| Key messages | |
| • | Community play has the potential to improve knowledge of the importance of maternal vaccines. |
| • | Staging community play in open community spaces offers members of the public an opportunity to engage in complex health issues in an environment that encourages reflection and exchange of knowledge. |
| • | Co-creation of the play with the local community theatre group is useful to frame research results in a way that is relatable to community members. |
Introduction
Maternal vaccines confer protection against morbidity and mortality to both the pregnant mother and the infant (Omer, 2017). However, the success of these vaccines is threatened by an increasing number of people who are hesitant to take vaccines (Dubé et al., 2013). Factors contributing to vaccine hesitancy are complex and vary across time, place and vaccine (Larson et al., 2014).
One way of addressing vaccine hesitancy includes holding dialogues and open communication with the community to address uncertainty and risks while educating them about the safety and efficacy of vaccines (Corpuz, 2022). Over the last several decades, theatre or dramatic representation has emerged as one way of addressing various health issues and promoting the uptake of health interventions (Cheadle et al., 2012; Islam et al., 2001; Pelto & Singh, 2010). Drama and theatre are spaces and processes that work with fictive plots, roles, characters and relationships to help generate a wide range of emotions or outcomes (Wall et al., 2019).
Theatre offers many advantages which differ from other forms of engagement, such as face-to-face meetings and digital strategies. It can draw community members to the story and character and therefore foster emphatic understanding of the health issues. It overcomes literacy barriers, has the potential to break complex issues into simple and accessible ways to a diverse audience, and can break down hierarchies, allowing participants to engage in an open and safe space (Bowman, 2017).
Theatre can also be extended to assist in interpreting, translating and disseminating research findings. There are broadly four ways that theatre has been used for health-related research or health in general: a) dramatisation of health issues such as transforming interview transcripts into monologue performances; b) creation of theatre pieces based on research, for example creating ‘real life’ vignettes from ethnographic notes; c) plays that theatricalise or fictionalise data, which includes a performance that dramatises research participant’s experiences and/or the researcher’s interpretation of the data; and d) performances for healthcare education not necessarily anchored on research (Wall et al., 2020).
Although there is a long-standing tradition of using theatre for social change (van Vuuren et al., 2021), the dramatisation of research findings has emerged fairly recently. Literature suggests that there is variation in how researchers have incorporated the use of theatre, including the extent of dramatic structure, how many narratives are included in the performance, whether the audience should be included during the performance, and whether performers should use scholarly versus lay syntax (Denzin, 1997). Gray et al. (2000) used research-based theatre to disseminate results from a qualitative study on metastatic breast cancer. In their production of Handle with Care? researchers worked with a theatre group and across a team of women who had lived experiences of breast cancer and oncologists to produce a script that navigated through healthcare and patient issues around the disease (Gray et al., 2000). Another study from South Africa applied results from research to investigate the prevalence and social context of stroke to produce a dramatised play. They report that using theatre allowed them to validate their data and elicit ideas for how future interventions can be designed (Stuttaford et al., 2006).
Applied performance and theatre involves the use of drama, theatre and performance to achieve outcomes beyond mere artistic expression. In his seminal work, Theatre of the Oppressed, Boal (2000) argues that theatre should serve as a tool for exploring potential solutions to real-life problems. This perspective contrasts with traditional theatre, where performances are designed to convey messages or advocate for behavioural change to a largely passive audience. Instead, Boal’s approach emphasises active participation, encouraging individuals to engage in theatrical creation as a means of critically examining, challenging and reimagining solutions to pressing issues in their lives (Boal, 2000).
Among the many forms of applied theatre, forum theatre stands out for its participatory and transformative potential. In this method, actors first perform a scene based on a shared community issue, deliberately concluding with an unresolved or oppressive outcome – one that feels uncomfortably familiar to the audience. Rather than leaving spectators as passive observers, forum theatre invites them to intervene; they can step onto the stage, take the protagonist’s place and test alternative choices to reshape the narrative. Yet this very interactivity, while empowering in theory, can also raise ethical tensions (Baldwin, 2009).
One challenge lies in the perceived inevitability of the original ending. When the scene’s conclusion is framed as a ‘realistic’ or unavoidable outcome, audience members may resist proposing alternatives, fearing their interventions might seem forced or unrealistically optimistic. The weight of lived experience can make hopeful revisions feel like denial rather than liberation. A second tension arises from the aesthetic and emotional power of the performance itself. A well-crafted scene, with its raw authenticity, often carries a sense of tragic unity – a completeness that resonates deeply. For some, disrupting that artistic integrity can feel like vandalism, as though rewriting the ending cheapens the truth it initially conveyed. Finally, structural barriers complicate the exercise. In tightly knit or hierarchical communities, individuals may struggle to see how personal action could ever overturn systemic injustice. If the scene reflects a world where power is rigidly held, audience members might dismiss their own agency (Baldwin, 2009).
Our study utilises results from a mixed-method study on the factors contributing to the refusal to take up a maternal vaccine to produce a dramatised play of the results (Kiyuka et al., 2024). Our study adopts a distinct approach by actively involving community members in the co-creation of the theatrical content. Collaborating closely with a local lead theatre group, we facilitated a participatory process in which community voices shaped the narrative and messaging of the play. Recognising the cultural and social hierarchies that might make some individuals hesitant to engage directly in performance, we adapted our methodology to ensure inclusive participation. Rather than requiring on-stage involvement, we invited community members to reflect on the play’s dilemmas in small group discussions after the performance. This post-play dialogue allowed them to share perspectives, critique the scenarios and explore solutions in a more comfortable, culturally appropriate setting. Our primary objective was to leverage this participatory theatre model not only to disseminate information but also to foster deeper shifts in both knowledge and attitudes towards maternal vaccination.
Methods
Setting and context
The project ran from May 2020 to February 2021. It was conducted in Kilifi County, located along the Kenyan Coast. Kilifi County, one of the 47 counties in Kenya, has a population of about 1.5 million people, according to the 2019 Kenya Population and Housing Census (Kenya National Bureau of Statistics, 2019). According to the Demographic Health Information System data (accessed by authors in 2021), there is variation is maternal vaccine uptake within the county. Overall, in Kenya it is estimated that the uptake is at 51 per cent, far below the universal target for effective coverage (Otieno et al., 2020). This project was part of a larger study to determine factors contributing to low maternal vaccine confidence (Kiyuka et al., 2024). Kilifi County was selected as the study site due to its persistently low maternal vaccination coverage rates. Investigating the barriers to vaccine uptake in this region provides policymakers with critical insights to develop targeted interventions.
Study population
The community play targeted adults of reproductive age residing in Kilifi town. The population in this region is predominantly composed of the Mijikenda ethnic group, who primarily engage in small-scale subsistence farming. A significant proportion of the population works in the informal sector, although increasing urbanisation has been observed following Kenya’s 2010 constitutional reforms, which established devolved county governments, stimulating urban growth in the area (Council of Governors, 2023; World Bank Group, 2021). Furthermore, the education levels are low in this setting.
Development of the community play
The research team worked with a local community theatre group to produce the play, and the steps taken to develop the play are shown in Figure 1. The theatre group draws its members from the local community and has experience using dramatisation to address various social and health issues. The group has 10 active members ranging from youth to adults, allowing them to capture a wider age range of audiences. The research team had a mix of senior social scientists, infectious disease experts, healthcare workers and junior researchers supporting the group.
Flow diagram of the process of developing a play to address maternal vaccine issues
Stage 1: Conceptualisation
The research team reviewed the data from the survey of men and women of reproductive age, and together with the local community theatre group, listened to the recordings from the focus group discussions and the key informant interviews to select themes on issues around maternal vaccines (Kiyuka et al., 2024). The emerging themes were grouped according to the World Health Organization (WHO) Measuring Behavioural and Social Drivers of the vaccination framework (WHO, 2022).
Stage 2: First draft of the script
In response to the discussion from the conceptualisation meetings, the theatre group produced the first draft of the script for the play. To maintain cultural relevance, the casts and the scenes were carefully selected to mirror what a typical expectant woman in the community has to navigate, including social norms, practical issues and the motivation on whether to go for a vaccine at the local antenatal clinic.
Stage 3: Modification
Once the initial script was drafted, it was reviewed by the research team. The team also had a communication specialist and a public engagement expert who, together with the scientists, reviewed the script to assess whether the play brought out the themes that emerged from the data analysis. The information was also checked to ensure that its presentation was suitable for a public audience while maintaining scientific accuracy. The theatre group then staged the revised script to the research team, where further changes were made to how the cast presented the issues.
Stage 4: Finalisation
Following the incorporation of feedback from the research team, the theatre group produced a final script (Kiyuka, 2024). The play was staged in open community spaces followed by semi-structured evaluation of what the audiences thought of the play (Figure 2).
Photo of the community members watching a scene of the play in one of the community open spaces
The play was staged in the local language, Kiswahili. For the post-performance discussions, community members were divided into groups based on randomly assigned numbers. As these were members drawn from the same locality and who may have been familiar with each other, we did not separate the groups per gender to avoid biasing the discussion as we may have ended having well- acquainted members in the same group.
The group discussions were led by an experienced research team member (Kiyuka, Moindi and a research assistant). The audience discussions were audio recorded, transcribed verbatim and translated into English. We used a thematic approach for the data on group discussion post-performance (Kiger & Varpio, 2020), which is detailed as follows: team members read the transcript to gain initial insights into the data; Kiyuka and Onsomu generated the initial codes with discrepancies resolved by Mutua using an adaptable open-coding approach; codes were then grouped into themes that aligned with the research question; the themes were then reviewed and refined; the meaning of the themes was clarified by analysing the response patterns; the data was then presented in textual format. Finally, the research team analysed field notes from the outreach sessions to assess community engagement and comprehension.
Results
Implementation and staging of the community play
This study was conducted during the Covid-19 pandemic, and in adherence to Ministry of Health guidelines, we limited the number of attendees at each play performance. Approximately 100 adults were directly invited to the three different community spaces, but the staging also attracted people who were in the vicinity. The play was staged in three separate open community spaces, selected based on accessibility for participants and the availability of sufficient outdoor area to maintain physical distancing as per pandemic regulations. After the staging of the play, community members were put into smaller groups of seven to ten members for post-performance discussions and evaluation. A total of nine group discussions were done (three per each session) with each having a mix of both men and women. The discussions were held immediately after the staging of the play in the open community spaces.
A key challenge in selecting community spaces for the play was our inability to access additional sites to stage the play due to Covid-19 movement restrictions. This limitation was particularly regrettable as some excluded locations included communities where potential audience members felt that the play’s educational content was needed the most there:
Now this education [referring to the play] should reach those in the interior [referring to remote areas] because you find that most of them do not have this education. Community member 10
However, some audience members appreciated the style and format of the play and the use of Kiswahili as the medium for the play, as this linguistic choice helped overcome literacy barriers while enhancing audience engagement:
According to the play it has taught us a lot and educated us here in the village. Some are literate they understand but in the villages a lot are not so educated so they do not know, and they cannot understand a lot of things. The way the play is presented, they will be able to learn and also understand how vaccines protect them while pregnant. Community member 30
Addressing misinformation and rumours on maternal vaccines
A key theme from the mixed-methods study (Kiyuka et al., 2024) was that vaccine refusal was heavily influenced by widespread rumours and misinformation surrounding maternal vaccines in the community. One particularly widespread misconception was the belief that vaccines administered during pregnancy were family planning methods. We sought to explore whether participants perceived the play as effective in addressing these misconceptions and providing a forum for them to improve their understanding of maternal vaccines:
I have seen it is a very good play because a lot of women in the villages refuse to go to clinics because they do not know the purpose of the vaccines. But the play has been able to open up the minds, and they came to the clinic in plenty because their problem is usually that vaccine. The vaccine is usually a family planning method. There’s a lot of banter going on about these vaccines, so if it goes on like this, they will be able to be educated and their minds opened. Community member 3
The community play stimulating audience engagement around maternal vaccines
We engaged a local theatre group to leverage their nuanced understanding of the community customs and norms. This approach allowed for authentic representation of local challenges through culturally grounded narratives. To assess the intervention’s effectiveness, we evaluated audience identification with characters and examined how this relational dynamic facilitated comprehension and retention of key health messages. We found that audiences were very specific to which characters they found most relatable and why. For instance, participants explained their connection to a specific character as follows:
The actor who made me happy was nurse Grace. She educated them [the women in the play] on the importance of pregnant women going for clinic and getting vaccinated. Maybe some of us did not have that education but for now we have understood. Community member 20
Concerns about the side effects of maternal vaccines
One of the most persistent concerns about vaccination is the fear of adverse side effects – a legitimate apprehension that directly impacts vaccine acceptance. Our community play evoked firsthand accounts: community members openly shared experiences of what they believed to be harmful reactions to maternal vaccines. These personal testimonies provide insights into the community perceptions of these vaccines:
A lot of information comes from the neighbouring women that vaccines bring harm or to make the hands swell. Community member 8
Improving awareness on the importance of maternal vaccines
Participants reported that watching the play helped them recognise the importance of vaccines and appreciated the intervention’s dual benefits for both mothers and babies:
I have been educated today, and I can go and tell my neighbours, my friends, and all so that they know that these vaccinations benefit our bodies and our children. Community member 8
For me, it has taught me that pregnant women must get vaccinated so that they do not endanger their lives and [those] of their unborn babies. Community member 10
For male audience members, the community play alleviated fears about their pregnant partners visiting the clinic by clarifying what occurs during these visits. We intentionally designed the play for both men and women, recognising that clinic attendance decisions depend heavily on social networks – with partners’ advice and financial support playing a pivotal role:
To say the truth, I was very afraid but from today henceforth I have got educated so I will take my wife to clinic. Community member 30
Discussion
Our project highlights the use of theatre to present research findings to members of the public. Working across a team of experts in communication, public engagement, infectious diseases and social science in collaboration with a local community theatre group, we were able to produce a community play that highlighted the issues, concerns and reservations the community had about the maternal vaccines. Most importantly, the play sought to counter the misinformation, rumours and safety concerns that expectant mothers had about the vaccine. The play was video recorded during one of the outreach sessions and is available with English subtitles on Vimeo at https://vimeo.com/manage/videos/882613386.
Staging of the community play in open community spaces offers some advantages, such as inviting the public to discuss health issues in their own spaces or environments. In a way, this hands over the controls of the discussions to the members of the public, unlike their being invited to a research institution or healthcare space. In open community spaces, members of the public can discuss their views freely, enabling a more authentic sharing of thoughts, attitudes and perspectives (Bultitude & Sardo, 2012). Situating audiences in familiar environments and providing scenes and dilemmas to which they can relate provide what some authors describe as ‘border-crossing’, whereby audiences move from familiar worlds to the unfamiliar world of science and research, hence enabling education (Aikenhead, 1996).
Our study builds on existing evidence on the use of theatre to promote understanding of the health and research issues in rural communities. Previous studies have demonstrated that theatre can effectively raise awareness, build trust and increase demand for vaccines while reducing the proportion of zero-dose children. For instance, by employing a human-centred design approach to educational theatre, Kaduru et al. (2023) achieved a 38 per cent increase in childhood vaccinations, alongside a reduction in community concerns and mistrust, similar to our study where we observed positive attitudes towards maternal vaccines after staging the play to community members. Beyond promoting health interventions, theatre has also been utilised as a tool for public engagement in research (Sanga et al., 2021).
In recent years, there has been increasing recognition of the value of transforming qualitative research data into theatrical performances to enhance accessibility and emotional engagement. By grounding narratives in people’s lived experiences and authentic voices, theatre allows audiences to explore health issues through a dramatic lens – one that both intensifies and clarifies understanding, fostering introspection and inspiring action. In our study, the community play resonated with audiences, many of whom identified with specific characters, probably due to personal relatability. Similar effects have been documented elsewhere, such as in an Australian study that used theatre to address mental health stigma within the Macedonian community (Blignault et al., 2010). By crafting a play that authentically reflected the community’s experiences, the researchers not only made the production more engaging but also ensured that key messages were clearly understood. The performance fostered empathy towards individuals with mental illness and their families, sparking meaningful community dialogue.
Our project had some limitations. The project was implemented during the Covid-19 pandemic, so we could not stage the play to as many members of the public as we would have wished. We also recognise that we were unable to assess the effectiveness of the play, which would have necessitated audience follow-up over time, a wider challenge in analysing the efficacy of theatre in health interventions (Rossiter et al., 2008). However, in the short term, the community play provided a platform for the audience to form a good understanding of the importance of vaccines.
In conclusion, theatre has been used to engage the public on health issues (Islam et al., 2001; Nisker et al., 2006) and to foster dialogue with citizens on pertinent health policy matters (Nisker et al., 2006). Our project provides an example of how theatre can be extended to build vaccine confidence in settings where vaccine uptake remains low. Our approach can be adapted by other researchers to develop contextually relevant theatre performances aimed at addressing vaccine hesitancy in diverse regional settings.
Authors’ contributions
| PKK: | conceptualisation, funding acquisition, investigation, methodology, visualisation and writing the original proposition. |
| ROM: | investigation, project administration, writing, review and editing. |
| MNM: | methodology, funding acquisition, resources, validation, writing, review and editing. |
| HS: | funding acquisition, project administration, investigation, methodology, resources, supervision, writing, review and editing. |
| NM: | investigation, methodology, resources, writing, review and editing. |
Acknowledgements
We thank the Kilifi County Department of Health, Community Health Volunteers, local chiefs and community members who participated in the study in one way or another. We thank Kesho Kenya for the administrative support they provided for the grant. This manuscript was submitted for publication with the permission of the KEMRI Director.
Declarations and conflicts of interest
Research ethics statement
The authors declare that research ethics approval for this article was provided by Pwani University Ethics Review Committee; ERC/PU-STAFF/002/2020.
Consent for publication statement
The authors declare that research participants’ informed consent to publication of findings – including photos, videos and any personal or identifiable information – was secured prior to publication.
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