Adriana Baban, PhD Professor, Babes-Bolyai University, Cluj-Napoca, Romania May 10, 2006

1. WWhat Happens When Women’shat 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

3. 1990 the year of a new start1990 the year of a new start

4. 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

5. 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

6. Life expectancy at birth (women,Life expectancy at birth (women,
2002)2002)
Country/Country/
RegionRegion
RomaniaRomania EUEU USAUSA
Life expectancyLife expectancy 75.175.1 82.182.1 79.979.9

7. Standardised death rates per 100,000Standardised death rates per 100,000
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

8. Maternal Mortality (2002)Maternal Mortality (2002)
Country/Country/
RegionRegion
RomaniaRomania EUEU USAUSA
Maternal mortality/Maternal mortality/
100,000 live births100,000 live births
33.933.9 9.89.8 8.98.9

9. Cervical Cancer Mortality Rates inCervical 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

10. Trends in mortality from cervical cancerTrends in mortality from cervical cancer
0
3
6
9
12
15
1970 1975 1980 1985 1990 1995 2000
Romania
Lithuania
Poland
Czeh R.
Slovenia
EU average

11. 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

12. 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

13. Study Methods
KAP structured survey
Semi-structured interviews
In-depth interviews
Focus groups

14. Perceived
susceptibility
Perceived
susceptibility
Perceived severity
Perceived severity
Perceived barriers
costs
Perceived barriers
costs
Perceived benefits
Perceived benefits
PSYCHOSOCIAL
FACTORS
PSYCHOSOCIAL
FACTORS
Social support
Social 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 beliefs
Normative beliefs

16. Study Participants
 National representative sample (1053
women)
 30 women
 35 key informants
 50 health care providers

17. 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't
know
Cervical screening history

18.
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

19. 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 %

20. 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

21. Predictors of Screening Behavior
Dimension Model 4
Residence*Residence* 1.90 [1.13-3.20]
KnowledgeKnowledge 1.58 [1.37-1.83]
Normative beliefsNormative beliefs 1.27 [1-1.61]
AgeAge 1.03 [1.00-1.05]
Perceived psychological costsPerceived psychological costs .88 [.83-.94]
Frequency of gynecologicalFrequency of gynecological
examsexams
.71 [.56-.90]
Marital status (married)Marital status (married) .35 [.14-.82]
Nagelkerke RNagelkerke R22
0.43

22. 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”.

23. 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?”

24. 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”.

25. 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”.

26. 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 that
part of a woman’s body. This is why he’s called a
specialist, while the GP is a “generalist”, he
knows a little of everything.”

27. 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).

28. 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).

29. 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

30. 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)

31. 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).

32. 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

33. 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.