Int J Tuberc Lung Dis. 2017 Feb 1;21(2):140-148. doi: 10.5588/ijtld.16.0399.

Participatory theatre and tuberculosis: a feasibility study with South African health care workers.

PubMed link

Full text link



Introduction and Methods

South Africa has one of the world’s highest tuberculosis (TB) burdens, with 834 TB cases per 100,000 population in 2015.1 The high incidence rate of TB ranks this country as having the third highest TB burden in the world, only surpassed by China and India.1 Healthcare workers (HCWs) working in high TB burden settings are at considerably further elevated risk of occupational transmission of TB – up to 4 times higher than in the populations they serve.2-6 In order to minimize occupational TB infection, the WHO, International Labor Organization (ILO), and Joint United Nations Programme on Human Immunodeficiency Virus (HIV) /Acquired Immunodeficiency Syndrome (AIDS) (UNAIDS) collaboratively developed guidelines to improve TB prevention activities (including administrative and environmental controls, personal protective equipment, and management of HIV) as well as access to treatment (including prophylaxis for latent TB infection) and care services for HCWs working in high HIV and TB-burden settings.7 These guidelines urge workplaces to strengthen occupational health services and infection control measures, implement workplace educational programs on TB and HIV, and adopt interventions to reduce stigmatization of and discrimination against HCWs diagnosed with TB or HIV. However, these efforts have so far shown limited success in changing HCW attitudes and practice towards both adopting prevention measures and disclosing possible TB symptoms to appropriate healthcare professionals.8 Research suggests that the barriers to adherence and compliance are not lack of information but social and cultural norms resulting in fear of discrimination and stigma, and denial of being at risk. 9-11


The current project responded to the need for educational interventions that address occupational TB in South African healthcare workplaces. To be successful, educational interventions are best served by participatory educational methods that promote a non-judgmental environment, allow participants to explore personal values, and create a sense of ownership in improving knowledge and awareness.12,13 Arts-based techniques are one such participatory method. These techniques, using drama, storytelling, drawing, photos and other art forms, are potent at creating dialogue and engaging participants in ways that go beyond the typical didactic lecture.14 These methods also allow unexpected issues to arise, and are thus useful at uncovering barriers and issues previously unnoticed. In particular, the techniques developed by Augusto Boal have been widely used to empower oppressed populations.15 These Boal techniques have been used for public health purposes.16-18


Participatory theatre techniques are used to promote learning by posing problems and searching for solutions in a contextually and culturally appropriate way. Two of Boal’s main techniques include “image theatre” and “role play”, adapted from his “forum theatre” technique. The goal of image theatre is to prompt people to express themselves through their bodies, instead of vocally. The exercise asks participants to identify and represent attitudes to a topic. Working through the body (without words), they distill and strengthen their understanding of the power relationships through kinaesthetic expression. The role- play exercise asks participants to step into a role in order to introduce a solution to a problem depicted.


The current study aimed to gain insight into whether a participatory theatre educational intervention is a feasible approach to empowering HCWs in public healthcare settings to address the risks of occupational TB more effectively. There was particular interest in overcoming known barriers to adherence to infection prevention and control (IPC) measures, and promoting TB self-disclosure to enable prompt diagnosis and treatment. It was hypothesized that other beliefs influencing HCWs’ willingness to disclose their TB status or to comply with IPC measures would be uncovered during the sessions. Our secondary objective was thus to also gather this information.


The intervention consisted of a 2-hour session utilizing participatory theatrical methods based on the work of Augusto Boal. The sessions were held at six different community health centres across Cape Town, and participants held a variety of position. During the session, statements or scenarios relevant to TB and its control in the workplace were presented and participatory techniques were used to elicit individual and group reactions, and to uncover beliefs pertaining to occupational TB.


For the evaluation stage, each session was viewed as a case with multiple forms of data including researchers’ field notes, videos of the entire sessions, follow-up interviews, and a questionnaire presented at the end of each session to record participants’ experiences.


Results and Discussion

The theatre work confirmed that participants generally knew the appropriate IPC measures, but were not applying this knowledge in practice. This theme was recurrent across sessions, where HCWs acknowledged their resistance to some IPC measures. This quote by a participant exemplifies this theme: “We fear for TB but we still do not want to use the mask because it is claustrophobic”. The lack of adherence to IPC measures reported by participants in our study is consistent with findings in other studies, such as gaps in practice regarding TB IPC in the Free State, signaled by infrequent hand washing between patients, inadequate needle recapping, and failure to use respiratory protection even when HCWs knew it was indicated, and gaps in practices regarding IPC measures in HCWs in KwaZulu-Natal, South Africa.19-21


Our results also suggested that embodied techniques show promise in helping HCWs relate to colleagues and promoting dialogue regarding occupational TB. For example, several HCWs were willing to disclose their TB history to a group of co-workers. TB infection takes place in a social context, where interpersonal relationships as well as practices and processes (such as stigma, gender, taboo, and victim blaming) need to be addressed as part of TB prevention activities.10 In the case of the healthcare workplace, TB infection of staff is at least partly a taboo and stigmatized subject, as reflected in the sessions when some participants initially preferred to focus on the patient when discussing TB scenarios rather than on the fear that they themselves are at-risk. The initiation of an open, person-centered dialogue about personal TB vulnerability in this environment was a first step in changing the negative socially patterned attributes that contribute to denial of being at risk.11 Creation of an environment in which TB status is highly visible has the potential to reduce negative attitudes and practices concerning TB, and the psychology literature on disclosure confirms that disclosure can improve psychological wellbeing.9,22 It is worth noting that ill employees are more likely to reap the benefits of disclosure if their workplace offers a supportive environment and encourages an open culture.23


The prevalence of TB in HCWs in endemic countries such as South Africa remains unacceptably high, despite the availability of various guidelines and measures put in place to control occupational TB. Stigma, as well as loose interpretations of IPC measures amongst HCWs, continued to inhibit the effectiveness of occupational health programs and many HCWs still fail to recognize their own risk.11,21 Traditional information-based education explaining TB causes, routes of transmission, and appropriate personal protection are thus limited in their ability to break through these barriers.9 Our results suggested that participatory theatre methods have potential for such breakthroughs. By presenting (through drama) social problems they encounter every day, participants are given the opportunity to “solve” hypothetical but relevant problems and to transcend their habitual responses to TB-related dilemmas, to react in a new, more conscious way. Theatrical methods intercede at a cognitive, emotional, and physical level for the participants, creating a powerful incentive to change.24 Moreover, proponents in this field assert that using one’s body in learning facilitates future recall.25 In this study, interviewees indeed reported that the embodied approach was useful for remembering some of the key messages. Whether this type of approach is more useful for remembering than the traditional information-based lectures requires further research.


Our study suggests that integrating embodied theatrical techniques into staff TB education is a promising option for engaging participants, allowing misconceptions to emerge and be addressed, and increasing awareness of the often-longstanding emotional reaction of staff to this disease. In light of the TB pandemic it may be time to recognize that more needs to be done beyond writing policies and providing “chalk and talk” educational session. Participatory theatre techniques may offer a useful, culturally appropriate alternative or supplement to the more traditional didactic lectures.


*This is a summary of an article originally published as: Parent, S. N., Ehrlich, R., Baxter, V., Kannemeyer, N., & Yassi, A. (2017). Participatory theatre and tuberculosis: a feasibility study with South African health care workers. The International Journal of Tuberculosis and Lung Disease, 21(2), 140-148.



1. World Health Organization. Global tuberculosis report 2016. Geneva: World Health Organization;2015.
2. Baussano I, Nunn P, Williams B, Pivetta E, Bugiani M, Scano F. Tuberculosis among health care workers. Emerging infectious diseases. 2011;17(3):488.
3. Claassens MM, Van Schalkwyk C, du Toit E, et al. Tuberculosis in healthcare workers and infection control measures at primary healthcare facilities in South Africa. PloS one. 2013;8(10):e76272.
4. O’Donnell MR, Jarand J, Loveday M, et al. High incidence of hospital admissions with multidrug-resistant and extensively drug-resistant tuberculosis among South African health care workers. Annals of internal medicine. 2010;153(8):516-522.
5. Tudor C, Van der Walt M, Margot B, et al. Tuberculosis among health care workers in KwaZulu-Natal, South Africa: a retrospective cohort analysis. BMC Public Health. 2014;14(1):891.
6. Van Rie A, McCarthy K, Scott L, Dow A, Venter W, Stevens W. Prevalence, risk factors and risk perception of tuberculosis infection among medical students and healthcare workers in Johannesburg, South Africa. SAMJ: South African Medical Journal. 2013;103(11):853-857.
7. World Health Organization, International Labour Organization, UNAID. The joint WHO ILO UNAIDS policy guidelines for improving health workers’ access to HIV and TB prevention, treatment, care and support services. . Geneva2010.
8. Reid M, Saito S, Nash D, Scardigli A, Casalini C, Howard A. Implementation of tuberculosis infection control measures at HIV care and treatment sites in sub-Saharan Africa. The International Journal of Tuberculosis and Lung disease. 2012;16(12):1605-1612.
9. Courtwright A, Turner AN. Tuberculosis and stigmatization: pathways and interventions. Public health reports. 2010;125(4 suppl):34-42.
10. Mason PH, Degeling C, Denholm J. Sociocultural dimensions of tuberculosis: an overview of key concepts. The International Journal of Tuberculosis and Lung Disease. 2015;19(10):1135-1143.
11. von Delft A, Dramowski A, Khosa C, et al. Why healthcare workers are sick of TB. International journal of infectious diseases. 2015;32:147-151.
12. Nyblade L, Stangl A, Weiss E, Ashburn K. Combating HIV stigma in health care settings: what works? Journal of the international AIDS Society. 2009;12(1):15.
13. Siegel J, Yassi A, Rau A, et al. Workplace interventions to reduce HIV and TB stigma among health care workers–Where do we go from here? Global public health. 2015;10(8):995-1007.
14. Finley S. Arts-based research. Handbook of the arts in qualitative research. 2008:71-81.
15. Boal A. The rainbow of desire: The Boal method of theatre and therapy. Routledge; 2013.
16. Christensen MC. Using theater of the oppressed to prevent sexual violence on college campuses. Trauma, Violence, & Abuse. 2013;14(4):282-294.
17. Mitchell KS, Freitag JL. Forum theatre for bystanders: A new model for gender violence prevention. Violence Against Women. 2011;17(8):990-1013.
18. Sullivan J, Petronella S, Brooks E, Murillo M, Primeau L, Ward J. Theatre of the oppressed and environmental justice communities: A transformational therapy for the body politic. Journal of Health Psychology. 2008;13(2):166-179.
19. Engelbrecht M, van Rensburg A, Rau A, et al. Tuberculosis and blood-borne infectious diseases: workplace conditions and practices of healthcare workers at three public hospitals in the Free State. Southern African Journal of Infectious Diseases. 2015;30(1):23-28.
20. Nkoko L, Spiegel J, Rau A, Parent S, Yassi A. Reducing the risks to health care workers from blood and body fluid exposure in a small rural hospital in Thabo-Mofutsanyana, South Africa. Workplace health & safety. 2014;62(9):382-388.
21. Zelnick JR, Gibbs A, Loveday M, Padayatchi N, O’donnell MR. Health-care workers’ perspectives on workplace safety, infection control, and drug-resistant tuberculosis in a high-burden HIV setting. Journal of public health policy. 2013;34(3):388-402.
22. Pachankis JE. The psychological implications of concealing a stigma: a cognitive-affective-behavioral model. Psychological bulletin. 2007;133(2):328.
23. Munir F, Leka S, Griffiths A. Dealing with self-management of chronic illness at work: predictors for self-disclosure. Social Science & Medicine. 2005;60(6):1397-1407.
24. O’Connor P, Anderson M. Applied Theatre: Research: Radical Departures. Bloomsbury Publishing; 2015.
25. Powers B, Duffy PB. Making invisible intersectionality visible through theater of the oppressed in teacher education. Journal of teacher education. 2016;67(1):61-73.