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W hat Happens When Women’s Preventive Care Is Undervalued? Lessons from Romania
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Transcript of W hat Happens When Women’s Preventive Care Is Undervalued? Lessons from Romania
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.