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):
Melany Cueva

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Public Health

What specific topics does your product address?

Cancer

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?

movie

Application Narrative

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

‘Awakening Choices: Colon Health, Our Stories’ is a 28-minute movie available on DVD that shares the stories of Alaska Native men and women talking about recommended colorectal cancer screening exams and wellness ways to decrease cancer risk. Yupik dolls, symbols of the old ones, guide our artistic movie journey showing us ways to keep our bodies strong and our communities healthy. Viewers can experience stories of wellness; celebrate the gift of life through the beauty of Alaska Native people’s songs, dances, and culture. We learn the importance of colorectal screening through the stories of Alaska Native people. “Inspired, motivated, comfortable, relieved, encouraged, hopeful”, words expressed in response to watching the movie. Other Alaskan viewer comments: “I felt a part of the people in the movie-same fears, same relief;” “I want to go and get colon screening now.” The movie is recommended for viewers of all ages to support community wellness. Men and women age 50 and older are especially encouraged to learn more about recommended screening exams to prevent colorectal cancer or to find colorectal cancer early when it can be best treated.
The DVD also includes a 5-minute preview of the movie and a 30-second public service announcement designed for television use.
A booklet and a 24-page activity guide with four interactive activities accompany the movie to support continued learning and community cancer education.

2. What are the goals of the product?

The goal was to create a movie with and for Alaska’s diverse Native people to increase knowledge of colorectal cancer screening and healthy choices to decrease colorectal cancer risk. The movie is grounded in Alaska Native people’s storytelling traditions. Viewers learn the signs and symptoms of colorectal cancer, basic colon/rectum anatomy and function and recommended screening exams and guidelines for colonoscopy and sigmoidoscopy screening.
Helpful messages identified during focus groups and included in the movie are summarized below.
1. know what colorectal screening is (sigmoidoscopy and colonoscopy), how it is done, when it is recommended, and why
2. understand that having a mother, father, sister, brother, son, or daughter who has been diagnosed with colorectal cancer increases your risk of developing colorectal cancer and you may need to begin screening earlier
3. know supportive ways to overcome common barriers (embarrassment, fear, and lack of accurate information) to choose colorectal cancer screening
4. show Alaska Native people living in wellness ways to prevent or decrease cancer risk - being active, choosing tobacco free, gathering and eating traditional foods (berries, greens, fish) and having colorectal cancer screening

Our goal is to stop deaths from colorectal cancer. After seeing this movie everyone will want to rush out and have their colon screened! Colorectal cancer is the second leading cause of cancer death among Alaska Native people and it is almost totally preventable by finding and removing colon polyps before they become cancer.

Additionally, the movie could be a catalyst for conversation by inviting viewers’ to share their ideas about having recommended colorectal cancer screenings. By listening to viewers’ experiences it may bridge cultural differences to facilitate a more meaningful and relevant learning opportunity. The movie may provide ideas for other communities to develop their prioritized health messages grounded in the wisdom of people’s stories and culture.

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

The movie ‘‘Awakening Choices: Colon Health, Our Stories’ was made with and for Alaska Native people in Alaska. The movie grew out of Alaska’s village-based Community Health Aides’ and Community Health Practitioners’ (CHA/Ps) desire to learn more about colorectal cancer and to have an educational movie to share with people in their communities. Although the movie was developed in Alaska, it is requested and distributed nationally through Native CIRCLE to share colorectal cancer information with other American Indian people. In the words of an American Indian viewer, “It was good to see Native people in the movie, What beautiful people and beautiful way of life-they look like my people and my land so I relate well to the tasteful way the information is presented.”

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.

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 people (Surveillance, Epidemiology, and End Results (SEER) Program data.), yet it can be detected through colonoscopy screening and even prevented by finding and removing colon polyps before they become cancer. For the period, 1999-2003, the age-adjusted CRC incidence rate for Alaska Native people was twice that of the US Whites (102.9 vs 51.7 per 100,000). Alaska Native people also have nearly twice the mortality of CRC as US Whites (39.4 vs 20.0 per 100,000). An analysis of diagnosis by stage from 1993 to 2002 found that 60% of Alaska Native people with colorectal cancers were diagnosed beyond the local stage. (1)

‘Awakening Choices: Colon Health, Our Stories’, highlights Alaska Native people sharing their stories related to colorectal cancer. Story was identified by Alaska’s Community Health Aides and Community Health Practitioners (CHA/Ps) as a preferred way of learning (2). Utilizing storytelling to transmit educational messages is a traditional pedagogical method practiced by many American Indian tribes to share ideas and values (3).
Yupik dolls serve as movie narrators. In the words of Rose, the doll maker, “I like to think the dolls represent the best of our culture, my culture, Eskimo dancing, singing, hunting these are the things that keep us healthy.” Within Alaska’s diverse Native cultures, values and knowledge were traditionally passed from elders to youth in a living circle of songs, dances, stories, and crafts. The dolls also add an element of humor to the serious subject of colorectal cancer. Cultural values of Alaska Native people acknowledge laughter as good medicine. It is heard in their words and stories. Laughter was identified by Alaska’s CHA/Ps as supporting a comfortable learning environment, relieving stress, and enhancing learning (4).

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, AP, Kelly JJ, Maxwell J, et al. (2006). Cancer in Alaska Natives 1969-2003. Thirty –five year report. Office of Alaska Native Health Research and Alaska Native Epidemiology Center. ANTHC.

2. Cueva, M., Kuhnley, R., Lanier, A., & Dignan, M. (2007). Story: The heartbeat of learning. Convergence, 39 (4) 81-88.

3.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, 13(1), 6-11.

4. Cueva, M., Kuhnley, R., Lanier, A., & Dignan, M. (2006). Healing hearts: Laughter and learning. Journal of Cancer Education, 21 (2) 104-107.

5. Mayo, W., & Natives of Alaska. (2002). Alaska Native ways: What the elders have taught us. Portland, OR: Graphic Arts Center.

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.

The movie ‘Awakening Choices: Colon Health Our Stories’ was developed with and for Alaska Native people over a two year period (2005-2006) and updated in 2009. A registered nurse and adult educator working in the field of cancer education with and for Alaska Native people at the Alaska Native Tribal Health Consortium since 1998 served as the project coordinator. Medical experts within the Alaska Native Tribal Health System, colorectal cancer survivors, and Alaska’s Community Health Aides/Practitioners provided ongoing movie direction and content. The idea grew out of Alaska’s village-based primary providers of rural health care called Community Health Aides and Community Health Practitioners (CHA/Ps) desire to learn more about colorectal cancer and have a movie for people in their community to learn about colorectal cancer prevention and screening as shared during a cancer education presentation at their annual statewide conference. CHA/P suggestions, shared during their conference, were woven into the movie: use humor to make the topic less scary and embarrassing, show people from different areas of Alaska telling their stories and experiences, and include cultural values of family and community.
Additionally, CHA/Ps wrote colorectal cancer messages that informed movie content. Representative comments are listed below.
? Among Alaska Native people cancer is the leading cause of death, find out about your risk factors and if you have a family history.
? Cancer can be a silent potential killer. There can be No signs or symptoms until too late.
? If you have signs or symptoms don't wait to have them checked, early detection has a better chance of cure.
? Cancer can happen to anyone.
? Prevention is the best medicine-quit tobacco, eat healthy Native foods, be active, everyone can benefit from screening.
? Keep getting screenings, once isn't enough-Do screenings for your loved ones if not for yourself.

Additionally, the project coordinator solicited input from the CHAP Directors. While meeting in Anchorage, Alaska, 11 statewide CHAP Directors identified movie content as well as movie messengers. They emphasized the importance of Alaska Native people telling their stories and experiences as well as including colorectal cancer signs and symptoms, age of recommended colorectal screening exams, the difference between colonoscopy and sigmoidoscopy screening exams, and the importance of colorectal screening.

Two medical providers primarily responsible for colonoscopy and sigmoidoscopy screening at the Alaska Native Tribal Health Consortium shared their ideas. Prioritized movie footage included showing both men and women talking about the importance of colorectal screening and a person having a screening exam. Helpful messaging included: highlighting colorectal screening as a wellness choice to prevent colorectal cancer by finding and removing polyps before they become cancer and early colorectal cancer may have NO signs or symptoms and therefore screening when a person is healthy to stay healthy is recommended. Medical providers acquainted with colorectal cancer survivors invited people to participate in the movie and share their story. Interested people contacted the project coordinator to participate in the movie making process.

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.

Dialoguing with Alaska’s CHA/Ps and medical experts was a continuous process throughout movie development. Initially, important health messages as well as messengers were identified by Alaska’s Community Health Aides/Practitioners (CHA/Ps), CHA/P program Directors and medical providers at the Alaska Native Tribal Health Consortium. The movie was then filmed on location in four diverse regions of Alaska. Alaska Native people were invited to share their story which was then edited to highlight the main points in a concise format. Additional content was shared by including Yupik dolls as narrators. Yupik dolls -the hunter, the gatherer, the dancer, the drummer, represent the ancestors we all carry inside. In the words of the narrator, “They remind us of who we were, who we are, and who we yet can be. Do the dolls speak? Do they carry the spirit of life? Do they help us find our rhythm, discover new wisdom? Sometimes, when the day is fading and the people begin their dreaming, it’s almost certain they do.”
Five movie pilots were conducted during the development phase which included medical providers from throughout Alaska at the Alaska Health Summit, Alaska’s CHA/Ps at their annual statewide conference, medical providers involved in the CHAP program at their annual conference and two community focus groups in Anchorage with non- medical people. A total of 52 people participated in the movie pilots, 11 men and 41 women. By ethnicity 54% were Alaska Native. Questions asked about medical content, film length, affective response to the movie, clarity of health information, usefulness of information, and viewer recommendations. Minor changes were made as a result of viewer comments which included the addition of colonoscopy exam footage and anatomy. Words were also added to the screen to emphasize colorectal cancer warning signs. CHA/Ps at their annual conference named the movie.

Additionally, CHA/Ps requested continuing education to accompany the movie which resulted in the development of a 24-page activity guide to extend learning. CHA/Ps also requested a booklet to support community learning, which was developed.

Select questions and responses from the movie pilots are highlighted below.

How do you feel after watching this movie? Inspired, motivated, comfortable, relieved, encouraged, hopeful, aware, educated are all words people used in response to this question. "Helps to feel comfortable about talking about colorectal screening."

What stuck with you?
? "I feel a part of the people in the movie-same fears, same relief."
? "I am important. I want to see my children's children"
? "Take Care of yourself. If you don't you can't take care of others."
? "Don't wait. It's important to get screening."

Was the movie easy to understand? 100% responded Yes "very sensitive to culture”
Would you recommend this movie? 100% yes

What else do you want us to know about this movie?
? "It makes me want to go have a colonoscopy."

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.

The final movie was shown and evaluated during six gatherings (2 community presentations and 4 CHA/P cancer education workshops) over a six month period in which 80% (74/92) of viewers completed a one-page written evaluation. By gender 20% (15) were male and 77% (57) were female with 2 evaluations being blank. By ethnicity 66% were Alaska Native, 4% American Indian, 16% non Native, and 14% blank. 100% of respondents stated they would show the movie to others including family, friends, community members, and clients. The movie had a wide age appeal with comments such as “anyone can see and understand”, “it is culturally responsible for everyone to see”. All viewers felt the movie was easy to understand. Additionally viewers responded to the stem ‘How do you feel after watching the movie?’ It is not enough to share medically accurate information if your viewers leave feeling more apprehensive or scared. 100% of respondents (68) wrote a positive response to movie viewing. Representative comments include: “I feel less scared of colonoscopy. I thought it was helpful to know others had fears.” “Encouraged to be screened - life’s a gift.” “Made me want to pay closer attention to my body.” “Feel better about explaining colonoscopy to patients.” “Great to have a source of information for the patient to watch who has questions but are afraid to ask.” 91% of viewers described detailed information of things they learned. Written comments reflected the key points: “Get checked and encourage others to be checked.” “Talk to your patients and family about screening-it’s important.” “To care for my own body.” “Colon cancer is preventable get screening tell the doctor everything-all symptoms.” “Don’t wait to be seen if you have symptoms-Prevention and screening are key.” “Polyps can turn into cancer.” “If someone had it before the close family member should get it done 10 years before.” “Don’t ignore early screening no matter how embarrassing.”
As a result of movie viewing, 79% of respondents wrote healthy choices they planned to make to take better care of themselves, their family, their patients, and their community. Getting screened was the most commonly written response. “Wow I better get screened. 55 and haven’t yet.” Additional healthy choices included ways to decrease cancer risk: “Try to quit tobacco use.”, “Need to change diet- Eat more wild vegetables or greens and do more activity.”
Written comments also included sharing cancer information and encouraging screening with family and community. “Make sure to tell my husband to be screened.” “I’ll get a colonoscopy when I turn 50 and I’ll make my husband do it too.” “Encourage patients to screen for cancers early and live healthier lives.”

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

A movie format was chosen by Alaska’s CHA/Ps to support the use of story as a traditional way of sharing knowledge and understanding. Additionally, a movie can share information visually as well as verbally to highlight the stories of Alaska Native cancer survivors and show the colorectal cancer screening procedures.

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.

The movie, although initially developed in 2006 and updated in 2009, continues to be relevant and is distributed nationally to support colorectal health messaging and conversations. A strength of the movie is the cultural wisdom of Alaska Native people woven throughout the movie tapestry of learning. Cultural values shared by Alaska’s diverse Native people include the gifts of spirituality, traditions, humor, showing respect to others-each person has a special gift, honoring of the elders who show us the way, seeing connections-all things are related, and taking care of self, taking care of community (5).

The movie is in English and could be improved as a health communication tool by being translated into diverse Native languages.

The movie will not replace a conversation to discuss individual wellness recommendations with a health care provider. It is important that people are active partners in their health care by continuing to learn the most current up-to-date information, asking questions to develop understanding, and sharing their health concerns with their health care provider to support their wellness journey.

All of our evaluation outreach efforts were conducted immediately post-movie viewing. Long term evaluation could be done to learn how watching the movie may have inspired colorectal cancer screening conversations, or supported people to have a recommended colorectal screening exam.

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.

‘Awakening Choices: Colon Health, Our Stories’ is a culturally respectful colorectal cancer movie developed in collaborative ways with and for Alaska’s diverse Native people. From inception to movie premiere Alaska’s CHA/Ps provided vital movie input. Specifically, CHA/Ps requested the movie, identified helpful colorectal cancer movie messages, determined the length of the movie, and named the movie. This dynamic movie making process included informal conversations as well as five interactive group discussions. Medical providers reviewed the movie content for medical accuracy. CHA/Ps and community members ensured the movie was easy to understand and provided helpful information in ways that honored Alaska’s land and people. This fluid process resulted in a meaningful movie for Alaska’s diverse Native people. As the project coordinator, I am grateful for the many people who shared their time, talents, and wisdom to make this movie a reality. Together, we are making a difference in colorectal cancer.

The movie was developed as part of a NCI R25 ‘Cancer Education for Community Health Aides in Alaska’ project which was reviewed by the Alaska Area IRB and found to be IRB exempt.