Cancer is the second leading cause of death in the United States, causing almost 600,000 deaths in 2016 alone. However, most Americans do not know about common cancer risk factors like obesity and lack of exercise . In Alaska, cancer is the leading cause of death, with Alaska Native people disproportionately burdened by cancer and associated risk factors ]. Between 2009-2013, the cancer mortality rate for Alaska Native people was 40% higher than U.S. Whites. However, the leading causes of cancer incidence among Alaska Native people are lung, colorectal, and breast cancer, which all have modifiable risk factors.
This presents an opportunity for health promotion efforts to support reduced cancer risk
Cancer risk factors disproportionately impact Alaska Native people: in 2015-2017, 36.5% of Alaska Native adults reported current smoking (compared with 16.1% of Alaska White adults), and 36.8% reported BMI of 30 or greater (compared to 29.5% of Alaska White adults) [8]. In 2015-2017, only 14.4% of Alaska Native adults reported eating at least 5 fruits or vegetables a day (compared to 19.4% of White Alaska adults) [9].
However, health promotion efforts have the potential to reduce modifiable cancer risk factors among Alaska Native people and alleviate disparities. For example, the proportion of Alaska Native adults receiving colorectal and breast cancer screenings has recently attained parity with rates for both Alaska White adults and U.S. White adults ]. Additionally, cervical cancer screening rates for Alaska Native people are now only slightly lower than Alaska White women.
To promote wellness in rural Alaska and reduce cancer risk factors, Alaska’s Community Health Aides/Practitioners (CHA/Ps) are vital.
Alaska’s CHA/Ps are tribal primary care providers who live and work in rural Alaska. CHA/Ps are often recruited from the communities they serve, and work under the supervision and standing orders of senior medical providers. CHA/Ps are often the only health care providers in their communities, and can have an impact on the information their families and patients hear about tobacco, weight management, physical activity, cancer screenings, and nutrition.
CHA/Ps are uniquely situated to support positive behavior change in their communities. As the health care providers, they are central to each village’s health and wellness network. This work partners with CHA/Ps to support them to share information and support positive behavior change through existing social networks. Patients receiving information from healthcare professionals, such as Alaska’s CHA/Ps, is a significant determinant of patient behavior.
This information sharing has also been found to effectively reduce patients’ cancer risk factors. In a study of over 8,000 patients, talking with a healthcare professional and hearing an adequate explanation about the need for colorectal cancer screening was significantly correlated with patients receiving that screening. A meta-analysis also found that a healthcare professional sharing advice about tobacco cessation increased the rate of patients who quit tobacco . Further, a systematic review found a positive correlation between patients’ physical activity and healthcare providers’ counseling about exercise . The aim of shifting patient behaviors by improving CHA/P-patient education is consistent with the literature, which has documented that counseling by healthcare professionals is a significant determinant of patient behavior.
The Alaska Community Health Aide Program (CHAP) was developed in the 1960s, and remains a core component of Alaska’s healthcare delivery system ]. Alaska’s CHA/Ps are trained to practice according to the guidelines of the Alaska Community Health Aide Manual (CHAM), which details protocols to evaluate patients and provide basic and emergency medical care. To become a Community Health Practitioner, individuals engage in four 3-4 week basic training sessions, then complete a clinical skills preceptorship and examination]. Out of the 588.5 hours of basic training, only 2 hours (.3% of the total training) are dedicated to information about cancer.
Due to this lack of information, and the large burden of cancer in their communities, Alaska’s CHA/Ps have requested additional cancer education], resulting in the CHAP cancer education project team developing and instructing in-person cancer and wellness courses starting in 2001. However, the recent statewide financial crises, coupled with Alaska’s large distances, expensive airfare, remote communities, and harsh weather patterns, restrict CHA/Ps ability to receive in-person education. Fortunately, increased access to high-speed Internet in rural Alaska has provided an opportunity for CHA/Ps to engage in cancer education without the cost or burden of leaving their communities.
In response to Alaska’s tribal health workers’ desires to have access to information about cancer while remaining in their own communities, we developed a framework for culturally relevant cancer education that guided the creation of online learning modules for Alaska’s tribal rural primary care providers. These modules were also incorporated into a for-credit university course, however, when the course was offered in Spring 2018, no learners were able to participate in it, but several expressed a desire to participate in the course’s synchronous sessions. Consequently, we offered ten 1-hour webinars for Alaska’s tribal primary care providers.
In response, the CHAP cancer education project team has developed 12 stand-alone culturally relevant online cancer education modules: cancer basics, cancer and our genes, nutrition and physical activity, tobacco, cancer treatments, cancer survivorship, cancer pain, grief and loss, children and grief, colorectal cancer, men’s health, and women and cancer. Modules were published online as they were developed between March 2015 and June 2018. The modules were designed to inform CHA/Ps about specific cancer information, to support learners to engage in cancer risk reduction behaviors, and to improve learners’ capacity and intent to share cancer information with their patients, families, friends, and communities. End-of-module evaluation surveys documented that learners reported an intent to reduce their own cancer risk and share cancer information as a result of the learning, and changed their perceptions of comfort and capacity to engage with patients about cancer and their intent to talk with patients about cancer.
The modules were included as part of a semester-long university course that included both the online learning, and synchronous sessions that connected learners electronically for group video calls. However, in spring 2018, no learners were able to commit to a full semester course. However, several expressed a desire to participate in synchronous sessions on cancer topics. Consequently, we developed, advertised, offered, and evaluated ten webinars for Alaska’s CHA/Ps. This manuscript describes the implementation of those webinars, and evaluation findings.
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