-based participatory approaches in entertainment-education has the potential to involve communities to directly shape their engagement with scientific research, and ensure that content and cultural elements closely align to community needs. Some participatory entertainment-education projects have demonstrated evidence of impact, for example using a telenovela format improved contraception, family planning and HIV prevention in low- and middle-income countries (Bouman, 1999), and theatre and song-based interventions have reduced prejudice and stereotypes related to mental-health-related stigma in high-income settings (Gilfoy and Young, 2001; Paukste and Harris, 2015; Rowe et al., 2013; Twardzicki, 2008). In addition, since the 1960s, Theatre-in-Education has been used as a pedagogy and strategy generating ‘immediacy of concern’ and is a ‘primary cause of energy surges in learning’, by establishing a connection between actors and an audience (Wooster, 2007). However, there is a lack of evidence of the effectiveness of using participatory approaches in entertainment-education (Tufte, 2005), including Theatre-in-Education.

In India, participatory entertainment-education strategies have been developed. Local artists have performed pre-scripted folk theatre on subjects such as malaria (Ghosh et al., 2006) and provided theatre workshops on reproductive health (Harter et al., 2007). Medical students have also developed street theatre to sensitise others to the challenges in medical education (Gupta and Singh, 2011). However, evaluation of these studies did not measure impact on knowledge or behavioural intent among participants. Thus, although street theatre is envisioned as a participatory tool for social change in public health (Das and Rabb, 2012), there is debate concerning its success in galvanising public concern and involvement (Mallick et al., 1997).

Street theatre is a common entertainment-education component in programmes that have been successful in changing gender norms (Barker et al., 2010), hygiene behaviours (Biran et al., 2014) and HIV-related sex and sexuality education (Van Rompay et al., 2008). It aims to develop social attitudes (Srampickal, 1994) and has the advantage of overcoming literacy barriers, using local experiences and provoking emotional and analytic responses by an audience (Mbizvo, 2006). The potential for using street theatre was demonstrated in a recent multi-component study in rural India, which found that the public preferred to receive information related to mental disorders through street plays (Maulik et al., 2018).

Lack of evidence of the effectiveness of participatory, street-theatre-based public health education to address multiple health issues in India prompted the development of the Actor–Doctor project, a street theatre project to improve public understanding of multiple public health issues. This study provides preliminary data on the feasibility of collaboration between artists and medical professionals to jointly develop street theatre on multiple public health issues; the acceptability of developing street-theatre-based public health education among actors and doctors; and the impact of the Actor–Doctor project on understanding of public health messages by actors and members of the audience at street theatre performances. The project took place in Ahmedabad, India.

Method

Study design

A mixed-methods post-intervention study design was used to evaluate the work of the project over a 6-month period in 2017. Data were collected after the Actor–Doctor intervention was complete in a retrospective study. Quantitative data were collected from actors, members of the audience and a control group using post-intervention surveys to assess knowledge, attitudes and intended behaviour. Qualitative data on feasibility, acceptability and self-reported impact on knowledge, attitudes and intended behaviour related to five public health themes were collected through two focus group discussions with actors, five telephone surveys with doctors and three semi-structured interviews with programme manager/implementers.

Participant recruitment

Actors volunteered to participate and were recruited via poster advertisements. The audience comprised people who volunteered to attend street plays performed by actors at varied locations. The control group comprised people who were contacted through door-to-door household visits, located at least 15 kilometres away from street play performance locations.

Intervention design

The intervention – Actors and Doctors: Staging Public Health Matters – was developed as a collaboration between performing artists and medical specialists. Five public health themes were selected through brainstorming sessions with doctors and social activists, and previous experience at Darpana, a leading arts training and performance centre.

Steps involved in developing the project included (1) a public competition to create public health theatre performances that attracted local theatre groups and college students; (2) 2-day training of 30 volunteers on creating impactful theatre performances related to public health, by doctors and experienced artists; (3) volunteers developing 12 scripts and concept notes corresponding to five public health issues; (4) the selection of the top five scripts based on accuracy and relevance of public health messages, cultural appropriateness, entertainment quotient, sensitivity to vulnerable groups, originality and creativity; and (5) teams of volunteers (actors) interacting with medical specialists (doctors) over a period of 1 month to receive at least two rounds of feedback on scripts and to finalise street play performances. Steps 2 to 5 involved mentorship by Darpana on script-writing, acting and presenting a complete performance, including scientific messages, in an engaging storyline.

Measures

Demographic data were collected on age, gender, level of education and occupation.

Feasibility of the Actor–Doctor project

Indicators of study feasibility include achieving project milestones and operational aspects of the study such as recruitment of participants (actors, audience and control group); completion of training, actors developing and staging performances; and completion of data collection. Topic guides for focus group discussions with actors and interviews with doctors included probes about time commitment and ease of communication/understanding.

Acceptability of the Actor–Doctor project

Focus group discussions were conducted using a topic guide, comprising questions and probes to examine actors perceptions of the intervention process and outcomes (see online supplementary file for the topic guide). Topic guides for focus group discussions with actors and interviews with doctors asked about their experiences; perceptions about usefulness of the project for actors, doctors and audience; challenges related to each step in the Actor–Doctor project (training, scripting, collaborative refinement of scripts, rehearsal and final performances); and recommendations to improve project activities.

Impact on understanding of public health issues

Based on the content of public health messages in each street play, we selected relevant items related to knowledge, attitudes and intended behaviour from validated survey instruments to assess whether the play would likely have any impact on these outcomes (Table 1). As the length of time available to complete the survey was short, we were unable to include complete scales for each public health theme and selected individual items instead. The topic guide for focus group discussions assessed actors self-reported knowledge, attitudes and intended behaviour related to their chosen public health theme, before and after the project.

Table 1.

Post-intervention survey measures.

Public health issue	Survey instruments	Rationale for use
Mental health: prevention of depression (lack of self-worth, external pressures)	Rosenberg Self-Esteem Scale (Robins et al., 2001)	• Brevity • Widely used scale, including in India (Schmitt and Allik, 2005)
	Depression Attitude Questionnaire (R-DAQ) (Haddad et al., 2015)	• Simple wording • Previously used in India (Desai et al., 2018)
Mental health stigma and suicide	Items 5–8. Reported and Intended Behaviour Scale (RIBS) (Evans-Lacko et al., 2011)	• Brevity • Measures intended behaviour rather than attitude alone • Previously used in India (Maulik et al., 2018)
Mental health stigma and suicide	Items 9–11. Suicide Opinion Questionnaire (Anderson et al., 2008; Rogers and DeShon, 1992)	• Widely used • Previously used in India (Nebhinani et al., 2016)
Environmental health: How shall we change?	Environmental Knowledge Scale (Gambro and Switzky, 1996)	• Validated in the USA, items included for simplicity • Used with high school students and likely to be easy to understand
	Children’s Environmental Attitude and Knowledge Scale (CHEAKS) (Leeming et al., 1995)	• Global application (Duerden and Witt, 2010; Pe’er et al., 2007) • Suitable among adolescents (Taff et al., 2010)
	Attitudes and behaviours towards energy consumption (Paço and Lavrador, 2017)	• Individual item related to plastic. Use of plastic is widely reported in Indian media and is currently banned in India.
Sex education: Silence and misconceptions	Contraception and risk behaviour (Centers for Disease Control and Prevention, 2017)	• Applied in annual national surveys in the USA • Simple wording • Responses ask participants to reflect on intended and actual behaviour
Sex education: Silence and misconceptions	Safe sex behaviour measures (DiIorio et al., 1992)	• Previously used in India (Rappai, 2005) • Assesses risky behaviours and assertiveness in taking protective measures
Gender barriers in meeting nutritional needs of girls and women	Items 5–7. Baseline Nutrition and Food Security Survey (Ministry of Health − Albania, 2012)	• Applied in Albania, an upper-middle-income country
	Item 8. National Family Health Survey–3 (India) (Tiwari, 2013)	• National survey in India • Assesses actual differential in food consumption, which may be compared by gender

Data collection procedures

After completion of all street plays, focus group discussions were conducted with the actors by the first and second author (average duration of 1 hour) and interviews were conducted by the first author with doctors (average duration of 30–45 minutes each). Immediately after the performance of the street plays, actors contacted every fifth member of the audience and the control group to administer post-intervention surveys. Actors orally translated the survey to the local language (Gujarati), as necessary. Actors self-administered the same post-intervention survey following the completion of all street play performances in English. On average, it took 5 to 7 minutes to complete a survey.

Data analysis

Participant characteristics were used to describe the study sample. Quantitative responses to the survey were analysed by study group, that is, actors, members of the audience and control group, as the level of exposure and engagement with public health messages differed. Effect sizes for difference in proportions (related to knowledge, attitudes and behaviour) between members of the audience and control group were calculated as omega-squared (Olejnik and Algina, 2003) in order to address likely variations in population sizes at between audience and control group, and to account for small samples.

Although the significance level was set to ⩽.05, exact p values are reported for completeness in the absence of prior comparative data from studies examining the statistical effects of a theatre-based methodology. Quantitative analyses were conducted using STATA 13 (StataCorp LP, 2007). A thematic analysis was conducted for each focus group discussion and interview transcript to inductively generate categories and conceptual themes (Braun and Clarke, 2012). Data were triangulated and presented based on study objectives and qualitative themes emerging. We used the COREQ criteria for reporting qualitative studies (see supplementary material).

Ethical approval

An ethical exemption waiver for this study was granted by the Indian Council of Medical Research – Regional Medical Research Centre (ICMR-RMRCBB) Bhubaneshwar, Orissa, India (ICMR-RMRCB/IHEC-2019/035) on the grounds that it was a low-risk behavioural study. Participation in this study was voluntary, anonymous, with oral informed consent and the benefit of improving understanding about public health issues. Doctors and social activists reviewed the street theatre prior to public performance and were also physically present to observe any signs of distress among the audience as unintended outcomes.

Results

Study intervention groups included actors (n = 29), members of the audience who watched a street theatre performance on any public health issue (n = 181) and members of a control group who did not receive any intervention (n = 271). The mean age of the actors was 24.03 (± 3.55) years, the mean age of the audience was 21.51 (±11.66) years, and the mean age of the control group was 24.11 (±11.44) years. Members of the audience were significantly older than the control group (t = 2.34, 95% confidence interval = 0.41–4.76; p = .019). Most actors were men (83%). In comparison to the control group (56%), significantly more members of the audience were women (60%) (χ² = 10.77; p = .001). The actors comprised 13 professional artists, seven college students, five service professionals and three businessmen. Most participants in the audience (83%) and control group (64%) were currently enrolled school and college students.

Feasibility of the Actor–Doctor project

Achievement of project milestones indicated that the Actor–Doctor project was feasible to implement. Through the Actor–Doctor project, 29 actors created 20 performances on five public health themes to reach 1,350 members of the audience in Ahmedabad.

The public health themes selected were depression prevention (self-worth, managing external pressures), treatment of people with mental health disorders and suicide prevention, environmental health, sex education, and gender barriers to nutrition of girls and women. For each theme, an average of six actors reached an audience of 225 members. The performance on sexual health education was delayed due to protests by specific groups around Valentine’s Day that sexual health education was against Indian family and social values. Ultimately, this particular performance was held at a school. The lowest audience turnout was at the performance on sex education and the highest was at the performance on gender barriers to achieving adequate nutrition.

Data collection among actors, doctors and implementers was completed within 2 weeks post-intervention. Although it had been planned to collect data from every fifth member of the audience, data were collected only from every sixth member of the audience due to the audience leaving soon after the performance. Approximately 18% of members of the audience gave incomplete responses, which were then excluded from this study.

The experience of doctors was generally positive, although there was scope for additional support so that they could more effectively partner with actors. As providers of scientific knowledge to improve scripts and performances, doctors provided time for script reviews and guidance. Overall, three doctors felt that they would have liked to have had more time to go into greater depth about the relevant health issues with the actors, and two doctors found it difficult to explain the subject matter in simple terms.

Acceptability of the Actor–Doctor project

Actors and doctors identified a number of factors that motivated them to join the project and continue their engagement with it.

Making a difference to the community

By learning about public health challenges and urban poverty, actors took pride in being sensitive and empathetic. Actors felt that enhancing awareness about public health issues could potentially inspire change, especially if they talked about social taboos and used creative media:

I found it very striking and felt I should get involved in this activity because this seemed like a good way to work in slum areas, feel their problems and issues and try and bring about a change . . .’ (FGD2, R5, female actor)

On this topic [sexual health], there is no acceptance by the public . . . for example, I couldn’t even talk about this to my younger brothers, like condoms! But, during the project . . . I felt it was very important to . . . speak about . . . diseases related to sex and precautions one must take. (FGD2, R9, male actor)

People would have learned about mental health through lectures . . . motivational speaker-led videos, but street plays have not been used. (FGD1, R4, male actor)

Four out of five doctors felt that the project provided them with a sense of satisfaction because they felt they were going beyond the call of duty, that their role as an expert was valued and that actors asked questions. Overall, doctors described the project as ‘egalitarian’, stating that the project facilitated public information-sharing that they often feel constrained to do.

Really good initiative for creating awareness, for bursting myths, very good method and idea to reach out. We know the facts, but as a doctor, there are limitations to reach out especially even if we want to. With a partner, it is made possible. (Semi-structured interview, R3, psychiatrist advising the actors preparing a street play on depression)

Relevance to prior experiences and learning about public health issues

During the process of developing scripts and performances, actors recalled personal experiences relevant to the public health theme they were working on. They expressed enhanced self-awareness as they identified or introspected into characters emotions and the situations they found themselves in.

I’ve seen a suicide from very close quarters. My uncle did it. No one knows why . . . he told no one what he was going through. Had he told others . . .’ (FGD1, R3, male actor)

. . . gets very angry or depressed or doesn’t talk to anyone or sits alone . . . Now, after the play I feel he also needs me. (FGD1, R6, male actor)

Actors described how training and collaboration with doctors strengthened their understanding of public health issues and, therefore, the street theatre scripts.

They gave basic facts, correct facts, what symptoms . . . they were accurate, confirmed. We can show wrong stuff too. We had Google, but not all questions can be answered by Google. We learned from doctors what to convey as the topics were quite vast. (FGD1, R2, male actor)

One doctor expressed how she was able to understand more about addressing lay perceptions through her meetings with actors.

This was a really interesting and new experience for me and I myself learned a lot in the importance of better communication skills for doctors. I have asked the actors to keep in touch for any help they would require in the future. (Semi-structured interview, R1, heart specialist advising the actors preparing a street play on nutrition)

Improving artistic skills and credibility

An actor said, ‘to explain something, you need to learn something first’. Actors previous work had on the whole related to historical or mythological theatrical work rather than developing content for a slice-of-life theatre. They found the process of creating science-based communication more engaging and challenging than ‘pure theatre’ because artistically, they felt the need to prioritise clear public health messages and balance entertainment elements with impact in a street play of short duration. Actors introduced interactive techniques such as freeze-frames, which involved stopping the performance and asking questions about specific characters responses to assess audience understanding during the performances.

We were making changes. Making it crisp in a dialogue. The message had to go in full. That was difficult. Three times we made changes. We tried to retain reality, not make it too positive. Then, the public should stay there and stop. If there’s a disconnect (with the audience), even for a second, they leave. (FGD1, R5, male actor)

Actors expressed that traditional reverence for doctors and health-related knowledge was an additional pull-factor towards the project. In addition, the project’s name, Actor–Doctor, aroused curiosity. Actors perceived an association with a leading arts centre and researchers as factors that would enhance their artistic credibility in street theatre and in creating impactful entertainment.

Most doctors had previously never been involved in any theatre-based activity or iterative message development. One doctor spoke about her experience of working with actors to balance accuracy in messages with entertaining elements, a factor that was improved upon through mentorship by Darpana and continuous engagement with actors:

I was surprised how serious they were about the issue and almost scared of offending someone, which made their play quite preachy. Ironically, in subsequent meetings, I helped them make their skit more entertaining. (Semi-structured interview, R5, gynaecologist, obstetrician and urogynaecologist advising the actors preparing a street play on sex education)

Satisfaction from performance and public outreach

Actors described the audience as appreciative, receptive, visibly enjoying the performances and asking questions at the end of performances. Actors felt a sense of achievement when audiences indicated that public-health-related messages included in street theatre performances were understood:

A girl came to me . . . and said – my father is facing this . . . she said she changed her thinking about how to consider this problem . . . (FGD1, R7, male actor)

. . . the audience really appreciated our humour and when we asked them, they said that we got the message – in our family there is differentiation between girls and boys for nutrition . . . (so) they also enjoyed, and later clapped for us again! (FGD2, R3, male actor)

To a limited extent, the audience response affected the morale of actors. Actors found audience turnout and participation were lower among educated or older audience members. Actors also reported that audience response to some public health issues was stronger than others:

Sex education performances could not take place for some time because there was resistance to it. [But] ultimately we went ahead. (FGD2, R6, male actor)

Three out of five doctors felt that developing theatrical plays was new. At the initial training workshop, doctors felt that actors held several myths related to the public health issue that they were aiming to create a performance on, but by the end of the project, actors had shifted from basic knowledge to accurately portraying scientific information in interesting plays that resonated with the public. One doctor suggested that she would like the project to scale up beyond ‘a one-off exercise’ to involve additional public health issues.

Impact of public health messages

On actors

Post-intervention, actors involved in the Actor–Doctor project indicated having learned about the public health issues involved in street theatre performances.

Following the intervention, five out of the eight actors working on the prevention of depression street play reported higher than average self-esteem. After the intervention, only three actors still believed that depression was caused by lack of self-discipline and will power. Although half the actors understood that depression and suicide were linked, the feeling that people who commit suicide are cowards remained among actors.

Among actors, some gaps in understanding remained. For example, most actors who worked on the theme of environmental health did not agree that the way they personally used energy made a difference to the national energy situation. Two actors working on gender as a barrier to nutrition expressed an interest in learning more about meeting family nutritional needs. Overall, actors described how the Actor–Doctor project prompted them to research a public-health-related subject in depth:

First of all, we were not aware of the seriousness of this topic . . . we visited some organisations . . . working in this area for the past 30–35 years . . . our team worked with them and visited these areas. And, studied their research documents, papers and reports. They gave us a lot of material – videos, documentaries . . . in the process we realised that there are a lot of things we ourselves don’t know. So, we studied all this and then readied a kit for ourselves (and) following that we starting designing our script . . . In general, we don’t give much emphasis on nutrition for women. (FGD2, R1, male actor)

One actor suggested that he felt that the Actor–Doctor project first targeted actors with key messages and used the change they experienced to spread the word to others:

The play and performance was for the audience. But it affected us as much. If it affects us, we can convey it more effectively. (FGD2, R1, male actor)

On the audience and control group

Members of the audience, after watching the respective street theatre performances, were significantly more favourable towards oral supplementation to reduce anaemia and environmental health (particularly the ill-effects of plastic and coal) compared to the control group (Table 2). Similar to actors, members of the audience also did not agree that the way that they personally used energy made a difference to the national energy situation, although members of the control group had a better understanding of this concept.

Table 2.

Desirable response to public health issues, by study group (%).

Public health issues	Audience (n = 181)	Control group (n = 271)	Omega-squared^a	p value*
Depression and self-esteem	n = 70	n = 70
Prolonged sadness could require a doctor’s intervention	60.00	55.71	0.01	.223
Lack of self-discipline and will power does not cause depression	17.14	14.28	0.01	.685
Depression is a disease like any other	51.42	61.42	<0.01	.364
High self-esteem (⩽4 on a scale of 1–7)	85.71	84.28	0.02	.941
Mental health problems: Stigma and suicidality	n = 52	n = 21
In the future, I would be willing to live with a person who has a mental health problem	57.69	57.14	0.01	.327
In the future, I would be willing to work with a person who has a mental health problem	65.38	71.42	<0.01	.570
In the future, I would be willing to live near a person who has a mental health problem	57.69	47.61	0.02	.262
In the future, I would be willing to continue a relationship with a person who has a mental health problem	75.00	76.19	<0.01	.406
I would not feel ashamed if a member of my family committed suicide	34.61	47.61	0.07	.066
Individuals who are depressed are more likely to commit suicide	42.30	61.90	<0.01	.517
Those who commit suicide are not cowards	48.07	38.09	0.09	.073
Environmental health	n = 68	n = 75
The burning of coal releases pollutants into the air	88.23	81.33	0.24	<.001*
Traditional plastic bags do not decompose in landfills	32.35	30.66	0.17	<.001*
The way I personally use energy makes a difference to the national energy situation	23.52	30.66	0.17	<.001*
Sexual health	n = 9	n = 57
In the past 12 months, I have not had anal/vaginal sex without using a condom	100.00	87.71	0.13	.014*
In the future, I will not likely have anal/vaginal sex without using a condom	88.88	94.73	0.03	.200
It is not difficult for me to discuss sexual issues with my sexual partners	100.00	40.35	0.18	.004*
Multiple sexual partners are desirable	44.44	35.08	0.09	.053
I will ask my potential sexual partners about their history of IV drug use	66.67	91.22	0.01	.320
Gender barriers to nutrition of girls and women	n = 11	n = 48
Women participate in decisions about how food is consumed by the family	63.63	77.08	0.76	.105
Diet and oral supplements can help to avoid anaemia	9.09	54.16	0.22	.001*
In my family, we consume more than one source of protein	90.90	56.25	0.02	.261

Effect size adjusted for confounding by age, gender, highest level of education completed and current occupation.

Statistical significance at p < .05.

Post-performance group discussion and one-to-one interactions suggested members of the audience were interested and comfortable to learn more. The audience shared their observations about the mind-set and behaviour of different characters in street plays and were able to identify learning related to each public health issue. Some members of the audience also recalled personal experiences related to the issues showcased and described past events. During performances related to mental health, several members of the audience reached out to the actors, seeking guidance for their personal mental health issues. Those doing so were referred to specialists and collaborating doctors.

Discussion

Actors and doctors involved in the project developed five street plays and staged 20 theatrical performances for public health education. The Actor–Doctor project was feasible to implement, engaging, challenging and satisfying for both actors and doctors. Actors and doctors expressed how they felt engaged and satisfied from collaboratively developing and showcasing street play performances aimed at public health education. Actors cited how their interest in public health was heightened by the opportunity to understand prior health-related experiences, an artistic motive to improve communication skills and to gain credibility through association with other artists and doctors. Doctors were engaged by the prospect of reaching a wider population with preventive messages. Post-performance, members of the audience showed better knowledge and attitudes towards sexual health, anaemia prevention and environmental health compared to the control group.

This is the first study from India measuring the impact of a collaborative partnership between actors and doctors, thereby generating evidence to inform future participatory theatre-based public health education methodology. In the majority of responses related to knowledge, attitudes and intended behaviour on the five public health themes, there was little difference between responses of the audience, compared to the control group. Our study shows that knowledge and attitudes of the audience and control group were not as easy to change across all public health issues, that is, no changes were noted for themes related to depression and self-esteem and mental-health-related stigma and suicidality. At the same time, qualitative data on acceptability show that the Actor–Doctor intervention design used here is appropriate to discuss multiple health issues.

Experience implementing the Actor–Doctor project highlighted a long-standing challenge in entertainment-education: namely, the need to balance clarity of messaging with attractive content. During the course of the work, a role-reversal between actors and doctors took place. At the start of the project, actors placed lower emphasis on technicality, often reducing big ideas to simplistic and sometimes incorrect messages. This approach may have been due to the demands of street theatre: short duration, the use of informal language and highly localised, context-specific messages. Doctors in contrast started by being overly cautious, often using technical jargon. By the end of the project, however, doctors were asking actors to add in more fun and humour, while actors wanted to convey simple technical messages to the extent that doctors felt they were ‘spoon-feeding’ the audience. Mentorship by the experienced theatre artists from Darpana played an important role in developing performances that communicated scientific information without the loss of artistic or aesthetic quality. By working together over time, performances were able to retain colloquial and humorous elements, while sharing important messages.

Limitations

Our study goal related to public engagement and was informed by the experience of artists conducting street theatre performances. Thus, a pragmatic survey study was designed, which placed emphasis on attracting audience members and making them stay for the performance. Due to resource and pragmatic constraints, it was not feasible for actors involved in the performance to collect baseline, post-intervention and follow-up surveys with the audience at a later date. Other studies assessing the impact of street theatre rely on an extensive project network to reconnect with members of the audience (Pelto and Singh, 2010). Furthermore, marketplaces were a prime location of performances to reach a wider and more diverse audience but members of the audience had limited time to spend watching the performances. Overall, the absence of a baseline prevented between-group and within-group impact analysis to assess effectiveness of the intervention among all study groups. Furthermore, the evaluation design was conceptualised and developed retrospectively. Future studies should include a baseline and ensure the early and ongoing involvement of personnel trained in health communication evaluation.

Conclusion

The Actor–Doctor project has the potential to be scaled up across multiple locations to engage with a range of public health issues. Alternatively, the work undertaken here may have a place in a national public health theatre festival. Such a festival might provide an opportunity to local artists or those using lesser known folk art forms to engage and collaborate with doctors to generate theatre better suited for low-resource contexts.

In future work, additional drama techniques such as the use of theatre of the oppressed, may be useful to engage with health inequities and the social determinants of health (Singh et al., 2012). Furthermore, the social media space may be used to showcase performances and as a platform for connecting with a wider audience. This may be especially appropriate when engaging with sensitive issues such as sexual health.

Overall, the Actor–Doctor project was successful in fostering collaboration between artists and doctors to generate participatory public health theatre. The methodology used in the Actor–Doctor project provides preliminary evidence that knowledge and attitudes related to multiple public health issues improved, particularly related to sexual health, environmental health and anaemia prevention. While it was challenging for actors and doctors to balance aesthetics/entertainment with public health messaging, good quality scientific content was created and to a degree conveyed.

Supplemental Material

HEJ-20-0052_supplementary_file_(2) – Supplemental material for Actor–doctor partnership for theatre-based public health education

Supplemental material, HEJ-20-0052_supplementary_file_(2) for Actor–doctor partnership for theatre-based public health education by Kartik Sharma, Shivani Mathur Gaiha, Sanghamitra Pati and Mallika Sarabhai in Health Education Journal

Footnotes

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article. The Project was funded by Wellcome Trust-DBT India Alliance an initiative of Wellcome Trust, UK and Department of Biotechnology, India.

ORCID iD

Kartik Sharma

Supplemental material

Supplemental material for this article is available online.

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