Repeat At-Home Saliva Collection to Measure Cortisol Awakening Response (CAR): Protocol Feasibility Study Among Black...

Emerging evidence supports that women with histories of abuse have heightened stress and immune dysregulation. Few studies have examined the biological plausibility of this association in US Black women-a population disproportionately affected by gender-based violence (GBV), health disparities, and generally underrepresented in research. Biomarkers of stress and immune health remain challenging to study due to barriers in recruitment, retention, and protocol adherence.

This study developed and examined the feasibility of an at-home, self-collected, and minimally invasive salivary cortisol awakening response (CAR) collection protocol among Black women with histories of abuse in Baltimore City, Maryland.

Black women were recruited from November 2015 to May 2018 from Baltimore City sexually transmitted disease clinics. Participants received in-person instruction and demonstration on saliva self-collection using the passive drool method, and were provided study-issued cell phones for reminders and adherence tracking. Participants self-collected saliva samples upon waking and 30 minutes post waking on 3 consecutive days to assess CAR. Outcomes included protocol completion, self-reported adherence, and experiences (via saliva collection logs), a weighted protocol adherence score, and cortisol measures (waking, post waking, and CAR). Differences in sociodemographic characteristics and outcome measures were assessed by adult forced sex exposure status using chi-square tests and ANOVA. The Pearson correlation coefficient assessed the day-to-day reproducibility of cortisol measures among women with 2 full days of valid samples.

Of the 305 women completing the study survey, 228 completed the saliva specimen collection protocol, with no significant differences in completion between women with and without forced sex histories. Protocol feasibility was high, with 84% (191/228) completing at least 1 full day of adherent saliva collection and more than half (132/228) completing 2 full days. While feasibility did not differ by exposure status, women with adult forced sex exposure demonstrated lower protocol adherence scores compared to their unexposed counterparts. Between-day cortisol measures demonstrated variable reproducibility across waking, post waking, and CAR measures.

This at-home salivary cortisol collection protocol was feasible in our robust sample of Black women with histories of abuse. The process of at-home collection of salivary biomarkers, including cortisol measures, was well-documented, and participants were able to adhere to it. The protocol yielded usable data that will facilitate the examination of the physiological and health repercussions of GBV.