Project in Dearborn, Michigan
Improving rates of cervical cancer screening among Arab American women through HPV self-collection testing
Madiha Tariq, MPH, Deputy Director, Arab Community Center for Economic and Social Services (ACCESS) Community Health and Research Center (CHRC), Celeste Leigh Pearce, PhD, MPH, Associate Professor and Associate Chair, Department of Epidemiology, University of Michigan School of Public Health and Cancer Epidemiology and Prevention Program Co-Leader, University of Michigan Rogel Cancer Center, and Rafael Meza, PhD, Associate Professor, Department of Epidemiology, University of Michigan School of Public Health, Associate Professor of Global Health, and Cancer Epidemiology and Prevention Program Co-Leader, University of Michigan Rogel Cancer Center
To assess the potential of HPV self-collection testing to improve cervical cancer screening rates among Arab American women in metro Detroit.
Michigan is home to the second largest Arab population in North America, an estimated 500,000 individuals after accounting for under reporting, with the majority residing in metropolitan (metro) Detroit. There are concerning disparities in cervical cancer screening in Michigan between Arab American, non-Hispanic White and Black women, with Arab American women faring the worst. In 2013, 67.9% of Arab American women reported having been screened compared to 93.1% of non-Hispanic White and 91.3% of African American women. This rate in Arab American women has not improved based on a 2016 survey and remains lower than all other racial/ethnic group at 64.2%. Understanding the barriers to screening and follow-up is critical to design effective strategies to improve cervical cancer prevention for Arab American women. Previous research suggests that there are five broad areas affecting screening in Arab American populations: (1) cervical cancer screening and prevention knowledge, (2) attitudes and beliefs, (3) healthcare provider and setting, (4) socio-demographics (education, marital status, income) and social support, and (5) nativity, immigration and acculturation. Specifically, issues related to modesty and the need for a female provider have also been described as barriers; these concerns can all be addressed by Human Papilloma Virus (HPV) self-collection sampling.
This study will determine the acceptability and feasibility of HPV self-collection sampling in an under screened Arab American community as an alternative to screening in a traditional healthcare setting. HPV self-collection sampling in “safe” community meeting points for Arab American women may help to address some of their barriers to screening. We will thus test the feasibility of offering HPV self-collection sampling through a community meeting point accessible to women. The Arab Community Center for Economic and Social Services (ACCESS) is the largest Arab American non-profit community center in the United States, has been operating for 47 years, is located in metro Detroit, and is trusted by the community. We have partnered with ACCESS (see letter of support) for this study. The US Preventive Services Task Force has specifically stated in its recent cervical cancer screening recommendations that “it is necessary to find effective strategies to reach inadequately screened and unscreened women”. The Arab American population in Michigan is one such community.
Study design and methods
We plan to recruit women receiving services at ACCESS to better understand the utilization of and barriers to accessing cervical cancer screening among Arab American women in the metro Detroit area. This area of Detroit is home to the second largest Arab community in North America. We will also determine the feasibility of utilizing high risk human papillomavirus (HPV) self-collection sampling for cervical cancer screening in this population. Lastly, we will determine the prevalence of HPV positivity and the viral genotype distribution in this population. The short name for our study is SAHA-HPV; SAHA means “health” in Arabic.
We will enroll Arab American women who are between the ages of 30 and 65. We define Arab Americans as individuals who have their self-identified ancestral roots in the 22 nations comprising the Arab League of Nations (which includes ethnicities in these countries, including Chaldean). We are excluding women aged 29 and younger because HPV testing as a cervical cancer screening modality is not recommended in this age group. In addition, women 66 and older are excluded because cervical cancer screening is not recommended in this age group. We define women as appropriate to be screened if they have not had cervical cancer screening via a Pap smear test in the previous three years. Eligible women will be asked to (a) complete a brief questionnaire and (b) administer a self-collection HPV swab. Women may choose to only complete the questionnaire or to complete both the questionnaire and the self-collection swab. Women may also participate in the focus groups without completing the questionnaire and self-collection swab.
We have established a recruitment plan in conjunction with ACCESS. Designated University of Michigan research staff will be located at a recruitment table in the lobbies of ACCESS buildings. Women accessing services at ACCESS will be asked if they are interested in participating in a research study. In addition, ACCESS employees may refer women to participate in study. All subjects, regardless of their participation in the study, will be reminded that their participation or lack thereof will not impact the services that they receive or may receive at ACCESS. At least one study team member who speaks Arabic will be present during all recruitment activities.
Women will be provided a HerSwab self-collection kit with infographic and text instructions in English or Arabic and offered the opportunity to ask questions and clarifications prior to collection. Self-collection will occur at private rooms in ACCESS. Samples will be tested using the COBAS® 4800 HPV Test which screens for the 13 high-risk HPV types (16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 68). Testing will be done through the University of Michigan Clinical Microbiology Laboratory, a CLIA certified lab. All women will be able to call to find out the HPV swab results. Women with HPV positive tests will be called by the study team to inform them of their results and arrange for follow-up care.
The focus groups will be held at various beauty salongs and meeting spaces around Dearborn, MI. They will be conducted in either English or Arabic. A focus group guide has been developed to cover the topics of HPV screening, attitudes on self-collection, and vaccination.
Descriptive and regression analyses will be carried out to characterize prior screening practices, cervical cancer risk factors, and HPV vaccination history. Depending on the proportions, we will attempt to stratify analyses by acceptance of sample self-collection (yes/no) and compare the two groups, and similarly for past history of screening (yes/no). Reasons for declining self-collection will be described.
Anticipated undergraduate/graduate student activities on project
The student(s) will participate in: (i) obtaining of written informed consent for the study procedures, (ii) conducting recruitment and surveys, (iii) assisting with focus groups, (iv) instructing participants on self-collection procedures, (v) post-collection sample processing, (vi) data entering, and analysis, and (vii) transcribing focus groups and uploading to qualitative analysis software. There is a possibility for doctoral students to propose additional related work.
Due to the COVD-19 pandemic, there is a pause on in person human subjects research. As such, the focus group arm of the project will procced during the summer months remotely.
The timeline will be reassessed in June/July, and assuming that we are allowed to return to in-person human subjects research, the screening arm of the project will recommence then.
Techniques/methods students should become familiar with in advance
- Human subjects training, cervical cancer screening methods.
Suggested readings (minimum of 3-5 articles)
- United Services Preventive Services Task Force, Curry SJ, Krist AH, Owens DK, Barry MJ, Caughey AB, et al. Screening for Cervical Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;320(7):674-86.
- Abboud S, De Penning E, Brawner BM, Menon U, Glanz K, Sommers MS. Cervical Cancer Screening Among Arab Women in the United States: An Integrative Review. Oncol Nurs Forum. 2017;44(1):E20-E33.
- Ogilvie GS, van Niekerk D, Krajden M, Smith LW, Cook D, Gondara L, et al. Effect of Screening With Primary Cervical HPV Testing vs Cytology Testing on High-grade Cervical Intraepithelial Neoplasia at 48 Months: The HPV FOCAL Randomized Clinical Trial. JAMA. 2018;320(1):43-52..
- Kobetz E, Seay J, Koru-Sengul T, Bispo JB, Trevil D, Gonzalez M, et al. A randomized trial of mailed HPV self-sampling for cervical cancer screening among ethnic minority women in South Florida. Cancer Causes Control. 2018.
- Gottschlich A, Rivera-Andrade A, Grajeda E, Alvarez C, Mendoza Montano C, Meza R. Acceptability of Human Papillomavirus Self-Sampling for Cervical Cancer Screening in an Indigenous Community in Guatemala. J Glob Oncol. 2017;3(5):444-54.