Abstract
There is an immediate need to advance knowledge around the effective prevention of intimate partner violence (IPV), which is responsible for significant negative health and well-being outcomes for women around the world. Creative approaches are being explored internationally—this systematic review provides a timely synthesis of applied theater interventions addressing primary, secondary, and tertiary IPV prevention. Six hundred and ten articles were identified through a comprehensive search of five cross-disciplinary databases. Eleven studies discussed in 15 quantitative and qualitative peer-reviewed articles and one book chapter met the inclusion criteria and were included in the review. Articles were appraised using a standardized quality assessment tool and were analyzed within the context of IPV prevention. Of the reviewed studies, five were classified as primary prevention, four secondary, and two focused on tertiary prevention. Specific strategies used by each of the studies included healthy relationship training, rising awareness and community advocacy, service provider training, bystander training, and working with survivors. While the paucity and quality of current literature make it difficult to determine overall efficacy, this review points to the potential of applied theater as a useful prevention strategy, particularly when interactive, participatory methods are incorporated. Further, applied theater could be an effective tool for working in culturally diverse settings as well as with minority groups. Future applied theater program planning needs to include comprehensive evaluation. More rigorous investigation, involving mixed-method research approaches, is required to fully understand the potential of applied theater as a tool in the context of IPV prevention.
Background
Intimate partner violence (IPV) is a global public health concern. A recent review of population-based studies indicated that 30% of women worldwide experience physical and/or sexual violence from an intimate partner (World Health Organization [WHO], 2013). Prevalence differs significantly across regions with some countries reporting rates of up to 71%, despite variations in definitions and design methods used across studies (Heise, Ellsberg, & Gottmoeller, 2002; WHO, 2005, 2013). Rates of emotional IPV, often not included in prevalence measures, reach up to 75% in some countries (Jewkes, 2010; WHO, 2013). Reports from 40 high-, middle- and low-income countries suggest IPV costs up to 2% of gross domestic product (Duvvury, Callan, Carney, & Raghavendra, 2013). The consequences for health include increased rates of HIV and other sexually transmitted infections, premature birth, injuries, abortion, nutritional deficiency, chronic pain, neurological issues, disability, depression, anxiety, post-traumatic stress disorder, and suicide (WHO, 2013).
Understanding the pervasiveness of IPV and its significant negative outcomes for women around the world has been advanced by intersectional research, which highlights the way certain population groups experience disproportional rates of IPV and exacerbated consequences (Charvis & Hill, 2008; Crenshaw, 1991; Sokoloff & Dupont, 2005). Intersectionality focuses on the way individual’s multiple identities (such as gender, sexuality, religion, age, (dis)ability, culture, and ethnicity) intersect with social and structural systems of power (such as racism, sexism, and classism) to create compounding experiences of oppression (Bowleg, 2012; Charvis & Hill, 2008; Sokoloff & Dupont, 2005). For example, evidence from the United States suggests women of color from low socioeconomic backgrounds experience some of the most severe IPV (Sokoloff & Dupont, 2005). Further, socioeconomic status and racism shape help seeking and reporting of IPV; women from low-income families may not report IPV to the police for fear of losing the family income if an abusive partner is incarcerated, and women of color may not report abusive partners for fear of subjecting them to racist treatment within the criminal justice system (Sokoloff & Dupont, 2005). Intersectional research has also shown how women from different cultural backgrounds define violence differently and has examined the role of homophobia and social constructions of gender (including binary understandings) in lesbian, gay, bisexual, transgender, queer, intersex, plus (LGBTI+) people’s experiences of IPV (Sokoloff & Dupont, 2005). Intersectionality emphasizes the importance of acknowledging culturally relevant understandings of violence and foregrounding the lived experience of individuals within their social and political contexts (Charvis & Hill, 2008; Jayashree & Stith, 2014; Sokoloff & Dupont, 2005).
Recent public health literature highlights an immediate need to advance knowledge and innovation around IPV prevention with increasing emphasis on three levels of prevention: primary, secondary, and tertiary (Colucci & Hassan, 2014; Heise, 2011; WHO, 2013). This public health model of prevention has been adapted from the seminal work of Caplan (1964) who advocated for a primary, secondary, and tertiary framework for promoting prevention in mental health (Caplan, 1964; Hill, Kloos, Thomas, & Wandersman, 2015). The model’s successful application in this field saw the framework expanded more broadly across public health disciplines and adapted to incorporate behavior change (Walden & Wall, 2014). The primary, secondary, and tertiary prevention framework has been modified to address violence prevention at a community level and is recommended for combating violence as a global public health issue (Krug, Mercy, Dahlberg, & Zwi, 2002). Some of the framework’s limitations, including complexities related to distinguishing between treatment and prevention and identifying the time of onset (Gordon, 1983; Institute of Medicine, 1994), have been addressed by refining definitions of each level of prevention and acknowledging the overlap between the levels (Krug et al., 2002; Our Watch, 2017; Walden & Wall, 2014). In relation to violence prevention, primary prevention aims to prevent violence before it occurs, secondary prevention focuses on the immediate response to violence, and tertiary prevention focuses on the long-term care after violence has occurred (Krug et al., 2002). This framework has further been applied to violence against women, and IPV more specifically, and demonstrated its effectiveness as a tool for supporting change across the spectrum of time that violence occurs (Walden & Wall, 2014; WHO, 2010).
With the acknowledgment that the terminology (primary, secondary, and tertiary) in IPV prevention is not always clear-cut and the levels of prevention are not mutually exclusive (Chamberlain, 2008; Walden & Wall, 2014), this public health framework is used in this article to describe the focus of prevention of the identified interventions. Investigating the spectrum across which applied theater may be potentially useful provides essential insights for specific recommendations for public health practitioners working within this framework. For addressing IPV, and violence against women more broadly, primary prevention includes challenging social norms that support and condone IPV, providing skill development for maintaining nonviolent intimate relationships, and addressing societal determinants such as laws that discriminate against women, poverty, and gender inequality (Harvey, Garcia-Moreno, & Butchart, 2007; Murray & Graybeal, 2007; WHO, 2010). Common examples of primary prevention include mass media campaigns that aim to challenge harmful social norms and healthy relationship training for young people (Keating, 2015; Murray & Graybeal, 2007). Secondary prevention includes reforms of legislation and the criminal justice sector, such as compulsory arrest policies, early detection, and screening by health practitioners, and early intervention by bystanders witnessing acts of IPV (Banyard, 2015; Harvey et al., 2007; Murray & Graybeal, 2007). Criminal justice approaches may also work on a primary prevention level by influencing social norms that condone violence (Walden & Wall, 2014). Bystander interventions play an important role in both primary and secondary preventions by building community responsibility and action to address IPV and encouraging early intervention to halt acts of IPV (Banyard, 2015; Murray & Graybeal, 2007; Whitaker et al., 2006). Approaches to tertiary prevention include emergency shelters and long-term support services for survivors, training professionals to improve services, and strengthening ways in which perpetrators are held accountable (Harvey et al., 2007; Keating, 2015; Murray & Graybeal, 2007).
Recognizing the pervasiveness of IPV, prevention has become a focus for public health internationally (United Nations General Assembly, 2006; WHO, 2010). Reflecting this, a small body of literature has begun to explore creative approaches, such as interventions using the arts, to strengthen knowledge of the causes of IPV and enhance effective prevention at primary, secondary, and tertiary levels (Allen & Wozniak, 2010; Christensen, 2013; Crooks, Goodall, Hughes, Jaffe, & Baker, 2007; Mitchell & Freitag, 2011; Sliep, Weingarten, & Gilbert, 2004; Texas Council of Family Violence, 2013; Tucker & Trevino, 2011; Wagman et al., 2012; Wozniak, 2009). Applied theater is one potentially effective and creative approach to IPV prevention. Applied theater involves practices and principles that extend drama beyond conventional notions of theater and place it in the realm of political, people-centered tools for development, education, and social change (Prentergast & Saxton, 2009; Prentki & Preston, 2009).
Applied theater projects use a wide range of techniques and approaches that are generally participatory in nature and share the goal of creating social awareness and change with the audience (Connolly & Prentergast, 2009). Applied theater interventions can involve role-plays and playmaking with audiences, interactive workshops that aim to increase participants’ repertoire of responses to challenging social situations, and talk back sessions with actors who remain in character that explore perspectives and experiences from different points of view.
Applied theater projects have been conducted to tackle a range of health-related issues including trauma, depression, mental illness, drug and alcohol abuse, and sexual health, involving diverse range of participants including young people, older people, and disadvantaged groups such as prison populations (Etherton & Prentki, 2007; Heard, Mutch, Fitzgerald, & Pensalfini, 2013; Mienczakowski, 1992; Prentki & Preston, 2009; Prior, 2010; Yuen, Mueller, Mayor, & Azuero, 2011). Applied theater has also been used in wider contexts to address sociopolitical issues such as health and well-being concerns associated with homelessness, employment, and legislative change (Boal, 2002; Saeed, 2015; Schutzman & Cohen-Cruz, 1994; Woodson, 2012). Such projects demonstrate the potential for theater to impact positively on the health and well-being of a range of population groups.
Research investigating precisely how applied theater works as a vehicle for change highlights the creation of a safe space that allows for reflection and examination of complex human phenomena and an opportunity for embodied learning where new approaches to social and personal oppressions can be trialed and practiced (Boal, 2002; Rossiter et al., 2008; Saldaña, 2005; Somers, 2008). Applied theater interventions may incorporate an element of role-play that provides an experiential learning opportunity enhancing understanding of behaviors from an empathetic and problem-solving orientation (Anderson, 2004; Hughes & Wilson, 2004; Mienczakowski, 2009). Stepping into another role during an applied theater intervention has the potential to foster awareness and understanding of both one’s own and others’ thought processes (Anderson, 2004; Hughes & Wilson, 2004). Further, exploring new approaches to challenging situations through role-play can increase the repertoire of responses a person has in dealing with real-life situations (Anderson, 2004; Baldwin, 2009; Boal, 2002; Hughes & Wilson, 2004; Kisiel et al., 2006; Mienczakowski, 2009). The work of performance theorist Victor Turner highlights the “liminal space” created during theater, where people are free from the constraints of their ascribed roles, identities, routines, customs, and laws, to explore new ways of being and approaching their worlds (Hughes & Wilson, 2004; Turner, 1969). Less understood is the learning experience derived from being an audience member; however, witnessing and engaging with the content of a performance may provide an opportunity for vicarious experiences with similar outcomes to physical role-play (Boal, 2002; Mienczakowski, 2009; Schutzman & Cohen-Cruz, 1994).
Applied theater practitioners are not generally therapists or counselors (although often working closely with health and community development practitioners), but facilitators who use theater as a tool for active participation in creating social change. Applied theater shares some theoretical foundations with drama therapies, which use role-play as a healing process: reflecting on traumatic memories, engaging with upsetting or hurtful emotional states in a safe space, imagining new states of being and identities, and physically embodying new roles (Holmwood, 2014; Sajnani & Johnson, 2014).
In the context of health research, these key mechanisms of applied theater can create change through enhancing the understanding of human need, facilitating improvements in quality of care and best practice, providing spaces for the voicing of experiences leading to emancipatory outcomes for marginalized groups, and the rehearsal of behavior change for both health practitioners and clients (Ahmed et al., 2015; Baur, Abma, & Baart, 2014; Lapum, Church, Yau, Matthres, & Ruttonsha, 2012; Rossiter et al., 2008; Smith & Gallo, 2007).
There is a paucity of literature reviewing current evidence describing and assessing the effectiveness of applied theater in the context of IPV prevention. This systematic review addresses this gap, providing a timely synthesis of the empirical evidence investigating interventions involving applied theater. The review considers evidence from interventions conducted internationally, which engage diverse groups of participants, providing a global picture and considering cross-cultural differences in diverse social contexts. Further, this review uses a broad definition of applied theater that includes both interactive and participatory interventions and traditional theater interventions, to allow the authors to incorporate a wide variety of interventions and make comparisons across diverse intervention methods.
In investigating the role of applied theater in IPV prevention, the review considers interventions conducted at the primary, secondary, and tertiary levels. The analysis aims to understand the contribution of the identified interventions to each level of prevention and investigate how these interventions work to achieve change. This analysis will provide important recommendations for future applied theater and IPV prevention programming as well as highlighting key areas for future research and funding.
Method
A comprehensive, systematic database search was conducted and supplemented with hand searches of reference lists and key journals. Key authors were contacted in order to locate further articles or for information regarding outcomes or methods that were not clear in a publication (Higgins & Green, 2008).
Search Strategy
Database searches included Embase, JSTOR, PubMed, Scopus, Sociological Abstracts, and Web of Sciences; these databases were chosen to ensure a wide, cross-disciplinary reach and to capture peer-reviewed, publisher-controlled, and gray literature. Key terms “theatre” and “drama” were searched with Boolean code “AND” key terms related to IPV (see Figure 1). Searches were limited to articles published from the year 2000; the latest search was run on January 2, 2016. One study published prior to 2000 was included, as it reports the initial stages of a longitudinal study, the majority of which was conducted after the year 2000 (Foshee et al., 1998).
Search terms.
The initial search revealed 610 articles. The identified articles were screened for duplicates (77 excluded), and any obviously nonrelevant articles were excluded (such as articles using the key word “theatre” to refer to surgical theater; 484 excluded). The titles and abstracts of the remaining 49 articles were assessed to determine whether they involved an IPV intervention using applied theater (27 excluded). A further six articles were excluded if they did not provide enough information regarding the methods used, they described the development of an intervention without reporting outcomes, or they were not available in English (Figure 2). In total, 15 peer-reviewed articles and one book chapter were included for review (see Figure 3).
Inclusion and exclusion criteria.
Inclusion map.
Research involving a range of methodologies, incorporating both qualitative and quantitative data collection processes, were used to meet the aims of this review which included investigating the outcomes of applied theater interventions on IPV prevention, understanding how these interventions work, and identifying effective strategies or common intervention elements that work in particular sociocultural settings (Higgins & Green, 2008; Petticrew & Roberts, 2006). The importance of qualitative data in systematic reviews is recognized as a means to provide depth and understanding related to how and why phenomena occur (Higgins & Green, 2008; Petticrew & Roberts, 2006). Qualitative enquiry can be particularly important when investigating socially complex and sensitive phenomenon such as IPV and can be more appropriate than quantitative methods for understanding the impact and process of theater interventions (Daykin et al., 2008; Murray & Graybeal, 2007).
Study Quality Appraisal
Appraisal of articles was based on guidelines developed specifically for conducting systematic reviews in social sciences (Higgins & Green, 2008; Petticrew & Roberts, 2006). Each article was appraised against a standardized tool, which includes questions related to type of intervention, the relevance to the research question being asked, the context in which the intervention occurred, methodological rigor, appropriateness of data collection and presentation, and ethical considerations (National Institute for Health and Clinical Excellence [NICE], 2012). Appraisal criteria differed depending on the type of study (e.g., randomized control trial, cohort study, qualitative study); some key criteria important for a high-quality rating included length of follow-up, appropriateness of participant selection/representation of the larger population, rigorous reporting of data collection and analysis methods, and strong links between the article’s findings and discussion. Articles were assigned a quality score of ++ (all or most of the criteria met), + (some of the criteria met), or − (few or no criteria met; NICE, 2012). Articles were appraised by the primary author and independently checked in detail by two other authors to ensure interrater reliability (Liberati et al., 2009). Due to the relatively small size of the body of identified literature, articles were not excluded as a result of quality scoring; all articles were included for analysis.
Data Extraction
Data extraction was conducted using a set of standardized questions based on population, location, intervention strategies and aims, study design including theoretical approach and methods, study limitations, and outcomes. Data extraction was conducted by the primary author and reviewed by two other authors to ensure consistency and reliability (Petticrew & Roberts, 2006).
Data Synthesis
Due to the diversity of approaches and data collection methods used in the identified articles, narrative synthesis was conducted for this review (Petticrew & Roberts, 2006). Narrative synthesis includes clearly identifying key descriptive elements of each study, summarizing and sorting results into common themes, and noting methodological problems or biases (Petticrew & Roberts, 2006). Each article was then considered within the context of primary, secondary, or tertiary IPV prevention. Two other authors independently reviewed the literature and confirmed these themes, ensuring further interrater reliability (Liberati et al., 2009).
Findings
Description of Interventions
The outcomes of 11 different interventions were reported in the 16 articles included in this review (see Table 1). The interventions were conducted in three countries (United States, UK, and Australia), with four interventions conducted with ethnic minority groups (Indian, Latino, Asian), six with young people (school and university/college based), two with survivors of IPV, and two with service providers. Participants of some interventions fell into more than one category (e.g., immigrant survivors of IPV and university students training to be IPV service providers). Seven articles were rated high quality (++), seven as moderate quality (+), and two were low quality (−). Quantitative studies were rated as moderate and low quality due to key limitations including limited follow-up time, limited generalizability, lack of discussion regarding potential bias, and limited discussion around validity of measures used. Some key limitations of qualitative studies rated as moderate or low quality included limited description of data collection and analysis methods, alternative conclusions and limitations of the study not discussed, limited use of data extracts or unclear presentation of findings, and stronger links between the article’s findings and discussion sections required.
Summary of Literature.
Note. IPV = intimate partner violence.
Nine of the 11 interventions used interactive techniques (such as drama workshops, audience participation, and postperformance talk back sessions with actors) and 2 interventions engaged the audience in the passive role of spectator; one of these interventions included educational sessions alongside the theater production (Dill-Shackleford, Green, Scharrer, Wetterer, & Shackleford, 2015; Foshee et al., 1998).
Articles were grouped into three overarching themes: primary, secondary, and tertiary prevention. Five of the 11 reported interventions were classed as primary prevention, 4 as secondary, and 2 as tertiary. Two bystander interventions were classed as secondary prevention, as their focus was to build skills to intervene when witnessing an act of IPV (Ahrens, Rich, & Ullman, 2011; Lynch & Fleming, 2005). It is noteworthy that these interventions also worked to encourage collective, community responsibility and reduce social acceptance of IPV, a primary prevention goal (Banyard, 2015). Two interventions working with survivors of IPV were classed as tertiary prevention, as they engaged women in emergency shelters and transitional housing, working to provide longer term care after violence had occurred; however, interventions focused on empowerment for survivors can also be classed as secondary prevention (Murray & Graybeal, 2007). See Table 2 for a map of individual interventions’ goals at multiple levels of prevention.
Mapping Identified Interventions’ Goals at Multiple Levels of Prevention.
Note. X signifies the relevant goals that are applicable to each study. Interventions are listed in alphabetical order using the first author of related articles. Some interventions are not given a specific name in relevant publication; the names of such interventions are based on an easily identifiable aspect of the intervention.
Primary Prevention Interventions
Five interventions (reported in eight articles) were classed as primary prevention, using three approaches: healthy relationship training for young people (Belknap, Haglund, Felzer, Pruszynski, & Schneider, 2013; Foshee et al., 1998, 2000, 2004), raising awareness of IPV (Dill-Shackleford et al., 2015), and exploring and advocating for the needs of minority groups (Colucci et al., 2013; O’Connor & Colucci, 2016; Yoshihama & Tolman, 2015). The following discussion considers each of these approaches in turn, but it is notable that many of the studies integrated more than one approach.
Healthy relationship training
Two U.S.-based school interventions (reported in four papers), assessed as moderate and high quality, respectively, demonstrated significant decreases in participants’ acceptance of IPV as well as increased confidence and intention to act nonviolently in intimate relationships (Belknap et al., 2013; Foshee et al., 1998, 2000, 2004). Both interventions used noninteractive theater, where participants were spectators, followed by talk back sessions with the actors (Belknap et al., 2013) or educational classroom sessions (Foshee et al., 1998).
In particular, the randomized control trial conducted by Foshee et al. (1998, 2000, 2004) examined 10 rural schools (5 control and 5 intervention) involved in “Safe Dates”: a school-based program involving a 10-week educational curriculum and a 45-min theater production. In line with a primary prevention approach, the study’s main aim was to support students to recognize IPV warning signs and provide them with the skills and confidence to act nonviolently in intimate relationships (Foshee et al., 1998). The study also measured self-reported perpetration and victimization of IPV and encouraged help seeking should participants experience or witness IPV, further contributing to both secondary and tertiary prevention goals.
Conducted over a 4-year period, with data collected at 1 month, 1 year, and 4 years postintervention, Foshee and colleagues (1998) initially identified overall reductions in victimization and perpetration of IPV, reduced acceptance of IPV, reduced gender stereotyping, and increased knowledge about where to get help. At 1 year, behavioral differences (victimization and perpetration of IPV) across the treatment and control groups had disappeared, although the treatment group continued to show greater knowledge of where to get help, less acceptance of IPV, and less gender stereotyping (Foshee et al., 2000). Notably, at the 4-year follow-up, the treatment groups again demonstrated significantly less victimization and perpetration of IPV than the control (Foshee et al., 2004). The evaluation data for Safe Dates examined the program in its entirety, and the effectiveness of the theater component alone is unknown; however, it was a significant component of the program, thus warranting its inclusion in this review (Foshee et al., 2004).
Belknap, Haglund, Felzer, Pruszynski, and Schneider (2013) worked with secondary school students of Latino heritage to measure the impact of a culturally tailored theater production designed to challenge the acceptance of IPV and improve confidence and intention toward future nonviolent conflict resolution in intimate relationships. The production, developed by professional theater practitioners, was based on information and stories provided by the target community and included verbatim quotes; the intervention included post talk back sessions with actors and the director (Belknap et al., 2013). Pre- and postsurveys conducted with 66 adolescents (mean age 13), and postreflective essays indicated a decrease in acceptance of IPV and an increase in confidence to act nonviolently and to stand up for one’s self. Qualitative data indicated the culturally specific content enhanced the outcomes of the intervention, ensuring the participants identified with the characters (Belknap et al., 2013).
Raising awareness of IPV
A high-quality U.S.-based study indicated positive outcomes relating to increased knowledge of IPV and decreased acceptance of common myths related to IPV (Dill-Shackleford et al., 2015). The quasi-experimental study included an intervention play aimed at raising awareness of types of IPV, particularly coercive control, and addressing common IPV myths. The play, along with a second play presented to a control group, was performed in a public theater setting at an urban university campus. The control play examined broadly similar issues but did not emphasize IPV; both plays were advertised publicly and performed at similar times. One hundred and sixty-eight participants (members of the public attending either the intervention or control play) completed postproduction surveys measuring acceptance of IPV myths and knowledge of types of IPV. Intervention participants reported greater knowledge of IPV, particularly emotional abuse and coercive control, and were less likely to endorse myths about IPV than those who had attended the control play (Dill-Shackleford et al., 2015).
Community exploration and advocacy of needs
Two interventions (reported in three articles) used interactive applied theater as a tool for exploration and advocacy regarding the experiences of IPV for minority groups in the United States and Australia (Colucci et al., 2013; O’Connor & Colucci, 2016; Yoshihama & Tolman, 2015). These moderate- and low-quality studies focused on primary prevention by identifying the needs, current knowledge, and skill sets of specific groups in order to inform the development of effective prevention strategies (Colucci et al., 2013; O’Connor & Colucci, 2016; Yoshihama & Tolman, 2015).
Colucci et al. (2013) and O’Connor and Colucci (2016) conducted an in-depth study of the current experiences with IPV and barriers to help seeking with an immigrant Indian community in urban Australia. This study used interactive applied theater techniques to identify and share common experiences of IPV and map through current barriers to help seeking with 114 participants recruited using local media (radio station and flyers) and through participating Indian community organizations. Qualitative outcomes (including focus groups and audio recordings of theater productions) highlighted community acceptance of harmful gender norms and common types of IPV as well as cultural and structural barriers to help seeking (Colucci et al., 2013; O’Connor & Colucci, 2016). Outcomes suggested interactive, applied theater was an effective tool for sharing the community’s stories and experiences and created a space for open and honest dialogue regarding future possibilities (Colucci et al., 2013; O’Connor & Colucci, 2016).
Another study conducted with a South Asian community in urban United States used interactive applied theater at a public IPV awareness march to map community approaches to bystander actions (Yoshihama & Tolman, 2015). Peer educators, recruited from the target community, developed an interactive production based on data collected during community assessments of experiences and attitude toward IPV. The production aimed to assess community beliefs and skills related to bystander interventions (Yoshihama & Tolman, 2015). Qualitative outcomes, including video recording of theater interventions, indicated the acceptance of harmful gender norms and limited knowledge and skills required to intervene as an effective bystander within the community (Yoshihama & Tolman, 2015).
Secondary Prevention
Three interventions (reported in five articles) focused on secondary prevention using two approaches: service provider training and building effective bystanders. The following discussion outlines each of these studies and their contribution to the current knowledge related to enhancing secondary IPV prevention using applied theater. It is notable that the majority of these studies also include primary prevention goals related to building community responsibility and action to address IPV (Ahrens et al., 2011; Pomeroy et al., 2011; Rich & Rodriguez, 2007; Rodriguez, Rich, Hastings, & Page, 2006).
Service provider training
Two interventions (articles of moderate and high quality) reported advancing secondary IPV prevention through improved service provision by building empathy and awareness of client needs and increasing multidisciplinary collaboration (Baird & Salmon, 2012; Pomeroy et al., 2011).
Baird and Salmon (2012) investigated an interactive applied theater intervention aimed at enhancing IPV service provider collaboration. The UK-based intervention engaged participants from a wide geographic and professional scope (including 90 law enforcement officers, community support and health workers, and policy makers) in interactive theater that allowed for the mapping of professional roles and alternative responses for addressing client needs. This evaluation, which included researcher observation, postreflective feedback from participants, and 3-month follow-up telephone interviews, found the intervention successfully built cross-disciplinary relationships with some (mixed) indication of increased collaboration in the workplace. The intervention further enhanced participants’ empathy and awareness of client needs (Baird & Salmon, 2012). Participants attributed key outcomes related to understanding cross-disciplinary roles, practical skill development in responding to complex situations, and creating a support network among colleges to the interactive nature of the intervention design (which included actively reworking scenes to trial new approaches, postdiscussions with actors who remained in character and postperformance workshops; Baird & Salmon, 2012).
In a study of moderate quality, Pomeroy et al. (2011) explored an interactive applied theater intervention conducted with social work students in the United States. This intervention aimed to increase empathy, self-reflection, and analysis of IPV with participants (Pomeroy et al., 2011). Pre– and post–focus groups (2 months after intervention) were used to compare the applied theater intervention with a traditional, didactic peer education session and a control group who received no intervention. Applied theater intervention participants reported increased ability to recognize IPV, understand the complex dynamics of IPV, and respond effectively when witnessing or experiencing IPV, which were maintained over time (Pomeroy et al., 2011). Participants of both the applied theater intervention and the didactic peer education session showed increased factual knowledge related to IPV; however, only the applied theater intervention participants demonstrated comprehensive knowledge related to the complex dynamics of IPV and the ability to apply this knowledge to real-life situations (Pomeroy et al., 2011). Outcomes of this study link the interactive nature of the theater intervention (with participants actively engaging in role-plays) with these differences in outcomes for intervention and comparison groups (Pomeroy et al., 2011). Findings suggest important primary and secondary prevention outcomes promoting awareness and skill development at personal and professional levels for participants in their roles as social workers (Pomeroy et al., 2011).
Bystander training
Two U.S.-based interventions (described in four articles) engaged university students in applied theater interventions to build knowledge, skills, and confidence to intervene when witnessing IPV (Ahrens et al., 2011; Lynch & Fleming, 2005; Rich & Rodriguez, 2007; Rodriguez et al., 2006). While bystander interventions share important primary prevention aims, these were classed as secondary prevention interventions due to a focus on building empathy and willingness to comfort survivors of IPV and skills for intervening during and after witnessing an act of IPV.
The first bystander intervention, called “interACT (Sexual Assault Prevention Program),” is an ongoing university program in the United States, which uses applied theater to provide a space for students to view, brainstorm, and trial ways to intervene when witnessing potential acts of IPV (Ahrens et al., 2011). Preliminary evaluations (moderate quality) of the program used postsurveys with audience members; findings suggested positive outcomes in relation to developing empathy and perceived willingness to comfort a survivor of sexual assault (Rich & Rodriguez, 2007; Rodriguez et al., 2006). The most recent evaluation (high quality) of interACT included pre-, post-, and 3-month follow-up surveys with 509 communication studies students. Outcomes demonstrated an increase in participants’ beliefs in relation to the helpfulness of bystander interventions and an increased self-reported likelihood of intervening, which was maintained over time (Ahrens et al., 2011). The most significant changes were reported from male participants who rated the effectiveness of intervening as low before participating in the program (Ahrens et al., 2011). This study also attempted to measure differences in outcomes for participants who actively participated in the intervention compared with participants who maintained a more passive role as spectators. While results show no significant differences in outcomes for these two groups, the participatory nature of the intervention did require active engagement from all participants (whether acting on stage or remaining in a spectator role; Ahrens et al., 2011).
Finally, a low-quality study by Lynch and Fleming (2005) further supports the potential of applied theater to promote bystander skill development. An interactive theater intervention depicting situations of IPV aimed to increase bystander skills through discussion and role-play of different bystander actions (Lynch & Fleming, 2005). Pre- and postsurveys conducted with 1,104 orientation students at an urban university in the United States suggested increased perceived ability to intervene as a bystander and increased self-reflection on personal behavior as a bystander (Lynch & Fleming, 2005).
Bystander interventions commonly share both primary and secondary prevention goals (Banyard, 2015). It is notable that two primary prevention studies also made significant contributions to knowledge related to building effective bystanders. The study by Yoshihama and Tolman (2015) was classed as primary prevention due to the focus on exploration and advocacy of the community’s needs; however, it also aimed to build bystander skills within the community by offering a space to practice interventions, a secondary prevention goal. Similarly, Belknap et al. (2013) showed an increase in intention to intervene when witnessing an act of IPV, alongside significant primary prevention outcomes.
Tertiary Prevention Interventions
Two U.S.-based ethnographic case studies (moderate and high quality) provided exploratory evidence to support the role of applied theater in tertiary IPV prevention (Kumar, 2013; Wozniak & Allen, 2012). Kumar (2013) captured the transformative power of an applied theater intervention conducted with four women of South Asian heritage during an IPV survivor support group. The detailed description of one participant’s journey emphasizes the way embodied experiences created a space to develop strength, imagine new realities, and build supportive relationships (Kumar, 2013). These outcomes are linked to “process and action,” as participants were encouraged to transform their bodies, acting in ways that opened spaces for creating new opportunities and ways of approaching situations (Kumar, 2013, p. 727).
Wozniak and Allen (2012) describe the outcomes of a performance-based intervention conducted with approximately 40 women in five separate groups, across three IPV survivor support services. This study used rigorous ethnographic approaches to highlight the transformation participants experienced, as they embodied a change in self-identify from survivor to “thriver” (Wozniak & Allen, 2012, p. 95). The outcomes are attributed to the participatory nature of the intervention design, as participants were required to physically embody changes, providing a practical opportunity to explore what it felt like, physically, to be “thriving” (Wozniak & Allen, 2012, p. 95).
Discussion
This review aimed to develop an understanding of the potential role of applied theater in IPV prevention through the synthesis and analysis of current literature. The outcomes of this review indicate some potential for applied theater to have positive outcomes at primary, secondary, and tertiary levels of IPV prevention. At a primary level, applied theater has been used to successfully create awareness of IPV and as a tool for healthy relationship training with young people. Significant outcomes have included reducing gender stereotyping, dispelling myths related to IPV, recognizing IPV and warning signs for abuse, and engaging in nonviolent conflict resolution (Belknap et al., 2013; Dill-Shackleford et al., 2015; Foshee et al., 2004). Further, some of the current, exploratory literature points to the potential of applied theater as an effective research tool for exploring and assessing community experiences, attitudes, needs, and skills essential for advocacy and development of culturally tailored IPV prevention programming (Colucci et al., 2013; Yoshihama & Tolman, 2015). There is some evidence supporting the use of applied theater as a research tool in wider health and well-being contexts (Conrad, 2004; Dennis, 2009; Enria, 2016; Mienczakowski, 1997; Rossiter et al., 2008). More rigorous investigation is required to fully understand the potential of applied theater as a research tool in the context of IPV prevention, particularly in diverse cultural settings. Identified interventions did not specifically aim to address any sociopolitical primary prevention determinants such as laws that discriminate against women, poverty, or gender inequality. One intervention did indicate a decrease in gender stereotyping, which could point to the potential for applied theater interventions to be useful in addressing some of these upstream determinants (Foshee et al., 2004).
The evidence identified for this review suggests that applied theater may be effective in enhancing skills and understanding the complex nature of IPV for service providers as well as developing bystanders skills within diverse communities (Ahrens et al., 2011; Baird & Salmon, 2012; Belknap et al., 2013; Pomeroy et al., 2011; Yoshihama & Tolman, 2015). Finally, exploratory literature points to a role for applied theater in healing and transformation for survivors of IPV through the creation of supportive networks and the embodiment of positive self-identities (Kumar, 2013; Wozniak & Allen, 2012).
Despite the positive outcomes reported, this review highlights the paucity of literature investigating applied theater IPV prevention (with only 11 interventions identified), and evidence remains largely exploratory, limited by small sample sizes and geographic reach. Quality appraisal of the identified articles found less than half were of high quality. Evidence is hindered by a lack of reporting of rigorous methods in some studies, which limits the ability to draw conclusive outcomes from overall findings and a lack longitudinal data showing sustained outcomes over time. Additional comprehensive, rigorous evaluative research within the context of applied theater IPV prevention is warranted. There is a clear need for future research to build on the current, preliminary, and exploratory knowledge, investigating the long-term impacts of applied theater interventions at all levels of IPV prevention.
This review further aimed to uncover particular intervention strategies for achieving change. Of the total 11, 10 interventions included some form of follow-up discussion or audience participation. Audience interaction is a common design element linked to positive outcomes with articles reporting affective and embodied learning leading to changes in knowledge and intention to undertake bystander action (Ahrens et al., 2011; Belknap et al., 2013; Rich & Rodriguez, 2007; Rodriguez et al., 2006), increased empathy and understanding of the complexities surrounding IPV (Baird & Salmon, 2012; Pomeroy et al., 2011; Rodriguez et al., 2006), and positive changes in self-efficacy and self-esteem regarding intention to undertake nonviolent conflict resolution and seek help (Belknap et al., 2013; Foshee et al., 2004; Kumar, 2013; Wozniak & Allen, 2012).
While audience interaction appears to be a common factor linking the positive outcomes of these interventions, Dill-Shackleford, Green, Scharrer, Wetterer, and Shackleford (2015) showed a traditional, passive theater intervention also reported positive changes in audience knowledge. It is notable that this intervention, unlike the other 10, only aimed at increasing knowledge without a focus on applying this knowledge to real-life situations. It is plausible that interactive, embodied activities and postproduction workshops are integral for enhancing the application of new skills and knowledge regarding IPV, as identified in findings from Pomeroy et al. (2011).
Only one article attempted to measure outcomes for active participation from the audience compared with participants who remained spectators (Ahrens et al., 2011). While no differences were found, it is important to note that interventions based on Theatre of the Oppressed (such as, interACT) are designed, so that no participant is passively watching the performance, but all are actively engaged in the action regardless of whether they physically enter the stage (Ahrens et al., 2011; Boal, 2002). While it appears that some form of interactive participation is integral for applied theater interventions aimed at enhancing understanding and skills related to IPV prevention, the way this interaction works, the necessary extent of participation, and most effective methods requires further investigation.
Research investigating theater as a tool for social change emphasizes the importance of the aesthetic quality of a performance, essential for encouraging the audience to identify and empathize with the characters and enriching vicarious experiences (Mienczakowski, 2009; Saldaña, 2005; Schutzman & Cohen-Cruz, 1994). One of the identified articles attempted to measure outcomes related to cognitive and emotional immersion into the performance (Dill-Shakleford et al., 2015). While greater immersion did not predict greater gains in knowledge, immersion was uniformly high, potentially leaving limited variability to detect differential effects (Dill-Shakleford et al., 2015). This could also be a reflection of the limitation of quantitative measures in understanding complex outcomes related to the way theater works to create change. A deeper investigation of the importance of performance quality and what quality means for specific audiences is warranted.
This review aimed to understand the role of applied theater in IPV prevention in culturally diverse contexts. The productions performed as part of the four interventions that worked with ethnic minority groups were each developed either by members of the community (Belknap et al., 2013; Yoshihama & Tolman, 2015) or by the participants themselves (Colucci et al., 2013; Kumar, 2013). This was an integral element linked to the positive outcomes for these interventions with qualitative findings indicating participants could identify with the characters and these interventions created culturally safe environments where discussion and exploration of new, plausible alternatives could occur (Belknap et al., 2013; Colucci et al., 2013; Kumar, 2013; Yoshihama & Tolman, 2015). The evidence, albeit exploratory (using purposive samples) and relatively limited in size, points to the potential of applied theater as a useful tool when working with diverse groups, as long as the target community is involved in the process of creating the production/action. Further, these outcomes could suggest a potential for applied theater to promote an intersectional approach to IPV prevention, which foregrounds culturally diverse experiences and examines lived experience within complex social and political contexts.
The identified interventions included a diverse range of participants: different age groups (from 13 years up to 40 years), various levels of education (secondary school and university/college), and ethnic minority groups (including migrants from first to third generation), most of whom had limited or no prior experience with theater. While intervention outcomes did not appear to be dependent on any prior levels of knowledge or experience, future research exploring key groups with whom applied theater may be aptly suited is warranted. The current exploratory evidence suggests applied theater could be particularly useful for working in culturally diverse settings; however, future research must investigate this role further, including working with diverse participants such as men and women of all ages and LGBTI+ groups. Further, missing from the current knowledge is how applied theater could work as a tool for rehabilitation and behavior change with perpetrators of IPV. There is some wider, preliminary evidence that indicates positive outcomes for applied theater interventions working with violent criminals in prisons (Cogan & Paulson, 1998; Heard et al., 2013). Future research should investigate these outcomes, specifically within the context of tertiary IPV prevention.
The interventions identified by this review emphasize the diversity of applied theater approaches; understanding their outcomes requires creative and complex data collection and analysis. Measuring behavior change over the long term while delving into the ways applied theater works to create change with participants is an important challenge for future research. The development of innovative and rigorous mixed-method approaches is essential for understanding the potential role of applied theater in addressing IPV at all levels of prevention.
Limitations
The outcomes of this review must be considered within the context of a number of limitations. The paucity of studies available makes it difficult to draw strong conclusions in relation to some of the aims of this review. Specifically, while our ability to point to precise intervention elements that are effective in specific cultural or social contexts is somewhat limited, findings do suggest some indication for potentially effective strategies for working in culturally diverse settings. In relation to the limitations of the current review, interventions that included applied theater as part of a wider approach may have not been identified by the search strategy; however, the systematic methods, comprehensive search terms, and broad inclusion criteria used for this review ensured a wide breadth of literature was captured. Finally, as rigorous reporting of research methods was essential for meeting the aims of this study, which included a comprehensive quality appraisal process, only intervention articles that reported on methods of evaluation were included. This may have resulted in the omission of some interventions. The quality appraisal process provided important insights related to understanding outcomes and making meaningful recommendations for future research and program planning. It is notable that applied theater interventions (and other creative approaches) often have funding and time constraints, which may limit opportunities to publish outcomes. Further, the goals of arts-based interventions may not align with expectations and requirements of academic rigor, again limiting opportunities for academic publication. A broader review of creative approaches not included in this study could be useful in capturing and describing some innovative intervention methods and approaches, albeit limited in ability to draw comprehensive, evidence-based conclusions related to outcomes.
Conclusion
The findings of this review point to an exciting potential for applied theater to play a significant role IPV prevention; however, more in-depth knowledge is required to better understand this potential. This review identified 11 interventions that used a diverse range of strategies and approaches to achieve change at all three levels of prevention. While the paucity and quality of current literature makes it difficult to determine overall efficacy, finding do suggest that the interactive and participatory nature of many applied theater interventions is important for helping participants translate key messages into action and behavior change. Further, applied theater could be an effective tool for working in culturally diverse settings as well as with minority groups. Future applied theater program planning needs to be accompanied by comprehensive evaluation, specifically designed to explore these roles and outcomes in more depth. This will require the development of innovative, mix method research approaches that include uncovering the transformative experiences for participants and capturing long-term outcomes.
Critical Findings
There is exploratory evidence to suggest applied theater can be an effective tool for IPV prevention at primary, secondary, and tertiary levels. Participatory, interactive approaches, such as role-play and playmaking and talk back sessions with actors, can enhance interventions aimed at developing practical skills and knowledge for IPV prevention. Applied theater is a potentially effective tool for working with culturally diverse and minority groups when the target community is involved in the creating the action.
Implications for Policy, Practice, and Research
More comprehensive research is required to understand the role of applied theater in IPV prevention. To this effect, there is a need to develop innovative, mixed-method approaches for evaluative research in the context of applied theater IPV prevention. Future research should include diverse populations such as men and women of all ages and LGBTI+ groups. Applied theater IPV prevention intervention programming must be accompanied by comprehensive evaluation aimed at assessing long-term outcomes and capturing transformative experiences for participants.
Footnotes
Acknowledgments
We would like to acknowledge and thank Maxine Whittaker for her insights and support with this manuscript.
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) received no financial support for the research, authorship, and/or publication of this article.