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Voices from the Margins: Barriers and Facilitators to HPV Self-Sampling Among Structurally Marginalized People with a Cervix in the Greater Toronto Area and Ontario Sex workers and formerly incarcerated people with a cervix face significant structural, interpersonal, and emotional barriers to cervical cancer screening, despite being at elevated risk for HPV infection. HPV self-sampling (HPV-SS) is a validated, user-directed method that has the potential to address these barriers, yet it remains excluded from Ontario's organized screening program. This qualitative study explored the lived experiences of structurally marginalized individuals with a cervix who were offered HPV-SS as part of a mixed-methods pilot in the Greater Toronto Area. Five virtual focus groups were conducted with 34 participants, including both those who used the HPV-SS kit and those who declined it. Using inductive thematic analysis, we identified barriers to traditional screening including fear, stigma, mistrust of healthcare providers, logistical constraints, and a lack of accessible information. HPV-SS was widely described as more acceptable, empowering, and emotionally manageable, offering participants autonomy, privacy, and control over their care. Concerns included swab design, uncertainty about correct use, and unclear follow-up after positive results. Participants offered concrete, community-informed recommendations to improve HPV-SS implementation, including opt-in distribution models, gender-affirming language, and trauma-informed educational materials. The findings highlight the urgent need to integrate HPV-SS into organized screening programs to advance equitable access to cervical cancer prevention for marginalized populations. Toronto Metropolitan University Publication 2025-06-03 Navigating Equitable Access to Cancer and Mental Health Services During Pandemics: Stakeholder Perspectives on COVID-19 Challenges and Community-Based Solutions for Immigrants and Refugees—Proceedings from Think Tank Sessions Background: Increasing evidence shows that the COVID-19 pandemic has disproportionately impacted certain populations, particularly those facing structural marginalization, such as immigrants and refugees. Additionally, research highlights that structurally marginalized populations living with chronic conditions, such as cancer and/or mental health and addiction (MH&A) disorders, are more vulnerable to the adverse effects of COVID-19. These individuals face higher susceptibility to infection and worse health outcomes, including increased rates of hospitalization, severe illness, and death. To better understand the challenges faced by people living at the intersection of social and clinical disadvantages, we organized a series of Think Tank sessions to engage stakeholders in exploring barriers and identifying community-based solutions for immigrants and refugees living with cancer and/or MH&A disorders during the current and future pandemics. Objectives: Our main objectives were to gauge how earlier findings resonated with stakeholders, to identify any gaps in the work, and to co-develop actionable solutions to safeguard health and well-being during COVID-19 and future crises. Methods: Two virtual Think Tank sessions were held in September 2023 as integrative knowledge exchange forums. The Cancer Think Tank was attended by 40 participants, while the MH&A disorders Think Tank included 41 participants. Each group comprised immigrants and refugees living with or affected by cancer (in the Cancer Think Tank) or MH&A disorders (in the MH&A disorders Think Tank), alongside service providers, policymakers, and researchers from Ontario. This paper presents the key discussions and outcomes of these sessions. Results: Participants identified and prioritized actionable strategies during the Think Tank sessions. In the Cancer Think Tank, participants emphasized the importance of leveraging foreign-trained healthcare providers to address workforce shortages, creating clinical health ambassadors to bridge gaps in care, and connecting immigrants with healthcare providers immediately upon their arrival in Canada. In the MH&A disorders Think Tank, participants highlighted the need to remove silos by fostering intersectoral collaboration, empowering communities and building capacity to support mental health, and moving away from one-size-fits-all approaches to develop tailored interventions that better address diverse needs. Conclusions: The Think Tank sessions enhanced our understanding of how the COVID-19 pandemic has impacted immigrants and refugees living with cancer and/or MH&A disorders. The insights gained informed a series of actionable recommendations to address the unique needs of these populations during the current pandemic and in future public health crises. Toronto Metropolitan University Publication 2025-03-05 Vahabi, M. , Kimberly Devotta, Cliff Ledwos,
Wong, J. , Miya Narushima, Jennifer Rayner, Roula Kteily-Hawa, Kenneth Fung, Geetanjali D Datta, Axelle Janczur, Cynthia Damba, Aïsha Lofters
HIV testing among heterosexual Black men in Toronto: What are the determinants? Toronto Metropolitan University Publication 2025-02-19 Roger Antabe, Yujiro Sano,
Etowa, E. , Joseph B Nguemo Djiometio,
Vahabi, M. , Kenneth Fung,
Wong, J. , Winston Husbands
Navigating Equitable Access to Cancer and Mental Health Services During Pandemics: Stakeholder Perspectives on COVID-19 Challenges and Community-Based Solutions for Immigrants and Refugees – Proceedings from Think Tank Sessions Background: Increasing evidence shows that the COVID-19 pandemic has disproportionately impacted certain populations, particularly those facing structural marginalization, such as immigrants and refugees. Additionally, research highlights that structurally marginalized populations living with chronic conditions, such as cancer and/or mental health and addiction (MH&A) disorders, are more vulnerable to the adverse effects of COVID-19. These individuals face higher susceptibility to infection and worse health outcomes, including increased rates of hospitalization, severe illness, and death. To better understand the challenges faced by people living at the intersection of social and clinical disadvantages, we organized a series of Think Tank sessions to engage stakeholders in exploring barriers and identifying community-based solutions for immigrants and refugees living with cancer and/or MH&A disorders during the current and future pandemics. Methods: Two virtual Think Tank sessions were held in September 2023 as integrative knowledge exchange forums. The Cancer Think Tank was attended by 40 participants, while the MH&A disorders Think Tank included 41 participants. Each group comprised immigrants and refugees living with or affected by cancer (in the Cancer Think Tank) or MH&A disorders (in the MH&A disorders Think Tank), alongside service providers, policymakers, and researchers from Ontario. This paper presents the key discussions and outcomes of these sessions. Results: Participants identified and prioritized actionable strategies during the Think Tank sessions. In the Cancer Think Tank, participants emphasized the importance of leveraging foreign-trained healthcare providers to address workforce shortages, creating clinical health ambassadors to bridge gaps in care, and connecting immigrants with healthcare providers immediately upon their arrival in Canada. In the MH&A disorders Think Tank, participants highlighted the need to remove silos by fostering intersectoral collaboration, empowering communities and building capacity to support mental health, and moving away from one-size-fits-all approaches to develop tailored interventions that better address diverse needs. Conclusions: The Think Tank sessions enhanced our understanding of how the COVID-19 pandemic has impacted immigrants and refugees living with cancer and/or MH&A disorders. The insights gained informed a series of actionable recommendations to address the unique needs of these populations during the current pandemic and in future public health crises. Toronto Metropolitan University Publication 2025-01-27 Vahabi, M. , Kimberly Devotta, Cliff Ledwos,
Wong, J. , Miya Narushima, Jennifer Rayner, Roula Kteily-Hawa, Kenneth Fung, Geetanjali D Datta, Axelle Janczur, Cynthia Damba, Aïsha Lofters
Breaking Barriers: Empowering Cervical Cancer Screening with HPV Self-Sampling for Sex Workers and Formerly Incarcerated Women in Toronto Background: Although cervical cancer (CC) is highly preventable through appropriate screening methods like the Papanicolaou (Pap) test, which enables early detection of malignant and precancerous lesions, access to such screening has not been equitable across social groups. Sex workers and people with records of incarceration are among the most under-screened populations in Ontario. Little is known about the acceptability and feasibility of HPV self-sampling (HPV-SS) as an alternative cervical cancer screening method for these groups. This online, community-based mixed-methods pilot study aimed to address this knowledge gap. Methods: Eighty-four under- and never-screened sex workers and ex-prisoners aged 25–69 years and residing in the Greater Toronto Area, were recruited by community peer associates. Participants completed an online survey and viewed short videos about CC and screening with Pap and HPV-SS. Those who opted for HPV-SS conducted the test at one of two collaborating organizations. Results: The median age of participants was 36.5 years. Most had limited knowledge about CC and screening. Approximately 13% identified as non-binary, and 5% as two-spirit or trans men, with the majority having completed secondary education. Of the participants, 88% chose HPV-SS, and one-third tested positive for high-risk HPV types. The ability to self-sample without judgment from healthcare providers was noted as a key advantage. However, there was a need for training on proper HPV-SS techniques. Conclusions: To improve cervical cancer screening among sex workers, increasing awareness through participatory community co-creation of sexual health education is essential. Additionally, offering HPV-SS as a screening option is crucial, given its demonstrated acceptability and feasibility within this population, many of whom lack a primary care provider and face discriminatory attitudes in healthcare settings. Toronto Metropolitan University Publication 2024-12-17 945 Performance of HPV self-sampling for cervical cancer screening in urban, semi urban, rural, tribal and difficult to reach women in India Introduction/Background Cervical cancer is the second most common cancer among Indian women. Issues like unavailability of screening services, lack of awareness and discomfort associated with vaginal speculum examination makes screening unattractive. HPV self-sampling appears to overcome these challenges. In the present paper we present our data of three trials on HPV self-sampling, undertaken among diverse populations, aiming to investigate the attitudes, acceptability, barriers, predictors, validity and experiences with regards to HPV self-sampling among Indian women. Methodology These are community-based studies conducted among urban slum (500), urban non-slum (500), semi-urban (227), rural (600) and tribal (120 women) using HPV self-sampling for cervical cancer screening. Health awareness was delivered using different modalities like pamphlets, health education programme in groups, movie clips/videos etc. The tribal cluster also enrolled 120 male partners for awareness and semi-urban cluster also used point of care HPV test in addition to Hybrid capture. The studies involved, door to door visit to enlist the eligibles, obtaining informed consents, conducting personal interviews, distribution and collection of self-samplers and focus group discussions. Women with positive result on either tests, were offered further work up at the Nodal Hospital. Results The acceptance rate of self-sampling was 99.2%, 97%, 98.8% and 95.8% and HPV positivity was 7%, 7.8%, 7.8% and 8.7% in urban slum, urban non-slum, rural and tribal women. Overall, agreement rate between health personnel collected samples and self-collected samples was 95%. The major barriers of self-sampling were lack of confidence about performing the self-test correctly, fear that test would be painful, illiteracy and anxiety about test results. There was significant improvement in knowledge and attitudes about cervical cancer and screening. Conclusion HPV self-sampling has good acceptability among Indian women and this evidence can be used to advance public health policies to scale-up screening across rural India and other low middle income countries. Disclosures NIL. Toronto Metropolitan UniversityPublication 2024-03-01 Gauravi Ashish Mishra, Sharmila Pimple,
Vahabi, M. , Kavita Anand, Vasundhara Kulkarni, Sanjay Biswas,
Wong, J. , Aïsha Lofters, Vijayshree Prakash, Anil Patil, Usha Menon, Laura A Szalacha
Knowledge and Attitudes towards Cervical Cancer Screening and Acceptability of HPV Self-Sampling (HPV-SS) Among Under or Never Screened Racialized Immigrant Women in GTA, Ontario, Canada Background: Although Cervical cancer (CC) screening with the Papanicolaou (Pap) test has been effective in reducing CC incidence and mortality, the benefits have not equitably been distributed across different social strata. Immigrants and refugees, particularly South Asian (SA) and Sub-Saharan African (SSA) women, are among the most under-screened groups in Ontario. Little is known about the SA and SSA's beliefs about CC and screening or the acceptability of utilizing HPV self-sampling (HPVSS), an alternative method of screening for CC. This on-line communitybased mixed methods pilot study aimed to address this knowledge gap. Toronto Metropolitan University Publication 2024-01-01 The Impact of COVID-19 on Immigrants and Refugees Living with Mental Health and Addiction Disorders: A Population-Based Cohort Study in Ontario, Canada Background: While the COVID-19 pandemic has taken an enormous toll on communities across Canada and the globe, its negative impacts have not been experienced equally. People with mental health and addiction disorders (MH&A) have been found to be at greater risk of COVID-19 infection and worse COVID-19 outcomes. Similarly, although immigrants and refugees contribute to one-quarter of Ontario's population they make up nearly half of Ontario's COVID-19 cases. There is a paucity of information on the impact of COVID-19 on people who are at the intersection of MH&A and socioeconomic deprivation. Our study aimed to address this gap. Toronto Metropolitan University Publication 2024-01-01 Surviving the Storm: The Impact of COVID-19 on Cervical Cancer Screening in Low- and Middle-Income Countries According to the Center for Disease Control and Prevention's National Breast and Cervical Cancer Early Detection Program, the cervical cancer screening rate dropped by 84% soon after the declaration of the COVID-19 pandemic. The challenges facing cervical cancer screening were largely attributed to the required in-person nature of the screening process and the measures implemented to control the spread of the virus. While the impact of the COVID-19 pandemic on cancer screening is well-documented in high-income countries, less is known about the low- and middle-income countries that bear 90% of the global burden of cervical cancer deaths. In this paper, we aim to offer a comprehensive view of the impact of COVID-19 on cervical cancer screening in LMICs. Using our study, "Prevention of Cervical Cancer in India through Self-Sampling" (PCCIS), as a case example, we present the challenges COVID-19 has exerted on patients, healthcare practitioners, and health systems, as well as potential opportunities to mitigate these challenges. Toronto Metropolitan University Publication 2023-12-01 Vahabi, M. , Anam Shahil Feroz, Aïsha Lofters,
Wong, J. , Vijayshree Prakash, Sharmila Pimple, Kavita Anand, Gauravi Mishra
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