‘I learned to accept every part of myself’: the transformative impact of a theatre-based sexual health and HIV prevention programme

Abstract

Theatre-based interventions have been used in health promotion activities among young people to address HIV and sexual health. In this study, we explored the experience of undergraduate student performers participating in a theatre-based HIV prevention and sexual health education intervention for high school students in the USA. Undergraduate students enrolled in a credit-bearing course to learn about HIV and sexual health, participatory theatre and health education techniques. We analysed students’ reflective essays written throughout the semester to identify any changes and the intervention processes that promoted these changes. Students experienced five interrelated forms of transformation: (1) increased knowledge about HIV and sexual health; (2) changes in attitude and communication about sex; (3) artistic growth; (4) emotional growth; and (5) clarification of career goals and future plans. Intervention processes that contributed to these transformations included improvisation, guided writing exercises, the creation of a close-knit cohesive group, and interactions with a group of HIV-positive speakers. Theatre-based, peer-led sexual health programmes can provide a transformative experience for undergraduate student performers. The transformative effects are linked to specific activities and processes of the intervention and require examination in future research.

Introduction

Theatre-based interventions have been widely used in health promotion activities to address HIV (Denman et al. 1995; Glik et al. 2002; Heap and Simpson 2004; Francis 2011) and sexual health (Guzmán et al. 2003; Simons 2011; Lieberman et al. 2012). The positive effects of theatre-based HIV/AIDS or safer-sex-focused interventions among young people include improved knowledge and attitudes about HIV (Denman et al.1995), greater intention to delay sex and use contraceptives (Guzmán et al. 2003), and increased sexual health knowledge (Lieberman et al. 2012). Despite the wide uptake of these interventions, few evaluations have assessed their effectiveness in the USA (Glik et al. 2002). Furthermore, few studies describe the impact of participating in HIV and sexual health theatre-based interventions on the young performers themselves (Glik et al. 2002).

HIV and sexual health theatre-based interventions often utilise participatory theatre methods (Simons 2011). In contrast to conventional theatre, which separates audience members and performers, participatory theatre methods actively engage audience members and communities in the issues being explored aiming to a sense of ownership among those involved (Sloman 2011). Many of the participatory theatre methods used today draw from the work of Augusto Boal and the Theatre of the Oppressed (Conrad 2004; Francis 2011; Simons 2011). These theatrical techniques stem from the popular education movement developed by Paulo Freire that encourages participants to develop a critical consciousness and question their social and historical realities. The Theatre of the Oppressed challenges the idea of a passive spectator and re-defines the audience as ‘spect-actors’ whom performers prompt to actively engage with scenarios (Boal 1979; Freire 1993; Conrad 2004). Today, a variety of practices fall under the broader rubric of participatory theatre methods (e.g. techniques known as ‘popular theatre’ (Conrad 2004), ‘forum theatre’ (Francis 2011), and ‘process drama’ (Simons 2011)). Practitioners assert that these methods allow both the audience and performers to explore difficult issues, generate ideas, engage in problem-solving, and develop a critical understanding of health and social issues. Through modeling, or what Boal referred to as ‘rehearsal for real life,’ these methods can also raise awareness and support behaviour change (Boal 1979; Conrad 2004; Francis 2011; Simons 2011; Sloman 2011).

In this study, we explore the experience of undergraduate student performers engaging in a participatory, theatre-based HIV prevention intervention at a large, southeastern public university in the USA. The intervention was part of a credit-bearing course in which undergraduates from diverse academic backgrounds created and delivered a theatrical performance about HIV and sexual health to high school students. HIV among youth and adolescents is an urgent public health issue in the US South. According to the US Centers for Disease Control and Prevention (CDC), in 2011 the Southeast had some of the highest annual rates of new HIV diagnoses among adolescents and young adults in the USA. (CDC n.d.). The intervention sought to decrease stigma associated with HIV and Sexually Transmitted Infections (STIs), increase HIV/STI knowledge, and promote safer sex practices among high school youth. While the primary goal of this intervention was to improve attitudinal and behavioural outcomes among high school student audiences (results reported elsewhere [Lightfoot et al. in press]), we were also interested in the experience of the undergraduate performers, based on anecdotal evidence that the intervention had an effect on their own knowledge, attitudes, and behaviours. In this paper, we draw from both theatre-based and health behaviour theoretical frameworks to understand how the intervention experience may be transformative for young performers. In participatory theatre, transformation is hypothesised to occur by actively participating in the theatrical experience (Boal 1979; Jackson 2007). In the health education literature, transformation is operationalised as specific changes in knowledge, beliefs, attitudes, or behaviours (Glanz, Rimer, and Viswanath 2008). Thus, the idea of transformation was an important area of inquiry from both participatory theatre and health education perspectives.

Since little research exists on participation effects for those delivering theatre-based interventions, we took an exploratory approach to our research, seeking to broadly identify themes of transformation that were connected to both participatory theatrical techniques and health education methods. We sought to understand what students were gaining from this pilot programme and identify intervention processes that influenced the changes they underwent.

Methods

The intervention

AMP! (Arts-based, Multiple-intervention, Peer-education) is a theatre-based HIV prevention and sexual health education intervention developed by the Art & Global Health Center (AGHC) at the University of California, Los Angeles (UCLA) in partnership with the Los Angeles Unified School District HIV Prevention Unit. The intervention uses a ‘near-peer’ approach with undergraduate students who are close in age to the high school students. Such programmes have been shown to be effective in educating college-aged peer educators and their target audiences (Sloane and Zimmer 1993). In particular, peer-led HIV-related interventions have resulted in significant improvements in HIV knowledge, attitudes, and behavioural intention scales among adolescent and college-aged peer educators and participants (Shulkin et al. 1991; Pearlman et al. 2002).

AMP! was recently piloted in the US South through a partnership with a large, public university. Undergraduate students participated in a semester-long service-learning course in which they developed and performed an original theatre production about HIV prevention and sexual health to educate ninth grade high school students about these issues. The course was open to students of all academic disciplines with no prior knowledge of HIV or theatre experience required, and fulfilled the undergraduate requirement of ‘experiential education,’ meaning that students would be expected to engage with the local community during the course.

The course began with a two-week theatre intensive with the goal of encouraging students to reflect on their own experiences as a starting point for developing an informative and engaging script. They engaged in a variety of exercises including improvisation and guided writing to reflect on the current state of sex education and what they wished they had learned in their own high school. In addition to training in participatory theatre techniques, people living with HIV spoke about their experiences and graduate public health students delivered an introductory HIV 101 training course, which covered sexual health, HIV prevention information, and contextual and social issues related to HIV. This material was woven into the scenarios undergraduates created for the theatre performance and workshops they delivered to high school students.

By the end of the intensive, students had compiled their individual writing and collective improvisation into a 40-minute show broken into vignettes. The final script addressed HIV transmission and prevention, consent, proper condom use, stigma, and testing, as well as communication with partners and parents, barriers to contraception, abortion, abstinence, and inadequate sexual health education. Topics were addressed using both humour and personal narrative. Excerpts from the script are displayed in Table 1.

Table 1.

Examples of performance material development process.

Intervention Theme	Activities	Example Script Material	Excerpt
Critical reflection	Reflective freewrites and group improvisations of their sex ed experience	Satirical abstinence-only classroom scene: the teacher refuses to answer questions and two students have infants in class	Teacher: It's important to protect your innocence as long as you can. And how do we do that, girls? (hands raised, teacher ignores them) Abstinence, of course!
HIV 101	Historical timeline of HIV/AIDS; course readings on rates and current trends, presentation of transmission, testing and prevention	Undergraduates lead the high school students in a call and response singing the five fluids of HIV transmission	Conductor: Ladies and gentleman, the [university] sexaphonic choir is here to teach you the 5 fluids of HIV transmission. Blood. Semen. Pre-cum. Vaginal Fluid. Breast Milk.
Stigma	Presentation from HIV-positive speakers; course readings and multimedia on stigma; group discussion about stigma; presentation on common myths	A fake episode from The Real World with an HIV-positive participant in the household	Housemate 1: How am I supposed to be comfortable in this house when someone is running around with HIV or AIDS or whatever. Now I can't go barefoot, I can't sit on the toilet, I need to buy my own mini fridge to keep food in in case he touches the food. .... Housemate 2: How am I supposed to pretend to agree with this chick? Everything she is saying is wrong.... He is a normal guy, she needs to get over herself.
Condom Use	Forum theatre scenarios and improvisation addressing condom use; course readings on condom efficacy; presentation on correct use of condoms	A sportscaster inspired scene with two announcers commenting as two teenagers initiate sex in a car. The sportscasters “pause the play” drawing attention to issues of consent and condom use	Teen 1: so, do you um...have protection? Teen 2: ya, I brought a condom, don't worry! (takes a look at date) 2015? Phew, we're good. Teen 1: (rips with teeth, freezes with teeth on wrapper) Sportscaster 1: I'm seeing teeth on the condom. Yup. I'm seeing teeth on the condom...It just shows that even with a lot of experience and practice, players can still make these simple mistakes and it can potentially cost them the game.

Once the performance had been created, the undergraduates rehearsed and then performed the show for six classes of ninth grade students enrolled in the required health course at a local high school. Following each performance, undergraduates facilitated a discussion during which high school students could ask questions about the process of creating the show, specific scenes, or cast members’ experiences. The undergraduates returned a second time to lead interactive theatre-based condom demonstration and negotiation workshops. In addition to developing and delivering the performances and workshops, the undergraduates continued to learn about sexual health and participatory education theatre and reflect on their experience in this course through weekly class meetings and assigned readings, papers, and online discussion forums.

Design

In 2012-2013, the research team, which included a public health researcher with expertise in adolescent HIV prevention interventions, the AMP! project manager, and public health graduate students, conducted an evaluation of the effect of the AMP! programme on participating high school and undergraduate students. The team collected quantitative and qualitative data, including surveys, post-performance feedback, focus groups, in-depth interviews, participant reflection essays, and field notes. For this paper we analysed participant essays to gain a more nuanced understanding of undergraduates’ experiences in the course. The Institutional Review Board at the University of North Carolina at Chapel Hill approved this study.

Recruitment and sample

All ten students enrolled in the undergraduate course voluntarily consented to participate in the study. Eight students were female and two were male. Two identified as Black/African-American, one as South Asian, two as Hispanic/Latino, and five as Caucasian/White. Three students were first-year students, one was a second-year, two were third-years, and four students were fourth-years. Students had a variety of majors: three were Communication Studies majors, two Women's and Gender Studies, one Environmental Health Sciences, one Multimedia, and three undeclared. Half of the participants had previous theatrical training or experience.

Data source

The reflective essays were written at three points throughout the course; however, all analysis was conducted after the course had ended. These essays were required assignments and graded by the course instructor. The course instructor provided broad and open-ended essay prompts, allowing for variation in style and content in students’ responses. First, following the theatre intensive at the beginning of the course, students wrote an essay in which they reflected on what they did and learned during the intensive and how they grew. Mid-semester, students reflected on the difference between service and activism, relating their writing to class readings, their experiences in the course, and past experiences with service-learning. At the end of the course, students wrote a final essay in which they reflected on their experience in the course as a whole, detailed how they synthesised or made sense of what was explored, and described how their understanding of theatre as a tool for sexual health education grew through participating in the course. After the conclusion of the course, public health graduate student researchers who had no personal interaction with the undergraduate course participants analysed the student essays. Researchers de-identified essays prior to the analytic process and participants were assigned pseudonyms to ensure confidentiality.

Data analysis

The analysis process centred on the themes of ‘growth and transformation,’ which we conceptualised as personal changes undergraduates experienced throughout their participation in the intervention. Analysis was led by one member of the research team (MG), with ongoing discussion and input from the rest of the research team and the course instructors. We began by writing narrative summaries of each student's essays (Gibbs 2007a). These summaries helped us understand how individuals changed throughout the course and identify both the positive and the more challenging experiences and outcomes of course participation. We used the narrative summaries and other memos about thoughts and emerging themes across students to develop a codebook (Gibbs 2007b; Saldaña 2009). Examples of codes we created included ‘atmosphere,’ ‘emotional processes,’ ‘course improvement,’ ‘learning/growth,’ and ‘my life after.’ We then coded the essays using ATLAS.ti.v.7 (Scientific Software Development 2013).

With the coded data, we created matrices to compare the transformations experienced by students and how they were affected by various components of the course (Miles and Huberman 1994). We matched what each student wrote about the course with the transformations they experienced to explore how course content and transformations overlapped. Throughout data analysis we consulted course instructors and programme staff to provide context or details for specific activities or components of the course students referenced. This rigorous iterative process helped us enhance the confirmability, transferability, and trustworthiness of the data (Lincoln and Guba 1985).

Findings

All students experienced multiple types of transformations, many of which overlapped. Students described five types of transformations: 1) increased knowledge about HIV and sexual health; 2) changes in attitude and communication about sex; 3) artistic growth; 4) emotional growth; and 5) clarification of career goals or future plans. We describe these transformations below, along with components of the course and intervention experience that may have promoted the transformations. We also draw attention to some of the potentially negative aspects of the experience that students reported and note how these may have impacted the learning process.

Increased knowledge about HIV and sex

All but one of the students described transformations related to their knowledge and understanding of HIV and sexual health. For many, this entailed learning more about sexual health or biological facts about HIV. Laura described:

To be 100% honest, I think I could say I knew about none of the sexual health information we learned, previous to the class. I had never even touched a condom before being in this class...I had A LOT to learn. The material on how things physically work was very illuminating to me. I have never been in a real sexual health class before so honestly words such as ‘clitoris’ were very new for me.

Along with learning biological facts, students gained a greater understanding of social issues surrounding sexual health and HIV, ranging from issues of access to comprehensive sexual health education to the socio-historical context of HIV.

Students described feeling comfortable asking questions and admitting to not knowing information, something many had not experienced in other settings where they had been exposed to sexual health information. Jessica described:

It was so inspiring to be in a group full of people with such a varied amount of knowledge. It was comfortable to ask questions and to not know answers. This intensive is probably the first time in my life when the idea of ‘there are no stupid questions’ actually felt true.

This quote highlights how the atmosphere created in the course facilitated the learning process, normalising different levels of knowledge and creating a comfortable space for asking questions and sharing experiences, thus prompting students to seek additional information. Indeed, many students commented on the safe space established with their classmates and course leaders. Jessica pointed out how sharing their own experiences was an integral part of the learning experience. When describing discussions students had around their own sexual health education growing up, Jessica said, ‘Sharing all of our stories and seeing how much they had in common shifted us towards a conversation about the education system at large, and the very large lack of good sexual education.’

In addition, students emphasised that their new knowledge challenged their preconceived notions, particularly those related to HIV. Olivia said, ‘Too often (prior to this class) I have grouped HIV/AIDS together as an epidemic in queer communities or in Africa... Now...I actually know what it is, what it means, and how it can affect anyone.’ Others described how the class helped them debunk their own stigma around sex, HIV, and people living with HIV. For example, Josh wrote:

I knew that AIDS was incurable and that it has been more widespread in Africa and among homosexual men, but now I know that even the tidbits of knowledge I knew, served as platform to form stereotypes and stigma. To be educated/educate myself on HIV/AIDs and to hear the stories of [the HIV-positive speakers] served to inspire me to not only change my own stigma and preconceived notions surrounding the virus, but to further spread what I have learned.

Like Josh, other students expressed feeling inspired by the HIV-positive speakers and the stories they shared. The speakers served as a vital source of information during the theatre intensive early in the course, bringing a human face to the issues students were learning about.

Changes in attitude and communication about sex

Along with gaining general knowledge and understanding about HIV and sexual health, 6 out of 10 students described experiencing personal transformations related to sexual health in the form of three subthemes: (1) becoming more comfortable talking with others about sex, (2) being more accepting of their own sexual choices, and (3) clarifying their personal views about sex. Each of these sub-themes is discussed below.

Comfort talking about sex

Within this larger transformation, the most common change was to become more comfortable talking about sex in general. Alice wrote:

When I began this class, I felt a bit of shame. I knew that the work we were doing was powerful, but I also knew the stigma that came along with talking about sex, especially with teenagers. I remember explaining what my class was doing vaguely in order to avoid those asking questions that would embarrass me or make me feel guilty. Over the course of the semester I realised that my feeling of guilt and shame was senseless. Once I got over that feeling, I was able to freely express the programme and the impact it had of me and the people who I was working with.

Like Alice, other students described becoming more comfortable asking questions about sex, talking with others about sex, and sharing what they learned in the class with their peers. David, for example, described how listening to classmates share their experience during the course inspired him to advocate for condom use among his peer group:

This ability to speak on touchy subjects with ease was developed by the intensive and inspired by my classmate... Her monologue of revealing her life gave me not only reason to be honest with myself but also with others. I no longer wanted to be one that stands by and occasionally, intervenes.

Similarly, Josh described not expecting to share thoughts about sex with others at the beginning of the course, writing, ‘I did not imagine that we would create a space where I would share, basically all, of my insecurities, my obscurities, and my fears [about sex] within a wonderful group of people.’ While many students echoed Josh's sentiments about the value of listening to their classmates’ experiences, some also acknowledged the risk and sense of vulnerability sharing their own stories entailed. For example, in contrast to his previous quote, Josh also wrote about negative feelings he experienced while participating in an in-class writing exercise:

And then, there was the day when we wrote about religion. And I hit a wall. I was upset with the whole programme. That we had willingly created a safe space, and it felt as if we were now being a little coerced into sharing secrets which we share with only the best of friends.

Similarly, Emily described ambivalence about disclosing a sensitive personal experience, saying:

I feel that my monologue could make a difference and is powerful, I am afraid though, of the implications it may have. I often am conflicted if coming out about it is something I should do, and think about who could find out, but I feel like it's the right thing to do.

Thus, while students described sharing as helpful, and perhaps promoting of the transformations they experienced, for some, this was a stressful experience.

Greater acceptance of personal sexual choices

An additional transformation was feeling a greater acceptance of their own personal sexual choices, including whether or not to have sex, and if so, with whom. Laura wrote:

In high school, being a virgin was fine. It was the typical thing and I wasn't looked at any differently. But coming into college, it was weird for me to see myself as the minority. It wasn't something I talked about all the time because it made me uncomfortable. I grew as an individual during this process, because I learned to accept every part of myself.

David arrived at a similar conclusion:

Before the class, I felt it to be risky to tell my friends that I have casual sex and am okay with it. I realised within the intensive that sexual health is to the discretion of the individual and does not have a rigid set of rules. Society has played such a negative, stifling effect on my view on expression and sex, and I, now, feel liberated from the experiences I had during the intensive.

These two students had very different levels of sexual experience and different personal standards. Yet, through the course they both became more comfortable with the sexual choices they had made. Participants felt that the open, non-judgmental environment of the course facilitated this acceptance.

Clarification of personal views around sex

Finally, some students described their participation in the course as a time when they were able to reflect on their upbringing and reconcile what they had learned in the past about sex with their experiences as college students. For example, the theatre intensive included an exercise called The Gospel of My Body, which was used to spark discussion on religion and sex. Students were given a two-part prompt with ‘fill in the blank’ spaces that read: Part 1: ‘My religion told me____ about sex.’ Part 2: ‘The gospel of my body is_____.’ Many of the students had grown up in the US Bible Belt¹ and this exercise triggered reflections on the limitations and inadequacies of the abstinence-only education they had received. For Kate, a student who did not have a Christian upbringing, the exercise prompted her to do further research about her religion. Kate wrote:

It was as if I felt left out because my religion does not tell me the same ideas surrounding sex and marriage that it tells everyone else. [My religion] does not talk about sex or about how one man has to marry one woman. While I was writing, I was angry and was thinking ‘Why am I left to figure out all of this on my own?’ However, I went home and did some research and found to my amazement that the reason [my religion] does not discuss any rules is because there are none.

Through this experience, Kate shared that she learned her religion was actually more tolerant about sex and marriage than she had thought.

Others discussed how their sense of personal transformation led to changes in how they behave and conceptualise sex in their own lives and helped increase their confidence about making healthy decisions, as illustrated by Sara:

On a personal note, this experience has made sex a lot more important to me. For a while, I didn't know what to think of sex. I was trying so hard to reconcile what I was taught growing up with how I feel now as a...college student with a lot of past sexual partners. Now, my view of sex is much healthier, much more realistic. I believe that sex is something special, it is important, and it should be with partners who are also healthy and who I know well and trust... I knew a fair amount about sexual health before the start of the class, but I feel far more confident and empowered to make positive decisions now.

Like Kate, Sara wrote about being challenged by in-class exercises that required her to reflect on her religious upbringing and that may have helped her clarify and reconcile her personal views.

Emotional growth

While the focus of the course was on theatre, sexual health, and HIV, the majority of students (8 out of 10) experienced personal transformations that transcended beyond these topics and brought greater self-understanding, confidence, and acceptance to their lives in general. Some described developing a greater acceptance of themselves and their past experiences. For example, though Anna described coming to the disappointing realisation that she was not where she wanted to be in terms of being an activist, she wrote, ‘This programme has pointed out my flaws but cushioned the impact of accepting and moving forward with them as learning points within my life.’ Others became more comfortable with themselves, such as David, who wrote, ‘I, personally, grew more comfortable within my ideals, abilities, and body image.’ Similarly, Alice described growing more comfortable with her own voice and sharing that with others: ‘Before this class, I was comfortable talking about the injustices and disparities of the world, even writing about them, but I did not know how important it was to share my opinions and discourses with others until this class.’ Thus, many students experienced greater acceptance and comfort with themselves through participation in the course, even when becoming aware of personal flaws.

Students pointed out activities that promoted the emotional transformations they experienced. For example, Alice mentioned activities in the course that taught students to ‘put a clown nose on [your] inner critic,’ such as literally wearing a clown nose in public, saying that the clown nose reminded her not to take herself too seriously. Similarly, Anna described how the time-constrained writing exercises and improvisational games forced students to react in the moment without having time to ‘over-analyse’ what they were going to do or say. These exercises were challenging and anxiety provoking for some students, as they described feeling vulnerable, anxious, overwhelmed, and embarrassed during the activities. However, despite the challenging nature of the exercises, or perhaps because of them, students recognised improvisation and writing exercises as contributing to their personal growth.

Artistic growth

Over half of the students (6 out of 10) identified artistic growth as a major transformation they experienced from participating in the course. For some students, artistic growth entailed developing greater comfort as an actor, such as Emily, who stated, ‘Personal goals I reached were becoming comfortable on stage, learning to have fun with my parts, giving it my all even when I had learned all my lines and it felt natural.’ Others described feeling inspired about theatre and their future as an artist. Anna wrote:

As an artist, and more specifically as a writer and performer, this class helped motivate me to believe in a future that I thought may be impossible. Working within the context of this programme has provided a sense of hope towards my craft that I didn't have before and for that I am so grateful.

Two students described learning to be more authentic in their acting and portrayal of their characters. Laura wrote:

I really feel like I grew as an artist while doing this show just by being able to be comfortable in my own skin, and talking about my personal experiences in front of crowds of people I didn't know, and classes I didn't know... I grew as an individual during this process, because I learned to accept every part of myself. I learned to play [myself], instead of a disconnected character, as I had in all my previous theatre productions.

Here, there is a connection between Laura's personal transformation related to sex (becoming comfortable with being a virgin in college) and artistic growth. Learning to play her authentic self in the theatre production and learning to accept and be comfortable with her sexual choices were two related processes for Laura. Again, the improvisational exercises that were part of the course may have contributed to the transformations students experienced, as described by Laura: ‘We had to work off the top of our feet so it couldn't be something we thought about. Whenever that is the case, everything becomes more natural, and it isn't as fabricated. Also, the responses, because we didn't know what was coming next, were all real and authentic.’

It is important to note that the theatrical components of the course were not easy for everyone. For example, Sara wrote:

The week of intensive was difficult for me in many ways, but it was particularly challenging for me as a novice performer. I feel that I am still not a very confident and bold actor, although I have learned a great deal about trust [this] semester. I learned to trust myself, trust my instinct and most of all trust the other performers. I now have a good deal more confidence and feel capable of thinking on my feet and standing up for what I believe.

While Sara still did not gain complete comfort as a performer, this excerpt emphasises how the challenges she experienced onstage and learning to trust herself and other performers helped her gain confidence that may have transcended to other areas of her life.

Clarification of career goals and future plans

Finally, all students identified some way in which their experiences in the course influenced their career goals or future plans related to theatre, health education and activism. For example, Laura enthusiastically described:

Prior to this class I had never had any experience with activist theatre. I saw theatre as a pastime, which I had very often been told by teachers and parents and friends that I could not make a career or an impact out of. This class has shattered those misconceptions and opened a whole new world for me. This excitement is more than I can verbalise because education and theatre are two of my BIGGEST passions, so this illuminated an entire potential career path for my future.

Similarly, Kate explained, ‘This process has helped me align my interests in choosing a career. I would like to develop as an educator and activist by drawing from the concepts of theatre for social change to educate populations about environmental health risks or other health risks.’ Seeing how theatre could be used to promote sexual health demonstrated new potential career paths to these students.

The course not only helped students to develop their career goals, but also to identify other ways in which they will use what they learned in the future. For example, Emily described planning to use material from the course while working abroad the following summer: ‘I have the opportunity to create a space and curriculum having to do with sexual education that I can do anything with, and am [excited] about including Forum Theatre as one of the tools I use.’ While not a transformation per-se, this illustrates the ways in which students’ experiences in AMP! may inform how they think about their future work and the potential of programmes such as this for developing future sexual health professionals. Indeed, many students described learning that theatre is an effective tool for health education and social change in general and feeling empowered to make a difference in the future. Sara described this sense of empowerment she gained: ‘By being a member of this incredible team, I have been made aware that I have more of a voice in the world than I originally thought and that I have the ability to promote and inspire positive changes.’ Thus, participation in AMP! inspired students to seek future opportunities to engage in participatory theatre, sex education, and social justice endeavours.

Discussion

Undergraduate student performers participating in this intervention experienced many different types of transformations and positive outcomes, including increased knowledge about HIV and sexual health, changes in attitude and communication about sex, greater confidence and acceptance of themselves in general, and the discovery of future career interests. These findings add substantially to the limited research examining the effect of participating in theatre-based interventions on youth performers in the USA. The few other studies conducted have identified similar transformations occurring among youth theatre participants, though not all these interventions focused on HIV or sexual health. For example, in a qualitative study, Haines, Newmark-Sztainer, and Morris (2008) found that children who participated as performers in a theatre-based intervention in the USA targeting weight and body image reported increased resilience to withstanding negative comments from others, improvements in their communication, and improved body satisfaction. Douglas et al. (2000) reported a number of positive changes that diverse groups of young people (ages 11-21) experienced through participating and performing in a health-related theatre programme in London. These changes included developing greater confidence, improving interpersonal skills, and learning more about themselves. Finally, in a qualitative study of youth performers and adult leaders involved in US youth theatre programmes related to HIV, Glik et al. (2002) described a number of benefits to youth performers highlighted by respondents, including improved communication, leadership, and self-confidence.

Findings from our study of the transformations experienced by the undergraduate students in AMP!, such as increased confidence and greater understanding of themselves, corroborate these earlier studies. Though AMP! focused on HIV and sexual health, the transformative experiences of these students transcended these specific topics as their learning and growth applied to their lives as a whole. This finding highlights the fact that the transformations that youth performers may experience in theatre-based interventions are not limited solely to the health topic addressed.

In their essays, students provided evidence that specific components of their AMP! experience, such as improvisational exercises, sharing, guided writing exercises, and the creation of a safe space, transformed them in practical and profound ways. Other studies have also pointed out that a programme's atmosphere, such as the safe space that theatrical work can create, plays an important role in facilitating question-asking and exploration of difficult topics, like stigma (Heap and Simpson 2004; Francis 2011). When sharing their previous sexual health education experiences, the undergraduates pointed to the scarcity of safe spaces in which to pose questions about sex and receive answers in a medically accurate, stigma-free manner. This served as a theme in their skits, in which they discussed lacking access to information and adults they could trust with their questions when in high school. In contrast, students identified the safe space created in AMP! as central to being able to explore difficult and personal topics such as religion and sex. Moreover, students in AMP! discussed how the growth they experienced in one area, such as learning to be more authentic when acting, led to growth in other areas, such as being more confident in their own sexual health choices. Douglas et al. (2000) identified a similar phenomenon in their study saying, ‘Some [youth] reported that the development of confidence as performers had helped them to develop confidence in a more general sense’ (212).

While the findings presented here begin to shed light on processes of theatre-based programmes that contribute to participants’ transformative experiences, they also generate additional questions about the specific mechanisms and change processes through which theatre-based intervention programmes produce effects on performers. Ball (1994) outlined ways in which theatre and health education are intertwined and argued that both theatre and health education involve cognitive and affective exercises, such as sharing information and examining values and attitudes, and both use active learning. This notion may help explain the popularity of theatre-based interventions within health promotion activities. Furthermore, the improvisational theatrical approaches to education developed by Boal seek to raise participants’ consciousness of social and political forces that influence people's realities (Bell and Desai 2011). The exercises and processes in theatre-based programmes such as AMP! may promote student learning by allowing them to reflect on the role their upbringing, social context, politics, and school setting had on shaping their own values, attitudes, and decisions.

The actual process through which change occurs in theatre-based interventions, however, is not entirely clear (Glik et al. 2002). For example, a safe space has been identified as an important change-producing component of such interventions, but it is unclear how this safe space is created. Moreover, Simons (2011) pointed out that there is a lack of consistency in theatre-based interventions, with interventions varying by topic, location, and population. Because of this variation and lack of rigorous evaluation, it is difficult to know which components of such interventions can be attributed to various outcomes, presenting challenges in trying to replicate interventions. There is a need for future research linking processes used in theatre-based interventions and outcomes for performers. Understanding this link would enable researchers and practitioners to develop effective interventions that have identifiable and sustainable core elements. Additionally, longitudinal studies would permit us to explore whether there is a long-term impact on behaviours of undergraduate participants, and how they might integrate this teaching and learning experience into their future relationships, community involvement, and professional life. For example, one could examine how theatre-based interventions may affect students’ communication skills and self-efficacy to educate others about sexual health issues in the future.

We also identified the importance of addressing potential unintended consequences of theatre-based sexual health and HIV interventions. While students in this study reported many personal transformations and positive outcomes, they also described challenges they experienced throughout the process. Students reported negative feelings such as anxiety and embarrassment, difficulty exploring certain topics (like sex and religion), and mixed feelings around aspects of the process, such as sharing personal experiences. These potentially negative outcomes are an important area for future research. For example, one could investigate the negative feelings that arise when students explore sensitive topics, such as sex and religion, and whether these feelings contribute to shifts in attitude or behaviour. Additionally, learning more about potentially negative aspects of the experience may assist in training course facilitators to effectively lead discussions on difficult topics and help identify support that may be necessary for some participants, such as referrals to psycho-social support services.

Limitations

This study has several limitations. First, the students in our sample were participants in an elective university course and may have had a heightened interest in exploring and building skills in the areas of performance and sexual health. Thus, their thoughts and experiences may not be representative of other university students. Furthermore, the student essays were written as part of their course requirements, making it possible that the act of writing these for a grade influenced what they chose to share. There may have been social desirability bias in students wanting to show positive outcomes.

Conclusion

This study contributes to a growing body of literature on theatre-based HIV and sexual health interventions by providing evidence for the transformations that young performers themselves may experience from participating in such interventions. The transformations experienced by youth performers are overlapping and occur in multiple domains, from the health topic to more general personal growth. Given the popularity of theatre-based interventions, there is a need for further research on the effects of such experiences on youth performers and the processes promoting these changes in order to maximise the benefit of these interventions.