Engaging Indigenous youth through popular theatre: Knowledge mobilization of Indigenous peoples’ perspectives on access to healthcare services

Abstract

In Canada, Indigenous peoples bear a greater burden of illness and suffer disproportionate health disparities compared to non-Indigenous people. Difficult access to healthcare services has contributed to this gap. In this article, we present findings from a dissemination grant aimed to engage Indigenous youth in popular theatre to explore inequities in access to health services for Indigenous people in a Western province in Canada. Following an Indigenous and action research approach, we undertook popular theatre as a means to disseminate our research findings. Popular theatre allows audience members to engage with a scene relevant to their own personal situation and to intervene during the performance to create multiple ways of critically understanding and reacting to a difficult situation. Using popular theatre was successful in generating discussion and engaging the community and healthcare professionals to discuss next steps to increasing access to healthcare services. Popular theatre and short dramas provide a venue for mirroring stigmatized care and expose racial biases in the delivery of care. The contributions of the students, their input, and their acting were to increase our awareness even more of the pervasiveness of the stigmatized care that Indigenous people experience.

Keywords

Indigenous people popular theatre action research access to healthcare inequities in health

Historically, research with vulnerable groups experiencing health inequities has been problematic (Quinlan, 2009; Smith, 2012). The imposition of research agendas and failure to engage research participants at the very onset of a research project can yield findings that are incomplete and misrepresent the knowledge and resources of those being researched (Wilson & Neville, 2009). For example, throughout the world, Indigenous groups have been studied to their detriment, often without proper representation or rights during the research process, or interpretation and use of resulting data (Moodie, 2010; Smith, 2012). The imposition of western research epistemologies, methods, and ethics that exclude traditional approaches and the implicit construction of knowledge is called “epistemological domination” (Wilson & Neville, 2009). According to Smith (2012), for Indigenous peoples, epistemological domination represents another form of colonization as often in the process of research Indigenous people are seen as the Other and not as equals (Smith, 2012; Wilson & Neville, 2009). To fight epistemological domination, Indigenous scholars have delineated elements that are deemed integral to the conduct of respectful and ethical research with Indigenous peoples, namely respect, responsibility, relevance, and reciprocity (Kirkness & Barnhardt, 2001; Weber-Pillwax, 1999). Attention to these elements as well as recognition of an Indigenous research paradigm has fostered in Indigenous communities the conduct of research that “emanates from, honors, and illuminates their world views and perspectives” (Bourque-Bearskin, Cameron, King, & Pillwax, 2016; Wilson, 2003, pp. 169–170). Conducting research with Indigenous peoples also demands that researchers develop “a stronger sense of professional and ethical accountability” as so easily the so-called “unconscious irresponsibility” releases them from the harmful effects of their actions on Indigenous peoples (Weber-Pillwax, 1999, p. 38). In our research experience, Indigenous methodologies and community-based approaches have offered us a venue to attain a contextualized and rich understanding of access to healthcare services (Cameron, Camargo Plazas, Santos Salas, Bourque-Bearskin, & Hungler, 2014). We acknowledge that the production of expert knowledge is being re-conceptualized by the changing social, economic and political landscape (Quinlan, 2009). In this view, knowledge is more than information. It is the development of capacity for action (Quinlan, 2009). As community-based action researchers, we understand that the productivity capacity of knowledge actively contributes to the shaping of social experiences. In trying to address the elements of Indigenous research in our research and honor relation, respect, relevance, and reciprocity within the research process itself, a community-based participatory approach has helped us remain close to the voiced needs of Indigenous communities who were critical to the research team. In fact, the implementation of community-based approaches has fostered equity, mutuality, and capacity building and has created knowledge relevant to the needs of research participants (Cameron et al., 2014).

With the above in mind, the use of popular theatre became a unique research method for engaging Indigenous youth to mobilize knowledge regarding research participants’ experiences on access to healthcare services. For Conrad (2006), popular theatre is a process of theatre comprising communities in identifying issues, analyzing conditions, and searching for points of change. The ultimate goal of popular theatre is to develop practical knowledge for life improvements (Beck, Belliveau, Lea, & Wager, 2011). This was the goal of the dissemination work presented in this article. In our research study, popular theatre was used as a powerful tool to strengthen our collaboration with community members and deepen our understanding of access to healthcare services for Indigenous people in a rural setting. As a collaborative and expressive method, popular theatre assisted community members, healthcare professionals, and researchers to critically examine issues with racialized care, stigma, and discrimination while developing avenues for change. Youth participants viewed the process of making theatre as fun, participatory, and empowering. They were very excited about the potential for using popular theatre to address other key issues in their community. Popular theatre was a fruitful method to use in examining and making visible Indigenous peoples’ experiences of access to health services.

In this article, we present findings from a Canadian Institutes of Health Research—Institute of Aboriginal People’s Health (CIHR–IAHP)-funded research in access to health services for Indigenous peoples in a Western Canadian province. Next, we present features of popular theatre followed by a brief description of the access intervention study that led to this popular theatre undertaking. We then describe the beginning of the project, the process of moving the knowledge into action, performance and audience reception, and lessons learned.

Popular theatre

Globally, human beings have written and performed plays to explore ideas, experiences, and relationships with others and the world (Anderson, Michol, & Silverberg, 2001). In fact, since the beginning of history, theatre has served as a means of examining conflict and societal issues (Anderson et al., 2001; Conrad, 2004; Kontos & Naglie, 2006). Plays have been used as means of reflecting about one’s life and society. In the 1930s, through the work of German playwright Bertolt Brecht theatre reclaimed its political and community functions. Brecht argued that spectators tended to identify with the characters on the stage and become emotionally involved with them rather than being stimulated to think about their own lives. He developed his theory of epic theatre that encouraged the audience in adopting a more critical attitude to what was happening on stage (Conrad, 2004). Brecht believed that theatre should appeal not to the spectators’ feelings but rather it should provoke rational self-reflection and a critical view of the action on the stage (Anderson et al., 2001; Conrad, 2004). While still providing entertainment, Brecht used a range of devices to remind the audience that they were watching theatre and not real life (Anderson et al., 2001).

Popular theatre was established in the early 1970s by Brazilian director and activist Augusto Boal (Conrad, 2004). For Boal, theatre fosters a democratic and cooperative form of interaction among participants. Theatre is not merely a spectacle but rather an artistic means designated for people to learn ways of developing critical thinking against oppression in their daily lives (Beck et al., 2011; Singh, Khosla, & Sridhar, 2012). Popular theatre is a form of theatre that is used around the world for community education (Singh et al., 2012). It is a tool that uses an array of theatre games and exercises to help build community and communication skills and deepen understanding of oneself and others (Beck et al., 2011; Singh et al., 2012).

This particular type of interactive theatre is rooted in the pedagogical work of Brazilian educator Paulo Freire (Conrad, 2004). Freire (1973) developed an approach to adult literacy education that involved not only learning how to read and write but also critically reading the world and its circumstances and conditions with a view to the formation of critical consciousness. The development of critical consciousness assists people to question the nature of their historical and social situation—reading their world—with the objective of acting as critical subjects in the creation of a fair and democratic society (Freire, 2002). Freire encourages people to be active participants in their lives. It is through his method that Freire challenges traditional methods of education that were inherently oppressive and dehumanizing where students were mere recipients of teacher’s knowledge (Freire, 2002, 2004). According to Freire (2002, 2004), injustices and inequities exist in society and the world. These injustices and inequities make it necessary for people to analyze the issues and act upon them, to create a more just and equal society.

As with popular education, popular theatre has a long history around the world. This is particularly significant in countries where oppression is widespread (Anderson et al., 2001; Colantonio et al., 2008; Mabala & Allen, 2002). Popular theatre has the power to sensitize people to recognize their problems, analyze them, seek solutions, and change behaviors. Popular theatre also enables people to discuss and evaluate their own efforts to educate themselves and to make behavioral changes. Popular theatre has been used throughout the world to create awareness and improve health education (Mabala & Allen, 2002). Popular theatre is defined as a process of social and personal transformation that is based on audiences’ experiences to create scenes and engage in discussion of issues of importance through theatrical means (Conrad, 2006).

Popular theatre allows audience members to participate with a scene relevant to their own personal situation and to intervene during the performance to create multiple ways of critically understanding and reacting to a stressful situation (Rossiter et al., 2008). Advantages of using popular theatre are: (1) to make concrete the life experiences of research participants, (2) to engage the audience with research material, (3) to set up the potential for taking action on the findings, and (4) to validate results through a debriefing discussion leading to audience involvement through a representation of the play (Stuttaford et al., 2006). Popular theatre provides a unique means of allowing practitioners, informal caregivers, and patients alike the opportunity to rehearse reality (Rossiter et al., 2008).

Access research initiative: Its context, participants, and research projects

One key marker of the effect of inequities in health is the lack of Indigenous People’s involvement in the design and delivering of appropriate healthcare services across the globe. Indigenous people experience social, political, cultural, demographic, and nutritional changes that have a profound impact on their health status and well-being (Valeggia & Snodgrass, 2015; Wong, Allotey, & Reidpath, 2014). Regardless of their geographical location, traditional subsistence patterns, and diverse languages and culture, all Indigenous groups are united by a common thread: their low standard of health compared with their non-Indigenous counterparts in the same region (Valeggia & Snodgrass, 2015). The causes of these inequities in health are multiple, interactive, and synergistic (King, Smith, & Gracey, 2009).

The powerful effect of colonization and domination is a common thread in the health gap of Indigenous groups around the world (Valeggia & Snodgrass, 2015). The Truth and Reconciliation Commission of Canada (2015) has thoroughly documented the contemporary effects of discriminatory policies on Indigenous peoples. By removing Indigenous children from their families, health has been affected for generations (The Truth and Reconciliation Commission of Canada, 2015). By endangering distrust in government agencies, policies such as the forced removal of Indigenous children from their families and communities contribute to high levels of stress among Indigenous people (Peiris, Brown, & Cass, 2008, p. 985). To date, research evidence shows that stress, racism, and discrimination have been regularly associated with adverse health outcomes for Indigenous peoples (Allan & Smylie, 2015; Paradies, 2006; Peiris et al., 2008).

In Alberta, the situation is similar to the global scene. The link to poor health and residential schools is significant in that Alberta had the largest number of residential schools in operation. In fact, the high school in which students involved in this study attended was located in the exact same location as the original and largest residential school in Canada (Jackson, 2013). In addition to this history, Alberta has the third largest Indigenous territory in Canada comprised 45 First Nation communities over three Treaty areas: 6, 7, and 8 (Alberta Government, 2013). In these regions, healthcare services delivery is governed by multiple (Local, Provincial, and Federal) jurisdictions. Health Canada through the First Nations and Inuit Health department funds primary care and public health to Registered First Nation and Inuit Peoples living on reserve. However, over the past decade, health transfer agreements between Health Canada and First Nations require local communities to develop collaborative relationships with Provincial Healthcare Services who deliver all secondary and tertiary level of care (Anderson & Smylie, 2009).

Researchers claim that healthcare systems and services are not exempt from this historical policy context (Peiris et al., 2008). Poor health outcomes in Indigenous groups are the result of power imbalances imposed by biomedical paradigms and models (Peiris et al., 2008). There is little autonomy for Indigenous peoples to address their healthcare needs. The Canadian federal and provincial governments have committed to provide universal access to a high quality of care under the Healthcare Act. Yet inequities in access remain a pressing national concern for Indigenous peoples (Browne et al., 2011; Wong et al., 2014). To date, qualitative research evidence has demonstrated that Indigenous people are sensitive to power imbalances in their interactions with healthcare services (Browne et al., 2011; Cameron et al, 2014; Valeggia & Snodgrass, 2015; Wong et al., 2014). Stories of dismissal, stereotyping, and marginalization often appear in the literature (Cameron et al., 2014; Fiske & Browne, 2006; Smylie & Anderson, 2006; Tang & Browne, 2008).

Access to healthcare cannot be simply defined as the ability of individuals or groups to reach and obtain essential health services (National Collaborating Centre for Aboriginal Health, 2011). It also entails the opportunity for individuals or groups to identify their healthcare needs, to seek healthcare, to reach, to obtain, and to actually have the need for services fulfilled (Levesque, Harris, & Russell, 2013). Scholars have regarded access as an important social determinant of health (McGibbon, Etowa, & McPherson, 2008; National Collaborating Centre for Aboriginal Health, 2011). Inequities in access to healthcare are unacceptable and unfair and contribute to the gaps in health status between Indigenous and non-Indigenous peoples (Gao et al., 2008). In order to confront the inequities experienced by Indigenous communities, it is necessary to deal with the redistribution of social benefits to meet the needs of people in an equitable way. The lack of resources to provide health for everybody is a threat to the moral mandate of equality for all (Marmot et al., 2010). All human beings, despite their race, gender, social and economic conditions, or their political orientation, have the right to life, health, and well-being (Dahlgren & Whitehead, 2006).

The access intervention study

Under the umbrella of an Access Research Initiative led by Brenda Cameron at the University of Alberta and based on exploratory research, we undertook a larger access intervention study to improve access to healthcare services for Indigenous peoples in a Western Canadian province. The initiative and the access intervention study were led by Cameron together with an interdisciplinary team comprised of Indigenous and non-Indigenous researchers, graduate and undergraduate students, and postdoctoral researchers. The entire initiative was under the guidance of Eminent Scholar Elder Rose Martial. An important goal was to improve access to healthcare services through an Indigenous-led access intervention. The access intervention study also enacted a knowledge exchange process where Indigenous leaders, decision makers, researchers, and health services stakeholders provided their input into research decisions. In this access intervention study, we investigated the efficacy of Community Health Representatives (CHRs) easing Indigenous people’s access experiences in Emergency Departments. The intervention involved the placement of two Indigenous CHRs in one urban and one rural acute care setting. Findings showed that frightening stories of fear, bullying, intimidation, racism, and discrimination were common themes in Indigenous people’s experiences when accessing emergency services. We also found that CHRs eased people’s experiences in emergency and assisted them to understand the pathway of care. CHRs also brought a unique Indigenous understanding to healthcare professionals (Cameron et al., 2014).

We then designed a popular theatre activity to mobilize research knowledge and involve community participants to explore approaches to understand inequities in access to healthcare services for Indigenous people. Our goal was to disseminate key findings from our access intervention study. This activity was implemented within a diverse First Nations community located outside a rural municipality. Three narratives taken from research data were shaped and molded by the students into a popular theatre drama using their own experiences and creativity. During rehearsals, students shared their own views on health as well as engaged in the stories of access from the research data.

Setting the stage

Gaining entry to the community school system required that our team build on a previously held relationship with one community member of our research and advisory team as well as another community champion to advocate to both the Chief and Council, community health director, and the school principal to become involved in the popular theatre as a dissemination strategy. We had also previously worked with the community health director with our access intervention study. An invitation to present our project to the local School Board was issued to us, we attended the meeting and answered questions that concerned content, research practices, and ethics. Bringing in a popular theatre artist who had not been a member of our research team and was not a member of the Indigenous community represented a challenge. This was addressed in part by the involvement of the school liaison person well known to the students and a community member. This became a limitation of our process given that an Indigenous theatre artist would have enhanced further the community-based quality of this work.

Following written approval from the local school board, the Indigenous school liaison person talked with the student body about the project. We were then invited to present the popular theatre idea to the students at one of the Indigenous, rural schools. We proposed several drama workshops led by the theatre artist to enact research findings from the CHR intervention. The theatre artist at this first meeting talked to the students about what popular theatre was about and how this particular drama project would proceed. The youth were different ages and genders, and with varied experience with art-making (or theatre-making). Differences were honored during the process. There were many opportunities throughout the process for each of the participants to contribute these things, leading to a better understanding of each other and trust building. Exploring their own unique perspectives was very important for the program, as they were creating pieces drawing on how they related to the material. Student diverse backgrounds were key to crafting a rich experience and presentation in the end.

There were several key components that worked together to facilitate this popular theatre project. First, involving an Indigenous liaison person working at the school was pivotal to gaining student trust and attendance. He assisted the theatre artist to work with the youth and grounded her often in what was going on with the youth (e.g., family member ill, loss of jobs, the need for the student to work after school). Most importantly, he believed in the youth. In fact, he was always part of the team and assisted the theatre artist to engage with the students in this undertaking. He believed that the youth in this community had the potential to develop capacity for popular theatre. He was confident that the benefits to be gained from offering this drama education program to the students would be invaluable for them. We could not have undertaken the popular theatre project without him. Second, the project had to be done after school or outside of school hours (Saturdays) or when possible. Third, access to transportation and flexibility for rehearsals were fundamental for engaging the youth in the popular theatre activity. The theatre artist was able to show that she would accommodate student schedules and personal needs to deliver this popular theatre project. This was in some way communicated to the youth in her actions, in her constant fulfillment of being there even if there were only a few students.

A number of strategies were followed by the theatre artist to build trust with the students: (1) a facilitator needs to meet youth where they are, with their experiences of healthcare; (2) she must make certain to go through everything at the student’s pace and this may be slow; (3) the facilitator must be willing to take risks alongside participants, for example, be the first one to jump into a game, play or look silly; (4) she must continually be explicit and clarify the purpose of this popular theatre project; and finally, (5) stay with the youth no matter what, do not terminate it due to poor attendance. Rather continue to show commitment and flexibility to this process of learning culminating in the presentation of a popular theatre.

In community-based participatory research, the reality of working with a group of youth (or a group of any people) requires flexibility and willingness to adapt and “roll with the punches.” For example, there were a handful of sessions when a participant had to bring their younger sibling with them because of a lack of childcare. The participant was afraid that they might have to miss the sessions, and the facilitator was concerned for the potential disruption to the group. After a conversation about how things can work out for the situation, the younger sibling was invited to attend the rehearsal. This younger sibling participated in some discussion and had fun watching the group rehearse. They then came to a few more rehearsals happily, and the participant was relieved that they could still be a part of the group.

The rehearsals

The group of youth that eventually came together and committed to the process had some group building that was required. While they were all interested in “doing drama,” they were not all necessarily friends beforehand. This was not always easy as there were instances when one member would not be there thus upsetting the group. The theatre artist would talk to the group about it and ask them to be leaders and encourage commitment in the form of attendance. They would then talk with the participant who was missing for a few rehearsals and ultimately, the group would reform. Through the popular theatre process, the group took ownership over the program, and they saw it as part of their responsibility to work toward the common goal of presenting a product. The theater artist believes that it was due to this larger commitment that they were able to work through difficult interpersonal situations and challenges.

In keeping with Boal’s techniques for Theatre of the Oppressed, the theatre artist began with warm-up games and exercises into every step of the process to delve deeper into the experience of access to health services for Indigenous people. Each session consisted of a check-in circle while sharing snacks and drinks, warm-ups and cool downs, games and exercises, improvisation, and short vignettes. These games created trust among the youth and also in the theatre artist. She was just as involved as the students in these games. An example of a game is when you clap energy to each other. If there was a pause in clapping energy to one another, it led to a discussion about disconnects in life, when something stops making sense. A warm-up game can act as a metaphor as well, what happens when a disconnect occurs in other situations? How might this make you feel when this happens? This then led to theatre artist asking them about disconnects in healthcare, “how might this make you feel when you go to some place for care and experience the dismissal of your concerns?” The games often led to discussions about experiences of the youth or family members with the healthcare system. Rather than simply imposing the methods onto the students and expecting them to fit into a preformed, aesthetically pure dramatic process, the activities first had to have meaning for the students and be responsive to their realities, interests, and energy levels (Lee & De Finney, 2008). The theatre artist focused on popular theatre less as a prescriptive set of techniques and more on its ability to help develop playful interaction, nurture trust, and relationships and negotiate the sharing of stories and experiences. The process was deliberately left fluid and open-ended to allow the group to find its own identity and voice around the broad project themes.

After trust-building with warm-up games, the theatre artist shared with them some of the stories from our access research data. They read them together. This was followed by a group discussion responding to the stories. For example, a student would say, “this sounds like what happened to my Auntie.” The discussion would continue in a way, playing out the scripts as the students were developing a script of their own to portray the research story. They created scenes together in a collaborative way, throwing out some ideas that did not make sense to them after discussion, and created multiple possible scripts. Once the scenes were created based on the research narratives, the actual rehearsal of the script became more prominent, and changes were implemented as they progressed. In becoming actors, students revealed their own culturally derived consciousness about racialized and stigmatized care when accessing acute care. Popular theatre nourished critical self-reflection, relationship building, peer support, and community building (Smith, 2012).

Final product

During six months of almost weekly sessions, the students developed a 1-hour production of five skits that were fleshed out and refined in preparation for a community symposium with community members, managers, and healthcare professionals. Students developed the characters, plots, and storylines based on research data. This collaborative process of probing, expanding, and questioning through different types of languages, images, and rhetorical processes was important in coming to critical consciousness about lived experiences. The project provided space and time for the students to speak back to each other and engage in peer-to-peer sharing through performances, discussions, check-ins, or alternative storylines. Our initial idea was that the youth would modify the interventions with the scenes given feedback from the audience, a basic tenet of Theatre of the Oppressed. This would have required “Improvisation theatre.” Rather the youth chose to improvise after each scene was acted, by asking the audience, “How can things be different?” This was a way to engage the audience to respond to the scene and think about possibilities to change the healthcare situation presented in the scene. It also increased critical thinking about the healthcare system and generated additional questions and thoughts.

Key outcomes of the successful drama project and popular theatre presentation at the symposium were made clear during a postperformance meeting with the students. First, the liaison person assisting us to undertake the drama project commented on the apparent transformation in the students in terms of their interactions with our team, the theatre artist, their peers, and teaching staff at the high school. The staff at the school saw an increase in confidence, an ability to relate better to peers and teachers, and an increased level of comfort in other school activities. They saw the students gain in drama knowledge but also in life skills. The Indigenous high school students themselves asked to continue their learning of popular and forum theatre as well as comedy. We were able to provide additional drama teaching following the symposium, but the school was unable to continue the drama program due to a lack of funding. Students wanted to create their own scripts to present theatre to their Chief and Council around some key issues in the community and express how these problems affect the youth, such as exposure to gang activity and drug and alcohol abuse.

The symposium

Research findings from the Access Research Initiative regarding our access intervention study were presented via a variety of dissemination approaches. We began the day with formal papers presenting the research findings, information on the social determinants of health, the value of undertaking research, allowing time for questions and audience discussion following each paper. The afternoon started with the popular theatre presentation that consisted of the following skits: (a) “Health” is where students described what health means to them; (b) three narratives taken from research data shaped and molded by the students into a popular theatre drama using their own experiences and creativity; and (c) a final game show highlighting ER issues in a comical way. One highlight of the popular theatre presentation was the “Game Show” developed as the youth’s response to some of the research stories. As the youth played warm-up games as a main strategy utilized to connect the youth with each other, to the theatre artist as well as the research content, they wrote two scripts (Health and the Game Show) of their own. The youth felt the need to do something humorous as a response to the difficult topics portrayed in the stories such as stigmatized care, overt, and covert racism. The “Game Show” was a way that the youth chose to end the theatre presentation after a rather difficult to watch and act portrayal of hospital scenes. They decided to approach both the topic and the audience in a light-hearted way to show their understanding of the content as well as their capacity in undertaking popular theatre.

Performance and audience reception

In popular theatre, the performance of theatre skits before an audience is a way of validating and making visible oppressive experiences. The performance is the time when stories come full circle and are communicated publicly and shaped by the audience’s feedback and actors’ reactions (Butterwick & Selman, 2003; Lee & De Finney, 2008). We hoped that the presentation of skits would resonate with managers, healthcare professionals, and community members in the audience in a critical reflective and then empowering way. If audiences could engage with the skits, either by confirming that the images and words enacted on the stage were reflective of their experiences of care or by challenging the images, we would have succeeded in amplifying silenced voices and illuminating distorted realities (Lee & De Finney, 2008). Attendees at the symposium found the presentation engaging and an effective and stark way to portray how inequitable experiences of access to healthcare unfold moment-by-moment. The healthcare professionals, community members, and administrators in attendance discussed that while they have witnessed first-hand racialized care in the healthcare system, the popular theatre re-enacting distressing stories had a profound impact on them. Yet the participants were very clear that everyone in their communities already knew and had experienced much of this. Healthcare professionals in the audience were clear that they too had seen these types of care occurring in healthcare agencies. Between the students and audience there was a direct connection, because the skits were experienced as real. The most startling moment was hearing the open and straightforward dialogue in response to the interpretation of the youth on such a complex issue.

Lessons learned

Using popular theatre for dissemination of research was successful in generating discussion and engaging the community and healthcare professionals to discuss next steps to increasing access to healthcare services. These performative forms of communication opened up a space for critical consciousness and reflexivity to come to the fore. In research, popular theatre has been used to better understand and cope with complex, interpersonal, emotional, and embodied practice issues (Beck et al., 2011; Kontos & Naglie, 2006; Singh et al., 2012). The creation of real-life vignettes that emerged directly from data such as interviews, focus groups, and/or storytelling contains rich elements of dramatic tension that inevitably engage the audience in dialogue (Kontos & Naglie, 2006). We felt necessary to remain faithful to realistic, “in life” scenes, such as those that were portrayed by research participants in our studies.

Popular theatre has been known to aid vulnerable populations in transforming and transcending social oppressions through role-play, using scripted text as a start point for improvising (Beck et al., 2011; Singh et al., 2012). From the experience of the popular theatre artist, the process allowed the youth to connect their own lived experiences, thoughts, and feelings related to the issues explored. Initially the youth did not think they had any connection to issues around healthcare equity. Yet once we delved into the stories, participants were able to contribute to the creative process by offering their own experiences and reflections. The popular theatre creation process enabled the youth to learn more about the issues and ultimately want to do something to change them (Beck et al., 2011; Singh et al., 2012). Furthermore, the popular theatre presentation actively engaged the audience in the research material, as the scenes were interactive and allowed for discussion with the audience. While enacting the scripts, students explored the issues portrayed but also included lively discussions on “what to do” to work toward action to address the issues portrayed. One shortcoming was not following through with the actions discussed during the interactive performance event due to funding limitations. Ideally, popular theatre projects involve taking action afterward to move forward the suggestions raised.

By engaging the audience in dialogue with the question “How can things be different?” a feeling of collectivity grew out of the shared experience of collective problem-solving and sense-making. This growing awareness contributes to the changing Indigenous health landscape where Indigenous communities call for full self-governance in the design, development, and delivery of Indigenous health services. The current perceived lack of control for self-governance in Indigenous communities (Mashford-Pringle, 2016) hinders the progress. This study contributed to the internal community capacity to take up research within their communities that will help inform policy that supports self-determination of healthcare services.

What was clear in both the access intervention study and the popular theatre work was the impact of an Indigenous Healthcare worker on-site to reduce biased care, provide needed cultural connection, and evoke an immediate sense of cultural safety. Following this study, an Indigenous health worker was hired in the rural municipality hospital, and CHRs were also placed in adjacent rural health facilities. Study findings were used to lobby for more CHR positions at the provincial government level. The contributions of the students, their input, and their acting were to increase our awareness of the pervasiveness of the stigmatized care that Indigenous people experience.

Most urgent was the need to share these findings with other healthcare professionals who work in areas that serve Indigenous populations and to garner their participation in working toward effective solutions and actions to ease access experiences. Healthcare professional participants wanted to see the popular theatre used as cultural safety training for staff. The popular theatre for cultural safety teaching could include the following questions: Have you seen this? Has this happened to you? What would you like to see happen about this?

There is a great need to identify systemic, local, cultural issues that affect healthcare professionals and patients when accessing healthcare services. Popular theatre and short dramas provide a venue for mirroring stigmatized care as well as an opportunity to explore deeper meanings behind this. Popular theatre provides a way to engage in critical self-appraisal without feeling defensive. Our findings show that removal from the actual workplace context to view the stigmatized care as an observer only generated recognition of stigmatized care practices. We also found that workplace priorities for efficiency along with embedded assumptions about a population impede the ability to evoke best practices even though these can be as simple as a “hello, how can I help you today?”

Footnotes

Acknowledgements

We would like to thank Elder Rose Martial, Eminent Dene Suline Scholar for her wisdom and for being the heart and soul of the Access Research Initiative. We are grateful to the high school students from an Indigenous Junior Senior High School who participated with us in the popular theatre project. We acknowledge we are much better individuals having interacted with them. Their commitment to their communities for the improvement of access to healthcare will remain with us always. We thank them for their delivery of our research findings and enriching all our lives as a tangible outcome of this. We would also like to thank Terry Kostiuk, the Indigenous liaison person who gathered the students for us, mentored, and supported them in this drama program, and provided them with transportation home to and from the sessions. The value of the liaison person working at the school linked closely with the inauguration of this popular theatre project was pivotal to gaining student participation. Terry assisted the theatre artist to work with the youth and grounded her often in what was going on with the youth (e.g., family member ill, loss of jobs, the need for the students to work after school, Indigenous culture). Dr. Cora Weber Pillwax, Principal Investigator of CIHR-IAPH Alberta NEAHR, provided direct personal and financial support and initially along with Dr. Andrew Cave offered remarkable insights into the best way to present our access findings to community members, health professionals, and academic audiences. We are sincerely grateful to them. Without the support of Tracy Lee, Community Member, and Dr. Lisa Bourque Bearskin facilitating our Access Research Program entry to the Community, this study would not have been possible. We sincerely thank all who contributed to the popular theatre project named and unnamed.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was funded by the Canadian Institutes of Health Research—Institute of Aboriginal Peoples’ Health.

Author biographies

Pilar Camargo Plazas, RN, PhD, is an assistant professor in the School of Nursing at Queen’s University. Under the umbrella of interpretive inquiry and emancipatory approaches, Dr. Camargo’s program of research strives to describe and understand how societies organize and distribute resources and address attention toward economic, political, environmental and social factors and their effects on health outcomes, promotion and disease prevention. By focusing on health equity, her research program is oriented not only toward the identification of research needs, but it is also oriented toward the development of strategies for sustainable change and action.

Brenda L Cameron, RN, PhD, is a professor emeritus in the Faculty of Nursing at the University of Alberta. She is an influential thinker, leader, and researcher who has enjoyed wide Canadian and international recognition for her contributions to nursing, philosophy, and health care. In her research program on access to health care for Indigenous and marginalized populations, she led the implementation of innovative modalities to improve peoples’ access experiences in the health care system. Rooted in the philosophical tradition of the human sciences, her seminal work involves a treatise of nursing practices in contemporary Canada. She served as Director of the International Institute for Philosophical Nursing Research for over a decade. Her community engagement abilities, kindness and respect enabled much access to what was needed in order to undertake this very significant research project with a large research team.

Krista Milford, MSc, was the research coordinator for the Access Research Initiative over its lifetime. Along with this ongoing commitment, she organized and coordinated each detail of the popular theatre project ensuring a collaborative work among students, theatre artist, community liaison and researchers. Her attention to the ongoing and often complex situations during the popular theatre project was stellar. Currently, Krista is the project coordinator for the Benchmarking Food Environments Project, School of Public Health, University of Alberta.

Lindsay Ruth Hunt is a community-engaged theatre artist, researcher, and critical educator, most recently joining the Education Department at the Alberta Union of Provincial Employees. She is passionate about the role of transformative education and arts in/as activism and believes that they can provide a necessary means to work toward positive social change. Her background includes a BFA in Theatre and Development, an M.Ed. focusing on Popular Education and the arts, and she is currently a PhD candidate, investigating the potential of activist and interventionist art in education.

Lisa Bourque-Bearskin, RN, PhD, is a Cree/Metis Nurse from Beaver Lake Cree Nation, and associate professor at Thompson River University, School of Nursing. Dr. Bourque Bearskin’s leadership is in bringing together networks of community researchers. She initiates community-led research by Indigenous communities that enhances understandings of Indigenous nursing knowledge and social determinants of health, focusing on Indigenous wellness that maintains cultural integrity of nurses practice and supports Indigenous sovereignty.

Anna Santos Salas, RN, PhD, is an associate professor in the Faculty of Nursing at the University of Alberta. She investigates how social disparities such as poverty interact with individuals’ symptom experiences in palliative care populations. Through critical, interpretive and participatory methodologies, she seeks to inform the design of clinical approaches to meet the palliative care needs of socioeconomically vulnerable populations. Her studies engage low income, inner city, Indigenous, and immigrant populations, and health care teams.

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