Culturally Relevant Online Cancer Education Supports Tribal Primary Care Providers to Reduce Their Cancer Risk and Share Information About Cancer.

BACKGROUND: Culturally relevant education is an opportunity to reduce health disparities, and online learning is an emerging avenue for health promotion. In 2014-2019, a team based at the Alaska Native Tribal Health Consortium developed, implemented, and evaluated culturally relevant online cancer education modules with, and for, Alaska's tribal primary care providers. The project was guided by Indigenous Ways of Knowing and the principles of community-based participatory action research and was evaluated in alignment with empowerment theory. About 265 unique learners completed 1,898 end-of-module evaluation surveys between March 2015 and August 2019, and 13 people completed a follow-up survey up to 28 months post module completion. KEY FINDINGS: Learners described the modules as culturally respectful and informative and reported feeling more knowledgeable and comfortable talking about cancer as a result of the modules. About 98% of the learners planned to reduce their cancer risk because of the modules, and all follow-up survey respondents had reduced their risk, including by quitting smoking, getting screened for cancer, eating healthier, and exercising more. About 98% of the learners planned to share information with their patients, families, friends, and community members because of the modules, with all follow-up survey respondents indicating that they had shared information about cancer from the modules. IMPLICATIONS FOR PRACTICE AND FURTHER RESEARCH: Culturally relevant online modules have the capacity for positive behavioral change and relatively high correlations between intent and behavior change. Future research could determine which aspects of the modules catalyzed reduced cancer risk and increased dissemination of cancer information.

Learning Together: Sharing Circles in Rural Alaska on Cancer Education Priorities for Youth.

Culturally relevant health promotion with youth is an opportunity to reduce health inequities in cancer. This manuscript describes sharing circles conducted with three communities in the Northwest Arctic region of Alaska. The circles were designed to begin understanding community priorities and lay the foundation to develop culturally relevant cancer education. The project was guided by the principles of Community-Based Participatory Action Research (CBPAR), honored Indigenous ways of knowing, and was grounded in Empowerment Theory. The project team facilitated 13 sharing circles in November 2019 in three communities in the Northwest Arctic. There were a total of 122 participants, including teachers/school staff (31%), community members (30%), high school students (23%), and health professionals (16%). The circles explored youth knowledge, perceptions, questions, concerns, and hopes for cancer information; community members' desires for youth knowledge about cancer; and how teachers would like content to be formatted for effective inclusion in their classrooms. Common themes from the sharing circles included a desire for information on cancer prevention (all 13 sharing circles) and a need for information on cancer risk factors (12). In most sharing circles, participants shared that cancer information for youth should include stories like those of local people, cancer survivors, and role models (11), visuals (8), and local data and statistics (8). In addition, teachers and school staff in all communities wanted an online resource for teaching about cancer in their classrooms that had short videos/visuals with related lesson plans and activities."If I learn, I can reduce the chance of getting cancer in the future."

An Evaluation of Cancer Education Webinars in Alaska.

Culturally relevant health promotion is an opportunity to reduce health inequities in the cancer burden, and online learning is an emerging avenue for health promotion. To address a desire for synchronous online cancer education, a project team offered ten 1-hr cancer education webinars for Alaska's rural tribal health workers. The project was guided by the framework of Community-Based Participatory Action Research, honored Indigenous Ways of Knowing, and was informed by Empowerment Theory. The evaluation of this community-based intervention included end-of-webinar surveys. Between February and April 2018, 41 surveys were completed by 11 unique participants. All participants reported that, as a result of the webinars, they planned both to change their own behavior to reduce cancer risk, and to talk with their patients more often about cancer prevention strategies such as screenings, physical activity, tobacco cessation, and eating healthy. While the webinars addressed desires for synchronous actions to support cancer learning, and led to intentions to positive change behaviors, the ten webinars engaged far fewer unique learners than the team's asynchronous cancer education modules. This experience may inform other cancer educators' efforts to develop, implement, and evaluate online learning opportunities. Despite the small numbers, these webinars resulted in increased learners' intent to reduce cancer risk behaviors, share cancer information, and improved learners' capacity to talk about cancer in their communities.

A Framework for Culturally Relevant Online Learning: Lessons from Alaska's Tribal Health Workers.

Culturally relevant health promotion is an opportunity to reduce health inequities in diseases with modifiable risks, such as cancer. Alaska Native people bear a disproportionate cancer burden, and Alaska's rural tribal health workers consequently requested cancer education accessible online. In response, the Alaska Native Tribal Health Consortium cancer education team sought to create a framework for culturally relevant online learning to inform the creation of distance-delivered cancer education. Guided by the principles of community-based participatory action research and grounded in empowerment theory, the project team conducted a focus group with 10 Alaska Native education experts, 12 culturally diverse key informant interviews, a key stakeholder survey of 62 Alaska Native tribal health workers and their instructors/supervisors, and a literature review on distance-delivered education with Alaska Native or American Indian people. Qualitative findings were analyzed in Atlas.ti, with common themes presented in this article as a framework for culturally relevant online education. This proposed framework includes four principles: collaborative development, interactive content delivery, contextualizing learning, and creating connection. As an Alaskan tribal health worker shared "we're all in this together. All about conversations, relationships. Always learn from you/with you, together what we know and understand from the center of our experience, our ways of knowing, being, caring." The proposed framework has been applied to support cancer education and promote cancer control with Alaska Native people and has motivated health behavior change to reduce cancer risk. This framework may be adaptable to other populations to guide effective and culturally relevant online interventions.

Culturally-Relevant Online Education Improves Health Workers' Capacity and Intent to Address Cancer.

To address a desire for timely, medically-accurate cancer education in rural Alaska, ten culturally-relevant online learning modules were developed, implemented, and evaluated with, and for, Alaska's Community Health Aides/Practitioners (CHA/Ps). The project was guided by the framework of Community-Based Participatory Action Research, honored Indigenous Ways of Knowing, and was informed by Empowerment Theory. Each learner was invited to complete an end-of-module evaluation survey. The survey asked about changes in intent to share cancer information with patients as a result of the module. In 1 year, August 1, 2016-July 31, 2017, 459 surveys were completed by 79 CHA/Ps. CHA/Ps reported that, because of the modules, they felt more knowledgeable about cancer, and more comfortable, confident, and prepared to talk about cancer with their patients, families, and communities. All learners shared that because of the modules, they intended to talk with their patients more often about cancer screenings, tobacco cessation, physical activity, or nutrition. These findings suggest that the application of this collaboratively developed, culturally-relevant, health promotion intervention has supported increased CHA/P capacity and intent to interact with patients about cancer. In the words of a learner: "Doing all these courses makes me a ton times more comfortable in talking about cancer with anyone. I didn't know too much about it at first but now I know a whole lot. Thank you".

Culturally-Relevant Online Cancer Education Modules Empower Alaska's Community Health Aides/Practitioners to Disseminate Cancer Information and Reduce Cancer Risk.

To address a desire for timely, medically accurate cancer education in rural Alaska, ten culturally relevant online learning modules were developed with, and for, Alaska's Community Health Aides/Practitioners (CHA/Ps). The project was guided by the framework of Community-Based Participatory Action Research, honored Indigenous Ways of Knowing, and was informed by Empowerment Theory. A total of 428 end-of-module evaluation surveys were completed by 89 unique Alaska CHA/Ps between January and December 2016. CHA/Ps shared that as a result of completing the modules, they were empowered to share cancer information with their patients, families, friends, and communities, as well as engage in cancer risk reduction behaviors such as eating healthier, getting cancer screenings, exercising more, and quitting tobacco. CHA/Ps also reported the modules were informative and respectful of their diverse cultures. These results from end-of-module evaluation surveys suggest that the collaboratively developed, culturally relevant, online cancer education modules have empowered CHA/Ps to reduce cancer risk and disseminate cancer information. "brought me to tears couple of times, and I think it will help in destroying the silence that surrounds cancer".

Co-Creating a Culturally Responsive Distance Education Cancer Course with, and for, Alaska's Community Health Workers: Motivations from a Survey of Key Stakeholders.

To gain input on a proposed culturally responsive, distance-delivered cancer education course informed by empowerment theory and adult-learning principles, Alaska's Community Health Aides/Practitioners (CHA/Ps) and CHA/P leadership were invited to take an online survey in February 2015. The proposed course will be developed as part of the "Distance Education to Engage Alaskan Community Health Aides in Cancer Control" project. The results of the survey demonstrate that respondents are both interested in taking the proposed class and engaging in course development. The results also indicate that respondents have the technological comfort and capacity to be engaged in online learning and have primarily positive experiences and perceptions of distance education. This survey is the beginning of the interactive development of the online cancer education course and part of a continuing endeavor to promote wellness with, and for, Alaska's people by empowering Alaska's CHA/Ps and inspiring positive behavioral change to both prevent cancer and support those who feel its burdens.

Promoting Culturally Respectful Cancer Education Through Digital Storytelling.

Cancer is the leading cause of mortality among Alaska Native people. Over half of Alaska Native people live in rural communities where specially trained community members called Community Health Aides/Practitioners (CHA/Ps) provide health care. In response to CHA/Ps' expressed desire to learn more about cancer, four 5-day cancer education and digital storytelling courses were provided in 2014. Throughout each course, participants explored cancer information, reflected on their personal experiences, and envisioned how they might apply their knowledge within their communities. Each course participant also created a personal and authentic digital story, a methodology increasingly embraced by Indigenous communities as a way to combine storytelling traditions with modern technology to promote both individual and community health. Opportunities to learn of CHA/Ps' experiences with cancer and digital storytelling included a 3-page end-of-course written evaluation, a weekly story-showing log kept for 4 weeks post-course, a group teleconference held 1-2 weeks post-course, and a survey administered 6 months post-course. Participants described digital storytelling as a culturally respectful way to support cancer awareness and education. Participants described the process of creating digital stories as supporting knowledge acquisition, encouraging personal reflection, and sparking a desire to engage in cancer risk reduction activities for themselves and with their families and patients. As a result of creating a personalized digital story, CHA/Ps reported feeling differently about cancer, noting an increase in cancer knowledge and comfort to talk about cancer with clients and family. Indigenous digital stories have potential for broad use as a culturally appropriate health messaging tool.

Print Material in Cancer Prevention: an Evaluation of Three Booklets Designed with and for Alaska's Community Health Workers.

With increased internet access in rural Alaska and subsequent shifts in access to health information, we sought to understand the current role of printed cancer education booklets focused on recommended cancer screening exams. This evaluation reviewed three cancer education booklets specifically created with and for Alaska's Community Health Workers (CHWs) and the people in their communities. The booklets were created in an adaptation of empowerment theory, focused on working within a community-based participatory framework, in a culturally respectful manner, to shift cancer prevention norms by empowering CHWs to catalyze health behavior change for both themselves and their communities. The booklets incorporated traditional Alaska Native values and were designed to connect with readers at an affective and informational place that emphasized relationships. Since 2010, over 20,000 booklets have been distributed. Between January 2013 and March 2014, CHWs from throughout Alaska were invited to complete a three-page anonymous written evaluation of the booklets during community health trainings in Anchorage, Alaska. A total of 102 CHWs completed evaluations, with the vast majority indicating that they liked (100 %), and learned (96 %) from, the booklets. The evaluation results suggest that printed booklets designed in a culturally responsive manner, which both communicate medically accurate information and reach readers at an affective place to inspire action through raising awareness in relationship with others, are a helpful way to receive, discuss, and disseminate cancer screening information among Alaska Native people.

Engaging Elements of Cancer-Related Digital Stories in Alaska.

The tradition of storytelling is an integral part of Alaska Native cultures that continues to be a way of passing on knowledge. Using a story-based approach to share cancer education is grounded in Alaska Native traditions and people's experiences and has the potential to positively impact cancer knowledge, understandings, and wellness choices. Community health workers (CHWs) in Alaska created a personal digital story as part of a 5-day, in-person cancer education course. To identify engaging elements of digital stories among Alaska Native people, one focus group was held in each of three different Alaska communities with a total of 29 adult participants. After viewing CHWs' digital stories created during CHW cancer education courses, focus group participants commented verbally and in writing about cultural relevance, engaging elements, information learned, and intent to change health behavior. Digital stories were described by Alaska focus group participants as being culturally respectful, informational, inspiring, and motivational. Viewers shared that they liked digital stories because they were short (only 2-3 min); nondirective and not preachy; emotional, told as a personal story and not just facts and figures; and relevant, using photos that showed Alaskan places and people.

Digital storytelling: a tool for health promotion and cancer awareness in rural Alaskan communities.

BACKGROUND: The purpose of this study was to learn community members' perspectives about digital storytelling after viewing a digital story created by a Community Health Aide/Practitioner (CHA/P). METHODS: Using a qualitative research design, we explored digital storytelling likeability as a health-messaging tool, health information viewers reported learning and, if viewing, cancer-related digital stories facilitated increased comfort in talking about cancer. In addition, we enquired if the digital stories affected how viewers felt about cancer, as well as if viewing the digital stories resulted in health behaviour change or intent to change health behaviour. FINDINGS: A total of 15 adult community members participated in a 30-45 minute interview, 1-5 months post-viewing of a CHA/P digital story. The majority (13) of viewers interviewed were female, all were Alaska Native and they ranged in age from 25 to 54 years with the average age being 40 years. Due to the small size of communities, which ranged in population from 160 to 2,639 people, all viewers knew the story creator or knew of the story creator. Viewers reported digital stories as an acceptable, emotionally engaging way to increase their cancer awareness and begin conversations. These conversations often served as a springboard for reflection, insight, and cancer-prevention and risk-reduction activities.

Qualitative evaluation of a colorectal cancer education CD-ROM for Community Health Aides/practitioners in Alaska.

Colorectal cancer (CRC) is an important contributor to the cancer burden among Alaska Native people. CRC is the leading incident cancer and the second leading cause of cancer mortality among Alaska Native people. Completing recommended CRC screening procedures has the potential to reduce both CRC incidence and mortality. "Taking Action Colorectal Health," a multidimensional audiovisual, interactive CD-ROM, incorporates adult education learning principles to provide Alaska's Community Health Aides/Practitioners with timely, medically accurate, and culturally relevant CRC place-based education. Providing this resource on CD-ROM empowers learning within communities and places where people live or choose to learn. The dynamic process of developing, implementing, and evaluating this CRC CD-ROM was informed by a sociocultural approach to share health messages. Within this approach, cultural values, beliefs, and behaviors are affirmed as a place of wisdom and resilience and built upon to provide context and meaning for health messaging. Alaska Native values that honor family, relationships, the land, storytelling, and humor were included in CD-ROM content. Between January and May 2012, 20 interviews were conducted with individuals who had used the CD-ROM. Four categorical themes emerged from analysis of interview transcripts: likeability, utilization, helpfulness, and behavior change. As a result of self-paced learning through stories, movies, and interactive games, respondents reported healthy behavior changes they were making for themselves, with their families and in their patient care practices. This CD-ROM is a culturally based practical course that increased knowledge and activities around colorectal cancer screening by Community Health Aides/Practitioners in Alaska.

Evaluating arts-based cancer education using an internet survey among Alaska community health workers.

Cancer, considered a rare disease among Alaska Native people as recently as the 1950s, surpassed heart disease in the 1990s to become the leading cause of mortality. In response to Alaska's village-based Community Health Workers' (CHWs) desire to learn more about cancer for themselves and the people in their communities, cancer education that incorporated the expressive arts of moving, drawing, and sculpting was developed, implemented, and evaluated. Arts-based education integrates the dynamic wisdom and experiences of Alaska Native people and western medical knowledge to share cancer information in a culturally respectful way. Between May 2009 and March 2013, 12 5-day courses that included arts activities to support cancer information were provided for 118 CHWs in Anchorage, AK, USA. A post-course internet survey was conducted in April 2013, to learn how arts-based cancer education affected participants' knowledge, attitudes, and behaviors. Surveys were completed by 54 of the 96 course participants; 22 course participants were lost to follow-up. As a result of integrating the arts with cancer education, respondents reported an increase in their cancer knowledge and comfort with talking about cancer. Additionally, 82 % (44) of respondents described feeling differently about cancer. By integrating the arts with cancer information, participants reported healthy behavior changes for themselves (76 %), with their families (70 %), and in their work (72 %). The expressive arts of moving, drawing, and sculpting provided a creative pathway for diverse adult learners in Alaska to increase their cancer knowledge, comfort with talking about cancer, and wellness behaviors.

Bridging storytelling traditions with digital technology.

OBJECTIVE: The purpose of this project was to learn how Community Health Workers (CHWs) in Alaska perceived digital storytelling as a component of the "Path to Understanding Cancer" curriculum and as a culturally respectful tool for sharing cancer-related health messages. DESIGN: A pre-course written application, end-of-course written evaluation, and internet survey informed this project. METHODS: Digital storytelling was included in seven 5-day cancer education courses (May 2009-2012) in which 67 CHWs each created a personal 2-3 minute cancer-related digital story. Participant-chosen digital story topics included tobacco cessation, the importance of recommended cancer screening exams, cancer survivorship, loss, grief and end-of-life comfort care, and self-care as patient care providers. All participants completed an end-of-course written evaluation. In July 2012, contact information was available for 48 participants, of whom 24 completed an internet survey. RESULTS: All 67 participants successfully completed a digital story which they shared and discussed with course members. On the written post-course evaluation, all participants reported that combining digital storytelling with cancer education supported their learning and was a culturally respectful way to provide health messages. Additionally, 62 of 67 CHWs reported that the course increased their confidence to share cancer information with their communities. Up to 3 years post-course, all 24 CHW survey respondents reported they had shown their digital story. Of note, 23 of 24 CHWs also reported change in their own behavior as a result of the experience. CONCLUSIONS: All CHWs, regardless of computer skills, successfully created a digital story as part of the cancer education course. CHWs reported that digital stories enhanced their learning and were a culturally respectful way to share cancer-related information. Digital storytelling gave the power of the media into the hands of CHWs to increase their cancer knowledge, facilitate patient and community cancer conversations, and promote cancer awareness and wellness.

Telenovela: an innovative colorectal cancer screening health messaging tool.

BACKGROUND: Alaska Native people have nearly twice the rate of colorectal cancer (CRC) incidence and mortality as the US White population. OBJECTIVE: Building upon storytelling as a culturally respectful way to share information among Alaska Native people, a 25-minute telenovela-style movie, What's the Big Deal?, was developed to increase CRC screening awareness and knowledge, role-model CRC conversations, and support wellness choices. DESIGN: Alaska Native cultural values of family, community, storytelling, and humor were woven into seven, 3-4 minute movie vignettes. Written post-movie viewing evaluations completed by 71.3% of viewers (305/428) were collected at several venues, including the premiere of the movie in the urban city of Anchorage at a local movie theater, seven rural Alaska community movie nights, and five cancer education trainings with Community Health Workers. Paper and pencil evaluations included check box and open-ended questions to learn participants' response to a telenovela-style movie. RESULTS: On written-post movie viewing evaluations, viewers reported an increase in CRC knowledge and comfort with talking about recommended CRC screening exams. Notably, 81.6% of respondents (249/305) wrote positive intent to change behavior. Multiple responses included: 65% talking with family and friends about colon screening (162), 24% talking with their provider about colon screening (59), 31% having a colon screening (76), and 44% increasing physical activity (110). CONCLUSIONS: Written evaluations revealed the telenovela genre to be an innovative way to communicate colorectal cancer health messages with Alaska Native, American Indian, and Caucasian people both in an urban and rural setting to empower conversations and action related to colorectal cancer screening. Telenovela is a promising health communication tool to shift community norms by generating enthusiasm and conversations about the importance of having recommended colorectal cancer screening exams.

A Wellness Course for Community Health Workers in Alaska: "wellness lives in the heart of the community".

OBJECTIVES: To develop, implement, and evaluate a culturally respectful Wellness Course with and for Alaska's village-based Community Health Workers (CHWs) to support community health promotion and disease prevention. STUDY DESIGN: This article describes Wellness Course development, implementation, and evaluation. METHODS: Five 5-day Wellness Courses were provided for 55 CHWs from communities throughout Alaska. Fifty-two of 55 participants completed a post-course written evaluation. Post-course telephone interviews were conducted with participants (11/32) from the first 3 courses. RESULTS: On written post-course evaluations, all participants wrote detailed descriptions of what they learned and 98% (51/52) felt more confident in their knowledge and ability to present community wellness information. As a result of course participation, 88% (46/52) of CHWs wrote ways they would support family and community wellness, and 85% (44/52) wrote ways they planned to take better care of their health. During the in-depth post-course interviews, all 11 CHWs interviewed described ways the Wellness Course increased their health knowledge, helped them in their work, and prepared them to effectively engage with their communities to promote health. CONCLUSIONS: Learning wellness information with hands-on activities and practising health presentation and community engagement skills within the course design increased participants' wellness knowledge and skills, confidence, and motivation to provide community wellness activities. Techniques for active listening, engaging community, and using the arts and storytelling as culturally respectful health promotion are tools that when used by CHWs within their own community have potential to empower community wellness.

Creating dialogue, creating change through the arts.

The "wellness picnic," an interactive hands-on learning activity, was developed to engage people in reflective conversations about their health behaviors and wellness journey. Participants used pictures, colors, and words to transform a paper plate into a symbolic representation of what wellness looked like to them. Within the wisdom of each participant's paper plate drawing, there emerged pathways for living well, creating a respectful place for sharing wellness understandings and cancer risk reduction activities.

Readers' theatre: a communication tool for colorectal cancer screening.

UNLABELLED: Colorectal cancer (CRC) is the second leading cause of cancer mortality for Alaska Native people, yet it can be almost totally prevented through colonoscopy screenings. PURPOSE: A 25-minute Readers' Theatre script was developed with and for Alaska Native and American Indian Community Health Workers (CHWs) and the people in their communities to provide CRC screening information, model ways to talk about CRC screening, increase comfort with talking about CRC, and encourage healthy lifestyle choices. METHODS: Grounded in Indigenous methodologies, this paper describes the collaborative development, implementation, and evaluation of a CRC Readers' Theatre. RESULTS: 94% (161/172) of participants from 11 Readers' Theatre completed a written evaluation. 90% (145) of participants reported feeling more comfortable talking about CRC and 77% (124) described healthy changes they planned to make. Readers' Theatre was associated with increased knowledge, comfort talking about CRC, and served as a catalyst for positive intent to change behavior.

Learning about cancer has brightened my light: cancer education for Alaska Community Health Aides and Community Health Practitioners (CHA/Ps).

In response to Alaska's Community Health Aides/Practitioners (CHA/Ps) request for cancer information, the "Path to Understanding Cancer" course was developed, implemented, and extensively evaluated. Using a qualitative approach as one evaluation component, 128 of 168 course participants engaged in post-course telephone interviews. Of these, 116 (81%) CHA/Ps felt more comfortable in talking about cancer and 57% had increased cancer screening referrals for patients. Additionally, 28% of 110 CHA/P respondents and 21% of 114 CHA/Ps' family members sought and received cancer screening; they had also made lifestyle changes to reduce cancer risk, including tobacco cessation and healthy changes in nutrition and exercise. Through qualitative design, we gained insight into CHA/Ps' lived experience of cancer and an understanding of ways the course made a difference in patient care as well as cancer risk reduction, cancer screening, and prevention for themselves, their families, and people in their communities.