Cancer Education in the Northwest Arctic: Empowering Youth on Cancer in Rural Alaska

Abstract

Cancer is the leading cause of death in Alaska and the second leading cause of death in the USA, even though the most common cancers are largely preventable through screening and lifestyle changes. Consequently, interventions that promote sustainable behavioral change can reduce existing health disparities in cancer morbidity and mortality. In 2019, community sharing circles inspired the creation of a cancer education project for youth in the Northwest Arctic region of Alaska. We grounded the work in community-based participatory action research (CBPR), empowerment theory, and Indigenous ways of knowing, with a Community Advisory Board guiding the project. Eleven cancer education lessons were developed for young people in the Northwest Arctic, several of which were piloted remotely during the pandemic and delivered in-person in spring 2022. The project team visited each participating community in the spring of 2024 to support peer instructors in teaching cancer topics and presenting requested lessons to youth. Each participant was invited to complete a pre-lesson and a post-lesson survey. A total of 2303 pre-/post-surveys were completed. Respondents’ mean cancer knowledge scores were significantly higher after seven different lessons. In 90% of post-lesson surveys, respondents (795/887) said they planned to share information they had learned during the lessons, including lessons about cancer screening exams and eating healthier. In 90% of post-lesson surveys, respondents (799/890) said they planned to reduce their cancer risk in the next 6 months, including by staying tobacco-free and stopping alcohol use. As a learner shared: “Cancer fears hope. Medical research on cancer treatments advances every day. Hope is growing and cancer is soon to be no more.”

Background

Although cancer is the leading cause of death across Alaska, it disproportionately impacts Alaska Native people [1, 2]. In 2020, Alaska Native cancer mortality rates were more than 60% higher than those of White Alaskans [2]. Cancer disparities persist in the Northwest Arctic region of Alaska, where cancer mortality rates for Alaska Native people were 183.9 per 100,000 in 2016–2019, far higher than the White Alaskan cancer mortality rate of 135.4 statewide in 2019 [2, 3]. The Northwest Arctic region of Alaska is a rural area of 11 communities, each of which is only accessible via plane from larger cities, or via boat in the summer and/or snowmachine in the winter to smaller, neighboring communities. There are about 7500 people in the Northwest Arctic region, and about 80% identify as Alaska Native or American Indian [4]. Each life lost to cancer in rural Alaska not only represents an unnecessary tragedy, but also the significant loss of a site of intergenerational education—an opportunity to transmit resilient, but still threatened, Alaska Native cultural practices and ways of knowing.

Despite persistent disparities, cancer rates have generally declined in Alaska for both the White and Alaska Native populations over the past 20 years [2]. Further, the leading causes of cancer incidence among Alaska Native people (colorectal, lung, and breast) are largely preventable through early screening and modifiable behavioral changes, presenting an opportunity for health promotion efforts to reduce cancer rates and alleviate persistent inequalities [1].

Previous culturally relevant health promotion efforts developed with, and for, Alaska Native people have led to self-reported decreases in cancer risk and improved self-efficacy to share cancer-related health information [6, 7]. However, there is still work to be done. Health promotion that supports individuals in sustainably reducing their cancer risk—such as by staying tobacco-free, being physically active, and getting recommended screening exams—remains critical to reducing cancer disparities and realizing a future in which Alaska Native people live longer, healthier lives.

When a project team member from the University of Alaska Anchorage (UAA) was working as a wildlife biologist in the Northwest Arctic, she heard repeated concerns from community members about cancer. In response, she and another University of Alaska professor teamed up with community members to facilitate sharing circles in November 2019 in the Northwest Arctic. Together, researchers and community members investigated concerns, sought out ways to address those concerns, and identified community priority areas for cancer education. Sharing circle participants enthusiastically encouraged the development of cancer education for young people, which laid the foundation for this project (these sharing circles are described in more depth elsewhere [8]). In response, eleven culturally relevant lessons, based on regional data and incorporating locally specific audiovisuals and interactive activities, were developed for young people in the Northwest Arctic.

The COVID-19 pandemic began shortly after the sharing circles were conducted, complicating initial plans to teach students in person shortly after lessons were developed. However, the lessons were moved online during the pandemic, and when the largest of the three communities opened to outside travelers, the lessons were finally piloted in person. During the pilot, a total of 113 pre-/post-lesson surveys were completed, with promising findings indicating learning and intent to change behavior. However, the small number of surveys and lack of in-person instruction in the two smaller communities limited conclusions [9]. This paper includes findings from in-person instruction in all three participating communities, as well as instruction from both university professors and peers.

Theoretical Framework

This project began in response to community concerns and was co-led by community partners in alignment with the principles of community-based participatory action research (CBPR). The team also honored Indigenous ways of knowing to promote relevance, sustainability, and increased effectiveness [10]. This work was also conducted in alignment with a proposed framework for creating culturally relevant cancer education with Alaska Native peoples [11].

Following a CBPR approach and in alignment with empowerment theory, sharing circles are the first step in developing a cancer education program focused on empowering individuals to change behavior and shift social norms to reduce cancer risk and control cancer in the Northwest Arctic [12]. CBPR allows communities and academics to focus on community strengths as partners in order to address locally relevant issues and realize changes that promote community well-being [13, 14]. In alignment with the CBPR principles to work in “collaborative, equitable partnerships” and “promote co-learning and capacity building,” an invaluable Community Advisory Board guided the project [15].

While Indigenous ways of knowing are as diverse as the Indigenous peoples of the world, Indigenous thought systems are often more holistic than Western ways and include affective and subjective elements. Indigenous ways of knowing often acknowledge the importance of relationships, observations, and experiences [16, 17]. Consequently, this project sought both to create lesson plans that aligned with these ways of knowing and to build relationships with community members and potential collaborators. To reflect Indigenous ways of knowing in this project, the research team worked with local individuals to instruct lessons, leveraging their relationships with youth to hopefully inspire greater cancer protection. A group of elders in the Northwest Arctic also translated key messages into Inupiaq, the indigenous language of the region, and local images of the region, and data about cancer rates in the Northwest Arctic were incorporated into the lessons. The team also developed activities that emphasized cultural groundedness as cancer-prevention approaches (such as a potluck activity, an inventory of nutritional facts about traditional Alaskan foods, and an activity highlighting the communities’ core values) and forged ongoing relationships between communities, the Northwest Arctic School District, and the University of Alaska.

Empowerment theories are both a foundation of CBPR and a natural extension. For example, one effective health education strategy comes from Paulo Freire’s popular education, which advocates for empowering education that leads to social transformation of societies [18]. Empowerment-oriented approaches are also fundamental in working with Indigenous communities. Historical trauma precipitated by colonization has disrupted traditional Indigenous food systems, along with cultural practices that facilitated physical activity, healthy eating, and limited tobacco use. Some researchers connect this trauma with contemporary cancer disparities [19]. Acknowledging historical trauma and its impacts, CBPR theorists advocate that work with Indigenous communities focus on self-determination and empowerment [20], an approach actualized by this project’s focus on cultural relevancy and cultural strengths. Youth are uniquely situated to empower health behavior change due to their potential to influence social structures and community norms in the generations to come.

Based on cancer education with Alaska’s Community Health Aides and Practitioners, a proposed framework for culturally relevant online cancer education with and for Alaska Native people was proposed in 2018. This framework included four central constructs: (1) collaborate with potential learners and community members to develop and refine education; (2) deliver content in relevant ways, such as through personal stories and visuals; (3) contextualize content to learners’ unique experiences and cultures; and (4) allow space for relationship-building and connections to allow individuals to learn from/with each other [11]. This project followed that framework by first relationship-building with community members and potential learners; creating content that included stories and audiovisuals; collaborating with local partners to include culturally relevant visuals, stories, and language from the region; continuing a commitment to show up in participating communities to instruct lessons; and continuing communication with key stakeholders on project progress.

Methods

Lessons

In collaboration with the Community Advisory Board and local stakeholders, the project team created eleven lessons. The 11 cancer education lessons were (1) what is cancer?, (2) cancer diagnosis and treatment, (3) cancer and the environment, (4) physical activity, (5) healthy eating, (6) choosing tobacco-free, (7) alcohol and cancer risk, (8) sun health, (9) HPV, (10) screening exams, and (11) Northwest Arctic cancer data. For an example lesson plan, see the Appendix to read the “What is cancer?” lesson. All lessons are a part of the Northwest Arctic Borough School District curriculum and are freely available online at https://sites.google.com/view/akcancer/.

These lessons were developed to be culturally relevant to rural Alaska Native communities and promote protective factors of the leading causes of cancer incidence and mortality among Alaska Native people. For example, the “healthy eating” lesson was developed specifically to represent the food landscape of an Alaska community in the Northwest Arctic and promote protection from colorectal and breast cancer. This lesson focuses on promoting healthy traditional foods, such as fish and berries, and reducing consumption of foods containing saturated fat and processed sugar. Additionally, the lessons emphasized information specific to leading causes of cancer diagnosis and death among Alaska Native people (breast, colon, and lung cancer). The “screening exams” lesson contained focused information on colonoscopies and mammograms and highlighted that colonoscopies are recommended beginning at age 40 for Alaska Native people.

A Community Advisory Board member in Kotzebue instructed a program called Educators Rising, which was designed for talented high school students interested in becoming teachers. Within that program, the students were dually enrolled at the University of Alaska as part of two different courses. As part of this cancer education project, youth in the class were asked to choose one of the developed cancer education topics, adapt the existing lesson plan, and instruct the lesson to high school and middle school peers. While the youth-adapted lessons were shorter than the written lesson plans, the effect of a peer instructing a cancer lesson may have outsized effects given the existing relationship between the peers, their students, and the possibly more peer-relevant lesson content.

In 2022, students from the Educators Rising program used the lesson plans to deliver curriculum to multiple high school classes over a 2-week period. These students were then invited to present their lessons to health care workers at the Maniilaq Health Center.

In 2023, the students in the Educators Rising program in Kotzebue presented the cancer lessons in small class settings to elementary, middle, and high school students throughout a week of school dedicated to cancer awareness. The week culminated with a student-led all-school assembly which included a pig lung presentation with a UAA professor.

In 2024, the professors who led the project traveled to all three communities and instructed lessons as requested by school staff. This included teaching about tobacco use in Noatak and Noorvik to elementary, middle, and high school students, and holding public cancer awareness events. In Kotzebue, the Educators Rising students gave presentations on several cancer topics to elementary, middle, and high school classes. Middle and high school student groups rotated between the different topics to receive information from all peer presenters. Similar to previous years, this was student-led but also included support from two university instructors and displays from the Maniilaq Health Center.

Measures

Participants were invited to complete a pre-test before each lesson with 10–12 knowledge questions. Most questions were true or false, with a few multiple-choice questions. After the lesson, participants were invited to complete a post-test with the same set of knowledge questions. In addition, the post-test asked learners to rate their changes in comfort, confidence, preparedness to discuss cancer topics, and knowledge about cancer as a result of the lesson. Participants were also asked to select any behavior changes they planned to make from a drop-down list of options in order to reduce their cancer risk as a result of the lesson. Participants were asked if they planned to share information about cancer as a result of the lesson, and if so, who they planned to share with and what kinds of messages they intended to share. Finally, participants were asked to provide their demographic information on the pre- and post-tests.

Students were offered US $20 cash for completing pre- and post-test surveys. Surveys were collected via Qualtrics and cleaned and summarized in R and Excel. Participants were not required to fill out every section on each survey. To compare pre- and post-lesson changes, two-sample t-tests were performed on the knowledge section of the tests.

Funding and IRB

This work began through funding by the Alaska Native/American Indian Clinical and Translational Research Program, supported by the National Institute of General Medical Sciences of the National Institutes of Health under Award Number U54GM115371. The cancer lessons were piloted with funding through the Alaska IDeA Network of Biomedical Research Excellence (INBRE), funded by the National Institutes of General Medical Sciences of the National Institutes of Health under Award Number P20GM103395. The project was reviewed by the University of Alaska Anchorage Institutional Review Board (#1,416,366–8) and Maniilaq Association, the tribal nonprofit corporation in the Northwest Arctic that manages health, tribal, and traditional assistance programs as well as social services for the region. This manuscript was also reviewed and approved by the Maniilaq Association Board.

Results

A total of 3140 pre-/post-surveys were begun, and 2499 indicated consent for research. Of these, only 2312 were completed, although we have included data from all completed questions where consent was obtained to use the survey in research. Consequently, the number of respondents varies slightly by question.

Learner Demographics

The majority of surveys were completed by middle and high school students (99% of surveys). A total of 91% of surveys were completed by individuals from Kotzebue (the largest community), with 2% completed by individuals from Noatak and 2% from Noorvik. Respondents indicated on 92% of surveys that they were Alaska Native. Just over half (57%) of surveys were completed by individuals identifying as male. Demographic information is summarized in Table 1.

Table 1.

Demographic characteristics of survey respondents

	Completed surveys N (%)	Total respondents to item
Gender		2280
Male	1306 (54%)
Female	895 (38%)
Non-binary or genderqueer	18 (< 1%)
Other/prefer not to say	61 (3%)
Race/ethnicity *		2302
Alaska Native	2126 (92%)
White	411 (18%)
Hispanic	108 (8%)
American Indian	91 (4%)
Black	85 (4%)
Asian	79 (3%)
Pacific Islander	9 (< 1%)
Other	105 (3%)
Age		2304
14 or younger	1350 (59%)
15–17	766 (33%)
18–19	170 (7%)
20 or older	18 (< 1%)
Education		2309
Middle school student	1243 (54%)
High school student	1041 (45%)
Teacher or community member	10 (< 1%)
Other	15 (< 1%)
Where do you live		2308
Kotzebue	2104 (91%)
Noorvik	42 (2%)
Noatak	37 (2%)
Somewhere else in Northwest Alaska	49 (2%)
Somewhere else in Alaska	66 (3%)
Somewhere outside Alaska	10 (< 1%)

^*Respondents were able to check more than one race/ethnicity, so totals exceed 100%

Changes in Knowledge

On pre- and post-lesson surveys, learners were asked a series of knowledge questions tailored to the lesson content. Aggregated mean percent of questions answered correctly, as well as the number of completed pre- and post-lesson surveys and the number of knowledge questions on each survey, are summarized in Table 2.

Table 2.

Respondent changes in cancer knowledge

	Pre-surveys	Post-surveys	P valuea
What is cancer?
Number of completed surveys	165	142
Number of knowledge questions	12	12
Mean percent of questions correct	66%	72%	0.068
Alcohol
Number of completed surveys	127	120
Number of knowledge questions	8	8
Mean percent of questions correct	64%	82%	0.187
Diagnosis and treatment
Number of completed surveys	158	130
Number of knowledge questions	10	10
Mean percent of questions correct	55%	65%	0.554
Environment and cancer
Number of completed surveys	107	65
Number of knowledge questions	12	12
Mean percent of questions correct	58%	66%	< 0.001*
Healthy eating
Number of completed surveys	138	120
Number of knowledge questions	10	10
Mean percent of questions correct	61%	67%	0.298
Physical activity
Number of completed surveys	174	140
Number of knowledge questions	10	10
Mean percent of questions correct	54%	63%	0.004*
Screening for cancer
Number of completed surveys	135	109
Number of knowledge questions	10	10
Mean percent of questions correct	64%	78%	0.839
Sun exposure
Number of completed surveys	118	92
Number of knowledge questions	10	10
Mean percent of questions correct	63%	75%	0.035*
Tobacco
Number of completed surveys	146	117
Number of knowledge questions	12	12
Mean percent of questions correct	67%	73%	< 0.001*
Results summary
Number of completed surveys	1268	1035
Number of knowledge questions	94	94
Mean percent of questions correct	61%	71%	< 0.001*

^*p < 0.05

^aTwo-sample two-tailed t-test assuming unequal variance

In aggregate, learners improved their scores significantly across all lessons from pre- to post-survey. Of the nine lessons taught, learners had statistically significant changes in relevant knowledge after completing four lessons, and all trended positively, with learners answering more questions correctly after lessons than before.

Learners demonstrated more dramatic improvement on some questions than others, with the percentage of learners answering an individual question correctly ranging from an improvement of 35% points of improvement from pre to post, to just a 1% point change. To illustrate the kind of knowledge that the lessons were effective at changing, Table 3 contains the six questions with the largest score improvements. These questions are all formatted as true/false statements.

Table 3.

Changes in respondent’s scores on selected questions

Question (true/false response)	% of learners answering correctly on pre-test	% of learners answering correctly on post-test	Difference
Cancer can only be definitely diagnosed by looking at cells or tissue under a microscope	42%	77%	35%
Metastasis is the spread of cancer	35%	68%	33%
For concerns about changes in a mole, use the ABCD method to help decide if it needs to be checked by a healthcare provider	62%	88%	26%
A benign tumor means that you have cancer	33%	58%	25%
Pap tests beginning at age 21 for people with a cervix can find and treat precancerous cells before they become cancer	53%	77%	24%
Mammograms help to find breast changes early that may be cancer	58%	82%	24%

Intent to Share Cancer Information

Participants were asked what kind of cancer information they were most likely to share and who they would share the information with. Respondents indicated on 99% of post-lesson surveys that they planned to share information they had learned, including with family (76%), friends (54%), community members (19%), and teachers (16%). Respondents indicated that they planned to talk to people more often about staying tobacco-free or quitting tobacco (on 70% of surveys), eating healthier (59%), choosing not to drink alcohol or cutting down on alcohol use (57%), and increasing physical activity (47%).

Learners were significantly more likely to indicate that they planned to share information on staying tobacco-free and eating healthier after they had completed a relevant lesson (tobacco and healthy eating, respectively) (see Table 4). Lesson content did not make a significant difference in cancer-prevention messages learners planned to share otherwise. Some learners wrote specific messages they intended to share, including “eat healthy, don’t smoke, use sunglasses, and sunscreen,” “I want to encourage others around me to get screened,” and “be more eager to go hunting for better and more natural food sources.”

Table 4.

Respondent intent to share information as a result of the cancer education

	Completed post-surveys indicating intent to share cancer prevention information
	Participants who completed a relevant lesson N (%) Lesson		Other learners N (%)	P valuea
Staying tobacco-free	65/88 (74%)	Tobacco	484/798 (61%)	0.016*
Eating healthier	71/99 (72%)	Healthy eating	450/787 (57%)	0.006*
Stopping tobacco use	44/88 (50%)	Tobacco	315/798 (39%)	0.056
Increasing physical activity	59/124 (48%)	Physical activity	358/762 (47%)	0.905
Choosing not to drink alcohol	49/105 (47%)	Alcohol	334/781 (43%)	0.447
Having a recommended cancer screening exam	38/94 (40%)	Screenings	275/792 (34%)	0.276
Stopping alcohol use	46/105 (44%)	Alcohol	286/781 (37%)	0.153
Cutting down on drinking alcohol	33/105 (31%)	Alcohol	198/781 (25%)	0.184
Having the HPV vaccine as recommended	N/A	HPV	244/886 (28%)
Not make any changes		N/A	92/886 (10%)

Respondents were able to check more than one intended behavior, so totals exceed 100%

^*P value significant at < 0.05 level

^aTwo-tailed Z score

Intent to Change Behavior

Respondents were asked if they intended to change anything about their own behavior to reduce their personal cancer risk as a result of the lesson they had participated in. Individuals responded to the prompt on 890 post-surveys. Among surveys with a response, learners indicated in a total of 90% of post-surveys that they planned to change their behavior to reduce their cancer risk. The most common responses were planning to eat healthier (75% of surveys), increase physical activity (62%), and stay tobacco-free (43%). What lesson plans students participated in influenced the cancer risk factors they intended to reduce, with learners indicating on significantly more surveys (see Table 5) that they planned to stay tobacco-free, cut down on tobacco, or quit using tobacco after participating in the tobacco lesson, that they were significantly more likely to plan to eat healthier after the healthy eating lesson, and that significantly more planned to increase their physical activity after the physical activity lesson. The percentage of surveys where learners reported they planned to get screened, get more information about screening, or schedule a recommended screening exam was not different between learners who had just completed the screening lesson and those who had not. This serves as a useful comparison group, as most youth are not eligible to obtain a cancer screening exam due to their age, so motivating young people to get screened was not a focus of any lesson.

Table 5.

Respondent intent to reduce personal cancer risk as a result of the cancer education

	Completed post-surveys indicating intent to reduce cancer risk
	Participants who completed a relevant lesson N (%) Lesson		Other learners N (%)	P valuea
Eat healthier	87/109 (80%)	Healthy eating	506/769 (66%)	0.004*
Increase physical activity	87/121 (72%)	Physical activity	473/769 (62%)	0.028*
Stay tobacco-free	55/104 (53%)	Tobacco	330/782 (42%)	0.039*
Stop using tobacco	33/104 (32%)	Tobacco	172/782 (22%)	0.029*
Get information about having a recommended screening exam	26/94 (28%)	Screenings	179/796 (22%)	0.259
Get screened	25/94 (27%)	Screenings	210/796 (26%)	0.968
Cut down on tobacco use	26/104 (25%)	Tobacco	131/782 (17%)	0.039*
Schedule a recommended screening exam	19/94 (20%)	Screenings	156/796 (19%)	0.889
Not make any changes			88/890 (10%)

Respondents were able to check more than one intended behavior, so totals exceed 100%

^*P value significant at < 0.05 level

^aTwo-tailed Z score

Peer vs. Professor Taught

The university professors leading the research instructed several of the lessons to students in the participating communities. Additionally, one of the Community Advisory Board members also coached a class of high school students to choose one of the developed cancer education topics, adapt the existing lesson plan, and instruct the lesson to high school and middle school peers.

The “What is cancer?” and lesson on tobacco use had sufficient data to compare score outcomes between professor-taught and peer-taught lessons. In both instances, professor-taught lessons demonstrated more learner improvement than peer-taught lessons. Table 6 shows the number of surveys and the mean score change for the “What is cancer?” and tobacco lessons.

Table 6.

Score change comparison between professor- and peer-taught lessons

	Professor	Peer	P valuea
What is cancer?
Number of completed pre-surveys	29	136
Number of completed post-surveys	21	121
Mean difference in percent of questions answered correctly from pre to post	8%	5%	0.870
Tobacco
Number of completed pre-surveys	46	100
Number of completed post-surveys	36	81
Mean difference in percent of questions answered correctly from pre to post	10%	4%	0.014*

^*P value significant at < 0.05 level

^aWelch two-sample t-test

When compared across all tests, respondents’ intent to change behavior was not significantly different when comparing peer-taught to professor-taught lessons. Among learners in a professor-taught lesson, 73% reported intending to make at least one behavior change to reduce their cancer risk, as compared to 76% of learners in a peer-taught lesson. Table 7 displays the difference in learners’ intended behavior change between instructor types.

Table 7.

Respondent intent to reduce personal cancer risk as a result of professor- or peer-taught lessons

	Professor-taught lessons N (%)	Peer-taught lessons N (%)	P valuea
Make any change	137 (73%)	641 (76%)	0.401
Not make any changes	16 (9%)	75 (9%)	1.000
No response	34 (18%)	132 (16%)
Total	187 (100%)	848 (100%)

^*P value significant at < 0.05 level

^aWelch two-sample t-test

Discussion

These findings suggest that the developed cancer education lessons significantly increase learners’ cancer-related knowledge, inspire intent to share information, and reduce personal cancer risk. These findings are consistent with the results of the pilot, although the increased number of surveys has offered greater evidence to support these conclusions. Similarly, all lessons indicate positive change, even when the limited number of completed surveys reduced the ability to determine statistical significance. We also found that learners were significantly more likely to indicate they intend to reduce their cancer risk in a way aligned with the lesson they had been a part of (i.e., reducing tobacco use after having been a part of a tobacco lesson).

The involvement of the Community Advisory Board and key stakeholders facilitated this work and highlighted the essential role of community engagement in successful health promotion implementation and evaluation. This work, along with the development of a culturally relevant curriculum with key messages in Inupiaq, and the hosting of school-wide cancer days where peers adapted and instructed lessons, would not have been possible without the commitment and vision of the Community Advisory Board.

While learners’ tested knowledge changed significantly more after the professor-taught lessons, intent to change behavior was similar among both peer-taught and professor-taught groups. This suggests that peer teaching without professors could result in positive behavioral change, even if peers may not be instructing in a way that allows learners to respond correctly to the specific knowledge questions asked after the lessons. These peer teachers were also gaining invaluable hands-on knowledge in teaching, and gathering qualitative information on their perception of the experience and attitudes toward cancer risk reduction would be useful for further study. Investigating learners’ perceptions of what could be improved, and what was effective, about peer vs. professor-taught lessons would be another valuable area for future research, especially as enhancing the effectiveness of peer-teaching could be a pathway to ensure sustainability of cancer education in a remote area of Alaska.

Further research would be needed to follow up with learners and investigate whether intended behavior resulted in actual behavioral shifts. Previous research on cancer education with Alaska Native people has indicated that intending to change behavior led to between 77 and 85% of those individuals reporting they had made the change they intended [21]. However, this follow-up work has not been done with Alaska Native youth and remains a gap in research.

Single or annual health promotion events, while a positive step in an information-limited environment, may be unlikely to address social determinants of health that promote cancer risk. In addition, individual behaviors are constrained by community, societal, and political structures that limit or promote access to resources such as screening exams, healthy foods, physical activity opportunities, and tobacco products. This research is done in parallel with programs aiming to make a change on these levels, but does not explicitly address access to such resources, and a more multi-level intervention may yield additional results.

Limitations

Study findings may not be generalizable to non-participating communities in the region, to other regions in Alaska, or outside of Alaska. Further, this study was limited to middle and high school learners in three rural Alaska Native Inupiat communities and may not be generalizable to other age or cultural groups. While the intent to reduce personal cancer risk and communicate cancer-related information was broadly indicated by learners, without additional research, it is unclear whether these intentions were realized in behavior change. Further, the impact of sharing cancer-related messages in the participating communities is as yet unexplored.

Conclusions

The cancer education instructed in the Northwest Arctic region of Alaska during this project significantly improved learners’ knowledge about cancer and inspired an intent to reduce personal cancer risk and share cancer information more broadly. This project is a promising step in delivering fundamental cancer education to rural Alaska Native youth and is well aligned with a broader journey toward promoting well-being for the people of the Northwest Arctic in both current and future generations. Empowering youth to share cancer information and reduce their own cancer risk may change the story of cancer in rural Alaska for generations to come.

Appendix. Lesson Plan: What Is Cancer?

Alaska Curriculum Standards

Skills for a Healthy Life: A1, A2, A3, A5, B1, B5

Science: MS-LS1–3

Objectives:

At the end of this lesson, learners will be able to:

• Describe what cancer is.

• State how a cancer diagnosis is made.

• Identify basic vocabulary used when talking about cancer (biopsy, cells, primary site, stage of cancer, and metastasis).

• Know where to find medically accurate cancer information (American Cancer Society, National Cancer Institute).

Materials Needed:

Computer and internet access to the website: https://sites.google.com/view/akcancer/home• Activities posted on the website: (each activity with discussion can take about 30 min)

• Cancer Basics Radio Show

• If in a classroom, live, print the Cancer Basics Radio Show. Print and cut apart the questions with answers. Divide the questions and answers among players. Answers can be discussed as you play the game with the facilitator adding any additional information.

• The teacher can play the role of the radio show host.

• There are a total of eight callers and eight experts in the radio show.

• Role Play: Grandma’s Cancer Doctor Visit Part 1

• Print a copy of the script for each class participant.

• Ask for five volunteers to each read a role. There are five roles in this activity: nurse, doctor, patient (grandma), patient’s daughter, and patient’s grandson. After all characters have been selected, the teacher introduces each character and who is reading that part.

Resources to Learn More:

• American Cancer Society (ACS) https://www.cancer.org/cancer/cancer-basics.html

• National Cancer Institute (NCI) https://www.cancer.gov/about-cancer/understanding/what-is-cancer

Vocabulary:

Benign (beh-NINE)––A tumor that is not cancer. It does not invade nearby tissue or spread to other parts of the body.

Biopsy (BY-op-see)––The removal of a sample of tissue that is examined under a microscope, by a specially trained doctor called a pathologist, to look for cancer cells. A cancer diagnosis cannot be made by looking at a person. A biopsy is required to make a cancer diagnosis.

Cancer––A word for more than 100 different diseases in which abnormal cells divide without control or order.

Cell––Basic unit or building block of human tissue.

Leukemia (loo-KEE-mee-uh)––A cancer of the white blood cells formed from the blood-forming tissues, mainly the bone marrow, lymph nodes, and spleen.

Lymphoma (lim-FO-mah)––A cancer that develops in the lymphatic system, part of the body’s immune defense system.

Malignant (muh-LIG-nant)––A tumor that is cancerous and has the ability to spread to other parts of the body.

Metastasis (meh-TAS-tuh-sis)––The spread of cancer from one part of the body to another part of the body through the lymph system or blood system.

Myeloma (my-eh-LOW-muh)––A cancer that starts in plasma cells made in the bone marrow.

Primary site or primary tumor site––The location where the cancer first starts to grow.

Stage of cancer––Describes how far the cancer has spread from the original site to other parts of the body.

Tumor (TOO-mer)––An abnormal growth of cells or tissue. Uncontrolled growth that occurs in solid tissue, such as an organ, muscle, or bone. Tumors can be benign (not cancerous) or malignant (cancerous).

During the lesson, ask students to write down new words. As a class, discuss what the words mean and how they are pronounced.

Suggested Instructional Outline:

Class Session 1, Cancer Basics (60 min):

• As a class, ask students to share what they know in response to the question “What is cancer?” Write students’ ideas on the board (5 min.)

• On the Cancer Basics page of the website, watch the movie “What is cancer?” (2 min)

• Review the vocabulary listed in the lesson plan. Cancer often has a whole new set of words to learn and understand (5 min.).

• Facilitate the Cancer Basics Radio Show (20 min)

• Print a copy of the Cancer Basics Radio Show script and cut apart the caller questions and the expert answers.

• Give a caller question or an expert answer to each participant. There are eight callers and eight experts.

• The teacher has a copy of the entire radio script and reads the radio announcer’s words.

• Facilitate a discussion about what students know about cancer and what they have heard, and how that information compares to the information listed on the website and learned in the Cancer Basics Radio Show (10 min):

• What ideas are students wondering about? Is the information based on medically accurate facts, outdated information, or cancer myths?

• As part of the homework, ask students to research additional information using the recommended cancer resources (American Cancer Society or National Cancer Institute) to find answers to the ideas generated in the opening class discussion about cancer basics or another cancer question they are wondering about. Often, people have heard a variety of information that is not based on medically accurate science.

• Review helpful resources (American Cancer Society or National Cancer Institute) to learn where to find information about cancer (5 min).

• Introduce homework: cancer facts or myths (5 min).

• Ask students to research a question that they have about cancer or an idea that was generated in the opening cancer discussion using a medically accurate resource.

• Students should be prepared to report back to the class:

• What question they researched, what resources they used, and what they learned.

Class Session 2, Cancer Basics (50 min):

• Debrief homework cancer facts or myths (20 min)

• Ask each student to share how their homework went.

• Have students share what question they wanted to learn more about, what they learned, and the resources they used.

• Facilitate the Cancer Basics role play activity: Grandma’s Cancer Doctor Visit Part 1 (30 min)

• Print a copy of the script for each class participant.

• Ask for five volunteers to each read a role. There are five roles in this activity: nurse, doctor, patient (grandma), patient’s daughter, and patient’s grandson.

• After all characters have been selected, the teacher introduces each character and who is reading that part.

• Readers only need to read their words and not their character’s name. If people stumble over their words, that is OK. Talking with people is not usually rehearsed, and in life, we may stumble over our words and with what we are trying to say. The readers are bringing life to the characters on the page.

• Listeners also have a very important part. It is a gift to really listen by being present to peoples’ stories. This is an opportunity to practice listening skills.

• Post-reading conversation questions: The following are possible questions to start a conversation after reading “Grandma’s Cancer Doctor Visit Part 1.” Thank people for reading and listening. How was it for you to be a reader or a listener? Was there any part of the story that really connected with you? After reading this story, are there any things you are wondering about? Any parts that are confusing?

Evaluation:

• Participation in in-class activities.

• Completion of homework assignments.

• Cancer facts or myths

Data Availability

The original contributions presented in the study are included in the article, and further inquiries can be directed to the corresponding author. Restrictions may apply to primary sources of information based on principles of Indigenous data sovereignty. Pre-cautions will be taken to protect the privacy of research participants and maintain the confidentiality of their personal information.