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• Promoting cervical cancer screening through HPV self-sampling and art-based sexual health education in marginalized and underserved populations (Sex workers and women with a history of incarceration) in Ontario

Promoting cervical cancer screening through HPV self-sampling and art-based sexual health education in marginalized and underserved populations (Sex workers and women with a history of incarceration) in Ontario, Canada

Objective: Human papillomavirus (HPV) is the primary cause of cervical cancer (CC), with risk factors like early sexual activity, multiple sexual partners, and co-infection with other STIs. Although screening through the Pap test can prevent CC, it remains underutilized among low-income women, immigrants/refugees, sex workers, and ex-prisoners in Ontario. The proposed study focuses on women sex workers (WSWs), and women ex-prisoners (WEPs), because not only they are at elevated levels of HPV risk factors but also, they face multiple systemic generated barriers such as social stigma, discrimination, and limited knowledge about CC and screening. HPV self-sampling (HPV-SS), an alternative method of screening, allows women to self-collect samples in the privacy of their homes without requiring pelvic examination. It has been proven to be effective in removing identified socioeconomic, geographic, and cultural barriers associated with the uptake of CC screening. However, little is known about the feasibility of utilizing HPV-SS among WSWs and WEPs. Our online participatory community-based mixed methods study aims to reduce screening disparities through an innovative, evidence-based, and community-engaged intervention which includes two key components: 1) Art-based CC Education (ACCE), and 2) offering HPV-SS. We will design and implement peer-led ACCE in collaboration with community stakeholders and community champions. The ACCE focuses on (i) accurate health information on HPV and CC; (ii) critical reflection on personal and collective values; and (iii) informed health decision-making. We will recruit 15 peer associates/community champions from organizations like Maggie Toronto (supporting WSWs) and PASAN (WEPs health and harm reduction) to co-develop and co-lead the ACCE. Peer associates/community champions will approach potential participants, assess their eligibility, and provide study details. Eligible participants will be connected with the research team and receive a link to an online study consent form and initial questionnaire. Criteria for eligibility include having a cervix, having >4 years since the last Pap test, being aged 25-69 years, having a history of sexual activity, identification as a current or previous sex worker or ex-prisoner, residing in the GTA, and having English proficiency. Our goal is to recruit 300 WSWs and WEPs. Participants who consent to the study will be invited to participate in the online ACCE that will be co-led by a peer associate who recruited them, attend ACCE, and complete a post-study questionnaire. They will also choose their preferred screening option: Pap test, HPV-SS, or no screening. Those interested in HPV-SS will receive a video tutorial on sample collection and submission. Quantitative outcomes, including participation rates, education, screening, and acceptability and uptake outcomes, will be collected from recruitment processes and questionnaires. Post-study focus groups will explore participants' perceived barriers and challenges in using HPV-SS, motivators for screening, and preferred methods of HPV-SS delivery. Descriptive statistics will be used to describe study participants based on survey responses. Bivariate and multivariate analyses, if sample size allows, will identify variables associated with HPV-SS uptake and screening predictors. Focus group recordings will be transcribed and analyzed using inductive thematic analysis with reciprocal coding.. Team members will independently review each transcript and develop composite themes through dialogue. A coding framework will be created, and a descriptive summary will report common themes and unique aspects of participants' experiences. Our innovative approach will increase sexual health literacy, build the capacity of the community to take on a leadership role as peer associates and promote the uptake of CC through HPV-SS. The study is well aligned with the Canadian Cancer Society’s mission of reducing cancer incidence and mortality. The findings could ultimately lead to increased participation in screening for marginalized women and a resultant reduction in screening inequalities.