"Sorry for laughing, but it's scary": Humor and silence as cultural codes among American Indian and Alaska Native patients discussing colorectal cancer

Among American Indians and Alaska Natives (AI/ANs), colorectal cancer (CRC) is a leading cause of cancer-related death. AI/ANs are twice as likely to be diagnosed with advanced CRC as are non-Hispanic Whites. The U.S. Preventive Services Task Force recommends that average-risk patients 50 to 75 years of age obtain regular CRC screening. Nationally, CRC screening rates are above 60%. However, screening rates at our Urban Indian clinic partner sites are below 25%. We designed an 18-month educational intervention and tailored it to our target community by examining ways of speaking about colorectal cancer (CRC) and CRC screening among urban American Indian/Alaska Native (AI/AN) Elders. Seven focus groups with 46 participants were conducted in two urban clinics in the Pacific Northwest with the goal of adapting an evidence-based CRC screening intervention for AI/AN patients through the use of digital stories and a booklet. Facilitators used field guides based on The Health Behavior Framework to discuss awareness and knowledge about CRC, CRC screening and perceptions and concerns about the topics. These focus groups led to the development of culturally-appropriate educational digital stories and booklets to promote patient self-efficacy with respect to willingness to be screened for colorectal cancer. Our analyses describe culturally-appropriate ways of talking about issues related to CRC and CRC screening among urban AIAN populations to encourage health literacy and utilization of preventative medicine. Using speech codes theory, we suggest how uses of humor indicate norms that govern when, and how, to talk about colorectal cancer among Native Elders.