Breaking Barriers in Dearborn, Michigan

by Maliha Hussain

Earlier this year, a formal partnership was created between HEART and the Arab Community Center for Economic and Social Services (ACCESS). Located in Dearborn, MI, ACCESS is the nation’s largest community health center that serves the Arab population. In a series titled “Real Talk”, educational workshops on sexual health and healthy relationships were delivered across Southeast Michigan. Valuable research was collected from this partnership and presented at various academic conferences, including the 8th Arab Health Summit and the 2018 Annual Meeting of the American Public Health Association.

As sexual health is often considered taboo in faith-based communities, this pilot study specifically focused on Muslim and Arab American women who attended the workshops. There were three major aims: (1) to evaluate a community-based approach to sexual health education, (2) to provide insight into the cultural context that influences information-seeking behaviors and utilization of health care services, and (3) to contribute to the paucity of literature on this understudied population. By employing a theory-based framework, the study intended to de-stigmatize this topic while facilitating more informed decision-making related to women’s health.

Over 50 women attended the workshops and majority of study participants were Middle Eastern/North African, specifically Lebanese. The age ranged from 18-44 year olds while most were single, second generation American, possessed a minimum of a bachelor’s degree, and identified as “religious” or “highly religious”. The research study involved mixed methods, analyzing both quantitative and qualitative results.

Pre/post data on sexual health knowledge was collected from 32 participants. The mean increase in post-workshop knowledge was over two points; this difference was statistically significant (p<0.001). There was also a statistically significant increase between scores collected pre-workshop and one-month follow up (p<0.05), although fewer participants responded to surveys one month after they attended the workshop. The pre/post surveys helped to identify low-scoring questions at baseline and after the workshop. These survey questions involved concepts of fertilization and reproductive anatomy, identifying potential improvements of workshop content and delivery.

The following findings are important to highlight:

• 40% of participants believed sexual health information is difficult to obtain. There are specific religious and cultural expectations that may hinder access to and retrieval of sexual health information; therefore, culturally-competent information may also increase the likelihood that such women access accurate sexual health information.
• 23% believed sexual education would increase sex practices. This alludes to the commonly-held concern that the provision of sexual education increases engagement in pre-marital sex. Perhaps the widely-acknowledged failures of abstinence-only education need to be better communicated to this population.
• Only 8% reported that they would seek help from a religious leader if they had a problem or question about sexual health. This was contrary to the hypothesized potential influence of religious leaders in this population, given their knowledge on permissibility of certain issues like abortion. The most common selection for whom to seek information from was a qualified doctor (67%).

Sexual health self-efficacy, or confidence in the ability to perform positive sexual health behaviors, was also measured in this study since it is a key construct in health behavior change. Higher mean scores were reported for contraception than STI/HIV testing and self-breast exams. Cultural and religious expectations may explain this finding, since contraception is viewed more positively in Islam (it is permissible) while STI/HIV testing may elicit unfamiliar terminology and concepts that connote risky sexual behavior. Greater understanding of such clinical testing, from the cost and process to the confidentiality of testing, may improve sexual health self-efficacy in performing these positive health behaviors.

While the words “informative,” “educational,” and “helpful” were overwhelmingly used to describe the workshop, three themes emerged from the quantitative analysis. First, participants recognized the shift from traditional sexual education, citing discussions on consent and power dynamics as particularly beneficial. They also requested that the workshop be delivered to men, mosques, and schools. One participant noted, “This is a topic that is considered to be shameful and we need to change that. Education should be given to both the men and women.”

Second, the concept of stigma frequently surfaced as participants noticed the lack of educated discussion on this topic. As one attendee stated, “It is stigmatized to the point where we kind of should shun sexual experiences so it’s nice to be in an environment that is open with this information.” This highlights the third theme regarding environment and the importance of cultivating comfortable and representative spaces. “The workshop was very insightful and I’m grateful to hear it from another Muslim woman. I feel a lot more comfortable discussing it in this setting,” wrote one participant. Maintaining a women-only environment helped to foster openness, confidentiality, and light-heartedness. Suggested topics to address and expand upon included types of lubricant, female condoms, female genital mutilation, and non-heterosexual sex.

Limitations of this research study include small sample size, especially for one-month follow up data. There is low internal consistency of the knowledge scale as the workshop content and survey questions were developed separately. There is also a lack of generalizability to older/non-single women and lack of racial diversity in representing the Muslim community.

Overall, the study findings demonstrate the potential benefits of a community-based approach to sexual health education. Such findings may inform policy, funding, and support for preventative education in Muslim and Arab American populations. Educational health programs can help prevent social stigma about sensitive topics while promoting more informed decision-making. Public health efforts often pull strength from one of their greatest assets – the community. While communities may perpetuate certain norms leading to social stigma, they can also be the ones to end them. Access to sexual health education is a boulder on the road to health equity. It cannot be moved by one person; rather, it requires collective struggle to clear a path for all individuals attain the means to prosper.