Inside ‘Inside View’: reflections on stimulating debate and engagement through a multimedia live theatre production on the dilemmas and issues of pre‐natal screening policy and practice

Abstract

Background  The role of applied theatre in engaging both lay and professional publics with debate on health policy and practice is an emergent field. This paper discusses the development, production performance and discussion of ‘Inside View’. ¹

Objectives  The objectives were to produce applied theatre from research findings of a completed study on genetic prenatal screening, exploring the dilemmas for women and health professionals of prenatal genetic screening, and to engage audiences in debate and reflection on the dilemmas of prenatal genetic screening.

Methods  ‘Inside View’ was developed from a multidisciplinary research study through identification of emergent themes from qualitative interviews, and development of these by the writer, theatre producer and media technologist with input from the researchers.

Findings  Inside View was performed in London and the Midlands to varied audiences with a panel discussion and evaluation post performance. The audiences were engaged in debate that was relevant to them professionally and personally. Knowledge translation through applied theatre is an effective tool for engaging the public but the impact subsequently is unclear. There are ethical issues of unexpected disclosure during discussion post performance and the process of transforming research findings into applied theatre requires time and trust within the multidisciplinary team as well as adequate resourcing.

Introduction

Developing public engagement with science, technology and medicine is supported by charities, government and a range of policy makers and stakeholders including members of the public themselves. Its implementation utilizes a number of different approaches that include café scientifiques, citizen juries, ¹ and performance. ² , ³ Each of these means of public engagement have their own strengths and challenges in preparation and production although there is a paucity of evaluation in terms of reach and impact. Target audiences vary and the temporally limited nature of the activities makes it hard to assess their legacy. Owing to their nature, science in society events are often undertaken by multidisciplinary teams and this in itself presents its own challenges. Kerr et al. ¹ have argued that technical expertise is often deferred to rather than challenged in these public debates, limiting contestation. Applied theatre is however being used as a tool to engage people with complex issues and dilemmas both cognitively, morally and emotionally in many non‐theatre settings. It is increasingly recognized as a powerful means of social engagement. ⁴ , ⁵ , ⁶ This paper is a case study of applied theatre being used as a vehicle for stimulating debate and engagement with the complexities of prenatal screening developed by an interdisciplinary team of scientists, social scientists and artists.

Applied theatre was chosen as a vehicle to engage people in debate rather than another art medium such as film because it was felt that the interactivity of theatre enables this. Theatre, also typically enables multiple narratives to be presented and therefore it had the potential to represent the diversity of experiences and positions on a situation. Examples can be found from drama as diverse as Shakespeare’s King Lear or Ayckbourn’s trilogy the Norman Conquests. Presenting balanced information on a contested and complex issue such as prenatal screening is a challenge ⁷ and the interactive medium of theatre, enables the presentation of different perspectives.

This paper is a reflective case study of the use of applied theatre developed from the research findings. The play and post performance discussions were aimed to raise awareness and debate with the audiences which consisted of both health professionals and the public. The play and facilitator notes of ‘Inside View’ were subsequently available on the web as a training tool. ¹ The project followed a previous successful use of applied theatre ⁸ by two members of this team and drew on the expertise in the subject of the other members. The completed ESRC funded study on women’s and health professionals’ experiences of first and second trimester prenatal screening ⁹ , ¹⁰ , ¹¹ did not have the funds for this kind of dissemination so additional external funding sought.

Drama and theatre have been used widely in the field of health and social care, particularly internationally. Issue based theatre in health education (THE) can be a powerful vehicle for health promotion knowledge transfer and awareness raising for example in relation to HIV/AIDS. ¹² Soaps on TV and radio can be designed deliberately for this purpose such as in Soul City in South Africa. This type of work more has been called Theatre‐in‐Education – generally applied to work that takes place in schools or non‐theatre spaces. Community Theatre is used to describe theatre performed by non‐professional actors within a specific social context but the broader term ‘applied theatre’ allows a more inclusive approach.

Applied Theatre in health education and promotion often excels at conveying the complexity and dilemmas that are posed for individuals when faced with illness or health choices. For example a play on drug education aimed to inform primary school children about types of drugs also shows the different pressures and choices that are involved with drug use. ¹³ Whilst the use of Applied Theatre in health education opens up issues, these types of activities usually have some particular ‘messages’ intended either to raise the empathy of the audience or to empower them to make more informed choices in the future. ¹⁴

‘Inside View’ was an applied theatre performance; however, it was not conceived within the generally accepted genre of theatre in health education or promotion. There were no health promotion messages concerning the use of antenatal screening. It was aimed to enable the exploration of different perspectives and raise questions for debate in this complex area both cognitively and affectively. ¹⁵ , ¹⁶

Prenatal screening in pregnancy for anomalies such as Down’s syndrome, is an emotive and contested area. It is national policy in the UK to offer screening for Down’s syndrome for all pregnant women. The initial screening indicates the probability of this syndrome being present. The few women who are deemed to be at higher risk together with their partners may choose to have further diagnostic testing (chorionic vilius sampling or an amniocentesis depending on the stage of the pregnancy) and this may lead to a choice concerning possible termination of the pregnancy if the presence of Down’s syndrome or other chromosomal anomalies are confirmed. Prenatal screening is offered to all women in pregnancy and they have to give their informed consent. The information is given by midwives and other health care providers and the need for clear information and communication to underpin these decisions is paramount and well recognized. Nevertheless the information is complex and delivered within short routine consultations. Writers such as Kerr and Shakespeare ²² have raised concerns about the potentially coercive nature of prenatal screening and eugenic agendas.

Paget ¹⁷ has argued that by using performance, findings of research can be portrayed in a much richer medium than in standard academic texts, and can ‘reawaken and recover the audience’s capacity to participate’ (1990:151). One of the key ways in which Applied Theatre produces richer findings is through the inclusion of emotion. Although much social science research seeks to uncover informant’s experiences, a traditional form of dissemination transforms these into abstractions, flattening the emotions. ¹⁷ Learning is often seen to need rationality rather than emotion, but feelings are a powerful channel towards understanding. ¹⁸ The power of performance can be to raise questions about moral issues and may allow audiences to identify with characters, as well as ponder and debate choices and actions. ¹⁹ , ²⁰ , ²¹

In order to assess its effectiveness, applied theatre needs to be evaluated. Whilst evaluation is generally perceived as an essential component, it is more difficult in practice. ²² Although understanding of themes and changes in attitude can be measured, the impact over time is less clear and more rarely done. Evaluation can be planned to assess if the applied theatre performances have had an impact and enhanced understanding or practice in the short, medium and long term. This involves resourcing which may not always be available.

Methods

This multidisciplinary team had some shared expectations – namely to deliver a piece of theatre that was derivative from and faithful to the research project findings but that would engage and involve the public in debate on the topic of prenatal genetic screening. The data‐set included a survey of pregnant women’s views on prenatal screening, interviews with health providers in prenatal clinics and women and partners attending them, and ethnographic observation of clinic sessions. ⁹ , ¹⁰ , ¹¹ Three members of the research project team were members of the performance project, representing medical anthropology (GH), women’s health and midwifery (JS) and biochemistry (KS). They were joined by a theatre director (CB), media technologist (SC), a sociologist (PL), a script writer (TM) and actor (KJ).

The research team members recognized the need for dramatic interpretation as well as the time and space for the creative process. The artistic team were presented with the challenge of developing a very short engaging performance (40 min) with artistic integrity that was a composite representation of the themes derived from the research data, which would present complex issues for diverse audiences.

The development of the performance was an iterative process involving adaptation of the script through a dialogue between the theatre director, social scientists, medical technologist and biochemist at critical points. The main themes from the data set were extrapolated and summarized by the sociologist (PL). These were based on an agreed set of criteria identified by the medical anthropologist, sociologist and theatre director (GLH, PL, CB), that were key concerns for women and health providers in the research and that would also lend themselves to the theatre process. Iterative discussions enabled the theatre director CB to nurture the theatre making process with the writer and media technologist (SC), the aims of which were to develop a text and a digitally designed environment for performance. The theatre director, media technologist and sociologist (CB, SC, PL) also made a site visit to one of the prenatal clinics. The script was developed from the summaries of key themes. The visual material was developed through consultation with the biochemist, utilized some of his materials and some film of the clinic site. The script was shared with the team as it was developed, undergoing several drafts both before and during the rehearsal period which was attended by two of the social scientists (GH, PL).

‘Inside View’ was written with a protagonist as a generic character of ‘everywoman’ representing different women with diverse narratives. The actor explored through internal dialogues with herself and the foetus, possible scenarios of different outcomes to the pregnancy relating to disability, medical technology and exploring a range of aspirations for the unborn child. Dramatic tension was not character driven but driven by the choices inherent in prenatal screening. The representation of ‘everywoman’ was aimed to enable the audience to identify with her dilemmas positioning her within their own context. Diversity was also represented through a number of dramatic strategies that included a voice from the past (grandmother), a radio discussion on disability rights, and the representations of three health professionals – the phlebotomist, sonographer and midwife counsellor.

The debate about pre‐natal screening is one of complex cultural, moral and ethical dilemmas. The challenge for the director was to ensure that the passion for the debate remained vigorous and engaging throughout the performance without presenting a particular position. The medium of theatre allows for layered interpretation of material whatever text is chosen, so the challenge was considerable, yet alongside this for these very reasons it is a potent medium for exploring such debate.

In terms of content, the script was shared with the research team who read it and ensured that it was scientifically accurate and that it reflected the research data. There were some hard decisions to take concerning how much information could be included, particularly scientific information within a short piece for such a wide audience. The storyline involved a pregnant woman attending a prenatal screening clinic, and followed her physical and emotional journey through the clinic. A decision was taken to leave both the woman and the audience with unresolved possibilities and outcomes as a way of focusing on everywoman’s dilemma and choices.

A mini lecture on the biochemical processes of maternal serum screening was inserted to convey not only the information, but also to parallel the didactic nature of much of the information giving to women and was congruent with a performance that took place often in classrooms or lecture theatres.

Artistically, the theatre director had to broker these different perspectives on stage and this necessarily involved adapting and modifying the script with discussion between primarily the actor and writer with the media technologist. An artistic device of a favourite but flawed coffee mug was used to convey the possibility of valuing imperfection.

Like this mug‐here’s a print of the potter’s thumb. And here’s a bit of clay peeping through where the glaze didn’t stick – that’s why I brought it. It’s individual. Even the potter didn’t know for certain how the pot would come out.. All the time it’s in the kiln, it changes, becomes more itself…….. (Excerpt from script)

Visual technology was important throughout. At some point the audience would see a scanned foetus at 12 weeks, just as a pregnant woman on her first visit to the clinic would. An opening sequence accompanied by music with a foetal heartbeat, showed a waterfall that then transforming into the double helix of DNA. The use and reference to time both in the script but also in the visuals and sound track enhanced this theme. Set into the digitally created backdrop of the waiting room there was an interactive clock that synchronized to the duration of the time spent by a pregnant woman in a one stop first trimester screening clinic. This was accompanied by the sound of time ticking on in the sound track, and within the theatre piece were moments when time was suspended to allow the audience to have insight into the internal dialogue of the pregnant woman.

Owing to performing this piece in non‐theatre spaces mainly in lecture theatres without a stage to support a physically created space, the media technologist, developed film of the home and clinic that was projected onto a large purpose built screen to enable the back projection that was required. Images included a domestic kitchen, driving to the clinic, footage from the prenatal clinic to frame the scenes, visualization of the maternal serum analysis using a desk top Kryptor analyser and clips of foetal ultrasound scans as well as a number of ironic still images melding the faces of two well known celebrities to illustrate the media term ‘designer babies’. The visualization of the foetus using an ultrasound scan was one the main motifs and informed the title.

Multiple discourses and disciplinary perspectives

Differences in perspectives within the team were sometimes not easily resolvable. This was epitomized by the debate held concerning the use of a fruit machine to represent probability and the image used for the poster and programme for the performance.

The media technologist used the analogy of a digitally created fruit machine as a central image to convey the idea of probability. The artistic team felt that this represented the feelings of a pregnant woman that the chances of having a healthy baby are part of a lottery or due to fate or chance. However, this image provoked debate within the team, as some members felt that this would convey that screening was inexact. When seen in the context of the performance, it was understood as a visual device that portrayed the ambiguity of both the powerlessness and the sense of nervous expectation experienced by women at this stage of their pregnancies.

The image developed for the programme (Fig. 1) and poster was felt by the artistic team to be eye catching and provocative and the media technologist was particularly fond of the depiction of the foetus in the womb drawn by Leonardo de Vinci. However, the social scientists did not like the headless depiction of a pregnant woman, as she is absent as a person and disembodied with the womb focused on as a transparent vessel and herself as the passive carrier. They felt it was too provocative. For those with scientific training, the depiction of the foetus was too inaccurate. The poster did not feature this image for performances in some venues to accommodate these differences. These issues symbolized and signified the inevitable differences within a multidisciplinary team.

Figure 1.

 Poster of Inside View.

Panel discussions and evaluation of performances

Performances were held in non‐theatre and theatre spaces in Coventry and London to audiences ranging in size from nine people to 150. In total over 400 people attended the six performances between October 2005 to January 2006 and all participants received a summary of main research findings along with the programme. Audiences included young mothers (Coventry), students of bio‐medical engineering (Warwick), midwifery, nursing (London), medicine and social sciences (Warwick) and a range of academic researchers studying science, technology and society and policy makers (London). Each of the performances lasted 35 min and was followed by 20‐ to 30‐min discussion with the panel who included a media technologist, theatre director, actor, writer, social scientists, a midwife and a biochemist. The discussion was led by the issues raised by the audiences but panel members, also presented their perspectives from within the research. The panel discussions, facilitated by one of the team (GLH or CB), were held immediately after the performances were an integral part of the production and generally included the theatre director, actor, media technologist, scientist and social scientist. The questions asked were diverse covering healthcare provision, the scientific basis of screening, the experiences of pregnant women and their partners, the artistic process of transforming research into theatre, the personal, scientific, research, policy and practice and ethical issues. The discussions were tape recorded and transcribed. The panel involved the same members of the research team on four occasions although on two occasions the panel was smaller lacking one of the social scientists and the scientist.

There were opportunities for individuals to approach members of the panel informally at the end and this was particularly useful for individuals who wanted to pursue personal matters.

Post performance discussions

The performances elicited personal reflections that were sometimes shared spontaneously:

It reminded me just how much I hated being pregnant on three occasions, the reason being that each time you were set up as having a test that you cannot really pass, you go there with all this joy because you are pregnant, and you are being put through a process, where people look worried and concerned and put all sorts of doubts into your head. I thought that was one of the wonderful things that emerged from this piece (Audience participant Warwick Arts Centre)

There was some understanding that the research study and the performance were different and one member of the audience commented:

‘It works on a lot of different levels because it is a piece of theatre, not a piece of propaganda. It has come out of research but it is a piece of theatre and therefore it has a life of its own which may be something quite separate from the research or the things which you hoped and intended would come out of it’ (Audience participant – Warwick Art Centre).

The theatre director was able to describe to the audience the way of working from research to performance.

We worked if you like in a kind of reverse kind of play. Generally speaking, we think perhaps of the work we want to do and then we do the research and find out about it. Here we had the research and then we worked very hard to produce the piece.....Our chief aim has been to raise questions and debate (Theatre Director – Warwick Arts Centre).

Members of the audience also raised general ethical issues and sometimes there was spontaneous disclosure.

There is a limited debate about Downs Syndrome. Is it really that much of a problem that we need to abort these children? I am not talking from a religious point of view…. I have a niece who has Down’s syndrome…. These young people and their families have had a great deal of pleasure having these children and I think we need to have that debate (Audience member – Warwick Arts Centre).

Health professionals in the audience also reflected on their own practice openly:

I spend most of my time performing prenatal diagnosis including CVS. … In actual fact, it is the whole spectrum of the population that has difficulty with screening whether you come from a very educated or poorly educated background. I think the one thing we mustn’t forget and I thought you brought this over beautifully, is that it is a pregnancy. As healthcare professionals, we must respect that and that is so important. It breaks my heart when I see fellow colleagues perhaps not addressing this in the manner that it should be addressed (Warwick Arts Centre – health professional).

I automatically refer women for screening, just ticking a box. From now on, I will make sure that I will discuss it with them (GP, Kings College).

Some felt that the panel discussion was an essential part of the performance:

I think to do the play without the discussion would be wrong. But to have the discussion so that we can add things in.., by the audience is really important (London Church House – academic).

In all the performances, the facilitated post show discussion was lively and varied and in some cases, as long as the play itself. Excerpts from ‘Inside View’ have been made available with facilitator briefing notes and the main research findings on the web for use http://www2.warwick.ac.uk/fac/cross_fac/healthatwarwick/research/pastresearch/inside_view.

Evaluation

Evaluation sheets were handed out and about 35% of the students who attended filled in the forms. As would be expected, the midwifery students and health professionals were more enthusiastic than the bio‐medical engineers. The questions had a five point Likert scale and the table presents the percentages of those marked at 4 and 5 (Table 1).

Table 1.

 Responses of medical engineering and midwifery students and health professionals summarizing % who responded with 4 or 5 on a scale of 1–5

Questions	Medical Engineering students 65 respondents (%)	Midwifery students and health professionals 45 respondents (%)
Did you enjoy it?	69	91
Did it raise issues of new technologies in screening?	86	80
Did you feel it was relevant to your training or work?	56	80
Did it relate to experiences in your life?	31	76

Evaluations of medical engineering and midwifery students and health professionals summarizing % who responded with 4 or 5 on a scale of 1–5 are presented in Table 1.

The core questions on the evaluation were closed and addressed both the relevance of the content as well as the engagement with a piece of theatre. There was space for further comments which many of the participants utilized. A teacher of young single parents felt that the play and discussion ‘would be excellent for pupils prior to conception’. An organizer of a SureStart programme also felt that it was an ‘excellent idea, well produced and performed, thought‐provoking and slightly disturbing in parts’.

Trainee and practicing health professionals reported that the performance helped them to appreciate women’s perspectives on the issues and choices related to screening and some expressed a wish to sustain this awareness in their clinical work. This is similar to the findings of Gray et al. ²³ in their evaluation of a performance developed from qualitative research on the experiences of women with breast cancer in Canada. Health professionals reported there that the performance had enhanced their understanding and awareness of the situation and experience of patients with metastatic breast cancer and this could affect their future practice.

I am a medical student and feel the performance raised issues we had previously come across but from the mother’s perspective which is very enlightening before we begin working with pregnant women (Warwick medical student).

Working and training health professionals reflected on how to personalize their routine everyday work. One midwife wrote ‘It makes you sensitive regarding your routine work (bookings etc.) and similarly another trainee midwife reflected ‘There have to be enough midwives to be able to see women as individuals and make it less of a ‘conveyor belt’ experience’.

The biomedical‐engineering students were struck by how the technologies are experienced by people downstream from the laboratories they work within.

To see the problems mirrored by a real person helps to identify and analyse issues of new technologies.

The presentation made me realize that my degree will affect people other than me.

Discussion

Some issues were difficult to negotiate owing to the different perspectives of the team members. The poster for the programme produced different reactions – for the artists it was polemical and representational, whilst for the scientist and social scientists it was physically inaccurate and socially problematic.

The audience engaged cognitively and emotionally with the performances and in the discussions, there was disclosure and discussion of personal professional practice and experiences of those present or members of their families. The diversity of the post performance panels enabled a breadth of response that was both informative and supportive. In general, it is desirable to have support available for audience participants who attend this type of theatre and to provide opportunity for more informal and one to one discussion post performance although in this case no further information or support was requested. ²⁴ Training and practicing health professionals felt that they had gained an enhanced understanding of patient experience but to what extent this impacted on day to day practice subsequently would require a follow up evaluation. This is rarely done for reasons of logistics and resourcing.

Applied theatre can be a transformative process for all those involved with it and it can be a ‘multidirectional engagement tool’ (3:266), It did elicit debate and engagement with health policy and current practice post performance but the extent of the engagement and its lasting effects were not captured by the evaluation and presents a methodological challenge. It is a tool for change ²⁵ and in this case, was a way to engage a varied public in the policy implications of an important area of health care. There is growing interest in the use of applied theatre by social scientists and theatre practitioners owing to its effectiveness in enhancing understanding, stimulating debate and public engagement but there remain challenges to be addressed.

Conflicts of interest

No conflicts of interest.

Sources of funding

Wellcome Trust People Award for theatre production, ESRC for research study.