Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Exploring Youth Perceptions About Cancer Prevention and Preferences for Education: a Qualitative Study

Exploring Youth Perceptions About Cancer Prevention and Preferences for Education: a Qualitative... This study aimed to characterize adolescents’ perspectives on cancer and cancer prevention and to explore their preferences for cancer education. A total of 188 middle and high school students participated in 25 focus groups. Focus groups were led by study team members and included five to ten participants each. Adolescents were asked to discuss their cancer and cancer prevention knowledge, sources of cancer education, and preferences for cancer prevention education. Focus groups were audio-recorded, and professionally transcribed. Transcripts were content and thematically analyzed by two study team members using NVivo qualitative data software. Six themes were identified in focus groups: knowledge about cancer, negative perceptions of cancer, awareness of cancer prevention, engagement in cancer prevention, facilitators and barriers for action, and preferences for cancer education. Adolescents described a wide range of cancer education sources, including friends, family, healthcare professionals, school, technology, and pamphlets. Participants associated cancer with negative emotions, such as sadness and fear. Participants expressed interest in learning about cancer and cancer prevention, but also identified barriers to engaging in preventative behaviors, such as discomfort, lack of knowledge, and lack of personal connection to cancer. Adolescents preferred learning through personal presentations, online videos, school, educational games, and social situations. Adolescence is a critical period for learning and developing healthy behaviors. Awareness of cancer and cancer prevention is crucial to lowering cancer risk in the future. To be effective, cancer education for adolescents should target specific areas of cancer prevention and address barriers to engagement in preventative behaviors. Keywords Cancer knowledge · Adolescent knowledge · Adolescent education · Cancer education · Cancer awareness · Behavior · Attitudes Introduction disease, including adolescents [2]. The Centers for Disease Control and Prevention (CDC) estimates that the overall Cancer is the second leading cause of death worldwide [1]. cancer incidence rate among adolescents and young adults The World Health Organization (WHO) estimates that cancer rose by 0.9% on average per year during 2012 to 2016 [3]. deaths are likely to surpass that of ischemic heart disease, the Awareness is key to identifying personal risk factors and leading cause of death worldwide, in the next four decades [1]. preventing cancer at an early age. However, studies dem- Additionally, cancer poses a dramatic clinical burden, disrupts onstrate that adolescents are not well informed about can- social standards, and erodes many economic resources [1]. cer risk factors [4]. Current literature suggests that many People of all ages, genders, and race can be affected by this adolescents and college students in the USA lack cancer- preventative knowledge and engage in cancer risk behaviors such as unhealthy diet, frequent alcohol consumption, and * Olufunmilola Abraham low physical activity [5, 6]. In one study, only 49% of ado- olufunmilola.abraham@wisc.edu lescents reported awareness of the human papillomavirus (HPV) vaccine and cervical cancer [7]. Addressing this lack Social and Administrative Sciences Division, University of Wisconsin-Madison School of Pharmacy, 777 Highland of awareness is crucial to empowering adolescents to make Avenue, Suite 2515, Madison, USA choices to prevent cancer and reduce cancer risk factors. Social and Administrative Sciences Division, University Awareness of modifiable risk factors is an important start - of Wisconsin-Madison School of Pharmacy, Madison, ing point in the promotion of positive health outcomes [4]. WI 53705, USA 1 3 Journal of Cancer Education (2023) 38:50–59 51 A systematic review showed six trials involving educational Recruitment interventions for adolescents reported a positive effect on composite sun protection behaviors [8]. Another study using Adolescents were recruited from one middle school and one a Cancer Awareness Measure (CAM) showed improvement high school in Wisconsin from January to February 2020. of cancer warning signs within two weeks of the interven- Students were eligible if they were enrolled in grades 7 to tion and a statistically significant decrease in the percentage 12 and could speak and understand English. School staff of adolescents who reported that they did not know cancer distributed packets containing a letter of introduction to risk factors [9]. Moreover, studies show early interventions the study, consent forms, and a request to return completed can reduce the long-term impact of unhealthy behaviors forms on a later date. All consent documents were avail- acquired in adolescence [10]. Educating adolescents about able in English and Spanish for adolescents with Spanish- cancer prevention is a crucial step to improving the number speaking parents or guardians. One school distributed the of cancer-related deaths each year. recruitment packets to all students in a required health class, Adolescence provides a window of opportunity for can- and one school made recruitment packets available to a spe- cer risk education and intervention. Cancer prevention and cific science class. Parental consent and student assent were education should be targeted at this group because they are required for participants under the age of 18; students aged in an age of active learning but are also in a stage where 18 and older were able to consent and participate without risky behaviors, such as smoking, begin [11]. Data suggests parental consent. Participants were each given $10 in cash that adolescents are under-informed about the relationship as an incentive for participation. This study was approved between health behaviors and cancer risk [12]. Although by the University’s Institutional Review Board. improving cancer awareness among adolescents is critical for life-long patterns of healthy behavior, little is known about adolescents’ perceptions of cancer risk factors and Data Collection their preferences for receiving cancer education [4]. The aim of this study was to characterize adolescents’ perceptions Each focus group consisted of five to ten participants, one facilitator from the study team, and one to two other study about cancer and cancer prevention and to understand their preferences for receiving cancer prevention education. team members as moderators. One study team member led the focus group discussion, while the other moderator(s) took observation notes and asked clarifying questions as needed. To ensure privacy and confidentiality for partici - Methods pants, schools provided separate rooms for each focus group, and participants were encouraged not to share identifying Study Design information. Each focus group lasted approximately 35 to 50 min, was audio-recorded, and professionally transcribed The study team developed a focus group guide consisting of verbatim. All identifying information was redacted from questions that explored adolescents’ perceptions and knowl- the transcripts before analysis. Participant demographic edge of cancer as well as cancer prevention and preferences information was collected via paper survey at the end of for cancer education (see appendix). The guide consisted each focus group. Focus group facilitators and modera- of open-ended questions divided into sections pertaining tors debriefed and created reflection notes following each to cancer knowledge, cancer prevention knowledge, cancer session. education, and cancer prevention education. Most focus group questions were generated by the study team or adapted Data Analysis from Cancer- Educate to Prevent [13]. Two questions about participants’ perceptions of cancer were modified from a Two members of the study team independently verified focus study regarding mothers’ and high school students’ per- group transcripts for accuracy before beginning data analy- ceptions of cervical cancer, human papillomavirus (HPV), sis. Transcripts were content and thematically analyzed by and the HPV vaccine [14]. The study team used feedback two study team members using NVivo 12 (QSR) qualitative from the University’s Survey Center to revise the guide for software. Each study team member reviewed all transcripts content and clarity. Focus groups were chosen to capture to develop relevant codes using both an inductive and deduc- group interaction and discussion and to allow participants tive approach. Relevant codes were then combined to create to expand on their responses and opinions. This qualitative the master codebook. The study team held biweekly meet- methodology provided a collaborative environment for par- ings to discuss codes, review the master codebook, and cod- ticipants to build on each other’s responses and for focus ing structure, and address discrepancies. Microsoft Excel group facilitators to ask follow-up questions as needed. 1 3 52 Journal of Cancer Education (2023) 38:50–59 was used to determine the intercoder reliability, and the final parents, family members, friends, doctors, and people who average Kappa score was 0.86. Thematic analysis of preva- had been diagnosed with cancer. Exposure to cancer content lent codes was completed using Microsoft Excel, and codes also occurred at schools, libraries, and hospitals. A variety were categorized into major themes and subthemes. of information sources were cited, such as television, books, the news, pamphlets or posters, podcasts, social media, web- sites, and online videos. Results Unstructured Cancer Learning Experiences Study participant characteristics are described in Table 1. Verbatim quotes are provided in Table 2. Some participants could not define a specific source for their A total of 188 adolescents participated in 25 focus groups. cancer knowledge and described “hearing about cancer” Participants ranged in age from 12 to 18 years old and grades from others. Participants described the process as confus- 8 to 12. Participants were 54.8% female, 89.4% white, and ing, stating that they learned “bits and pieces” rather than 83.5% middle school students. Six major themes were iden- receiving in-depth information. tified including (1) knowledge about cancer, (2) negative perceptions of cancer, (3) awareness of cancer prevention, (4) engagement in cancer prevention, (5) facilitators and bar- Knowledge About the Causes of Cancer riers for action, and (6) preferences for cancer education. Participants described cancer as physiological, behavioral, Knowledge About Cancer and multifactorial in origin. They identified physiological factors, such as changes in cell development, metastasizes, Sources of Cancer Knowledge and the role of genetics in cancer development. Some par- ticipants defined cancer as an illness, disease, and cause Participants reported being exposed to cancer content and of mortality, “a disease that happens when like, cells start topics from a wide range of sources. Sources included growing uncontrollably”, or “mutation of the cells.” Cancer was described as multifactorial, with multiple causes and risk factors. Participants stated that actions such as engag- Table 1 Participant demographics ing in preventative behavior and participating in screenings could lower cancer risk. Demographics N % Age (y) Awareness of Cancer Types and Cancer Statistics 12–13 89 47.3 14–15 68 36.2 Participants identified a wide variety of cancers, particu - 16–18 31 16.5 larly skin, breast, lung, brain, colorectal, pancreatic, liver, Gender leukemia, lymphoma, and osteosarcoma. Less frequently Male 85 45.2 mentioned cancers included eye, uterine, and stomach can- Female 103 54.8 cer. Some participants shared knowledge of cancer survival Level of education rates, cancer prevalence, and the difference in cancer risk Middle school 157 83.5 based on sex. As stated by one participant, “If you are a High school 31 16.5 woman of a certain age, you might be more at risk for certain Race/ethnicity cancers.” American Indian or Native American 1 0.5 Asian 6 3.2 Black or African American 4 2.1 Knowledge of Cancer Diagnosis and Treatment Hispanic or Latino 7 3.7 Other 1 0.5 Most participants associated tumors with cancer, while a few Reported more than one race/ethnicity 14 14 participants recognized that cancer could be asymptomatic. White 155 82.4 A few participants displayed knowledge about the diagnostic Number of youths at home (excluding the participant) process, including the primary site of cancer, staging, and 1–2 110 58.5 the biopsy process. Participants discussed cancer treatments 3–4 64 34 and their side effects and cited chemotherapy as the most 5 or more 14 7.4 common treatment. Cancer was described as incurable and potentially recurring. Participants were given the option to select “Other” for race/ethnicity 1 3 Journal of Cancer Education (2023) 38:50–59 53 Table 2 Themes, subthemes, and verbatim quotes Theme Subtheme Verbatim quotes Knowledge about cancer Sources of cancer knowledge “There’s also like a lot of cancer pamphlets, like, you know, at the doctor’s office, like schools sometimes, like libraries, a bunch of other resource places, where you can read about it. And that’s like how I kind of know about some stuff.” – FG 2 “I’ve learned it from like sometimes in schools, but it’s never really like a huge thing. But I’ve learned it mostly from like the media in general, like news and like other things, like commercials and like campaigns.” – FG 15 Unstructured cancer learning experiences “You just like learn about it everywhere, like family, friends, like teachers, pretty much like everywhere you go, like a little bit of information about it.” – FG 3 “I kind of just learn about it from hearing what goes on, kind of. You just hear it out in the open that you kind of just pick up on it.” -FG 10 Knowledge about the causes of cancer “Yeah. I think like my grandma and my dad both had large B-cell lymphoma, and it’s like genetically in my family. So like I know a lot about that and like risks for that too.” – FG 30 “And it’s also heavily like influenced by, like, yes, your genetics but also the way that your environ- ment is and the way your lifestyle, like how you live. And it’s just like there’s a ton of different factors that go into it that, which is what makes it hard to really identify, truly, what it is.” – FG31 Awareness of cancer types and cancer statistics “Leukemia, lung cancer, skin cancer, breast cancer, those are the ones that I know a lot about.” – FG 13 “I’ve heard of like breast cancer, bone cancer. And like I know breast cancer can, a lot of times, spread to other parts of your body, and then bone cancer is pretty fatal because like it breaks down the, your bones.” – FG 14 Knowledge of cancer diagnosis and treatment “I think of chemotherapy because it’s like stuck in me that they put radioactive material through you.” – FG 16 “Usually, it’s just like you see a mole. You can cut it out. Like you’re usually okay. And then there’s like pancreatic, which is really hard to catch, so normally, it’s really late stage. Well, pancreatic isn’t even measured in stages. And then like brain cancer is pretty fatal.” – FG 31 Negative perceptions of cancer “I think of a really emaciated person lying in a hospi- tal bed about to die.” – FG 13 “I think of [cancer as] scary or can kill you, in a way, and ruin your life.” – FG 21 Awareness of cancer prevention “Drinking and smoking and like chewing tobacco. Stuff that usually harms your body can be, like smoking can cause lung cancer or something like that.” – FG 7 “I guess like knowing your family history and if you’re more like at risk than other people would help too because then you’d know what to be look- ing out for and what to be trying to avoid.” – FG 34 1 3 54 Journal of Cancer Education (2023) 38:50–59 Table 2 (continued) Theme Subtheme Verbatim quotes Engagement in cancer prevention Interest in learning about cancer and cancer preven- “I feel like some people would care, but some tion wouldn’t. And it might just turn out being like another lesson in school that you learn about and then like take a test on but then not really sure about it. Like it’s important, but that just might be how it turns.” – FG 1 “I think it just depends because I feel like if someone in their family has had cancer, then they’d be more interested in learning about it. Then if maybe you’ve never really experienced what cancer can do, then maybe you wouldn’t be so interested.” – FG 14 Engagement in cancer prevention behavior “Well, I just like don’t even do any of the smoking, drugs, alcohol stuff just because I know it’s bad for you. And then the, like being in the sun, I try to put on sunscreen whenever I go outside for a good, long period of time.” – FG 4 “I guess I always think about skin cancer when I put on sunscreen, which is a little weird, but because my dad had melanoma, and they like tracked it back to like he got this like really bad sunburn once.” – FG Attitudes toward cancer prevention “Well, I’m pretty sure no one wants cancer, so it’s important when you think about like all the things that can help prevent it and things that can help cause it and how you can avoid it.” – FG 2 “I think it’s very important to make sure that you can do everything you can because nothing is 100%. But you really have to try and make sure that you can do what you can so that you don’t get sick.” – FG 8 Facilitators and barriers for action Facilitators—reasons for learning about cancer or “Well, I think people just like, we’ve seen the effects engaging in preventative behavior before. And like especially people who have had younger siblings or like people who like it’s your job to take care of, like we want to make sure that we’re well informed so that not only like we make sure that we don’t get sick but like they don’t get sick, you know. Like we can lower anyone’s chances who we’re close to.” – FG 2 “I definitely try to avoid smoking and drinking as well, kind of just like not just for cancer but like just being healthy in general.” – FG 34 Barriers—limiting factors to cancer education or “Yeah. It’s like if you’re not affected by it, it would preventative behavior be kind of like, well, it doesn’t affect me, so it’s not really a big deal in my eyes.” – FG 10 “But it’s, it always slips your mind and too, and you notice it with other people that, you know, you just forget to put on sunscreen, and then you’re out in the sun for hours on end, and you have no protection.” – FG 30 1 3 Journal of Cancer Education (2023) 38:50–59 55 Table 2 (continued) Theme Subtheme Verbatim quotes Preferences for cancer education Method of learning about cancer “It depends on who’s like giving the video because there’s a lot of influential people out there that people would rather watch videos on than like these weird doctors that they probably wouldn’t really trust or find interesting.” – FG 17 “I think for me, learning about cancer in a classroom setting makes it feel less real to me, whereas if I hear it from family or friends, it feels like it’s a more pertinent issue.” – FG 34 Learning online and misinformation “If I knew it was official, like this is the official account of Hospital A, I would trust it and maybe look into it a bit. But it’s just like I have no idea, and it would be kind of edgy.” – FG 12 “They could be telling something that’s not true. So I wouldn’t really trust it if it’s... not Mayo Clinic or something like that.”- FG 13 Desired features of cancer education “As long as the video isn’t like super long because if I go onto a video and I notice that it’s like really long, I’m just like, I’m not going to listen to this whole thing.” – FG 7 “I feel like if you focus it more to like our age group and make it a little more interesting to what we want to hear, and like it still can be about cancer but like in a more fun activity way to help us learn about it. Then kids might want to learn about it more.” – FG Negative Perceptions of Cancer Engagement in Cancer Prevention Participants associated cancer with negative emotions. Can- Interest in Learning About Cancer and Cancer Prevention cer was described as “scary,” “bad,” and “sad” and associ- ated with fear, suffering, and the loss of hope. Addition - Participants expressed interest in learning about cancer ally, participants discussed the negative physical and social and cancer prevention and stated that it was important to economic impacts of cancer. Participants described cancer learn about cancer. However, some participants expressed as life-threatening, life-altering, causing physical changes no interest. Participants shared that their desire to learn such as hair loss and causing death. Cancer was described about cancer may be influenced by a personal connection as costly, a cause of lost time with family and friends, and to someone who has experienced cancer, such as family by one participant as a “waste of time.” members or friends. Awareness of Cancer Prevention Engagement in Cancer Prevention Behavior Participants identified behavioral, physiological, and envi - Participants reported engaging in multiple types of can- ronmental risk factors for cancer. Individual behavioral fac- cer prevention behaviors, including using sunscreen, tors included sun safety (such as sunscreen use), smoking maintaining a healthy diet, exercising, and avoiding alco- or tobacco use, diet, alcohol use, drug use, and maintaining hol, tobacco, and drugs. Sunscreen use and avoiding alco- healthy habits. Other behavioral factors include engaging in hol were the two most described behaviors, and most par- cancer screenings, keeping up to date on vaccines, and medi- ticipants reported prevention behavior in three areas: cal checkups. Participants stated that physiological factors eating healthy, exercising, and using sunscreen. Addition- influence cancer risk, including genetics, age, family history, ally, participants stated that their behavior was influenced infection, stress, and viral infection. Environmental factors by parents, peer support, peer pressure, and family con- cited include radiation, asbestos, chemicals, and radon. nection to cancer. 1 3 56 Journal of Cancer Education (2023) 38:50–59 Attitudes Toward Cancer Prevention Another participant claimed that “too much, too soon would kind of like turn us away from the topic” and “you get told it The majority of participants agreed that cancer prevention so much that you almost start to like not believe it.” was important, and some participants agreed that engage- ment in these behaviors lowers cancer risk. However, par- Preferences for Cancer Education ticipants also acknowledged that engaging in preventative behavior may not prevent cancer. Method of Learning About Cancer Facilitators and Barriers for Action Participants discussed various methods for cancer educa- tion, such as presentations given by a cancer survivor or an Facilitators—Reasons for Learning About Cancer expert in the field, videos, websites, podcasts, social media, or Engaging in Preventative Behavior video games, educational games, television, advertisements, and field trips. Learning at school, self-study, or learn - Participants expressed interest in cancer education and ing via family, friends, and doctors were discussed. Learn- preventative behaviors for personal health reasons and to ing through online videos, presentations, and at school were expand their current understanding of cancer. Personal preferred, followed by educational games and social situa- health factors included a desire to prevent cancer, stay tions. Some participants stated that their learning preference healthy, prevent other diseases or conditions, and act before depended on the content delivered. it is “too late.” In addition, participants wanted to expand their current understanding of cancer to build knowledge, Learning Online and Misinformation find cure(s), build awareness, and educate others. Online videos, websites, and social media were identified Barriers—Limiting Factors to Cancer Education as potential sources of misinformation. One participant or Preventative Behavior highlighted how “some people might not know what they’re talking about, maybe, and you might be getting Participants identified several barriers to learning about can - false information.” Participants were concerned about social cer and engaging in preventive behavior. Some participants media being an untrustworthy source for medical or cancer perceived cancer as low risk, stating, “people just assume information. it’s not going to happen to them.” Participants also expressed that preventative behavior has a small impact on overall Desired Features of Cancer Education cancer risk, so they “don’t even bother.” Some participants stated that they forget to engage in preventative behavior, Participants preferred learning about cancer in an interac- such as wearing sunscreen, while one participant expressed tive, entertaining, relatable, and engaging manner. Partici- that cancer prevention information could be easily forgot- pants desired fun, interesting, and knowledge-building con- ten. Lack of prior experience with cancer was described as tent, visuals, and graphics to aid in learning, and a personal a barrier to engaging with cancer content. One participant connection to the material. stated, “some people haven’t had like family members have cancer, so they don’t know as much about it and just don’t think it’s a big deal, whereas some people have had it hap- Discussion pen to family members.” A general lack of knowledge about cancer prevention was also cited as a barrier to preventative Study participants reported being exposed to cancer content behavior. Participants discussed the desire to fit into cultural and topics from a wide variety of sources. Many partici- and social norms as a barrier to engaging in preventative pants stated that cancer is multifactorial in origin and relies behavior. Examples of cultural and social norms included on both physiological and behavioral factors. However, few the view that “sunscreen is bad for you” and “if you’re participants recognized that cancer could be asymptomatic, darker-skinned, like you don’t need to wear sunscreen.” and many identified tumors as the primary symptom of Participants described emotional behaviors to engaging in cancer development. This suggests that there is a lack of cancer education and prevention, including the futility of effective cancer and cancer prevention education for adoles - prevention behavior, comfort level with talking about can- cents. Inadequate knowledge of the signs and symptoms of cer, and the frequency they learn about cancer (“getting cancer can lead to delayed presentation and diagnosis of can- tired of topic”). One participant stated that “people are just cer, resulting in worse outcomes [15]. Providing adolescents like really uncomfortable talking about medical stuff and with the learning opportunities needed to influence healthy stuff like that. So a lot of people would not be interested.” behaviors that persist into adulthood and the integration of 1 3 Journal of Cancer Education (2023) 38:50–59 57 formal instruction may better inform adolescents of the diag- increased incidence rates for several cancers among rural nostic process associated with cancer [16]. populations [27]. Cancer disparities in the United States are Adolescents in this study associated cancer with nega- well established and should be considered when develop- tive emotions, views, and attitudes. Most frequently, partici- ing cancer education materials and programs. For instance, pants described cancer as life-altering, costly, and potentially factors such as lower socioeconomic status (SES), genetics, fatal. Emotional states influence adolescents’ self-efficacy decreased treatment adherence, and other health conditions and can assist in improving individual learning regarding may contribute to higher cancer incidence and mortality in cancer prevention and education [17]. By addressing the certain populations [28]. Adolescents in this study supported emotions associated with cancer, adolescents may be better the importance of culturally competent educational materi- equipped to process cancer education and their experiences als that address population-specific concerns and barriers. with cancer, leading to improved overall cancer awareness. Adolescents reported using online resources such as web- Participants identified numerous risk factors for the devel - sites, videos, and social media to learn about cancer. How- opment of cancer, including behavioral, physiological, and ever, youth also identified these resources could be sources environmental elements. They recognized individual factors of potential misinformation and emphasized the importance such as sun exposure, smoking/tobacco use, diet, alcohol, of trustworthy sources when learning about cancer online. and drug use that can contribute to cancer development. Adolescents utilizing the internet as a source of informa- However, some participants shared that they lacked can- tion has been described in previous literature and our study cer prevention knowledge. The World Health Organization further supports these findings [ 29]. Implementation of a (WHO) predicts that about 30 to 50% of cancer deaths could personalized, interactive educational program using already have been prevented by avoiding key risk factors, along with established resources will allow for the promotion of cancer early detection and diagnosis [18]. Therefore, being aware prevention. of the signs and symptoms of cancer can reduce cancer mor- tality if cases are detected and treated in the early stages of Limitations cancer development [19]. Educational cancer interventions for adolescents will result in increased knowledge of can- Adolescent perspectives and preferences may have limited cer prevention and could potentially have life-long impacts, generalizability to the overall adolescent population in the improving survival rates [4, 20, 21]. United States, as data were collected from one Wisconsin Many participants acknowledged the importance of high school and middle school. In addition, the sample was cancer prevention and expressed interest in learning more mostly comprised of white middle school students in a spe- about prevention. Some reported engaging in preventative cific geographic region. Due to the COVID-19 pandemic, behaviors, such as sunscreen use, healthy diet, and exercise. data collection was canceled at multiple sites, including Many of these healthy habits and behaviors emerge during high schools, thus leading to a majority middle school-aged adolescence as adolescents develop independence and begin sample. Additionally, due to the seriousness and sensitive to take responsibility for their lifestyle choices around this nature of discussing cancer, some adolescents may have felt time [22]. However, risky behaviors may also develop during uncomfortable sharing their perspectives or knowledge in a adolescence and carry on into adulthood. Dietary choices, focus group in front of their peers and the study team. Future sun exposure, and exposure to carcinogens are common can- research should examine the perspectives and preferences cer risk factors in adolescence [23–25]. In 2020, 4.7% of of a more representative sample and incorporate other data middle school students reported using electronic cigarettes, collection measures. and 6.7% reported using any tobacco product [26]. Target- ing these cancer prevention areas is essential to lowering adolescent cancer risk. Engagement of adolescents through Conclusion education is ideal due to their ability to actively learn at this stage of life and provides researchers and educators with an This study explored adolescents’ perceptions about cancer optimal opportunity for education and engagement in pre- and cancer prevention and their preferences for receiv- ventative behaviors [11]. ing cancer education. Adolescents learned about cancer Participants reported wanting to engage in preventative through a variety of sources, including family and friends, behavior, but shared numerous barriers to proper cancer edu- healthcare professionals, online resources, such as social cation and preventative behaviors. Barriers to preventative media, websites, and videos, and written materials. Ado- behaviors included social and cultural norms, lack of knowl- lescents preferred interactive, relatable, and engaging edu- edge, discomfort when talking about cancer, and forgetful- cational content delivered through online videos, personal ness. These perceptions are mirrored by national data show- presentations, and educational games. Many expressed an ing higher cancer death rates for African Americans and interest in learning about cancer and cancer prevention and 1 3 58 Journal of Cancer Education (2023) 38:50–59 Open Access This article is licensed under a Creative Commons Attri- recognized the importance of cancer prevention. However, bution 4.0 International License, which permits use, sharing, adapta- some adolescents identified personal barriers to engaging tion, distribution and reproduction in any medium or format, as long in preventative behaviors and avoiding cancer risks. Ado- as you give appropriate credit to the original author(s) and the source, lescents cited forgetfulness, lack of knowledge, desire to provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are fit into social norms, and lack of personal connection to included in the article's Creative Commons licence, unless indicated cancer as barriers to engaging in healthy behaviors. Edu- otherwise in a credit line to the material. If material is not included in cational interventions and programs should address bar- the article's Creative Commons licence and your intended use is not riers to preventative behavior and target specific areas of permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a cancer prevention, such as having a healthy diet, limiting copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . sun exposure, and avoiding tobacco products. Educating adolescents on cancer prevention is essential to lowering their risk of cancer in the future. References Supplementary Information The online version contains supplemen- 1. Mattiuzzi C, Lippi G (2019) Current cancer epidemiology. J Epi- tary material available at https://doi. or g/10. 1007/ s13187- 021- 02077-0 . demiol Glob Health 9(4):217–222. https://doi. or g/10. 2991/ jegh.k . 191008. 001 Acknowledgements The authors appreciate Claire Rosenberger for her 2. Siegel RL, Miller KD, Jemal A (2020) Cancer statistics, 2020. CA assistance with editing the manuscript and providing feedback through- Cancer J Clin 70(1):7–30. https:// doi. org/ 10. 3322/ caac. 21590 out the writing process. We express gratitude to Erin Bailey for her 3. Cancer among children, adolescents, and young adults. 2020. assistance with management of the IRB protocol, revising the focus h t t p s : / / w w w . c d c . g o v / c a n c e r / a n n u a l - r e p o r t / c h i l d r e n - ay a . h t m. group guide, data collection, and data analysis and Laura Stephenson Accessed April 15, 2021. for assisting with data collection. We would also like to thank Cody 4. Kyle RG, Nicoll A, Forbat L, Hubbard G (2013) Adolescents’ Fredrick for assisting with drafting the focus group guide and data awareness of cancer risk factors and associations with health- collection. related behaviours. Health Educ Res 28(5):816–827. https:// doi. org/ 10. 1093/ her/ cyt055 Author Contribution Olufunmilola Abraham contributed to the over- 5. Xu L, Odum M (2019) Cancer awareness and behavioral deter- all study conception, design, supervision, and implementation of this minants associated with cancer prevention—a quantitative study project. Material preparation and data collection were performed by among young adults in rural settings. J Cancer Educ 34:562–570. Olufunmilola Abraham and Lisa Szela. Data analysis was performed https:// doi. org/ 10. 1007/ s13187- 018- 1342-8 by Emilie Feng. All authors contributed drafting and editing the manu- 6. Kang J, Ciecierski CC, Malin EL, Carroll AJ, Gidea M, Craft LL, script. All authors read and approved the final manuscript. Spring B, Hitsman B (2014) A latent class analysis of cancer risk behaviors among U.S. college students. Prev Med 64:121–125. Funding This study was supported in part by American Cancer Society https:// doi. org/ 10. 1016/j. ypmed. 2014. 03. 023 (ACS) grant IRG-15–213-51 and the UWCCC (University of Wiscon- 7. Bhatta MP, Phillips L (2015) Human papillomavirus vaccine sin-Madison Carbone Cancer Center). This study was supported by the awareness, uptake, and parental and health care provider com- KL2 grant KL2 TR002374-03 and grant UL1TR002373 to UW ICTR munication among 11- to 18-year-old adolescents in a rural by the Clinical and Translational Science Award (CTSA) program, Appalachian Ohio county in the United States. J Rural Health through the NIH National Center for Advancing Translational Sciences 31(1):67–75. https:// doi. org/ 10. 1111/ jrh. 12079 (NCATS). The content is solely the responsibility of the authors and 8. Henrikson NB, Morrison CC, Blasi PR, Nguyen M, Shibuya KC, does not necessarily represent the official views of the NIH. Patnode CD. 2018.Behavioral counseling for skin cancer preven- tion: a systematic evidence review for the U.S. preventive services task force. Rockville (MD): Agency for Healthcare Research and Data availability Verbatim quotes from focus group participants have Quality (US). been included in the manuscript. To facilitate openness, transparency, 9. Kyle RG, Forbat L, Rauchhaus P, Hubbard G (2013) Increased and reproducibility of our research, we have attached the focus group cancer awareness among British adolescents after a school-based discussion guide used for this study in Appendix A. educational intervention: a controlled before-and-after study with 6-month follow-up. BMC Public Health 13:190. https:// doi. org/ Declarations 10. 1186/ 1471- 2458- 13- 190 10. Romer D (2010) Adolescent risk taking, impulsivity, and brain Ethics Approval This study was approved by the University of Wiscon- development: implications for prevention. Dev Psychobiol sin Institutional Review Board. 52(3):263–276. https:// doi. org/ 10. 1002/ dev. 20442 11. Barros A, Santos H, Moreira L, Ribeiro N, Silva L, Santos-Silva Consent to Participate Written informed consent was obtained from all F (2016) The cancer, educate to prevent model-the potential of participants aged 18 or older and parents or guardians of participants school environment for primary prevention of cancer. J Cancer under age 18. Written assent was obtained from all participants under Educ 31(4):646–651. https://d oi.o rg/1 0.1 007/s 13187-0 15-0 892-2 the age of 18. 12. Merten JW, Parker A, Williams A, King JL, Largo-Wight E, Osmani M (2017) Cancer risk factor knowledge among young Consent for Publication Parents and participants consented to the use adults. J Cancer Educ 32(4):865–870. https:// doi. org/ 10. 1007/ of deidentified data in publications and presentations. s13187- 016- 1093-3 13. Barros A, Moreira L, Santos H et al (2014) “Cancer- educate to prevent” – high school teachers, the new promoters of cancer Conflict of Interest The authors declare no competing interests. 1 3 Journal of Cancer Education (2023) 38:50–59 59 prevention education campaigns. PLoS ONE 9(5):e96672. https:// 22. Wardle J, Jarvis MJ, Steggles N, Sutton S, Williamson S, Far- doi. org/ 10. 1371/ journ al. pone. 00966 72 rimond H, Cartwright M, Simon AE (2003) Socioeconomic dis- 14. Morales-Campos DY, Markham CM, Peskin MF, Fernandez ME parities in cancer-risk behaviors in adolescence: baseline results (2013) Hispanic mothers’ and high school girls’ perceptions of from the Health and Behaviour in Teenagers Study (HABITS). cervical cancer, human papilloma virus, and the human papilloma Preventative Medicine 36(6):721–730. https:// doi. org/ 10. 1016/ virus vaccine. J Adolesc Health 52(5):S69–S75. https:// doi. org/ s0091- 7435(03) 00047-1 10. 1016/j. jadoh ealth. 2012. 09. 020 23. Carpenter DO, Bushkin-Bedient S (2013) Exposure to chemicals 15. Jassem J, Ozmen V, Bacanu F, Drobniene M, Eglitis J, Laksh- and radiation during childhood and risk for cancer later in life. maiah KC, Kahan Z, Mardiak J, Pieńkowski T, Semiglazova T, J Adolesc Health 52(5):S21–S29. https:// doi. org/ 10. 1016/j. jadoh Stamatovic L, Timcheva C, Vasovic S (2013) Delays in diagnosis ealth. 2013. 01. 027 and treatment of breast cancer: a multinational analysis. Eur J Pub 24. Frazier AL, Rosenberg SM (2013) Preadolescent and adolescent Health 24(5):761–767. https:// doi. org/ 10. 1093/ eurpub/ ckt131 risk factors for benign breast disease. J Adolesc Health 52(5):S36– 16. Hansen DM, Larson RW, Dworkin JB. 2003. What adolescents S40. https:// doi. org/ 10. 1016/j. jadoh ealth. 2013. 01. 007 learn in organized youth activities: a survey of self-reported 25. Green AC, Wallingford SC, McBride P (2011) Prog Biophys Mol developmental experiences. Journal of Research on Adolescence. Biol 107(3):349–355. https://d oi.or g/10. 1016/j. pbiom olbio. 2011. 13(1):25–55. https://psycnet.apa.org/doi/https:// doi. org/ 10. 1111/ 08. 010 1532- 7795. 13010 06 26. Centers for Disease Control and Prevention. 2020. Smoking & 17. Kyle RG, Macmillan I, Rauchhaus P, O’Carroll R, Neal RD, For- Tobacco Use. https:// www. cdc. gov/ tobac co/ data_ stati stics/ fact_ bat L, Haw S, Hubbard G (2013) Adolescent Cancer Education sheets/ youth_ data/ tobac co_ use/ index. htm (ACE) to increase adolescent and parent cancer awareness and 27. National Institutes of Health National Cancer Institute. 2020. Can- communication: study protocol for a cluster randomised controlled cer disparities. https:// www. cancer. gov/ about- cancer/ under stand trial. Trials 14:286. https:// doi. org/ 10. 1186/ 1745- 6215- 14- 286ing/ dispa rities. Accessed 28 April 2021. 18. World Health Organization. Cancer. https://www .who. int/ healt h- 28. Zavala VA, Bracci PM, Carethers JM et  al (2021) Cancer topics/ cancer# tab= tab_2. Accessed 26 April 2021. health disparities in racial/ethnic minorities in the United 19. World Health Organization. 2021. Cancer. https:// www. who. int/ States. Br J Cancer 124:315–332. https:// doi. or g/ 10. 1038/ news- r oom/ fact- shee ts/ de t ail/ cancer. Accessed on April 27th, s41416- 020- 01038-6 2021. 29. Magni C, Segrè C, Finzi C, Veneroni L, Clerici CA, Massimino 20. Al-Azri M, Al-Saadi WI, Al-Harrasi A, Panchatcharam SM M, Casanova M, Martinella V, Chiaravalli S, Ricci A, Biondi A, (2019) Knowledge of cancer risk factors, symptoms, and barriers Ferrari A (2016) Adolescents’ health awareness and understand- to seeking medical help among Omani adolescents. Asian Pac J ing of cancer and tumor prevention: when and why an adolescent Cancer Prev 20(12):3655–3666. https://d oi.o rg/1 0.3 1557/A PJCP. decides to consult a physician. Pediatr Blood Cancer 63(8):1357– 2019. 20. 12. 3655 1361. https:// doi. org/ 10. 1002/ pbc. 25985 21. Yako-Suketomo H, Katanoda K, Kawamura Y, Katayama K, Yuasa M, Horinouchi H, Saito K (2019) Children’s knowledge of Publisher's note Springer Nature remains neutral with regard to cancer prevention and perceptions of cancer patients: comparison jurisdictional claims in published maps and institutional affiliations. before and after cancer education with the presence of visiting lecturer -guided class. J Cancer Educ 34(6):1059–1066. https:// doi. org/ 10. 1007/ s13187- 018- 1408-7 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cancer Education Springer Journals

Exploring Youth Perceptions About Cancer Prevention and Preferences for Education: a Qualitative Study

Loading next page...
 
/lp/springer-journals/exploring-youth-perceptions-about-cancer-prevention-and-preferences-ptTkAgEkKz
Publisher
Springer Journals
Copyright
Copyright © The Author(s) 2021
ISSN
0885-8195
eISSN
1543-0154
DOI
10.1007/s13187-021-02077-0
Publisher site
See Article on Publisher Site

Abstract

This study aimed to characterize adolescents’ perspectives on cancer and cancer prevention and to explore their preferences for cancer education. A total of 188 middle and high school students participated in 25 focus groups. Focus groups were led by study team members and included five to ten participants each. Adolescents were asked to discuss their cancer and cancer prevention knowledge, sources of cancer education, and preferences for cancer prevention education. Focus groups were audio-recorded, and professionally transcribed. Transcripts were content and thematically analyzed by two study team members using NVivo qualitative data software. Six themes were identified in focus groups: knowledge about cancer, negative perceptions of cancer, awareness of cancer prevention, engagement in cancer prevention, facilitators and barriers for action, and preferences for cancer education. Adolescents described a wide range of cancer education sources, including friends, family, healthcare professionals, school, technology, and pamphlets. Participants associated cancer with negative emotions, such as sadness and fear. Participants expressed interest in learning about cancer and cancer prevention, but also identified barriers to engaging in preventative behaviors, such as discomfort, lack of knowledge, and lack of personal connection to cancer. Adolescents preferred learning through personal presentations, online videos, school, educational games, and social situations. Adolescence is a critical period for learning and developing healthy behaviors. Awareness of cancer and cancer prevention is crucial to lowering cancer risk in the future. To be effective, cancer education for adolescents should target specific areas of cancer prevention and address barriers to engagement in preventative behaviors. Keywords Cancer knowledge · Adolescent knowledge · Adolescent education · Cancer education · Cancer awareness · Behavior · Attitudes Introduction disease, including adolescents [2]. The Centers for Disease Control and Prevention (CDC) estimates that the overall Cancer is the second leading cause of death worldwide [1]. cancer incidence rate among adolescents and young adults The World Health Organization (WHO) estimates that cancer rose by 0.9% on average per year during 2012 to 2016 [3]. deaths are likely to surpass that of ischemic heart disease, the Awareness is key to identifying personal risk factors and leading cause of death worldwide, in the next four decades [1]. preventing cancer at an early age. However, studies dem- Additionally, cancer poses a dramatic clinical burden, disrupts onstrate that adolescents are not well informed about can- social standards, and erodes many economic resources [1]. cer risk factors [4]. Current literature suggests that many People of all ages, genders, and race can be affected by this adolescents and college students in the USA lack cancer- preventative knowledge and engage in cancer risk behaviors such as unhealthy diet, frequent alcohol consumption, and * Olufunmilola Abraham low physical activity [5, 6]. In one study, only 49% of ado- olufunmilola.abraham@wisc.edu lescents reported awareness of the human papillomavirus (HPV) vaccine and cervical cancer [7]. Addressing this lack Social and Administrative Sciences Division, University of Wisconsin-Madison School of Pharmacy, 777 Highland of awareness is crucial to empowering adolescents to make Avenue, Suite 2515, Madison, USA choices to prevent cancer and reduce cancer risk factors. Social and Administrative Sciences Division, University Awareness of modifiable risk factors is an important start - of Wisconsin-Madison School of Pharmacy, Madison, ing point in the promotion of positive health outcomes [4]. WI 53705, USA 1 3 Journal of Cancer Education (2023) 38:50–59 51 A systematic review showed six trials involving educational Recruitment interventions for adolescents reported a positive effect on composite sun protection behaviors [8]. Another study using Adolescents were recruited from one middle school and one a Cancer Awareness Measure (CAM) showed improvement high school in Wisconsin from January to February 2020. of cancer warning signs within two weeks of the interven- Students were eligible if they were enrolled in grades 7 to tion and a statistically significant decrease in the percentage 12 and could speak and understand English. School staff of adolescents who reported that they did not know cancer distributed packets containing a letter of introduction to risk factors [9]. Moreover, studies show early interventions the study, consent forms, and a request to return completed can reduce the long-term impact of unhealthy behaviors forms on a later date. All consent documents were avail- acquired in adolescence [10]. Educating adolescents about able in English and Spanish for adolescents with Spanish- cancer prevention is a crucial step to improving the number speaking parents or guardians. One school distributed the of cancer-related deaths each year. recruitment packets to all students in a required health class, Adolescence provides a window of opportunity for can- and one school made recruitment packets available to a spe- cer risk education and intervention. Cancer prevention and cific science class. Parental consent and student assent were education should be targeted at this group because they are required for participants under the age of 18; students aged in an age of active learning but are also in a stage where 18 and older were able to consent and participate without risky behaviors, such as smoking, begin [11]. Data suggests parental consent. Participants were each given $10 in cash that adolescents are under-informed about the relationship as an incentive for participation. This study was approved between health behaviors and cancer risk [12]. Although by the University’s Institutional Review Board. improving cancer awareness among adolescents is critical for life-long patterns of healthy behavior, little is known about adolescents’ perceptions of cancer risk factors and Data Collection their preferences for receiving cancer education [4]. The aim of this study was to characterize adolescents’ perceptions Each focus group consisted of five to ten participants, one facilitator from the study team, and one to two other study about cancer and cancer prevention and to understand their preferences for receiving cancer prevention education. team members as moderators. One study team member led the focus group discussion, while the other moderator(s) took observation notes and asked clarifying questions as needed. To ensure privacy and confidentiality for partici - Methods pants, schools provided separate rooms for each focus group, and participants were encouraged not to share identifying Study Design information. Each focus group lasted approximately 35 to 50 min, was audio-recorded, and professionally transcribed The study team developed a focus group guide consisting of verbatim. All identifying information was redacted from questions that explored adolescents’ perceptions and knowl- the transcripts before analysis. Participant demographic edge of cancer as well as cancer prevention and preferences information was collected via paper survey at the end of for cancer education (see appendix). The guide consisted each focus group. Focus group facilitators and modera- of open-ended questions divided into sections pertaining tors debriefed and created reflection notes following each to cancer knowledge, cancer prevention knowledge, cancer session. education, and cancer prevention education. Most focus group questions were generated by the study team or adapted Data Analysis from Cancer- Educate to Prevent [13]. Two questions about participants’ perceptions of cancer were modified from a Two members of the study team independently verified focus study regarding mothers’ and high school students’ per- group transcripts for accuracy before beginning data analy- ceptions of cervical cancer, human papillomavirus (HPV), sis. Transcripts were content and thematically analyzed by and the HPV vaccine [14]. The study team used feedback two study team members using NVivo 12 (QSR) qualitative from the University’s Survey Center to revise the guide for software. Each study team member reviewed all transcripts content and clarity. Focus groups were chosen to capture to develop relevant codes using both an inductive and deduc- group interaction and discussion and to allow participants tive approach. Relevant codes were then combined to create to expand on their responses and opinions. This qualitative the master codebook. The study team held biweekly meet- methodology provided a collaborative environment for par- ings to discuss codes, review the master codebook, and cod- ticipants to build on each other’s responses and for focus ing structure, and address discrepancies. Microsoft Excel group facilitators to ask follow-up questions as needed. 1 3 52 Journal of Cancer Education (2023) 38:50–59 was used to determine the intercoder reliability, and the final parents, family members, friends, doctors, and people who average Kappa score was 0.86. Thematic analysis of preva- had been diagnosed with cancer. Exposure to cancer content lent codes was completed using Microsoft Excel, and codes also occurred at schools, libraries, and hospitals. A variety were categorized into major themes and subthemes. of information sources were cited, such as television, books, the news, pamphlets or posters, podcasts, social media, web- sites, and online videos. Results Unstructured Cancer Learning Experiences Study participant characteristics are described in Table 1. Verbatim quotes are provided in Table 2. Some participants could not define a specific source for their A total of 188 adolescents participated in 25 focus groups. cancer knowledge and described “hearing about cancer” Participants ranged in age from 12 to 18 years old and grades from others. Participants described the process as confus- 8 to 12. Participants were 54.8% female, 89.4% white, and ing, stating that they learned “bits and pieces” rather than 83.5% middle school students. Six major themes were iden- receiving in-depth information. tified including (1) knowledge about cancer, (2) negative perceptions of cancer, (3) awareness of cancer prevention, (4) engagement in cancer prevention, (5) facilitators and bar- Knowledge About the Causes of Cancer riers for action, and (6) preferences for cancer education. Participants described cancer as physiological, behavioral, Knowledge About Cancer and multifactorial in origin. They identified physiological factors, such as changes in cell development, metastasizes, Sources of Cancer Knowledge and the role of genetics in cancer development. Some par- ticipants defined cancer as an illness, disease, and cause Participants reported being exposed to cancer content and of mortality, “a disease that happens when like, cells start topics from a wide range of sources. Sources included growing uncontrollably”, or “mutation of the cells.” Cancer was described as multifactorial, with multiple causes and risk factors. Participants stated that actions such as engag- Table 1 Participant demographics ing in preventative behavior and participating in screenings could lower cancer risk. Demographics N % Age (y) Awareness of Cancer Types and Cancer Statistics 12–13 89 47.3 14–15 68 36.2 Participants identified a wide variety of cancers, particu - 16–18 31 16.5 larly skin, breast, lung, brain, colorectal, pancreatic, liver, Gender leukemia, lymphoma, and osteosarcoma. Less frequently Male 85 45.2 mentioned cancers included eye, uterine, and stomach can- Female 103 54.8 cer. Some participants shared knowledge of cancer survival Level of education rates, cancer prevalence, and the difference in cancer risk Middle school 157 83.5 based on sex. As stated by one participant, “If you are a High school 31 16.5 woman of a certain age, you might be more at risk for certain Race/ethnicity cancers.” American Indian or Native American 1 0.5 Asian 6 3.2 Black or African American 4 2.1 Knowledge of Cancer Diagnosis and Treatment Hispanic or Latino 7 3.7 Other 1 0.5 Most participants associated tumors with cancer, while a few Reported more than one race/ethnicity 14 14 participants recognized that cancer could be asymptomatic. White 155 82.4 A few participants displayed knowledge about the diagnostic Number of youths at home (excluding the participant) process, including the primary site of cancer, staging, and 1–2 110 58.5 the biopsy process. Participants discussed cancer treatments 3–4 64 34 and their side effects and cited chemotherapy as the most 5 or more 14 7.4 common treatment. Cancer was described as incurable and potentially recurring. Participants were given the option to select “Other” for race/ethnicity 1 3 Journal of Cancer Education (2023) 38:50–59 53 Table 2 Themes, subthemes, and verbatim quotes Theme Subtheme Verbatim quotes Knowledge about cancer Sources of cancer knowledge “There’s also like a lot of cancer pamphlets, like, you know, at the doctor’s office, like schools sometimes, like libraries, a bunch of other resource places, where you can read about it. And that’s like how I kind of know about some stuff.” – FG 2 “I’ve learned it from like sometimes in schools, but it’s never really like a huge thing. But I’ve learned it mostly from like the media in general, like news and like other things, like commercials and like campaigns.” – FG 15 Unstructured cancer learning experiences “You just like learn about it everywhere, like family, friends, like teachers, pretty much like everywhere you go, like a little bit of information about it.” – FG 3 “I kind of just learn about it from hearing what goes on, kind of. You just hear it out in the open that you kind of just pick up on it.” -FG 10 Knowledge about the causes of cancer “Yeah. I think like my grandma and my dad both had large B-cell lymphoma, and it’s like genetically in my family. So like I know a lot about that and like risks for that too.” – FG 30 “And it’s also heavily like influenced by, like, yes, your genetics but also the way that your environ- ment is and the way your lifestyle, like how you live. And it’s just like there’s a ton of different factors that go into it that, which is what makes it hard to really identify, truly, what it is.” – FG31 Awareness of cancer types and cancer statistics “Leukemia, lung cancer, skin cancer, breast cancer, those are the ones that I know a lot about.” – FG 13 “I’ve heard of like breast cancer, bone cancer. And like I know breast cancer can, a lot of times, spread to other parts of your body, and then bone cancer is pretty fatal because like it breaks down the, your bones.” – FG 14 Knowledge of cancer diagnosis and treatment “I think of chemotherapy because it’s like stuck in me that they put radioactive material through you.” – FG 16 “Usually, it’s just like you see a mole. You can cut it out. Like you’re usually okay. And then there’s like pancreatic, which is really hard to catch, so normally, it’s really late stage. Well, pancreatic isn’t even measured in stages. And then like brain cancer is pretty fatal.” – FG 31 Negative perceptions of cancer “I think of a really emaciated person lying in a hospi- tal bed about to die.” – FG 13 “I think of [cancer as] scary or can kill you, in a way, and ruin your life.” – FG 21 Awareness of cancer prevention “Drinking and smoking and like chewing tobacco. Stuff that usually harms your body can be, like smoking can cause lung cancer or something like that.” – FG 7 “I guess like knowing your family history and if you’re more like at risk than other people would help too because then you’d know what to be look- ing out for and what to be trying to avoid.” – FG 34 1 3 54 Journal of Cancer Education (2023) 38:50–59 Table 2 (continued) Theme Subtheme Verbatim quotes Engagement in cancer prevention Interest in learning about cancer and cancer preven- “I feel like some people would care, but some tion wouldn’t. And it might just turn out being like another lesson in school that you learn about and then like take a test on but then not really sure about it. Like it’s important, but that just might be how it turns.” – FG 1 “I think it just depends because I feel like if someone in their family has had cancer, then they’d be more interested in learning about it. Then if maybe you’ve never really experienced what cancer can do, then maybe you wouldn’t be so interested.” – FG 14 Engagement in cancer prevention behavior “Well, I just like don’t even do any of the smoking, drugs, alcohol stuff just because I know it’s bad for you. And then the, like being in the sun, I try to put on sunscreen whenever I go outside for a good, long period of time.” – FG 4 “I guess I always think about skin cancer when I put on sunscreen, which is a little weird, but because my dad had melanoma, and they like tracked it back to like he got this like really bad sunburn once.” – FG Attitudes toward cancer prevention “Well, I’m pretty sure no one wants cancer, so it’s important when you think about like all the things that can help prevent it and things that can help cause it and how you can avoid it.” – FG 2 “I think it’s very important to make sure that you can do everything you can because nothing is 100%. But you really have to try and make sure that you can do what you can so that you don’t get sick.” – FG 8 Facilitators and barriers for action Facilitators—reasons for learning about cancer or “Well, I think people just like, we’ve seen the effects engaging in preventative behavior before. And like especially people who have had younger siblings or like people who like it’s your job to take care of, like we want to make sure that we’re well informed so that not only like we make sure that we don’t get sick but like they don’t get sick, you know. Like we can lower anyone’s chances who we’re close to.” – FG 2 “I definitely try to avoid smoking and drinking as well, kind of just like not just for cancer but like just being healthy in general.” – FG 34 Barriers—limiting factors to cancer education or “Yeah. It’s like if you’re not affected by it, it would preventative behavior be kind of like, well, it doesn’t affect me, so it’s not really a big deal in my eyes.” – FG 10 “But it’s, it always slips your mind and too, and you notice it with other people that, you know, you just forget to put on sunscreen, and then you’re out in the sun for hours on end, and you have no protection.” – FG 30 1 3 Journal of Cancer Education (2023) 38:50–59 55 Table 2 (continued) Theme Subtheme Verbatim quotes Preferences for cancer education Method of learning about cancer “It depends on who’s like giving the video because there’s a lot of influential people out there that people would rather watch videos on than like these weird doctors that they probably wouldn’t really trust or find interesting.” – FG 17 “I think for me, learning about cancer in a classroom setting makes it feel less real to me, whereas if I hear it from family or friends, it feels like it’s a more pertinent issue.” – FG 34 Learning online and misinformation “If I knew it was official, like this is the official account of Hospital A, I would trust it and maybe look into it a bit. But it’s just like I have no idea, and it would be kind of edgy.” – FG 12 “They could be telling something that’s not true. So I wouldn’t really trust it if it’s... not Mayo Clinic or something like that.”- FG 13 Desired features of cancer education “As long as the video isn’t like super long because if I go onto a video and I notice that it’s like really long, I’m just like, I’m not going to listen to this whole thing.” – FG 7 “I feel like if you focus it more to like our age group and make it a little more interesting to what we want to hear, and like it still can be about cancer but like in a more fun activity way to help us learn about it. Then kids might want to learn about it more.” – FG Negative Perceptions of Cancer Engagement in Cancer Prevention Participants associated cancer with negative emotions. Can- Interest in Learning About Cancer and Cancer Prevention cer was described as “scary,” “bad,” and “sad” and associ- ated with fear, suffering, and the loss of hope. Addition - Participants expressed interest in learning about cancer ally, participants discussed the negative physical and social and cancer prevention and stated that it was important to economic impacts of cancer. Participants described cancer learn about cancer. However, some participants expressed as life-threatening, life-altering, causing physical changes no interest. Participants shared that their desire to learn such as hair loss and causing death. Cancer was described about cancer may be influenced by a personal connection as costly, a cause of lost time with family and friends, and to someone who has experienced cancer, such as family by one participant as a “waste of time.” members or friends. Awareness of Cancer Prevention Engagement in Cancer Prevention Behavior Participants identified behavioral, physiological, and envi - Participants reported engaging in multiple types of can- ronmental risk factors for cancer. Individual behavioral fac- cer prevention behaviors, including using sunscreen, tors included sun safety (such as sunscreen use), smoking maintaining a healthy diet, exercising, and avoiding alco- or tobacco use, diet, alcohol use, drug use, and maintaining hol, tobacco, and drugs. Sunscreen use and avoiding alco- healthy habits. Other behavioral factors include engaging in hol were the two most described behaviors, and most par- cancer screenings, keeping up to date on vaccines, and medi- ticipants reported prevention behavior in three areas: cal checkups. Participants stated that physiological factors eating healthy, exercising, and using sunscreen. Addition- influence cancer risk, including genetics, age, family history, ally, participants stated that their behavior was influenced infection, stress, and viral infection. Environmental factors by parents, peer support, peer pressure, and family con- cited include radiation, asbestos, chemicals, and radon. nection to cancer. 1 3 56 Journal of Cancer Education (2023) 38:50–59 Attitudes Toward Cancer Prevention Another participant claimed that “too much, too soon would kind of like turn us away from the topic” and “you get told it The majority of participants agreed that cancer prevention so much that you almost start to like not believe it.” was important, and some participants agreed that engage- ment in these behaviors lowers cancer risk. However, par- Preferences for Cancer Education ticipants also acknowledged that engaging in preventative behavior may not prevent cancer. Method of Learning About Cancer Facilitators and Barriers for Action Participants discussed various methods for cancer educa- tion, such as presentations given by a cancer survivor or an Facilitators—Reasons for Learning About Cancer expert in the field, videos, websites, podcasts, social media, or Engaging in Preventative Behavior video games, educational games, television, advertisements, and field trips. Learning at school, self-study, or learn - Participants expressed interest in cancer education and ing via family, friends, and doctors were discussed. Learn- preventative behaviors for personal health reasons and to ing through online videos, presentations, and at school were expand their current understanding of cancer. Personal preferred, followed by educational games and social situa- health factors included a desire to prevent cancer, stay tions. Some participants stated that their learning preference healthy, prevent other diseases or conditions, and act before depended on the content delivered. it is “too late.” In addition, participants wanted to expand their current understanding of cancer to build knowledge, Learning Online and Misinformation find cure(s), build awareness, and educate others. Online videos, websites, and social media were identified Barriers—Limiting Factors to Cancer Education as potential sources of misinformation. One participant or Preventative Behavior highlighted how “some people might not know what they’re talking about, maybe, and you might be getting Participants identified several barriers to learning about can - false information.” Participants were concerned about social cer and engaging in preventive behavior. Some participants media being an untrustworthy source for medical or cancer perceived cancer as low risk, stating, “people just assume information. it’s not going to happen to them.” Participants also expressed that preventative behavior has a small impact on overall Desired Features of Cancer Education cancer risk, so they “don’t even bother.” Some participants stated that they forget to engage in preventative behavior, Participants preferred learning about cancer in an interac- such as wearing sunscreen, while one participant expressed tive, entertaining, relatable, and engaging manner. Partici- that cancer prevention information could be easily forgot- pants desired fun, interesting, and knowledge-building con- ten. Lack of prior experience with cancer was described as tent, visuals, and graphics to aid in learning, and a personal a barrier to engaging with cancer content. One participant connection to the material. stated, “some people haven’t had like family members have cancer, so they don’t know as much about it and just don’t think it’s a big deal, whereas some people have had it hap- Discussion pen to family members.” A general lack of knowledge about cancer prevention was also cited as a barrier to preventative Study participants reported being exposed to cancer content behavior. Participants discussed the desire to fit into cultural and topics from a wide variety of sources. Many partici- and social norms as a barrier to engaging in preventative pants stated that cancer is multifactorial in origin and relies behavior. Examples of cultural and social norms included on both physiological and behavioral factors. However, few the view that “sunscreen is bad for you” and “if you’re participants recognized that cancer could be asymptomatic, darker-skinned, like you don’t need to wear sunscreen.” and many identified tumors as the primary symptom of Participants described emotional behaviors to engaging in cancer development. This suggests that there is a lack of cancer education and prevention, including the futility of effective cancer and cancer prevention education for adoles - prevention behavior, comfort level with talking about can- cents. Inadequate knowledge of the signs and symptoms of cer, and the frequency they learn about cancer (“getting cancer can lead to delayed presentation and diagnosis of can- tired of topic”). One participant stated that “people are just cer, resulting in worse outcomes [15]. Providing adolescents like really uncomfortable talking about medical stuff and with the learning opportunities needed to influence healthy stuff like that. So a lot of people would not be interested.” behaviors that persist into adulthood and the integration of 1 3 Journal of Cancer Education (2023) 38:50–59 57 formal instruction may better inform adolescents of the diag- increased incidence rates for several cancers among rural nostic process associated with cancer [16]. populations [27]. Cancer disparities in the United States are Adolescents in this study associated cancer with nega- well established and should be considered when develop- tive emotions, views, and attitudes. Most frequently, partici- ing cancer education materials and programs. For instance, pants described cancer as life-altering, costly, and potentially factors such as lower socioeconomic status (SES), genetics, fatal. Emotional states influence adolescents’ self-efficacy decreased treatment adherence, and other health conditions and can assist in improving individual learning regarding may contribute to higher cancer incidence and mortality in cancer prevention and education [17]. By addressing the certain populations [28]. Adolescents in this study supported emotions associated with cancer, adolescents may be better the importance of culturally competent educational materi- equipped to process cancer education and their experiences als that address population-specific concerns and barriers. with cancer, leading to improved overall cancer awareness. Adolescents reported using online resources such as web- Participants identified numerous risk factors for the devel - sites, videos, and social media to learn about cancer. How- opment of cancer, including behavioral, physiological, and ever, youth also identified these resources could be sources environmental elements. They recognized individual factors of potential misinformation and emphasized the importance such as sun exposure, smoking/tobacco use, diet, alcohol, of trustworthy sources when learning about cancer online. and drug use that can contribute to cancer development. Adolescents utilizing the internet as a source of informa- However, some participants shared that they lacked can- tion has been described in previous literature and our study cer prevention knowledge. The World Health Organization further supports these findings [ 29]. Implementation of a (WHO) predicts that about 30 to 50% of cancer deaths could personalized, interactive educational program using already have been prevented by avoiding key risk factors, along with established resources will allow for the promotion of cancer early detection and diagnosis [18]. Therefore, being aware prevention. of the signs and symptoms of cancer can reduce cancer mor- tality if cases are detected and treated in the early stages of Limitations cancer development [19]. Educational cancer interventions for adolescents will result in increased knowledge of can- Adolescent perspectives and preferences may have limited cer prevention and could potentially have life-long impacts, generalizability to the overall adolescent population in the improving survival rates [4, 20, 21]. United States, as data were collected from one Wisconsin Many participants acknowledged the importance of high school and middle school. In addition, the sample was cancer prevention and expressed interest in learning more mostly comprised of white middle school students in a spe- about prevention. Some reported engaging in preventative cific geographic region. Due to the COVID-19 pandemic, behaviors, such as sunscreen use, healthy diet, and exercise. data collection was canceled at multiple sites, including Many of these healthy habits and behaviors emerge during high schools, thus leading to a majority middle school-aged adolescence as adolescents develop independence and begin sample. Additionally, due to the seriousness and sensitive to take responsibility for their lifestyle choices around this nature of discussing cancer, some adolescents may have felt time [22]. However, risky behaviors may also develop during uncomfortable sharing their perspectives or knowledge in a adolescence and carry on into adulthood. Dietary choices, focus group in front of their peers and the study team. Future sun exposure, and exposure to carcinogens are common can- research should examine the perspectives and preferences cer risk factors in adolescence [23–25]. In 2020, 4.7% of of a more representative sample and incorporate other data middle school students reported using electronic cigarettes, collection measures. and 6.7% reported using any tobacco product [26]. Target- ing these cancer prevention areas is essential to lowering adolescent cancer risk. Engagement of adolescents through Conclusion education is ideal due to their ability to actively learn at this stage of life and provides researchers and educators with an This study explored adolescents’ perceptions about cancer optimal opportunity for education and engagement in pre- and cancer prevention and their preferences for receiv- ventative behaviors [11]. ing cancer education. Adolescents learned about cancer Participants reported wanting to engage in preventative through a variety of sources, including family and friends, behavior, but shared numerous barriers to proper cancer edu- healthcare professionals, online resources, such as social cation and preventative behaviors. Barriers to preventative media, websites, and videos, and written materials. Ado- behaviors included social and cultural norms, lack of knowl- lescents preferred interactive, relatable, and engaging edu- edge, discomfort when talking about cancer, and forgetful- cational content delivered through online videos, personal ness. These perceptions are mirrored by national data show- presentations, and educational games. Many expressed an ing higher cancer death rates for African Americans and interest in learning about cancer and cancer prevention and 1 3 58 Journal of Cancer Education (2023) 38:50–59 Open Access This article is licensed under a Creative Commons Attri- recognized the importance of cancer prevention. However, bution 4.0 International License, which permits use, sharing, adapta- some adolescents identified personal barriers to engaging tion, distribution and reproduction in any medium or format, as long in preventative behaviors and avoiding cancer risks. Ado- as you give appropriate credit to the original author(s) and the source, lescents cited forgetfulness, lack of knowledge, desire to provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are fit into social norms, and lack of personal connection to included in the article's Creative Commons licence, unless indicated cancer as barriers to engaging in healthy behaviors. Edu- otherwise in a credit line to the material. If material is not included in cational interventions and programs should address bar- the article's Creative Commons licence and your intended use is not riers to preventative behavior and target specific areas of permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a cancer prevention, such as having a healthy diet, limiting copy of this licence, visit http://cr eativ ecommons. or g/licen ses/ b y/4.0/ . sun exposure, and avoiding tobacco products. Educating adolescents on cancer prevention is essential to lowering their risk of cancer in the future. References Supplementary Information The online version contains supplemen- 1. Mattiuzzi C, Lippi G (2019) Current cancer epidemiology. J Epi- tary material available at https://doi. or g/10. 1007/ s13187- 021- 02077-0 . demiol Glob Health 9(4):217–222. https://doi. or g/10. 2991/ jegh.k . 191008. 001 Acknowledgements The authors appreciate Claire Rosenberger for her 2. Siegel RL, Miller KD, Jemal A (2020) Cancer statistics, 2020. CA assistance with editing the manuscript and providing feedback through- Cancer J Clin 70(1):7–30. https:// doi. org/ 10. 3322/ caac. 21590 out the writing process. We express gratitude to Erin Bailey for her 3. Cancer among children, adolescents, and young adults. 2020. assistance with management of the IRB protocol, revising the focus h t t p s : / / w w w . c d c . g o v / c a n c e r / a n n u a l - r e p o r t / c h i l d r e n - ay a . h t m. group guide, data collection, and data analysis and Laura Stephenson Accessed April 15, 2021. for assisting with data collection. We would also like to thank Cody 4. Kyle RG, Nicoll A, Forbat L, Hubbard G (2013) Adolescents’ Fredrick for assisting with drafting the focus group guide and data awareness of cancer risk factors and associations with health- collection. related behaviours. Health Educ Res 28(5):816–827. https:// doi. org/ 10. 1093/ her/ cyt055 Author Contribution Olufunmilola Abraham contributed to the over- 5. Xu L, Odum M (2019) Cancer awareness and behavioral deter- all study conception, design, supervision, and implementation of this minants associated with cancer prevention—a quantitative study project. Material preparation and data collection were performed by among young adults in rural settings. J Cancer Educ 34:562–570. Olufunmilola Abraham and Lisa Szela. Data analysis was performed https:// doi. org/ 10. 1007/ s13187- 018- 1342-8 by Emilie Feng. All authors contributed drafting and editing the manu- 6. Kang J, Ciecierski CC, Malin EL, Carroll AJ, Gidea M, Craft LL, script. All authors read and approved the final manuscript. Spring B, Hitsman B (2014) A latent class analysis of cancer risk behaviors among U.S. college students. Prev Med 64:121–125. Funding This study was supported in part by American Cancer Society https:// doi. org/ 10. 1016/j. ypmed. 2014. 03. 023 (ACS) grant IRG-15–213-51 and the UWCCC (University of Wiscon- 7. Bhatta MP, Phillips L (2015) Human papillomavirus vaccine sin-Madison Carbone Cancer Center). This study was supported by the awareness, uptake, and parental and health care provider com- KL2 grant KL2 TR002374-03 and grant UL1TR002373 to UW ICTR munication among 11- to 18-year-old adolescents in a rural by the Clinical and Translational Science Award (CTSA) program, Appalachian Ohio county in the United States. J Rural Health through the NIH National Center for Advancing Translational Sciences 31(1):67–75. https:// doi. org/ 10. 1111/ jrh. 12079 (NCATS). The content is solely the responsibility of the authors and 8. Henrikson NB, Morrison CC, Blasi PR, Nguyen M, Shibuya KC, does not necessarily represent the official views of the NIH. Patnode CD. 2018.Behavioral counseling for skin cancer preven- tion: a systematic evidence review for the U.S. preventive services task force. Rockville (MD): Agency for Healthcare Research and Data availability Verbatim quotes from focus group participants have Quality (US). been included in the manuscript. To facilitate openness, transparency, 9. Kyle RG, Forbat L, Rauchhaus P, Hubbard G (2013) Increased and reproducibility of our research, we have attached the focus group cancer awareness among British adolescents after a school-based discussion guide used for this study in Appendix A. educational intervention: a controlled before-and-after study with 6-month follow-up. BMC Public Health 13:190. https:// doi. org/ Declarations 10. 1186/ 1471- 2458- 13- 190 10. Romer D (2010) Adolescent risk taking, impulsivity, and brain Ethics Approval This study was approved by the University of Wiscon- development: implications for prevention. Dev Psychobiol sin Institutional Review Board. 52(3):263–276. https:// doi. org/ 10. 1002/ dev. 20442 11. Barros A, Santos H, Moreira L, Ribeiro N, Silva L, Santos-Silva Consent to Participate Written informed consent was obtained from all F (2016) The cancer, educate to prevent model-the potential of participants aged 18 or older and parents or guardians of participants school environment for primary prevention of cancer. J Cancer under age 18. Written assent was obtained from all participants under Educ 31(4):646–651. https://d oi.o rg/1 0.1 007/s 13187-0 15-0 892-2 the age of 18. 12. Merten JW, Parker A, Williams A, King JL, Largo-Wight E, Osmani M (2017) Cancer risk factor knowledge among young Consent for Publication Parents and participants consented to the use adults. J Cancer Educ 32(4):865–870. https:// doi. org/ 10. 1007/ of deidentified data in publications and presentations. s13187- 016- 1093-3 13. Barros A, Moreira L, Santos H et al (2014) “Cancer- educate to prevent” – high school teachers, the new promoters of cancer Conflict of Interest The authors declare no competing interests. 1 3 Journal of Cancer Education (2023) 38:50–59 59 prevention education campaigns. PLoS ONE 9(5):e96672. https:// 22. Wardle J, Jarvis MJ, Steggles N, Sutton S, Williamson S, Far- doi. org/ 10. 1371/ journ al. pone. 00966 72 rimond H, Cartwright M, Simon AE (2003) Socioeconomic dis- 14. Morales-Campos DY, Markham CM, Peskin MF, Fernandez ME parities in cancer-risk behaviors in adolescence: baseline results (2013) Hispanic mothers’ and high school girls’ perceptions of from the Health and Behaviour in Teenagers Study (HABITS). cervical cancer, human papilloma virus, and the human papilloma Preventative Medicine 36(6):721–730. https:// doi. org/ 10. 1016/ virus vaccine. J Adolesc Health 52(5):S69–S75. https:// doi. org/ s0091- 7435(03) 00047-1 10. 1016/j. jadoh ealth. 2012. 09. 020 23. Carpenter DO, Bushkin-Bedient S (2013) Exposure to chemicals 15. Jassem J, Ozmen V, Bacanu F, Drobniene M, Eglitis J, Laksh- and radiation during childhood and risk for cancer later in life. maiah KC, Kahan Z, Mardiak J, Pieńkowski T, Semiglazova T, J Adolesc Health 52(5):S21–S29. https:// doi. org/ 10. 1016/j. jadoh Stamatovic L, Timcheva C, Vasovic S (2013) Delays in diagnosis ealth. 2013. 01. 027 and treatment of breast cancer: a multinational analysis. Eur J Pub 24. Frazier AL, Rosenberg SM (2013) Preadolescent and adolescent Health 24(5):761–767. https:// doi. org/ 10. 1093/ eurpub/ ckt131 risk factors for benign breast disease. J Adolesc Health 52(5):S36– 16. Hansen DM, Larson RW, Dworkin JB. 2003. What adolescents S40. https:// doi. org/ 10. 1016/j. jadoh ealth. 2013. 01. 007 learn in organized youth activities: a survey of self-reported 25. Green AC, Wallingford SC, McBride P (2011) Prog Biophys Mol developmental experiences. Journal of Research on Adolescence. Biol 107(3):349–355. https://d oi.or g/10. 1016/j. pbiom olbio. 2011. 13(1):25–55. https://psycnet.apa.org/doi/https:// doi. org/ 10. 1111/ 08. 010 1532- 7795. 13010 06 26. Centers for Disease Control and Prevention. 2020. Smoking & 17. Kyle RG, Macmillan I, Rauchhaus P, O’Carroll R, Neal RD, For- Tobacco Use. https:// www. cdc. gov/ tobac co/ data_ stati stics/ fact_ bat L, Haw S, Hubbard G (2013) Adolescent Cancer Education sheets/ youth_ data/ tobac co_ use/ index. htm (ACE) to increase adolescent and parent cancer awareness and 27. National Institutes of Health National Cancer Institute. 2020. Can- communication: study protocol for a cluster randomised controlled cer disparities. https:// www. cancer. gov/ about- cancer/ under stand trial. Trials 14:286. https:// doi. org/ 10. 1186/ 1745- 6215- 14- 286ing/ dispa rities. Accessed 28 April 2021. 18. World Health Organization. Cancer. https://www .who. int/ healt h- 28. Zavala VA, Bracci PM, Carethers JM et  al (2021) Cancer topics/ cancer# tab= tab_2. Accessed 26 April 2021. health disparities in racial/ethnic minorities in the United 19. World Health Organization. 2021. Cancer. https:// www. who. int/ States. Br J Cancer 124:315–332. https:// doi. or g/ 10. 1038/ news- r oom/ fact- shee ts/ de t ail/ cancer. Accessed on April 27th, s41416- 020- 01038-6 2021. 29. Magni C, Segrè C, Finzi C, Veneroni L, Clerici CA, Massimino 20. Al-Azri M, Al-Saadi WI, Al-Harrasi A, Panchatcharam SM M, Casanova M, Martinella V, Chiaravalli S, Ricci A, Biondi A, (2019) Knowledge of cancer risk factors, symptoms, and barriers Ferrari A (2016) Adolescents’ health awareness and understand- to seeking medical help among Omani adolescents. Asian Pac J ing of cancer and tumor prevention: when and why an adolescent Cancer Prev 20(12):3655–3666. https://d oi.o rg/1 0.3 1557/A PJCP. decides to consult a physician. Pediatr Blood Cancer 63(8):1357– 2019. 20. 12. 3655 1361. https:// doi. org/ 10. 1002/ pbc. 25985 21. Yako-Suketomo H, Katanoda K, Kawamura Y, Katayama K, Yuasa M, Horinouchi H, Saito K (2019) Children’s knowledge of Publisher's note Springer Nature remains neutral with regard to cancer prevention and perceptions of cancer patients: comparison jurisdictional claims in published maps and institutional affiliations. before and after cancer education with the presence of visiting lecturer -guided class. J Cancer Educ 34(6):1059–1066. https:// doi. org/ 10. 1007/ s13187- 018- 1408-7 1 3

Journal

Journal of Cancer EducationSpringer Journals

Published: Feb 1, 2023

Keywords: Cancer knowledge; Adolescent knowledge; Adolescent education; Cancer education; Cancer awareness; Behavior; Attitudes

References