Evaluating the Sharing Stories youth theatre program: an interactive theatre and drama-based strategy for sexual health promotion among multicultural youth

Key words: arts-based strategies, CALD, culturally and linguistically diverse, evaluation, peer education.

Drama and theatre are forms of interactive art that are well known for their dynamic components that create visual and auditory expression through the active process of engagement.¹ By drawing upon participants’ life experiences and creating discussion around relevant and personal issues, theatre is an effective way of collectively investigating and shaping participants’ experiences and attitudes towards new ideas and understandings.²

Sexually transmissible infections (STIs) are common among young people in Australia aged 15–24 years, with increasing notification rates for most STIs, in particular chlamydia and gonorrhoea. In 2014 in Western Australia (WA) there were 11 417 chlamydia notifications, 23% of which were among the 15–19 years age group. The largest proportion of gonorrhoea notifications (41%) in WA were among 15–24 year olds.³

The use of theatre and drama for education has been well established in many countries and is being increasingly used in the field of sexual health for family planning and prevention of STIs and blood-borne viruses (BBVs).⁴ Theatre and drama-based sexual health education has been shown to be a reliable strategy that is understood and enjoyed by many different communities and age groups.^4,5 The present study evaluated a theatre-based program in WA designed to educate multicultural youth on sexual health and relationship topics. The research also provided insights into using drama as an evaluation method as well as a health promotion strategy.

Between 2008 and 2013 there were 2025 humanitarian youth arrivals in WA.⁶ Migrant youth under the age of 18 years may experience disrupted schooling prior and post arrival in Australia, and therefore have limited opportunity to receive accurate sexual health information during adolescence.^7,8 (The term ‘migrant’ refers to a person who has chosen to leave their home country to settle in a different country.) Studies show that migrant youth have little experience accessing sexual health services due to language, social and environmental barriers, and may experience stigma and discrimination that can have adverse effects on quality of life, sexual health, self-esteem and sense of belonging.^8–10 Reproductive and sexual health education is important for young people from both refugee and non-refugee backgrounds in order to prevent future health complications, however it is often a subject that is overlooked by settlement services and programs.⁸

Established in 2008, the Sharing Stories youth theatre program was coordinated by the Metropolitan Migrant Resource Centre (MMRC) in Perth, WA and was designed based on recommendations from a report on the sexual health education of young people in WA.¹¹ Sharing Stories delivers a suite of programs using theatre, filmmaking, art and drama to empower multicultural community members to become peer educators who can break through cultural barriers to communicate about sexual health education. Increasing STI and BBV health literacy and the uptake of harm minimisation strategies is a key objective of Sharing Stories. Within this program a range of issues related to sexual health are addressed such as sex and the law and consent.

The program uses techniques and methodology adapted from Theatre of the Oppressed (TO).¹² Using performance techniques, TO attempts to liberate groups or individuals from their internal and external burdens and restrictions. By using a ‘learned self-relevance’ process, it enables participants to become aware of their potential and recreate their own reality through drama and role-plays.^12–14 These techniques enable a participatory and appealing process for engaging young people in the Sharing Stories workshops, and in the evaluation process.²

The content of the weekly Sharing Stories drama workshops is relatively unstructured, allowing participants to discuss topics that are relevant to them or topical at the time, such as condom use, sex and the law, consent, bullying and sexting. Workshops generally involve different forms of creative expression such as dance, drama scenarios, role-plays, improvisation and filmmaking, which involve some or all participants who attend the workshop.

The Sharing Stories youth theatre program up-skills participants to become peer educators, helping to maintain program sustainability. Peer education has been shown to be a highly effective method of promoting safe behaviours among young people as there is a positive interaction between peers.¹⁵ The present evaluation of the Sharing Stories program used a combination of arts-based and survey-based evaluation methods. The findings provide direction for other practitioners involved in sexual health education for multicultural groups where there is likely to be community support for arts-based interventions. The effectiveness of the arts-based evaluation methods chosen for this project is also discussed.

The aim of this evaluation was to assess if the Sharing Stories youth theatre program contributed to an increase in knowledge of STIs, healthy relationships, and support and referral pathways for young people from multicultural backgrounds. The outcomes sought for the participants were:

1. Confidence talking to their friends about sexual health and supporting their friends with regards to safe sex;

2. Confidence in seeking STI testing if they have had sex without a condom;

3. Knowledge of where to access accurate information about sexual health and where to go for STI testing;

4. Positive attitudes towards carrying condoms or asking their partners to use condoms.

5. 1. The study was approved by the Curtin University Human Research Ethics Committee (approval no: HR 69/2013). A waiver of parental consent was obtained and considered necessary due to the sensitive nature of the research and as some of the participants were younger than 18 years.

Eighteen young people aged 14–21 years from three drama workshop groups took part in this evaluation over 12 weeks during April–June 2013. All study participants were already enrolled in the Sharing Stories youth theatre program workshops and were approached during their usual drama class. All participants received an information sheet and consent form, which were explained verbally by the researcher. Participants were advised that their participation was voluntary, all information was confidential and that they could withdraw at any time. The characteristics of the sample and the drama groups are summarised in Table 1. Due to the widespread age range of participants, issues relating to the legal age of consent were included in the study and addressed during the drama workshops.

Table 1.  Sharing Stories youth drama workshop details
MMRC, Metropolitan Migrant Resource Centre

A mixed-methods design was used to ensure the evaluation process was engaging and to enable a comprehensive evaluation of the program. The methods reported here are sexual health drama scenarios and a sexual health questionnaire. Six retrospective interviews with long-standing participants of the Sharing Stories youth theatre program were also undertaken by the researcher, and provided valuable information on the long-term effects of the program. Field notes documented by the researcher throughout the evaluation were used to record observations but were not included in the data analysis. These interview data and field notes are reported elsewhere.¹⁶

Four sexual health drama scenarios were devised in consultation with a small group of Sharing Stories peer educators, to ensure that the content, language, and topic of each scenario were realistic and relevant. The intention of this method was for participants to react and respond to the scenarios as if the situation happened in real life. The scenarios provided a way for participants to demonstrate and articulate their knowledge and skills in action, and in front of their peers, known to be challenging for young people in relation to discussing sexual health topics.¹²

Young people completed the four drama scenarios in self-selected pairs at their first Sharing Stories drama workshop, and then again after 12 weeks. Each scenario lasted between 10 and 20 min. The performances of each sexual health drama scenario were video recorded to ensure that all responses were captured. Participants gave written consent to be filmed. The four drama scenarios developed for this evaluation are shown in Table 2.

Table 2.  Results from the sexual health drama scenarios (Scenarios 1–2)
STI, sexually transmissible disease

Participants completed a sexual health questionnaire before the commencement of the Sharing Stories youth theatre program and then again after 12 weeks. The paper-based sexual health questionnaire was anonymous and collected quantitative data measuring changes in participants’ knowledge, confidence, attitudes and skills in relation to sexual health. The questionnaire included nine questions using a combination of Likert scale, dichotomous and open-ended questions. The questionnaires were administered at the beginning of a drama workshop and took ~5–10 min to complete. Participants were able to ask questions and receive clarification from the researcher if required.

Video recordings were viewed by the researcher and examined for specific statements, comments, demonstrations of knowledge and provision of advice relevant to the evaluation. Audio recordings were transcribed and the data were analysed based on the frequency of the answers for each statement. Frequencies are expressed as proportions (%) since the number of participants who took part in the pre- and post-scenarios differed slightly owing to varying attendance rates at the drama workshops. The pre- and post-scenario frequency results were compared and the findings summarised in relation to the evaluation objectives. Descriptive statistics were calculated for the sexual health questionnaire data.

All participants (n = 18) in the Sharing Stories youth theatre program agreed to participate in the evaluation. All participants took part in the pre-evaluation sexual health drama scenarios and 15 participants took part in the post-evaluation drama scenarios. Reasons for non-attendance were primarily due to work and study commitments. Due to the fluid nature of the program not all participants took part in all four scenarios in either the pre- or post-evaluation (pre-scenario/post-scenario). Participation numbers are shown in Table 2.

In Scenario 1, 63% of post-scenario participants correctly mentioned two or more STIs to a friend who had engaged in unprotected sex compared with 38% of the pre-scenario participants. In addition, half of the participants compared with a quarter of the participants advised their female friend that they could be pregnant as a result of unprotected sex in the post- and pre-scenario groups respectively. There were no post-scenario participants who said to their friend that they could contract AIDS as a result of having sex without a condom in contrast to 13% of pre-scenario participants. The proportion of participants who were able to recognise Scenario 4 as being a potential sexual assault or rape was higher in the post-scenario (86%) than the pre-scenario (40%).

Chlamydia was the most commonly mentioned STI in any scenario. Post-scenario recordings showed participants speaking about the fact that if untreated, chlamydia can cause infertility. This was followed by conversation around family values, and the disappointment among family and parents if their child was not able to have children in the future as a result of chlamydial infection.

A higher proportion of participants told their friend who had unprotected sex that they should get an STI test (pre-scenario 6%, post-scenario 25%). This result corresponds with the higher proportion of participants who told their friend that ‘they could have caught a disease or STI’ (pre-scenario 13%, post-scenario 63%).

In Scenario 4, 43% of post-scenario participants accurately referred their friend who had potentially been sexually assaulted to the Sexual Assault Resource Centre compared with 20% of pre-scenario participants.

In Scenario 2, all post-scenario participants (100%) noted that condoms protect against STIs compared with 63% of pre-scenario participants. The proportion of participants who accurately mentioned two or more STIs was also higher (38% pre-scenario, 57% post-scenario). Additional comments included further justification for carrying condoms, such as carrying condoms in case a friend needed one at a party (43% post-scenario). No pre-scenario participants mentioned this.

Seventeen pre-evaluation questionnaires and 13 post-evaluation questionnaires were completed by participants. The overall number of male and female respondents remained the same (30% male, 70% female). Participants’ confidence in relation to discussing sexual health remained relatively stable (Table 3).

Table 3.  Confidence talking about sexual health
STI, sexually transmissible infection

The questionnaire asked participants to list three places they could go for STI testing. The answers provided in the pre- and post-evaluation questionnaires included a family doctor or health clinic, Family Planning WA (now Sexual Health Quarters, a provider of specialist services in sexual and reproductive health), and Quarry Health Centre (a specialised sexual health service for young people under 25 years, offering clinical, counselling and education services), with family doctor or health clinic remaining the most common answers. The Sexual Assault Resource Centre was an additional site mentioned in the post-evaluation questionnaires. The number of people (n = 3) who answered ‘can’t think of any’ remained the same for both pre- and post-evaluation responses.

The post-evaluation data identified a higher proportion of participants who answered ‘false’ to the question ‘buying condoms is embarrassing and shameful’, with 53% answering false in the pre-evaluation compared with 92% post-evaluation. There were no participants stating they were ‘unsure’ to the same question post-evaluation compared with 35% pre-evaluation.

As demonstrated in Table 4, the proportion of young people who reported feeling ‘very comfortable’ carrying condoms was higher post-evaluation (62%) compared with pre-evaluation (24%). The number who reported feeling ‘uncomfortable’ decreased to 15% post-evaluation, with no participants reporting they felt ‘very uncomfortable’ in the post-evaluation questionnaire compared with 18% who did so pre-evaluation. As shown in Table 5, when asked to list three questions or statements of advice to a friend who is planning to have sex, the pre- and post-evaluation answers were relatively similar, though there were no participants who answered the question with ‘can’t think of any’ in the post-evaluation.

Table 4.  Responses to the question ‘How comfortable would you feel carrying condoms?’

Table 5.  Responses to the statement ‘List three questions or advice you would give a friend who is planning to have sex’

When asked how likely it would be that they would go for an STI test after having unprotected sex, the proportion of participants who said it was ‘likely’ was higher post-evaluation (54%) than pre-evaluation (35%). In addition, there were no participants who answered they were ‘unlikely’ to get an STI test post-evaluation compared with 24% pre-evaluation.

Drama and theatre are known to be appropriate methods of engagement for multicultural young people opening up dialogue on sensitive topics such as sexual health.⁴ The present study shows that drama-based research and evaluation methods can engage young people in innovative ways that produce rich research findings, especially in regards to sexual health education. The findings of this evaluation confirm that regular participation by young people in the Sharing Stories youth theatre program improves sexual health knowledge, increases confidence levels, and creates positive attitudes towards sexual health.

Based on this study, sexual health appears to be a topic which young people are more likely to discuss with their peers than with a family member. It was evident from the sexual health drama scenarios that participants gained confidence discussing sexual health in front of their peers. However, confidence talking about sexual health with family members did not increase over the 12-week evaluation. Participants’ cultural and religious beliefs may prevent open discussions about sexual health within a family environment.⁸ These results warrant investigation for further development of the program.

The content of the weekly drama workshops appeared to influence some participants’ knowledge and retention of sexual health information. For example, the topic of consent was discussed in detail at various drama workshops during the 12-week period and post-scenario participants discussed the importance of consent when talking to a friend planning to have sex. Post-scenario participants also had a better understanding of the differences between HIV and AIDS and understood that a person cannot contract AIDS from unprotected sex, they were also more competent in identifying common STIs, such as chlamydia.

Additional information provided by post-scenario participants on the negative health effects of STIs indicated an increase in STI knowledge. The impact of having an STI on an individual’s family was demonstrated when young people would tell their friends that ‘chlamydia causes infertility’ and that ‘their parents would be upset if they were not able to have children’. The child-bearing abilities of young people across cultures are often valued by parents and grandparents.¹⁷ This suggests that acknowledging family values and expectations in sexual health education may be effective for promoting safe sexual behaviours among young people.

The range of STI testing outlets that participants listed in the post-evaluation questionnaire were similar to those listed pre-evaluation. A medical centre or doctor’s surgery was the most common response in both the pre- and post-evaluation questionnaires. This finding suggests that there may be further opportunities to educate participants on other STI testing locations within metropolitan WA.

Increased positive attitudes and beliefs around purchasing condoms were conveyed by participants in the post-evaluation questionnaire responses. These results indicate that participants were less likely to express negative judgment or stigmatise someone for carrying or buying condoms. Participants also revealed a higher level of knowledge and understanding on the protective benefits of using condoms.

Providing the opportunity for practice and rehearsal of delivering key messages is important for understanding the context in which to apply them and to allow time for changes in attitudes and confidence to occur.^5,18 This was evident through discussion around condom use, and the use of condoms as props throughout the drama workshops contributed to normalising the idea of carrying condoms. This experience appeared to have a positive impact on the attitudes and beliefs of the participants in relation to buying and carrying condoms.

Using sexual health drama scenarios to allow participants to demonstrate their knowledge and skills in front of their peers proved to be an extremely successful evaluation strategy with high internal validity. The drama scenarios represented participants’ actual confidence, knowledge and skills gained as a result of the Sharing Stories youth theatre program and not perceived competencies should these scenarios occur in real-life. The drama scenarios were also consistent with the fluid and creative nature of the Sharing Stories youth theatre program. Participants’ confidence and enthusiasm during the scenarios were particularly notable given the known taboo and cultural barriers surrounding the subject of sexual health in many cultures.

A limitation of the study was that feedback on the evaluation process itself was not sought from young people. Although work and study commitments were given as reasons for non-attendance during the post-evaluation, it is possible that some young people did not attend because they did not wish to participate in or repeat the drama scenarios at the end of the program. The varying numbers of participants for the pre-and post-evaluation also created challenges in reporting the results accurately. Using a different set of scenarios for the post-evaluation, which addressed the same program objectives, could be considered by other practitioners wishing to use drama scenarios for evaluation. The scenario video-recording and viewing of the videos was much enjoyed by participants. Other programs may wish to consider using technology to improve young people’s participation in evaluation, for example online questionnaires administered through a tablet, or classroom response systems (‘clickers’) providing real-time feedback.¹⁹

For many multicultural youth, talking about sexual health is considered shameful and taboo. Health professionals are, however, increasingly recognising that using interactive and creative strategies for sexual health promotion is an effective education method. The findings of this evaluation confirm that regular participation in the Sharing Stories youth drama workshops improved sexual health knowledge, increased confidence levels and created positive attitudes towards sexual health. The use of an arts-based data collection method in conjunction with a survey tool was shown to be effective for measuring changes in knowledge and skills. The sexual health drama scenarios were consistent with the drama-based program and resulted in better engagement of the participants in the evaluation.