WWhat Happens When Women’s hat Happens When Women’s Preventive Care Is Undervalued? Preventive Care Is Undervalued?

Lessons from RomaniaLessons from Romania

Adriana Baban, PhDAdriana Baban, PhD

Babes-Bolyai UniversityBabes-Bolyai University

Cluj-Napoca, ROMANIACluj-Napoca, ROMANIA

1990 the year of a new start1990 the year of a new start

Romania: demographics & socio-economic indicators (2003)

Capital: Bucharest

Population: 22.332.000

Ethnic groups: Romanian, Hungarian, German, Romany (Gypsy)

Religion: Orthodox, Catholic, Protestant

Literacy rate: 97% women; 99% men

Unemployment rate: 6.6%

GDP per capita: 7140 USD

14% absolutely poverty; 18%relative poverty

ROMANIAN’S HEALTH CARE SYSTEM

New Constitution (1990): the right to health care for all is guaranteed

Under-financing sector (2.6% - 4% from GDP)

Over-medicalized, accent on clinical treatment

One physician/580 people/10 beds; 40.8 nurses/100.000 population

Health sector reform (1999): Public Health Law Social Health Insurance Law Family doctors National strategy on sexual and reproductive health

Public and private health services

Life expectancy at birth Life expectancy at birth (women, 2002)(women, 2002)

Country/Country/

RegionRegionRomaniaRomania EU EU USAUSA

Life expectancyLife expectancy 75.175.1 82.182.1 79.979.9

Standardised death rates per Standardised death rates per 100,000100,000

Rank Group of diseases Romania 2000 EU 2000

1. Cardiovascular 667.8

257.8

2. Malignant tumours 172.2

184.7

3. Respiratory system 67.3

60.4

4. Digestive system diseases 65.2

61.5

5. Accidents, poisonings 64.0 39.8

6. Infectious diseases 15.8

7.3

7. TB 10.6

0.8

Maternal Mortality (2002)Maternal Mortality (2002)

Country/Country/

RegionRegionRomaniaRomania EUEU USAUSA

Maternal mortality/Maternal mortality/

100,000 live births 100,000 live births 33.933.9 9.89.8 8.98.9

Cervical Cancer Mortality Rates in Cervical Cancer Mortality Rates in Selected Countries (2000)Selected Countries (2000)((Levi, Lucchini, Negri et al, 2001Levi, Lucchini, Negri et al, 2001))

Country Mortality Rates (100,000)

USAUSA 3.33.3

CanadaCanada 2.82.8

UKUK 3.93.9

SwedenSweden 2.92.9

FinlandFinland 1.31.3

RomaniaRomania 11.211.2

Trends in mortality from cervical cancerTrends in mortality from cervical cancer

0

3

6

9

12

15

1970 1975 1980 1985 1990 1995 2000

RomaniaLithuaniaPolandCzeh R.SloveniaEU average

Psychosocial and Health System Dimensions of Cervical Cancer Screening In Romania* (2004-2005)

Babes-Bolyai University, Cluj-Napoca, Romania Romanian Association of Health Psychology EngenderHealth, New York

*Project funded by Bill & Melinda Gates Foundation

PROJECT AIMS Estimate the prevalence of cervical cancer screening

among Romanian women

Identify demographic and socio-economic correlates of screening behavior

Assess women’s knowledge, beliefs and attitudes about cervical cancer prevention

Elicit key health care system elements within which cervical cancer screening currently functions

Examine the providers’ knowledge, attitudes and practices related to the current screening program

Study Methods

KAP structured survey

Semi-structured interviews

In-depth interviews

Focus groups

Perceived susceptibility

Perceived susceptibility

Perceived severityPerceived severity

Perceived barriers costs

Perceived barriers costs

Perceived benefitsPerceived benefits

PSYCHOSOCIAL FACTORS

PSYCHOSOCIAL FACTORS

Social supportSocial support

Perceived stress/ well-being

Perceived stress/ well-being

FACTORSFACTORS SOCIOECONOMIC FACTORS

SOCIOECONOMIC FACTORS

DEMOGRAPHIC FACTORS

DEMOGRAPHIC FACTORS

Health Locus of Control

Health Locus of Control

HEALTH CARE SYSTEM: Access; pathways; organization of screening; structural barriers,

doctor-patient relations

HEALTH CARE SYSTEM: Access; pathways; organization of screening; structural barriers,

doctor-patient relations

BEHAVIORAL INTENTIONS

BEHAVIORAL INTENTIONS

SCREENING BEHAVIOR

SCREENING BEHAVIOR

EMOTIONS (Fear/ Worry)

EMOTIONS (Fear/ Worry)

Knowledge/Knowledge/

Normative beliefsNormative beliefs

Study Participants

National representative sample (1053 women)

30 women

35 key informants

50 health care providers

 

20,2%

73,3%

6,5%

0

20

40

60

80

Figure 6. Have you ever had a cervical smear? (N=1053)

Yes

No

Don'tknow

Cervical screening history

  

53,5%

46,3%

0,2%

0

10

20

30

40

50

60

Figure 10. Have you ever heard about cervical smear? (N=1053)

Yes

No

Don't know

Cervical Screening Awareness and Knowledge

Barriers frequency

Barriers Frequency (N=1053)

My doctor never suggested it 31.8 %

Gynecological visits are unpleasant 30.6 %

I fear a bad diagnosis 25.8 %

The costs of services and tests 25.5 %

Long lines and waiting 24.9 %

I don't think smears are necessary 18.2 %

I am too exhausted 16 %

I do not have time 15.9 %

Doctors might say I am complaining 13.4 %

Women’s Beliefs about Cervical Cancer and

Screening Ever had smear test (Mean, SD)

Never had smear test (Mean, SD)

tt pp

Severity 13.74 (3.32) 14.20 (3.08) -1.88 .05.05

Benefits 26.29 (3.71) 24.08 (3.79) 7.637.63 .000

Costs 10.87 (4.29) 14.43 (4.22) -10.94-10.94 .000

Self-efficacy 4.34 (1.01)4.34 (1.01) 3.8 (1.41)3.8 (1.41) 6.326.32 .001.001

Normative beliefs

3.4 (1.12)3.4 (1.12) 2.87 (1.06)2.87 (1.06) 6.456.45 .001.001

Positive attitudes

20.83 (2.3)20.83 (2.3) 19.55 (2.73)19.55 (2.73) 6.296.29 .001.001

Predictors of Screening BehaviorDimension Model 4

Residence*Residence* 1.90 [1.13-3.20]

KnowledgeKnowledge 1.58 [1.37-1.83]

Normative beliefs Normative beliefs 1.27 [1-1.61]

AgeAge 1.03 [1.00-1.05]

Perceived psychological costsPerceived psychological costs .88 [.83-.94]Frequency of gynecological Frequency of gynecological examsexams

.71 [.56-.90]

Marital status (married) Marital status (married) .35 [.14-.82]

Nagelkerke RNagelkerke R22 0.43

Women’s Constructions of Prevention

“My body is resistant and it hasn’t created me

any problems so far, at 49, so I’ve never had to

go to the doctor, except when I was pregnant”.

“I don’t even know my GP. I have registered with

him but I’ve never been there”.

“I am not the type of woman who goes to

the doctor for any little thing”.

WWomen’s Constructions of Prevention(cont)

  

“I did not go to ask for the Pap smear because I

can’t have cancer. I’m feeling okay. Cancer is

one of those diseases where you can’t feel

Healthy”.

 

“I feel that nothing is wrong with me, so why

should I have the test?”

 

Women’s Perceptions of Health Services

“As a young and healthy woman, I would feel really bad to take up the time of a doctor for a simple check-up, knowing that there are dozens of sick and old people waiting in front of his door in order to be seen and get treatment”.

 

Women’s Perceptions of Health Services

“When you go to doctors you get the impression

that you bother them, they give you an indifferent

and superficial look. They almost suggest that

unless you are dying why in God’s name you

bother them, that your problem is not something

they should be wasting their time with”.

 

Locating Responsibility for Cervical

Cancer Prevention

“The Pap test should only be performed by the gynecologist; no way by the GP! The gynecologist spends 5 years specializing in thatpart of a woman’s body. This is why he’s called aspecialist, while the GP is a “generalist”, he knows a little of everything.”

 

Health Professional’s Perceptions of Cervical Cancer Prevention Program

Legal and Policy FrameworkLegal and Policy Framework

The National Cervical Cancer Prevention Program NCCPP (1998)

“The national cervical cancer screening program is one

on paper rather than a real one. The Ministry of Health

maintains it exists and that it is financially sustained, but

this is not the case” (gynecologist).

Financing Cervical Cancer Prevention

NCCPP: low, fluctuating, uncertain budget

The National House for Health Insurance reimburses Pap smears only when there is a suspicion of a pathologic condition.

“The Ministry of Health is interested in the screening

program as long as you don’t ask for money. Their

good will stops here. As soon as you ask for funds, they

lose interest in screening and they no longer see

cervical cancer mortality as a priority” (gynecologist).

System Capacity: Infrastructure and

Human Resources “What national screening program could there be? With

whom and what?” (GP)

Facilities: ranged from minimally to well equipped

Inconsistency in the provision of supplies

Low number of cytologists involved in cervical screening

Low number of GPs provide cervical screening service

Practice Regulations

Regulations in accordance with EU norms Target groups (25 –65 years of age) (25 –65 years of age)

Interval for Screening (3 years) (3 years)

Active screening

GPs involved in screening

“We know all too well what we have to do!”

(gynecologist)

Information, Education and Communication

No training for medical doctors and nurses on counseling information and skills.

“We all know that preventing is better that treating, but you must understand that prevention is not part of our attributions” (key informant, National House for Health Insurance).

“We are clinicians, and by definition a clinician deals with medical problems, not with education and prevention” (gynecologist).

Providers’ Constructions of the Role of Women in Cervical Cancer Screening

Blaming the “victim”

Women as irresponsible

Women as needing surveillance

Women as needing to be penalized

Women as victims of health-care reform

  

Final Comments

An urgent need for interventions to reorganize

cervical cancer screening in Romania through:

influencing women’s awareness, knowledge, attitudes and practices through public education;

reducing barriers created by the health care system;

creating a new environment for the delivery of this preventive health care service.