Product Details

Author Information

Corresponding Author
Melany Cueva
Alaska Native Tribal Health Consortium
4000 Ambassador Dr
Anchorage, AK 99508
United States
p: (907) 729-2441
mcueva@anthc.org

Authors (listed in order of authorship):
Mark Dignan
University of Kentucky

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Community Cancer Education

What specific topics does your product address?

Cancer, Community health , Community-based education

Does your product focus on a specific population(s)?

American Indian/Alaska Native

What methodological approaches were used in the development of your product, or are discussed in your product?

Community-based participatory research

What resource type(s) best describe(s) your product?

Evidence-based practice, Readers' Theatre

Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

‘What’s the Big Deal?’ a 25-minute Readers’ Theatre script was developed with and for Alaska Native and American Indian Community Health Workers and the people in their communities to provide colorectal cancer screening information, increase comfort with talking about colorectal cancer screening, and encourage people to have recommended colorectal cancer screenings. Stories from colorectal cancer survivors, their families and care givers, medical providers, and Community Health Workers were woven into the lives of six characters who use humor and story to talk about common questions, concerns, and feelings related to colorectal cancer screening. The characters include Isaac, a man in his early 50s whose father died of colorectal cancer, his wife, Beverly who has recently turned 50 and has no family history of colorectal cancer and their two children, Rita and Freddie. Additionally, the script includes Isaac’s brother, Uncle Ward and the doctor who does the colonoscopy procedures. Readers’ Theatre is the coming together of a group of people to read aloud a written conversation. “What’s the Big Deal?” can be read as part of cancer education, school presentations, community gatherings, dinner theatre, or a radio show. Community Health Workers, community members, cancer survivors, and people of all ages interested in learning more about colorectal screening are possible participants. People of all ages can support recommended colorectal screening exams. The U.S. Preventive Services Task Force recommends men and women ages 50 to 75 have colorectal screening.

2. What are the goals of the product?

The goal of the script “What’s the Big Deal?” is to provide communities with a method that they can easily use to share basic information about colorectal cancer screening. The script becomes the starting point for community and family members to talk about the importance of colorectal screening for both men and women to prevent cancer or to find and treat cancer early. Through the reading of this scripted conversation we hope to increase participants’ knowledge of colorectal cancer screening, as shared within the content of the script, to increase participants’ comfort with talking about colorectal screening by role modeling conversations and familiarizing people with medical words, and to encourage people to have recommended colorectal screening exams as part of their wellness choices.

3. Who are the intended audiences or expected users of the product?

The script was developed with and for American Indian and Alaska Native people. However, it is recommended for anyone who has a colon. Readers’ Theatre participants, both on the written participant evaluations and in a post-play discussion, eagerly recommended the script for men and women of all ages. Knowledge sharing and support of wellness activities often happen among family and friends. Consequently, it is important for people of all ages to learn about colorectal screening recommendations. Lowering colorectal cancer risk with healthy lifestyle choices is something a person can do throughout their life. The script encourages eating a healthy diet, being physically active, and learning about your family history of colorectal cancer.

4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

Anyone willing to share cancer information can organize a Readers’ Theatre. A total of seven people are required, six people to read the characters and one person to read the narration. Men can read women’s parts and women can read men’s parts. Readers’ Theatre provides an opportunity for people to experience different perspectives. Both readers and listeners are given a copy of the script to read their part aloud or to follow along and listen. Readers read from their hand held script without memorizing anything. It is helpful to have a caring person, knowledgeable about colorectal cancer screening, available to facilitate a post-reading conversation, answer questions, and share local resources. Additional suggestions for organizing a Readers’ Theatre are included with the script.

5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

Colorectal cancer (CRC) is the second leading cause of cancer death for Alaska Native and American Indian people (1) yet it can be detected through colonoscopy screening and even prevented by finding and removing colon polyps before they become cancer. Alaska Native people have nearly twice the rate of CRC mortality and incidence as the U.S. White population. The age-adjusted CRC mortality rate (2000 – 2007) for men and women combined was 30.8 per 100,000 for Alaska Native people and 18.0 per 100,000 for U.S. Whites (2). The age-adjusted CRC incidence rate (2004 –2008) for Alaska Native men was 88.3 per 100,000 and for U.S. White men the rate was 52.1 per 100,000 (3). The age-adjusted CRC incidence rate (2004 – 2008) for Alaska Native women was 87.3 per 100,000 and for U.S. White women the rate was 39.4 per 100,000 (3).

Readers’ Theatre is grounded in story as a culturally respectful way to share understandings and broaden perspectives. Allison Cox, a founding member of the Healing Story Alliance stated, “Storytelling crosses over all boundaries for it speaks the language of heart” (4). Story was identified by Alaska Community Health Aides and Community Health Practitioners as a culturally respectful way of creating meaning and broadening understanding (5). Utilizing storytelling to transmit educational messages is a traditional pedagogical method practiced by many American Indian tribes to share ideas and values (6). Using theatre with Alaska Native people was found to be an effective means to share cancer information, and increase cancer knowledge and understanding which also prompted a lively post-play discussion in which participants shared their stories, concerns, beliefs, and feelings (7,8). Savitt used medical readers’ theatre to stimulate critical thinking about medical issues so that audience and cast could engage in meaningful conversations about social and ethical issues in medicine (9). Additionally, Readers’ Theatre has been used as an intervention to manage grief (10, 11). Gray and Sinding who used theatre to share narrative research findings about prostate, ovarian, and breast cancer affirmed, “Drama is one potent vehicle for opening our hearts” (12).

6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

1. Lanier, A. P., Kelly J. J., Maxwell J., McEvoy, T., & Homan, C. (2006). Cancer in Alaska Natives 1969-2003, 35-Year report. Anchorage, AK: Alaska Native Tribal Health Consortium Office of Alaska Native Health Research and Alaska Native Epidemiology Center.
2. National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch. (2010). Mortality - All COD, Aggregated with State, Total U.S. (1969-2007) , 2010 [Data file]. Underlying mortality data provided by NCHS (www.cdc.gov/nchs). Available from Surveillance, Epidemiology, and End Results (SEER) Program SEER*Stat Database, www.seer.cancer.gov
3. National Cancer Institute, DCCPS, Surveillance Research Program, Cancer Statistics Branch. (2011). Incidence - SEER 13 Regs Research Data, Nov 2010 Sub-Linked To County Attributes (1992–2008) – Total U.S., 1969–2009 Counties, 2011 [Data file]. Based on the November 2010 submission. Available from Surveillance, Epidemiology, and End Results (SEER) Program SEER*Stat Database, www.seer.cancer.gov
4. Cox, A., & Albert, D. (Eds.). The healing heart ~ communities. Gabriola Island, BC, Canada: New Society Publishers; 2003.
5. Cueva, M., Kuhnley, R., Lanier, A., & Dignan, M. Story: The heartbeat of learning.Convergence. 2007; 39 (4) 81-88.
6. Hodge, F. S., Pasqua, A., Marquez, C. A., & Geishirt-Cantrell, B. (2002). Utilizing traditional storytelling to promote wellness in American Indian communities. Journal of Transcultural Nursing. 2002; 13(1), 6–11.
7. Cueva, M. Readers’ Theatre as cancer education: An organic inquiry in Alaska. Journal of Cancer Education. 2010; 25 (1) 3-8.
8. Cueva, M., Kuhnley, R., Lanier, A. & Dignan, M. Using theatre to promote cancer education in Alaska. Journal of Cancer Education. 2005; 20 (1) 45-48.
9. Savitt, T. (Ed.). Medical readers’ theater: A guide and scripts. Iowa City, IA: University of Iowa; 2002.
10. Holleman, W. L. The play’s the thing: Using literature and drama to teach about death and dying. Family Medicine. 2000; 32(8), 523–4.
11. Levac, A. C., McLean, S., Wright, L. M., & Bell, J. M. A “reader’s theater” intervention to managing grief: Posttherapy reflections by a family and clinical team. Journal of Marital and Family Therapy. 1998; 24(1), 81–93.
12. Gray, R., & Sinding, C. Standing ovation: Performing social science research about cancer. Ethnographic Alternatives #11. Walnut Creek, CA: AltaMira Press; 2002.
13. Cueva, M., Dignan, M., & Kuhnley, R. (2011).Readers’ Theatre: A communication tool for colorectal cancer screening. Journal of Cancer Education.
14. MacKinnon, M. The readers’ theatre. In Native people’s wellness. [Booklet] (p. 9). Pine, CO: Native American Cancer Research Corporation; 2010. September.
15. Gouley, H., and Cueva, M. Reading theatre: Sharing colon health information. Spirit of Eagles newsletter; 2011. Spring/Summer, 12–13.

7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

• For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
• For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
• For other types of work, discuss how the project was developed and reasons for the methodological choices made.

This Readers’ Theatre script was developed as a colorectal cancer communication tool funded by Center for Disease Control Division of Cancer Prevention and Control, Colorectal Cancer Screening Health Communication Project and an American Cancer Society Mentored Research Scholar Award to the Alaska Native Tribal Health Consortium.

Community Health Worker input was central to the dynamic process of script development, implementation, and evaluation to create a meaningful CRC health education and communication tool. As part of four cancer education workshops, led by the project coordinator (a RN who has been working with and for Alaska Native and American Indian people in cancer prevention and cancer control since 1998 at the Alaska Native Tribal Health Consortium), 38 CHWs (32 women and 6 men) shared their CRC ideas to inform script development. Detailed notes were taken by the coordinator during the discussion. Additionally, CHWs were invited to share their ideas to support script development in writing. Helpful CRC messages Community Health Workers wanted to include in the script are highlighted by category.
Signs or Symptoms:
Colorectal cancer can be quiet. Don’t wait- if you have any signs or symptoms get them checked.
Importance of Screening:
? Do screenings for your loved ones and for yourself. Get check-ups for family sake. I think of the people not wanting to have the test done and I think of the family members of someone who has cancer.
? Keep getting screenings once isn’t enough.
? Don’t ignore early screening no matter how embarrassing. If you find the cancer early, outcome is better.
Empowerment:
? We want people to become more aware of their health and their bodies. Be active in their care - to find out about their risk factors and if they have a family history.
? Everyone has to spread the message-this is an exam like other exams which has to be done. Screening is worth it and should be normalized.
? If you don’t want to be afraid of the unknown you need to go for the test so you will be able to move forward. It takes courage to work through your fears.
? People can use us CHRs [Community Health Representatives] - we can help in a very nonthreatening way.
? Make cancer conversations every day. A colon check is something you do to take charge of your health.
CRC messages as shared by CHWs were woven into the lives of the characters, using the language of story and every day conversations. To compliment CHWs’ script development ideas, medical experts and colorectal cancer survivor input was sought to provide medically accurate information and ground the script in common concerns and experiences. It was important that the Readers’ Theatre story resonate in realistic ways with American Indian and Alaska Native people. Additional detail about script development is shared within the manuscript, Readers’ Theatre: A Communication Tool for Colorectal Cancer Screening (13). Additionally, a professional playwright was instrumental in creating a strong scaffolding for the Readers’ Theatre script which allows readers to make minor changes to reflect their common expressions and stories.

8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

The Readers’ Theatre script was developed over a six month time period that involved soliciting comments from approximately sixty diverse people including colorectal cancer survivors, their families and care givers, medical providers, and Community Health Workers. Medical providers within the Alaska Native Tribal Health Care system who provide patient navigation and screening and diagnostic colonoscopies reviewed the script content for medical accuracy. Throughout the script development process people reviewed drafts and commented to insure the script was medically accurate and grounded in the reality of people’s lived experiences. An informal script review process was utilized. As the script was revised it was shared back with people who provided comments to insure it reflected their ideas. The script was shared with people known to the project coordinator and they were invited to recommend additional people they felt would be helpful to review the script and provide suggestions. The professional playwright served as the primary author and was consulted throughout the process of character and plot revisions. Ultimately, two versions of the script were developed; one specifically for Alaska Native people living in Alaska and one script for Community Health Representatives and American Indian people living in the contiguous U.S. The script varies due to the unique context of people living in Alaska. Alaska has 178 rural communities not connected to a road system. Consequently, air travel is the most common form of transportation. Additionally, many people living in rural Alaska eat their traditional foods to stay healthy. Both versions of the script could be easily adapted to meet a region’s unique customs and verbal expressions.

9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

Based upon post-Readers’ Theatre written evaluation data from 11 Readers’ Theatre workshops between April 2010-March 2011, in which 94% (161/172) of participants completed a written evaluation, 98% (157) liked the play and 59% (95) wrote detailed information describing what they learned. 86% (139) of respondents were female and 12% (20) were male. Self-identified ethnicity was as follows: 30% (49) Alaska Native, 47% (76) American Indian, 11% (17) Caucasian, 7% (12) other, and 4% (7) blank. Age ranges were: 9% (15) 29 and younger, 24% (38) 30-39 years, 26% (42) 40-49 years, and 38% (62) 50 and older. As a result of this Readers’ Theatre, 90% (145) of respondents reported feeling more comfortable talking about colorectal cancer “This is a very good idea because it is very hard for me to talk to our men.” “It was so real and showed us how to deal with these situations.” Additionally, 77% (124) of respondents wrote healthy changes they wanted to make which included: getting screened (30%), supporting others to get screened (34%), sharing cancer information (35%), being more physically active (42%), eating healthier (34%), and quitting tobacco (6%) (12). Additional evaluation data is shared within the Journal of Cancer Education manuscript. (12)

Upon reading about the script in the Native People’s Wellness magazine (14), the script was shared and evaluated as part of a dinner theatre in Washington State (15). Participants as part of their dinner theatre felt the script was, “Informative and entertaining-liked that the community members provided the skit to our tribal community.” “I felt it was a fun, interactive way to get people to talk about this [colorectal screening] in a non-embarrassing way.” Another community shared how the school children read the script for their parents, “I think this is a wonderful tool that gives great info in a safe fun way. Adults love watching children plays and in doing so can walk away with good information.”

10. Please describe why you chose the presentation format you did.

Readers’ Theatre in a previous cancer education project nurtured healing, renewal, affirmation, and shifts in knowledge, attitudes, and beliefs, which empowered action (7). Readers’ Theatre created a respectful environment for adult learners from diverse ethnic and cultural backgrounds in Alaska to engage in meaningful conversations that awakened possibilities in a living spiral of understanding (7). Additionally, participants requested more scripts to bridge challenging conversations.

11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

‘What’s the Big Deal?’ is a new Readers’ Theatre script and holds promise as an educational tool to share colorectal cancer screening information, inspire conversations, and serve as a catalyst for healthy behavior change. As more people become familiar with Readers’ Theatre as a tool for cancer education and health communication, it will be helpful to evaluate its effectiveness among diverse groups of people. Our evaluation data was collected immediately after the reading of ‘What’s the Big Deal?’. Consequently, participants wrote ways they planned to take care of their health as a result of participating in the play. It would be helpful to do an extended –interval evaluation to learn how and in what ways Readers’ Theatre may have supported people’s wellness choices over time. Additionally, it would be helpful to learn what buzz if any was created as a result of participating in a Readers’ Theatre experience. As reported on the immediate post-reading written evaluations and during the verbal discussion, participants were eager to talk with family and friends about scheduling a recommended colorectal screening. “It was very informative and put it in simple terms and gave me a reminder to talk to my family over 50.” “I have family members at the age recommended so information learned in the play will be easier to communicate the importance.” “A good reminder to ‘bug’ those we love and know to get screened.” Occasionally, participants contacted me by email after their Readers’ Theatre experience to share ways the script connected with them “It helped me make an appt for both my parents.” People also expressed their gratitude for learning in a story way. “For Native people it was good, like storytelling - talking and laughing together.”

Another strength of Readers’ Theatre appears to be its adaptability. “Easily adaptable to your community.” “It’s easy to read and puts important info into the context of normal everyday conversations.” “The message is more personal by community member participation.”


Additionally, the story of the Readers’ Theatre was adapted into a telenovella movie series with the same title, What’s the Big Deal? and can be viewed through the ANTHC epi web page http://www.anthc.org/chs/epicenter/index.cfm by clicking on the see our videos on You Tube link.

12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

The Readers’ Theatre script, “What’s the Big Deal?” was developed as part of the Colorectal Cancer Screening Health Communication Project funded by Centers for Disease Control and Prevention, Division of Cancer Prevention and Control to the Alaska Native Tribal Health Consortium (ANTHC). Additional support was provided by an American Cancer Society Mentored Research Scholar Award. An abstract and manuscript sharing the Readers’ Theatre data were approved by the Alaska Native Tribal Health Consortium manuscript review committee as education evaluation.


Throughout the development process, the script was shared back with the people who offered suggestions. This provided a way to affirm that people’s comments were interpreted correctly and that the new words resonated in realistic ways. As the project coordinator we wanted to honor and respect the gift of people’s comments throughout this learning journey. All post Readers’ Theatre written evaluation data was shared anonymously. We appreciate the many people who generously shared their ideas to breathe life into this colorectal cancer script.