Addressing Cervical Cancer Disparities Among People Experiencing Homelessness

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PROJECT SUMMARY People experiencing homelessness are at increased risk of cervical cancer incidence and mortality and have disproportionately low screening rates compared to the general population. Innumerable social and structural barriers keep this underserved population from accessing preventive healthcare, including mental health and substance use disorders, low health literacy levels, mistrust in medical providers due to stigma and discrimination, and living conditions that disenfranchise them from health and social services. Homeless women also experience high rates of sexual violence and trauma, often leading to discomfort with cervical cancer screening and delays or refusals of Pap tests. Despite these issues, a common inability to engage these “hard-to-reach” communities has largely excluded people experiencing homelessness from cancer research or public health programs, resulting in a major paucity of data on this uniquely vulnerable population with excess cancer burden. The proposed community-based participatory research will meaningfully engage people experiencing homelessness and local health and social service organizations to: 1) estimate cervical cancer screening coverage and factors associated with unscreened or underscreened individuals in two major homeless communities in Indiana; 2) identify key barriers and facilitators to cervical cancer screening, follow-up, and linkage to care; 3) determine the acceptability of HPV self-sampling delivered by community health workers, as an alternative to traditional cervical cancer screening methods; 4) elucidate the feasibility of HPV self-sampling in terms of the ability of people experiencing homelessness to acquire an adequate cervical sample; and 5) provide an estimate of HPV point prevalence and distribution of infections by genotype, age, gender identity, and race/ethnicity, which is critical to informing primary and secondary prevention strategies for this highly mobile and undervaccinated population. By triangulating the perspectives of people experiencing homelessness and the medical and homelessness social service providers who serve them, this study will lead to a holistic understanding of multilevel influences on preventive health behaviors and the potential role of alternative cervical cancer screening modalities. Leveraging an established multisectoral campus-community partnership examining and addressing health disparities among homeless communities in Indiana, this project will integrate behavioral and biomedical research to identify optimal strategies that facilitate routine screening and preventive healthcare delivery for people experiencing homelessness.