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

Abstract

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

Full text

Article
Engaging Indigenous
youth through popular
theatre: Knowledge
mobilization of
Indigenous peoples’
perspectives on access to
healthcare services
Pilar Camargo Plazas
School of Nursing, Queen’s University, Kingston,
ON, Canada
Brenda L Cameron
Faculty of Nursing, University of Alberta, Edmonton,
AB, Canada
Krista Milford
School of Public Health, University of Alberta, Edmonton,
AB, Canada
Lindsay Ruth Hunt
Faculty of Education, University of Alberta, Edmonton,
AB, Canada
Lisa Bourque-Bearskin
School of Nursing, Thompson Rivers University, Kamloops,
BC, Canada
Anna Santos Salas
Faculty of Nursing, University of Alberta, Edmonton,
AB, Canada
Corresponding author:
Pilar Camargo Plazas, School of Nursing, Queen’s University, 92 Barrie Street, Kingston, ON K7L 3N6, Canada.
Email: mdpc@queensu.ca
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0(0) 1–18
!The Author(s) 2018
Reprints and permissions:
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DOI: 10.1177/1476750318789468
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Abstract
In Canada, Indigenous peoples bear a greater burden of illness and suffer dispropor-
tionate health disparities compared to non-Indigenous people. Difficult access to
healthcare services has contributed to this gap. In this article, we present findings
from a dissemination grant aimed to engage Indigenous youth in popular theatre to
explore inequities in access to health services for Indigenous people in a Western
province in Canada. Following an Indigenous and action research approach, we under-
took popular theatre as a means to disseminate our research findings. Popular theatre
allows audience members to engage with a scene relevant to their own personal
situation and to intervene during the performance to create multiple ways of critically
understanding and reacting to a difficult situation. Using popular theatre was successful
in generating discussion and engaging the community and healthcare professionals to
discuss next steps to increasing access to healthcare services. Popular theatre and short
dramas provide a venue for mirroring stigmatized care and expose racial biases in the
delivery of care. The contributions of the students, their input, and their acting were to
increase our awareness even more of the pervasiveness of the stigmatized care that
Indigenous people experience.
Keywords
Indigenous people, popular theatre, action research, access to healthcare, inequities
in health
Historically, research with vulnerable groups experiencing health inequities has been
problematic (Quinlan, 2009; Smith, 2012). The imposition of research agendas and
failure to engage research participants at the very onset of a research project can yield
findings that are incomplete and misrepresent the knowledge and resources of those
being researched (Wilson & Neville, 2009). For example, throughout the world,
Indigenous groups have been studied to their detriment, often without proper repre-
sentation or rights during the research process, or interpretation and use of resulting
data (Moodie, 2010; Smith, 2012). The imposition of western research epistemologies,
methods, and ethics that exclude traditional approaches and the implicit construction
of knowledge is called “epistemological domination” (Wilson & Neville, 2009).
According to Smith (2012), for Indigenous peoples, epistemological domination rep-
resents another form of colonization as often in the process of research Indigenous
people are seen as the Other and not as equals (Smith, 2012; Wilson & Neville, 2009).
To fight epistemological domination, Indigenous scholars have delineated elements
that are deemed integral to the conduct of respectful and ethical research with
Indigenous peoples, namely respect, responsibility, relevance, and reciprocity
(Kirkness & Barnhardt, 2001; Weber-Pillwax, 1999). Attention to these elements as
well as recognition of an Indigenous research paradigm has fostered in Indigenous
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communities the conduct of research that “emanates from, honors, and illuminates
their world views and perspectives” (Bourque-Bearskin, Cameron, King, & Pillwax,
2016; Wilson, 2003, pp. 169–170). Conducting research with Indigenous peoples also
demands that researchers develop “a stronger sense of professional and ethical
accountability” as so easily the so-called “unconscious irresponsibility” releases them
from the harmful effects of their actions on Indigenous peoples (Weber-Pillwax, 1999,
p. 38). In our research experience, Indigenous methodologies and community-based
approaches have offered us a venue to attain a contextualized and rich understanding
of access to healthcare services (Cameron, Camargo Plazas, Santos Salas, Bourque-
Bearskin, & Hungler, 2014). We acknowledge that the production of expert knowledge
is being re-conceptualized by the changing social, economic and political landscape
(Quinlan, 2009). In this view, knowledge is more than information. It is the develop-
ment of capacity for action (Quinlan, 2009). As community-based action researchers,
we understand that the productivity capacity of knowledge actively contributes to the
shaping of social experiences. In trying to address the elements of Indigenous research
in our research and honor relation, respect, relevance, and reciprocity within the
research process itself, a community-based participatory approach has helped us
remain close to the voiced needs of Indigenous communities who were critical to
the research team. In fact, the implementation of community-based approaches has
fostered equity, mutuality, and capacity building and has created knowledge relevant to
the needs of research participants (Cameron et al., 2014).
With the above in mind, the use of popular theatre became a unique research
method for engaging Indigenous youth to mobilize knowledge regarding research
participants’ experiences on access to healthcare services. For Conrad (2006), pop-
ular theatre is a process of theatre comprising communities in identifying issues,
analyzing conditions, and searching for points of change. The ultimate goal of
popular theatre is to develop practical knowledge for life improvements (Beck,
Belliveau, Lea, & Wager, 2011). This was the goal of the dissemination work
presented in this article. In our research study, popular theatre was used as a
powerful tool to strengthen our collaboration with community members and
deepen our understanding of access to healthcare services for Indigenous people
in a rural setting. As a collaborative and expressive method, popular theatre assis-
ted community members, healthcare professionals, and researchers to critically
examine issues with racialized care, stigma, and discrimination while developing
avenues for change. Youth participants viewed the process of making theatre as
fun, participatory, and empowering. They were very excited about the potential for
using popular theatre to address other key issues in their community. Popular
theatre was a fruitful method to use in examining and making visible Indigenous
peoples’ experiences of access to health services.
In this article, we present findings from a Canadian Institutes of Health
Research—Institute of Aboriginal People’s Health (CIHR–IAHP)-funded research
in access to health services for Indigenous peoples in a Western Canadian prov-
ince. Next, we present features of popular theatre followed by a brief description of
the access intervention study that led to this popular theatre undertaking. We then
Camargo Plazas et al. 3

describe the beginning of the project, the process of moving the knowledge into
action, performance and audience reception, and lessons learned.
Popular theatre
Globally, human beings have written and performed plays to explore ideas, experiences,
and relationships with others and the world (Anderson, Michol, & Silverberg, 2001).
In fact, since the beginning of history, theatre has served as a means of examining
conflict and societal issues (Anderson et al., 2001; Conrad, 2004; Kontos & Naglie,
2006). Plays have been used as means of reflecting about one’s life and society. In the
1930s, through the work of German playwright Bertolt Brecht theatre reclaimed its
political and community functions. Brecht argued that spectators tended to identify
with the characters on the stage and become emotionally involved with them rather
than being stimulated to think about their own lives. He developed his theory of epic
theatre that encouraged the audience in adopting a more critical attitude to what was
happening on stage (Conrad, 2004). Brecht believed that theatre should appeal not to
the spectators’ feelings but rather it should provoke rational self-reflection and a critical
view of the action on the stage (Anderson et al., 2001; Conrad, 2004). While still
providing entertainment, Brecht used a range of devices to remind the audience that
they were watching theatre and not real life (Anderson et al., 2001).
Popular theatre was established in the early 1970s by Brazilian director and
activist Augusto Boal (Conrad, 2004). For Boal, theatre fosters a democratic
and cooperative form of interaction among participants. Theatre is not merely a
spectacle but rather an artistic means designated for people to learn ways of devel-
oping critical thinking against oppression in their daily lives (Beck et al., 2011;
Singh, Khosla, & Sridhar, 2012). Popular theatre is a form of theatre that is used
around the world for community education (Singh et al., 2012). It is a tool
that uses an array of theatre games and exercises to help build community and
communication skills and deepen understanding of oneself and others (Beck et al.,
2011; Singh et al., 2012).
This particular type of interactive theatre is rooted in the pedagogical work of
Brazilian educator Paulo Freire (Conrad, 2004). Freire (1973) developed an
approach to adult literacy education that involved not only learning how to
read and write but also critically reading the world and its circumstances and
conditions with a view to the formation of critical consciousness. The development
of critical consciousness assists people to question the nature of their historical
and social situation—reading their world—with the objective of acting as critical
subjects in the creation of a fair and democratic society (Freire, 2002). Freire
encourages people to be active participants in their lives. It is through
his method that Freire challenges traditional methods of education that were
inherently oppressive and dehumanizing where students were mere recipients of
teacher’s knowledge (Freire, 2002, 2004). According to Freire (2002, 2004), injus-
tices and inequities exist in society and the world. These injustices and inequities
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make it necessary for people to analyze the issues and act upon them, to create a
more just and equal society.
As with popular education, popular theatre has a long history around the
world. This is particularly significant in countries where oppression is widespread
(Anderson et al., 2001; Colantonio et al., 2008; Mabala & Allen, 2002). Popular
theatre has the power to sensitize people to recognize their problems, analyze
them, seek solutions, and change behaviors. Popular theatre also enables people
to discuss and evaluate their own efforts to educate themselves and to make behav-
ioral changes. Popular theatre has been used throughout the world to create aware-
ness and improve health education (Mabala & Allen, 2002). Popular theatre is
defined as a process of social and personal transformation that is based on audi-
ences’ experiences to create scenes and engage in discussion of issues of importance
through theatrical means (Conrad, 2006).
Popular theatre allows audience members to participate with a scene relevant to
their own personal situation and to intervene during the performance to create
multiple ways of critically understanding and reacting to a stressful situation
(Rossiter et al., 2008). Advantages of using popular theatre are: (1) to make concrete
the life experiences of research participants, (2) to engage the audience with research
material, (3) to set up the potential for taking action on the findings, and (4) to
validate results through a debriefing discussion leading to audience involvement
through a representation of the play (Stuttaford et al., 2006). Popular theatre pro-
vides a unique means of allowing practitioners, informal caregivers, and patients
alike the opportunity to rehearse reality (Rossiter et al., 2008).
Access research initiative: Its context, participants, and
research projects
One key marker of the effect of inequities in health is the lack of Indigenous People’s
involvement in the design and delivering of appropriate healthcare services across
the globe. Indigenous people experience social, political, cultural, demographic, and
nutritional changes that have a profound impact on their health status and well-
being (Valeggia & Snodgrass, 2015; Wong, Allotey, & Reidpath, 2014). Regardless
of their geographical location, traditional subsistence patterns, and diverse lan-
guages and culture, all Indigenous groups are united by a common thread: their
low standard of health compared with their non-Indigenous counterparts in the
same region (Valeggia & Snodgrass, 2015). The causes of these inequities in
health are multiple, interactive, and synergistic (King, Smith, & Gracey, 2009).
The powerful effect of colonization and domination is a common thread in the
health gap of Indigenous groups around the world (Valeggia & Snodgrass, 2015).
The Truth and Reconciliation Commission of Canada (2015) has thoroughly
documented the contemporary effects of discriminatory policies on Indigenous
peoples. By removing Indigenous children from their families, health has been
affected for generations (The Truth and Reconciliation Commission of Canada,
Camargo Plazas et al. 5

2015). By endangering distrust in government agencies, policies such as the forced
removal of Indigenous children from their families and communities contribute to
high levels of stress among Indigenous people (Peiris, Brown, & Cass, 2008,
p. 985). To date, research evidence shows that stress, racism, and discrimination
have been regularly associated with adverse health outcomes for Indigenous peo-
ples (Allan & Smylie, 2015; Paradies, 2006; Peiris et al., 2008).
In Alberta, the situation is similar to the global scene. The link to poor health
and residential schools is significant in that Alberta had the largest number of
residential schools in operation. In fact, the high school in which students involved
in this study attended was located in the exact same location as the original and
largest residential school in Canada (Jackson, 2013). In addition to this
history, Alberta has the third largest Indigenous territory in Canada comprised
45 First Nation communities over three Treaty areas: 6, 7, and 8 (Alberta
Government, 2013). In these regions, healthcare services delivery is governed by
multiple (Local, Provincial, and Federal) jurisdictions. Health Canada through the
First Nations and Inuit Health department funds primary care and public health to
Registered First Nation and Inuit Peoples living on reserve. However, over the
past decade, health transfer agreements between Health Canada and First Nations
require local communities to develop collaborative relationships with Provincial
Healthcare Services who deliver all secondary and tertiary level of care (Anderson
& Smylie, 2009).
Researchers claim that healthcare systems and services are not exempt from this
historical policy context (Peiris et al., 2008). Poor health outcomes in Indigenous
groups are the result of power imbalances imposed by biomedical paradigms and
models (Peiris et al., 2008). There is little autonomy for Indigenous peoples to address
their healthcare needs. The Canadian federal and provincial governments have com-
mitted to provide universal access to a high quality of care under the Healthcare Act.
Yet inequities in access remain a pressing national concern for Indigenous peoples
(Browne et al., 2011; Wong et al., 2014). To date, qualitative research evidence has
demonstrated that Indigenous people are sensitive to power imbalances in their
interactions with healthcare services (Browne et al., 2011; Cameron et al, 2014;
Valeggia & Snodgrass, 2015; Wong et al., 2014). Stories of dismissal, stereotyping,
and marginalization often appear in the literature (Cameron et al., 2014; Fiske &
Browne, 2006; Smylie & Anderson, 2006; Tang & Browne, 2008).
Access to healthcare cannot be simply defined as the ability of individuals or
groups to reach and obtain essential health services (National Collaborating
Centre for Aboriginal Health, 2011). It also entails the opportunity for individuals
or groups to identify their healthcare needs, to seek healthcare, to reach, to obtain,
and to actually have the need for services fulfilled (Levesque, Harris, & Russell,
2013). Scholars have regarded access as an important social determinant of health
(McGibbon, Etowa, & McPherson, 2008; National Collaborating Centre for
Aboriginal Health, 2011). Inequities in access to healthcare are unacceptable
and unfair and contribute to the gaps in health status between Indigenous and
non-Indigenous peoples (Gao et al., 2008). In order to confront the inequities
6Action Research 0(0)

experienced by Indigenous communities, it is necessary to deal with the redistri-
bution of social benefits to meet the needs of people in an equitable way. The lack
of resources to provide health for everybody is a threat to the moral mandate of
equality for all (Marmot et al., 2010). All human beings, despite their race, gender,
social and economic conditions, or their political orientation, have the right to life,
health, and well-being (Dahlgren & Whitehead, 2006).
The access intervention study
Under the umbrella of an Access Research Initiative led by Brenda Cameron at the
University of Alberta and based on exploratory research, we undertook a larger
access intervention study to improve access to healthcare services for Indigenous
peoples in a Western Canadian province. The initiative and the access intervention
study were led by Cameron together with an interdisciplinary team comprised of
Indigenous and non-Indigenous researchers, graduate and undergraduate students,
and postdoctoral researchers. The entire initiative was under the guidance of
Eminent Scholar Elder Rose Martial. An important goal was to improve access
to healthcare services through an Indigenous-led access intervention. The access
intervention study also enacted a knowledge exchange process where Indigenous
leaders, decision makers, researchers, and health services stakeholders provided
their input into research decisions. In this access intervention study, we investigat-
ed the efficacy of Community Health Representatives (CHRs) easing Indigenous
people’s access experiences in Emergency Departments. The intervention involved
the placement of two Indigenous CHRs in one urban and one rural acute care
setting. Findings showed that frightening stories of fear, bullying, intimidation,
racism, and discrimination were common themes in Indigenous people’s experien-
ces when accessing emergency services. We also found that CHRs eased people’s
experiences in emergency and assisted them to understand the pathway of care.
CHRs also brought a unique Indigenous understanding to healthcare professionals
(Cameron et al., 2014).
We then designed a popular theatre activity to mobilize research knowledge and
involve community participants to explore approaches to understand inequities in
access to healthcare services for Indigenous people. Our goal was to disseminate
key findings from our access intervention study. This activity was implemented
within a diverse First Nations community located outside a rural municipality.
Three narratives taken from research data were shaped and molded by the students
into a popular theatre drama using their own experiences and creativity. During
rehearsals, students shared their own views on health as well as engaged in the
stories of access from the research data.
Setting the stage
Gaining entry to the community school system required that our team build on a
previously held relationship with one community member of our research and
Camargo Plazas et al. 7

advisory team as well as another community champion to advocate to both the
Chief and Council, community health director, and the school principal to become
involved in the popular theatre as a dissemination strategy. We had also previously
worked with the community health director with our access intervention study.
An invitation to present our project to the local School Board was issued to us, we
attended the meeting and answered questions that concerned content, research
practices, and ethics. Bringing in a popular theatre artist who had not been a
member of our research team and was not a member of the Indigenous community
represented a challenge. This was addressed in part by the involvement of the
school liaison person well known to the students and a community member.
This became a limitation of our process given that an Indigenous theatre artist
would have enhanced further the community-based quality of this work.
Following written approval from the local school board, the Indigenous school
liaison person talked with the student body about the project. We were then invited
to present the popular theatre idea to the students at one of the Indigenous, rural
schools. We proposed several drama workshops led by the theatre artist to enact
research findings from the CHR intervention. The theatre artist at this first
meeting talked to the students about what popular theatre was about and how
this particular drama project would proceed. The youth were different ages and
genders, and with varied experience with art-making (or theatre-making).
Differences were honored during the process. There were many opportunities
throughout the process for each of the participants to contribute these things,
leading to a better understanding of each other and trust building. Exploring
their own unique perspectives was very important for the program, as they
were creating pieces drawing on how they related to the material. Student diverse
backgrounds were key to crafting a rich experience and presentation in the end.
There were several key components that worked together to facilitate this pop-
ular theatre project. First, involving an Indigenous liaison person working at the
school was pivotal to gaining student trust and attendance. He assisted the theatre
artist to work with the youth and grounded her often in what was going on with
the youth (e.g., family member ill, loss of jobs, the need for the student to work
after school). Most importantly, he believed in the youth. In fact, he was always
part of the team and assisted the theatre artist to engage with the students in this
undertaking. He believed that the youth in this community had the potential to
develop capacity for popular theatre. He was confident that the benefits to be
gained from offering this drama education program to the students would
be invaluable for them. We could not have undertaken the popular theatre project
without him. Second, the project had to be done after school or outside of school
hours (Saturdays) or when possible. Third, access to transportation and flexibility
for rehearsals were fundamental for engaging the youth in the popular theatre
activity. The theatre artist was able to show that she would accommodate student
schedules and personal needs to deliver this popular theatre project. This was in
some way communicated to the youth in her actions, in her constant fulfillment of
being there even if there were only a few students.
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A number of strategies were followed by the theatre artist to build trust with the
students: (1) a facilitator needs to meet youth where they are, with their experiences
of healthcare; (2) she must make certain to go through everything at the student’s
pace and this may be slow; (3) the facilitator must be willing to take risks alongside
participants, for example, be the first one to jump into a game, play or look silly;
(4) she must continually be explicit and clarify the purpose of this popular theatre
project; and finally, (5) stay with the youth no matter what, do not terminate it due
to poor attendance. Rather continue to show commitment and flexibility to this
process of learning culminating in the presentation of a popular theatre.
In community-based participatory research, the reality of working with a group
of youth (or a group of any people) requires flexibility and willingness to adapt and
“roll with the punches.” For example, there were a handful of sessions when a
participant had to bring their younger sibling with them because of a lack of
childcare. The participant was afraid that they might have to miss the sessions,
and the facilitator was concerned for the potential disruption to the group. After a
conversation about how things can work out for the situation, the younger sibling
was invited to attend the rehearsal. This younger sibling participated in some
discussion and had fun watching the group rehearse. They then came to a few
more rehearsals happily, and the participant was relieved that they could still be a
part of the group.
The rehearsals
The group of youth that eventually came together and committed to the process
had some group building that was required. While they were all interested in
“doing drama,” they were not all necessarily friends beforehand. This was not
always easy as there were instances when one member would not be there thus
upsetting the group. The theatre artist would talk to the group about it and ask
them to be leaders and encourage commitment in the form of attendance.
They would then talk with the participant who was missing for a few rehearsals
and ultimately, the group would reform. Through the popular theatre process, the
group took ownership over the program, and they saw it as part of their respon-
sibility to work toward the common goal of presenting a product. The theater
artist believes that it was due to this larger commitment that they were able to
work through difficult interpersonal situations and challenges.
In keeping with Boal’s techniques for Theatre of the Oppressed, the theatre
artist began with warm-up games and exercises into every step of the process to
delve deeper into the experience of access to health services for Indigenous people.
Each session consisted of a check-in circle while sharing snacks and drinks, warm-
ups and cool downs, games and exercises, improvisation, and short vignettes.
These games created trust among the youth and also in the theatre artist.
She was just as involved as the students in these games. An example of a game
is when you clap energy to each other. If there was a pause in clapping energy to
one another, it led to a discussion about disconnects in life, when something stops
Camargo Plazas et al. 9

making sense. A warm-up game can act as a metaphor as well, what happens when
a disconnect occurs in other situations? How might this make you feel when this
happens? This then led to theatre artist asking them about disconnects in health-
care, “how might this make you feel when you go to some place for care and
experience the dismissal of your concerns?” The games often led to discussions
about experiences of the youth or family members with the healthcare system.
Rather than simply imposing the methods onto the students and expecting them
to fit into a preformed, aesthetically pure dramatic process, the activities first had to
have meaning for the students and be responsive to their realities, interests, and
energy levels (Lee & De Finney, 2008). The theatre artist focused on popular theatre
less as a prescriptive set of techniques and more on its ability to help develop playful
interaction, nurture trust, and relationships and negotiate the sharing of stories and
experiences. The process was deliberately left fluid and open-ended to allow the
group to find its own identity and voice around the broad project themes.
After trust-building with warm-up games, the theatre artist shared with them
some of the stories from our access research data. They read them together. This
was followed by a group discussion responding to the stories. For example, a student
would say, “this sounds like what happened to my Auntie.” The discussion would
continue in a way, playing out the scripts as the students were developing a script of
their own to portray the research story. They created scenes together in a collabo-
rative way, throwing out some ideas that did not make sense to them after discus-
sion, and created multiple possible scripts. Once the scenes were created based on the
research narratives, the actual rehearsal of the script became more prominent, and
changes were implemented as they progressed. In becoming actors, students revealed
their own culturally derived consciousness about racialized and stigmatized care
when accessing acute care. Popular theatre nourished critical self-reflection, relation-
ship building, peer support, and community building (Smith, 2012).
Final product
During six months of almost weekly sessions, the students developed a 1-hour pro-
duction of five skits that were fleshed out and refined in preparation for a commu-
nity symposium with community members, managers, and healthcare professionals.
Students developed the characters, plots, and storylines based on research data.
This collaborative process of probing, expanding, and questioning through different
types of languages, images, and rhetorical processes was important in coming to
critical consciousness about lived experiences. The project provided space and time
for the students to speak back to each other and engage in peer-to-peer
sharing through performances, discussions, check-ins, or alternative storylines.
Our initial idea was that the youth would modify the interventions with the scenes
given feedback from the audience, a basic tenet of Theatre of the Oppressed.
This would have required “Improvisation theatre.” Rather the youth chose to
improvise after each scene was acted, by asking the audience, “How can things be
different?” This was a way to engage the audience to respond to the scene and think
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about possibilities to change the healthcare situation presented in the scene. It also
increased critical thinking about the healthcare system and generated additional
questions and thoughts.
Key outcomes of the successful drama project and popular theatre presentation
at the symposium were made clear during a postperformance meeting with the
students. First, the liaison person assisting us to undertake the drama project
commented on the apparent transformation in the students in terms of their inter-
actions with our team, the theatre artist, their peers, and teaching staff at the high
school. The staff at the school saw an increase in confidence, an ability to relate
better to peers and teachers, and an increased level of comfort in other school
activities. They saw the students gain in drama knowledge but also in life skills.
The Indigenous high school students themselves asked to continue their learning of
popular and forum theatre as well as comedy. We were able to provide additional
drama teaching following the symposium, but the school was unable to continue
the drama program due to a lack of funding. Students wanted to create their own
scripts to present theatre to their Chief and Council around some key issues in the
community and express how these problems affect the youth, such as exposure to
gang activity and drug and alcohol abuse.
The symposium
Research findings from the Access Research Initiative regarding our access inter-
vention study were presented via a variety of dissemination approaches. We began
the day with formal papers presenting the research findings, information on the
social determinants of health, the value of undertaking research, allowing time for
questions and audience discussion following each paper. The afternoon started
with the popular theatre presentation that consisted of the following skits: (a)
“Health” is where students described what health means to them; (b) three narra-
tives taken from research data shaped and molded by the students into a popular
theatre drama using their own experiences and creativity; and (c) a final game show
highlighting ER issues in a comical way. One highlight of the popular theatre
presentation was the “Game Show” developed as the youth’s response to some
of the research stories. As the youth played warm-up games as a main strategy
utilized to connect the youth with each other, to the theatre artist as well as the
research content, they wrote two scripts (Health and the Game Show) of their own.
The youth felt the need to do something humorous as a response to the difficult
topics portrayed in the stories such as stigmatized care, overt, and covert racism.
The “Game Show” was a way that the youth chose to end the theatre presentation
after a rather difficult to watch and act portrayal of hospital scenes. They decided
to approach both the topic and the audience in a light-hearted way to show
their understanding of the content as well as their capacity in undertaking popular
theatre.
Camargo Plazas et al. 11

Performance and audience reception
In popular theatre, the performance of theatre skits before an audience is a way of
validating and making visible oppressive experiences. The performance is the time
when stories come full circle and are communicated publicly and shaped by the
audience’s feedback and actors’ reactions (Butterwick & Selman, 2003; Lee &
De Finney, 2008). We hoped that the presentation of skits would resonate with
managers, healthcare professionals, and community members in the audience in a
critical reflective and then empowering way. If audiences could engage with the
skits, either by confirming that the images and words enacted on the stage were
reflective of their experiences of care or by challenging the images, we would have
succeeded in amplifying silenced voices and illuminating distorted realities (Lee &
De Finney, 2008). Attendees at the symposium found the presentation engaging
and an effective and stark way to portray how inequitable experiences of access
to healthcare unfold moment-by-moment. The healthcare professionals, commu-
nity members, and administrators in attendance discussed that while they have
witnessed first-hand racialized care in the healthcare system, the popular theatre
re-enacting distressing stories had a profound impact on them. Yet the participants
were very clear that everyone in their communities already knew and had experi-
enced much of this. Healthcare professionals in the audience were clear that
they too had seen these types of care occurring in healthcare agencies. Between
the students and audience there was a direct connection, because the skits
were experienced as real. The most startling moment was hearing the open and
straightforward dialogue in response to the interpretation of the youth on such a
complex issue.
Lessons learned
Using popular theatre for dissemination of research was successful in generating dis-
cussion and engaging the community and healthcare professionals to discuss next
steps to increasing access to healthcare services. These performative forms of com-
munication opened up a space for critical consciousness and reflexivity to come to the
fore. In research, popular theatre has been used to better understand and cope with
complex, interpersonal, emotional, and embodied practice issues (Beck et al., 2011;
Kontos & Naglie, 2006; Singh et al., 2012). The creation of real-life vignettes that
emerged directly from data such as interviews, focus groups, and/or storytelling con-
tains rich elements of dramatic tension that inevitably engage the audience in dialogue
(Kontos & Naglie, 2006). We felt necessary to remain faithful to realistic, “in life”
scenes, such as those that were portrayed by research participants in our studies.
Popular theatre has been known to aid vulnerable populations in transforming
and transcending social oppressions through role-play, using scripted text as a start
point for improvising (Beck et al., 2011; Singh et al., 2012). From the experience of
the popular theatre artist, the process allowed the youth to connect their own lived
experiences, thoughts, and feelings related to the issues explored. Initially the
12 Action Research 0(0)

youth did not think they had any connection to issues around healthcare equity.
Yet once we delved into the stories, participants were able to contribute to the
creative process by offering their own experiences and reflections. The popular
theatre creation process enabled the youth to learn more about the issues and
ultimately want to do something to change them (Beck et al., 2011; Singh et al.,
2012). Furthermore, the popular theatre presentation actively engaged the
audience in the research material, as the scenes were interactive and allowed for
discussion with the audience. While enacting the scripts, students explored the
issues portrayed but also included lively discussions on “what to do” to work
toward action to address the issues portrayed. One shortcoming was not following
through with the actions discussed during the interactive performance event due to
funding limitations. Ideally, popular theatre projects involve taking action after-
ward to move forward the suggestions raised.
By engaging the audience in dialogue with the question “How can things be
different?” a feeling of collectivity grew out of the shared experience of collective
problem-solving and sense-making. This growing awareness contributes to the
changing Indigenous health landscape where Indigenous communities call for full
self-governance in the design, development, and delivery of Indigenous health serv-
ices. The current perceived lack of control for self-governance in Indigenous com-
munities (Mashford-Pringle, 2016) hinders the progress. This study contributed to
the internal community capacity to take up research within their communities that
will help inform policy that supports self-determination of healthcare services.
What was clear in both the access intervention study and the popular theatre work
was the impact of an Indigenous Healthcare worker on-site to reduce biased care,
provide needed cultural connection, and evoke an immediate sense of cultural safety.
Following this study, an Indigenous health worker was hired in the rural municipality
hospital, and CHRs were also placed in adjacent rural health facilities. Study findings
were used to lobby for more CHR positions at the provincial government level. The
contributions of the students, their input, and their acting were to increase our aware-
ness of the pervasiveness of the stigmatized care that Indigenous people experience.
Most urgent was the need to share these findings with other healthcare profes-
sionals who work in areas that serve Indigenous populations and to garner their
participation in working toward effective solutions and actions to ease access
experiences. Healthcare professional participants wanted to see the popular theatre
used as cultural safety training for staff. The popular theatre for cultural safety
teaching could include the following questions: Have you seen this? Has this hap-
pened to you? What would you like to see happen about this?
There is a great need to identify systemic, local, cultural issues that affect health-
care professionals and patients when accessing healthcare services. Popular theatre
and short dramas provide a venue for mirroring stigmatized care as well as an
opportunity to explore deeper meanings behind this. Popular theatre provides a
way to engage in critical self-appraisal without feeling defensive. Our findings show
that removal from the actual workplace context to view the stigmatized care as an
observer only generated recognition of stigmatized care practices. We also found
Camargo Plazas et al. 13

that workplace priorities for efficiency along with embedded assumptions about a
population impede the ability to evoke best practices even though these can be as
simple as a “hello, how can I help you today?”
Acknowledgements
We would like to thank Elder Rose Martial, Eminent Dene Suline Scholar for her wisdom
and for being the heart and soul of the Access Research Initiative. We are grateful to the
high school students from an Indigenous Junior Senior High School who participated with
us in the popular theatre project. We acknowledge we are much better individuals having
interacted with them. Their commitment to their communities for the improvement of access
to healthcare will remain with us always. We thank them for their delivery of our research
findings and enriching all our lives as a tangible outcome of this. We would also like to thank
Terry Kostiuk, the Indigenous liaison person who gathered the students for us, mentored, and
supported them in this drama program, and provided them with transportation home to and
from the sessions. The value of the liaison person working at the school linked closely with the
inauguration of this popular theatre project was pivotal to gaining student participation.
Terry assisted the theatre artist to work with the youth and grounded her often in what
was going on with the youth (e.g., family member ill, loss of jobs, the need for the students
to work after school, Indigenous culture). Dr. Cora Weber Pillwax, Principal Investigator of
CIHR-IAPH Alberta NEAHR, provided direct personal and financial support and initially
along with Dr. Andrew Cave offered remarkable insights into the best way to present our
access findings to community members, health professionals, and academic audiences. We are
sincerely grateful to them. Without the support of Tracy Lee, Community Member, and Dr.
Lisa Bourque Bearskin facilitating our Access Research Program entry to the Community,
this study would not have been possible. We sincerely thank all who contributed to the
popular theatre project named and unnamed.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, author-
ship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, author-
ship, and/or publication of this article: This study was funded by the Canadian Institutes of
Health Research—Institute of Aboriginal Peoples’ Health.
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Author biographies
Pilar Camargo Plazas, RN, PhD, is an assistant professor in the School of Nursing
at Queen’s University. Under the umbrella of interpretive inquiry and emancipa-
tory approaches, Dr. Camargo’s program of research strives to describe and
understand how societies organize and distribute resources and address attention
toward economic, political, environmental and social factors and their effects on
health outcomes, promotion and disease prevention. By focusing on health equity,
her research program is oriented not only toward the identification of research
needs, but it is also oriented toward the development of strategies for sustainable
change and action.
Brenda L Cameron, RN, PhD, is a professor emeritus in the Faculty of Nursing at
the University of Alberta. She is an influential thinker, leader, and researcher who
has enjoyed wide Canadian and international recognition for her contributions to
nursing, philosophy, and health care. In her research program on access to health
care for Indigenous and marginalized populations, she led the implementation of
innovative modalities to improve peoples’ access experiences in the health care
system. Rooted in the philosophical tradition of the human sciences, her seminal
work involves a treatise of nursing practices in contemporary Canada. She served
as Director of the International Institute for Philosophical Nursing Research for
over a decade. Her community engagement abilities, kindness and respect enabled
much access to what was needed in order to undertake this very significant research
project with a large research team.
Krista Milford, MSc, was the research coordinator for the Access Research
Initiative over its lifetime. Along with this ongoing commitment, she organized
Camargo Plazas et al. 17

and coordinated each detail of the popular theatre project ensuring a collaborative
work among students, theatre artist, community liaison and researchers. Her atten-
tion to the ongoing and often complex situations during the popular theatre proj-
ect was stellar. Currently, Krista is the project coordinator for the Benchmarking
Food Environments Project, School of Public Health, University of Alberta.
Lindsay Ruth Hunt is a community-engaged theatre artist, researcher, and critical
educator, most recently joining the Education Department at the Alberta Union of
Provincial Employees. She is passionate about the role of transformative education
and arts in/as activism and believes that they can provide a necessary means to
work toward positive social change. Her background includes a BFA in Theatre
and Development, an M.Ed. focusing on Popular Education and the arts, and she
is currently a PhD candidate, investigating the potential of activist and interven-
tionist art in education.
Lisa Bourque-Bearskin, RN, PhD, is a Cree/Metis Nurse from Beaver Lake Cree
Nation, and associate professor at Thompson River University, School of Nursing.
Dr. Bourque Bearskin’s leadership is in bringing together networks of community
researchers. She initiates community-led research by Indigenous communities that
enhances understandings of Indigenous nursing knowledge and social determi-
nants of health, focusing on Indigenous wellness that maintains cultural integrity
of nurses practice and supports Indigenous sovereignty.
Anna Santos Salas, RN, PhD, is an associate professor in the Faculty of Nursing at
the University of Alberta. She investigates how social disparities such as poverty
interact with individuals’ symptom experiences in palliative care populations.
Through critical, interpretive and participatory methodologies, she seeks to
inform the design of clinical approaches to meet the palliative care needs of socio-
economically vulnerable populations. Her studies engage low income, inner city,
Indigenous, and immigrant populations, and health care teams.
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