Drama: an innovative approach to diabetes education

Diabetes educators are constantly seeking innovative and imaginative ways to offer and present health education. Before 1996, the majority of diabetes education was delivered via lectures, slides, acetates and flip charts. Today most educational events also include enactment of a drama, allowing time for audience participation and feedback. 

The use of drama to deliver diabetes education was introduced at a BDA ‘Living with Diabetes’ conference, held in Peterborough in 1996. The sketch was performed by the two authors to an audience of more than 100, and depicted a hypoglycaemic attack treated by a carer. It highlighted signs and symptoms of ‘hypos’ and the panic and helplessness felt by the carer, who reacted by giving inappropriate treatment.

Kempe (1997) maintains that people’s feelings can be communicated through drama; therefore, the authors’ aim in this situation was to acknowledge the sense of insecurity experienced by the carer. By encouraging the audience to respond with correct management, their goal was to improve carers’ coping skills. Sotto (1994) tells us that ‘carers may need to entail endless practice and repetition of information.’

Although no formal evaluation of this innovative method of communication was undertaken at this first event, letters of appreciation were received and verbal comments showed that people were captivated by it.

Planning
This initial success resulted in the authors undergoing a process of reflection. They questioned whether consideration had been given to each individual’s level of understanding. Wagner (1979) found that planning was essential when using drama. She acknowledged that each part of the performance could present different difficulties. In planning future dramas, the authors therefore considered the audience members in terms of social class, gender, age, cultural beliefs and educational level.

Each sketch was performed by two or three members of the Peterborough diabetes team and lasted approximately 15 minutes. As Shillitoe (1994) explained, the use of simple language is beneficial and keeping the sessions short highlights key points. Kempe (1997) pointed out that drama is ‘a highly developed form of communication; it is an act which draws on a wide range of skills and traditions’. 

Six important components of drama identified at the first event were:

• Education
• Fun
• Knowledge
• Participation
• Feedback
• Evaluation.

Education
Each drama is ‘custom made’ to address the individual group’s preferences, needs, and level of understanding. 

Hawthorne (1994) stresses that prior assessment of the client’s linguistic literacy and educational skills is necessary if education is to be ‘tailored’ to the client, and feedback from the client is to show understanding. He also maintains that ‘communication is two-way’, so that educators can learn from patients’ experiences and adapt their message accordingly. Certainly the use of drama has enhanced the skills and knowledge of the performers.

Fun
Comedy is an intrinsic component of the sketches. Although many published articles have discussed the benefits of humour and its application to nursing, it is only recently that health professionals have incorporated humour into their practice (Smith, 1992). Glass (1993) argues that ‘an amusing example [recounted] during patient education can enliven the explanation and allow the patient time to mentally sort out key points.’ 

The actors use costume in every sketch: dressing up allows them to keep in character and helps the audience focus on the ‘real-life’ issues demonstrated. As Cassin Scott (1992) claimed, ‘costume tells the audience all there is to know about the character’s role, occupation and social standing’. 

Jokes are incorporated into the text, often in an off-the-cuff manner. However, Sheldon (1996) warns that the use of humour can be risky, as it is possible for it to be used inappropriately, especially where there are cultural differences or extremely anxious parents.

Knowledge
When planning sketches it is important to address relevant areas of diabetes knowledge. According to Bolton (1984), ‘drama helps to develop the mind so that a common understanding of life can be mastered’.

Knowledge for everyone involved is necessary in order to empower patients so that they can make informed choices in diabetes care. Health education is a lifelong process and every healthcare worker has a professional responsibility to apply this. Tones and Tilford (1994) emphasise that effective health education can produce changes in knowledge or understanding. The topics incorporated into specific sketches are shown in Table 1. Each sketch aims to increase the audience’s knowledge and understanding of diabetes management. 

Participation
The majority of the sketches explore common myths about diabetes. Language communicates to an audience and sends out signals (Cooper and Mackey, 1995). Audience participation is encouraged. 

The actors may demonstrate incorrect management intentionally in order to stimulate a response from the audience. This has proved highly effective, particularly with children who love to shout out the answers. Cooper and Mackey (1995) maintain that drama can entertain and enlighten an audience, while Bond (1986) feels that creating the ‘right atmosphere’ allows the audience to participate freely.

Feedback
At the end of the session, time is allowed for questions and answers. This can be an effective method of assessing what has been learnt. It reinforces the education already provided by the team and gives feedback on the educational quality of the sketch. It also enables the team to find out whether the audience enjoyed the session. 

Bond (1986), describing feedback, claimed that one of the simplest methods of demonstrating whether someone has listened properly is to ask them to repeat back to the speaker a brief summary of what they have learnt. A question-and-answer session can reiterate and reinforce the message portrayed in the drama.

Evaluation
This was the most difficult part of the project. The audience may have loved the sketch, but did it change practice? Questionnaires proved ineffective, especially among ethnic minority groups. Despite the use of interpreters, there were difficulties in interpretation.

However, following a recent presentation to adolescents, members of the audience were sent letters requesting feedback on whether the session had given any new information. One replied: 

‘I learned a lot from it but I still enjoyed it. I think the main thing I learned is that your hormones can make your blood sugar levels very high first thing in the morning.’

Another said: 

‘It helped me to understand better why it was so hard for me to keep my blood sugars as low as they were before I started puberty.’ 

The team were encouraged by the evidence of a change in knowledge. 

Repertoire
When planning education sessions, specific sketches were created for the different audiences as follows.

Young children
A sketch depicting a ‘mischievous’ child with type 1 diabetes and a harassed mother prompted the children watching to shout out the correct management of diabetes in true pantomime style. Giving information improves confidence and reduces anxiety (Shillitoe, 1994), as demonstrated by the fact that these children felt able to express themselves freely.

Adolescents
A drama depicting an adolescent, her mother and the diabetes nurse discussing puberty was well received by the audience of adolescents and parents. It proved a valuable tool when discussing issues of sex, drugs and alcohol, and prompted positive feedback. As Kerr and MacDonald (1997) found, the ‘performing arts can help people to think and talk about sensitive issues more easily’. 

Kerr and MacDonald also felt that such a creative approach could promote empowerment. The adolescents enjoyed the performance and requested a ‘kids-only’ version. One young lady even offered to play the teenage part herself next time! 

Ethnic minority groups
Role play has constantly been incorporated into education sessions. By request, education sessions were held within the Asian community. The initial audience numbered around 20 women, but subsequent events have yielded an ever-increasing and mixed audience. The last session was attended by more than 100 people.

These audiences especially liked this method of communication and, despite some difficulties with timing when using interpreters, they found the sketches very funny. Sheldon (1996) advocated the use of humour, explaining that it allows the nurse to negotiate difficult topics and broach sensitive areas. She again warns that it can be risky when dealing with cultural differences. The authors recognised their limitations in this area, but with the help of interpreters and Asian link-workers were able to understand and respect differences in cultures and health beliefs.

Health professionals
A sketch depicting the work of the diabetes team among ethnic minority groups was created in response to a request for the diabetes nurses to speak at a one-day conference for clients, health professionals and the general public. Approximately 100 people attended this day, which was held in the local town hall. 

The sketch lasted only 15 minutes, but in that time managed to convey to the audience the work of the team and the prevalence of diabetes among the Asian communities, as well as discuss the differences between type 1 and type 2 diabetes. It prompted one member of the audience, a senior health promotion officer, to write ‘Excellent! Well done! Way to go! Probably the best presentation so far…and certainly the most entertaining’. 

The most recent sketch was written in response to a request to provide the after-dinner entertainment for the RCN Diabetes Nursing Forum Conference in Birmingham in September of this year. It involved an amusing interview between a consultant diabetologist and a rather ‘scatty’ young lady. The response from this audience was more difficult to gauge on the night. The authors found it more difficult to perform to their peers than to clients or lay people. However, verbal feedback the next day was extremely positive.

Conclusions
Different mediums can be used in an effective way to cross the barriers of culture and health beliefs. The use of drama by the Peterborough Diabetes Team has prompted much interest from fellow health professionals. It is important to remember that drama can be used by anyone. Riseborough (1993) maintains that health education/promotion involves good communication skills and that drama depends on similar skills.

The use of drama has proved to be an effective tool in diabetes education. However, there are difficulties in evaluating this means of communication and further research to find an effective method of evaluation is needed.