I Choose Health. It is OncoLogical!—Informative and Educational Campaign Dedicated to the High School Students in Poland

Cancer is the second most common cause of death in Poland and the number of new cases is expected to increase by 28% over the next 10 years. Despite modifications and expenditure growth in the Polish health care system, oncological treatment outcomes are lower comparing to the other European Union countries. Early preventative interventions are effective in reducing the total number of cancers and improving early detection. OnkoLogika is an educational campaign launched in 2016 by the Comprehensive Cancer Centre, aimed at improving cancer awareness. One hundred and twenty students from 25 high schools of the Lower Silesia region in Poland participated in the OnkoLogika program, which consisted of four-segment workshops containing pre-/post-tests, theoretical and practical parts within the project. The mean number of correct answers from the both tests improved after educational intervention (p < 0.001). Students’ knowledge increased, especially in relation to risk factors of breast cancer development (416.31% increase), HPV-related cancers (344.81% increase), risk factors and red flag signs of skin melanoma (120.31% and 99.05% increase respectively). Approx. 86% of participants were satisfied with the OnkoLogika with 14% of respondents being dissatisfied and 94% declared increased awareness about cancer prophylaxis. High schools students indicated insufficient time (250; 16.67%) and lack of details considering presented cancers (80; 5.33%) to be the major weaknesses of the program. Nevertheless, 94% of participants would recommend OnkoLogika to a friend. OnkoLogika promotes healthy lifestyle and helps acquire necessary knowledge about chosen cancers.


Introduction
Cancer is the second most common cause of death in Poland with 185 thousand new cancer cases and 113 thousand deaths each year [1,2].Further, 43.1% of noncommunicable diseases premature deaths in 2016 were caused by malignancies [2].It is estimated that in the next 10 years, the number of new cases will increase by 28% and cancer will become the leading cause of death in Poland [1].
Outcomes of oncological treatment in Poland are still unsatisfactory.EUROCARE-5 report showed that all cancers cumulative five-years survival rate for Poland is only 43% with the average for the EU27 at 54.6% [3].This disparity may result from insufficient health care expenditure and restricted access to innovative cancer drugs, given the stringent criteria for placing innovative drugs on the reimbursement list, which significantly limits their availability in Poland [4].
The National Health Fund (NHF) spent USD 2.5 billion on cancer treatment in 2018, while only USD 42 thousand were spent on prophylaxis in 2015, which constitutes about 0.24% of NHF annual expenditure on health care services [5,6].In 2015, productivity loss due to cancer disease constituted 0.58% (USD 228.6 million) of Gross Domestic Product (GDP) in comparison to 0.59% (USD 238.8 million) in 2016 [7].Moreover, the indirect costs of oncological diseases will increase to 1.30% of GDP in 2025 according to data presented by Polish Oncological Society [7].
Based on the data from the World Health Organisation (WHO), over 40% of all cancers can be prevented and many of them are curable if detected and treated early [8].As reported by the Supreme Audit Office, only 21.3% of men and 33.6% of women participated in prevention programs in 2014, while in the years 2012-2015, expenditure on the national cancer control program decreased by 10% and were inappropriately allocated.[6].As the costs of oncological treatment increase and the budget of the NHF is limited, the value of cancer education and prevention cannot be overstated.
It is considered that educational interventions dedicated to the high school students will improve cancer literacy and potentially increase effectiveness of cancer treatment in the future.Consequently, the students are targeted early because it is a perfect time frame for building up awareness about health behaviors [9,10].Since the risk of oncological diseases increases with age, development of health literacy among the young generation builds the basics for help-seeking behaviors later in life [11,12].
However, there is limited evidence regarding the longterm effectiveness of oncological education among high school students [13].
While there are researches reporting poor knowledge of polish high school students about cancer risk factors, there are some educational programs intended to fulfill this gapmainly based on community activity of medical students and dedicated to a limited number of students [14].
Therefore, despite various modifications to high schools curricula in recent years, the cancer prevention literacy level among polish students is still unsatisfactory [14].Further, the lack of regular physical activity in schools hampers efforts of medical professionals and significantly affects development of chronic diseases according to the US Centers for Diseases Control and Prevention (CDC) [15].
In 2016 the Wrocław Comprehensive Cancer Centre with the financial support from Lower Silesian Self-Government created an informative and educational campaign for the population of Lower Silesia, including a curriculum for high school students.The program titled OnkoLogika has following objectives: (a) to educate Lower Silesians about chosen cancers, (b) broaden the cancer awareness of Lower Silesians, (c) increase the number of preventive medical examinations, (d) develop pro-preventive attitude.Additionally, the project was aimed to dispel the myths about cancer and raise awareness that cancers detected early can be treated more effectively.
To achieve our goals, we used a mix of different methods and instruments.Each of program activities was connected with the media briefing and expert meetings.Involvement of mass media in promotion of healthy life-style is beneficial and can reduce the number of obstructive modifications in health-related behaviors across society [16].Moreover, impact of NGOs on health advocacy and formation of adequate health policies, both in urban and rural areas is visible and positive [17,18].Thus, conferences were divided into two parts: 1) the local media briefing-introduction to the campaign, 2) expert conference with discussion between health care professionals and members of the local community.Further, to spread the knowledge about oncological diseases and methods of prevention across the region, not only regional media, but also the organizations fighting against cancer and promoting pro-preventive attitudes were engaged.
In order to increase effectiveness and produce long-lasting effect of educational interventions, involvement of local communities is crucial and affects various determinants of health [19].Thanks to coverages prepared by journalists participating in the workshops, the local community could additionally benefit from the curriculum and oncological knowledge we presented.What is more, the leaflets and posters regarding aims of the OnkoLogika were prepared and distributed during press conferences and promotional action titled "day of health" to reach out to members of the community that could not participate in the events.
Our actions were not limited to in-person activities.Social media is extremely popular, especially among the younger generation and plays an important role in data dissemination [20].Consequently, to improve the reach of OnkoLogika campaign, the website and Facebook page of the project were created, as a source of knowledge regarding the campaign and cancer prevention.Short, interactive webinars and expert movies were made by medical experts from Comprehensive Cancer Centre to further disseminate information.Moreover, in order to raise oncological awareness in the communities we could not visit in person, educational materials were sent to more than 100 high schools across the Lower Silesia, and from the beginning of the project 12 billboards promoting healthy lifestyle and screening test were placed in the cities of the region.
The educational campaign was conducted in-person during the 2017-2019 school years.Since 2019, amid the COVID-19 pandemic most of the campaign activities were held online.This manuscript addresses the results of this project and discusses the usefulness and effectiveness of the OnkoLogika curriculum for education of the young generation.

Study Design and Materials
All high schools of Lower-Silesia were invited to participate in our study.The schools were chosen on first-come-first-service basis.Finally, twenty-five high schools participated in OnkoLogika.All students from chosen schools were asked to take part in our program.Participation was voluntary; however, the written informed consent of parents/guardians was required for minors.
Approximately 120 students of each school, aged 16-19 years took part in workshops with a total number of 3.000 participants.The curriculum was based on workshops conducted by trained psychologists and oncologists, dedicated to the subject of the most common, preventable or easily treatable when detected early cancers: breast, lung, cervical cancer and skin melanoma.
Each session consisted of 4 parts: a) pre-test, b) theoretical part, c) practical part and d) post-test (Table 1).1,500 participants returned correctly fulfilled surveys, which constituted the final study group (rr = 50.00%).
According to polish law, the IRB approval was not required for our study.Collected data was stored and analyzed by the Wrocław Comprehensive Cancer Centre according to the European Parliament and Council General Data Protection Regulation and institutional privacy policy [21,22].

Variables
Pre-and post-workshop surveys consisted of 9 multiplechoice questions, including the most common cancers among men and women, typical age range, risk factors for cancer development, alarming symptoms of cancer and knowledge about chosen types of cancer (breast, lung, cervical cancer and skin melanoma).Moreover, participants were asked to evaluate workshops and presenters according to a four-level Likert scale ("very satisfied", "satisfied", "unsatisfied", "very unsatisfied").At the end of the survey, participants were asked to indicate strengths and weaknesses of the project in the open-ended questions.Surveys did not include inquiries considering socio-demographic data of participants.Due to COVID-19 pandemic restrictions, it was not possible to collect surveys after 6-months, as it was planned initially.

Statistical Analysis
In the statistical analysis, the dependent t-test was used to assess the relationship between the studied means.Statistical analysis was performed using Statistica v.12.5 (StatSoft).

Results
Statistical analysis was conducted on a sample size of 1,500 correctly completed questionnaires.The number of correct answers for each of 9 questions from pre-and post-test was assessed (Table 2), with mean scores of 709 (47.3%) and 1275 (85%) respectively.The mean number of correct answers significantly improved after educational intervention (p < 0.001, Table 3).

Discussion
OnkoLogika is a campaign based on two pillars-promotion and education with a wide range of educational interventions dedicated to the community of Lower Silesia.Nevertheless, the curriculum dedicated to high school students constitutes the core activity of the program.
While the long-term effect of educational interventions is uncertain, there is a plethora of evidence that they increase cancer literacy in a short-term follow-up [13].In the analysis of 12 educational programs prepared by Khadija Al-Hosni et al. the duration of follow-up for these interventions was limited to the same academic year.Thus, long-lasting effects of these interventions cannot be concluded [13].
Nevertheless, there are analyses reporting development in cancer literacy knowledge levels as a result of educational interventions.[13].Recent study revealed a significant increase in cancer literacy levels immediately after the short educational intervention based on a 30-to 45-min PowerPoint presentation, dedicated to Kentucky high school students aged 15-18 [23].Unfortunately, there are many limitations of this study, mainly due to its cross-sectional character [23].
A 2018 study of Iranian students' knowledge about skin cancer risk factors and preventive behaviors used educational intervention based on the PRECEDE model, which is a systematic process for planning, presenting, and evaluating health promotion programs for defined populations [24].While the strong point of this analysis is presence of the control group, it should be noticed that gender was restricted and carried out only on male students.Four months after the intervention, the experimental group showed a significant increase in the knowledge, attitude, self-efficacy, enabling factors, social support, and skin cancer preventive behaviors compared to the control group [24].All mentioned studies are in line with our paper.
Despite the fact that some cancers are preventable, modifications of lifestyle and pro-preventive attitude are frequently started too late [25].Further, most of the funding and research available focuses on treatment rather than prevention [25].Therefore, it is important to raise awareness This study shows that whilst general knowledge about the most common cancers in Poland is acceptable, knowledge about risk factors of oncogenesis as well as red flags signs and symptoms is unsatisfactory.Consequently, this part of education was highlighted in OnkoLogika curriculum.
Further work is already planned to provide workshops for teachers to nurture the positive effects of the project through the provision of knowledge and resources and facilitating workshops themselves.In the next step, the long-term follow-up survey will be implemented in order to provide evidence about the long-term retention of the information in the participants.

Limitations
Despite its comprehensive, innovative character, our study has several limitations.First of all, there was no control group, thus it is not possible to assess the putative impact of other educational campaigns that might have occurred in the same timeframe.
Secondly, due to lack of follow-up, the impact of our onetime training cannot be evaluated in a long-term perspective.Consequently, the long-term retention of the information in the participants remains uncertain.Moreover, the increase of high school students' knowledge about chosen cancer may not be connected with the increased number of early detected oncological diseases.As the time is needed for students to reach an adequate age to enter screening programs, the real effectiveness and impact of our study can be observed in the following decades.
Another serious limitation is the lack of participants' characteristics.Pre-and post-test did not include questions considering socio-demographic data.As all the high school students were invited to take part in educational program and participation was voluntary, the study group is not representative.
Finally, this exploratory study should be interpreted cautiously and in context with its limitations.As a crosssectional study of a convenience sample, the results may not be generalizable.

Conclusion
Health literacy can be developed among the adolescents through educational interventions.OnkoLogika may help students acquire necessary knowledge about chosen cancers necessary to make health-oriented decisions in the future.
The project promotes a healthy lifestyle and can aid health-seeking behaviors.Our program met the expectations of the young generation.We suggest that high schools' curricula incorporate evidence-based cancer education modules like OnkoLogika.

Table 1
Sample workshop description

Table 2
Evaluation of students' knowledge on the group of 1,500 respondents