WWhat Happens When Women’shat Happens When Women’s
Preventive Care Is Undervalued?Preventive Care Is Undervalued?
Lessons ...
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: R...
ROMANIAN’S HEALTH CARE SYSTEM
 New Constitution (1990): the right to health care for
all is guaranteed
 Under-financing ...
Life expectancy at birth (women,Life expectancy at birth (women,
2002)2002)
Country/Country/
RegionRegion
RomaniaRomania E...
Standardised death rates per 100,000Standardised death rates per 100,000
Rank Group of diseases Romania 2000 EU
2000
1. Ca...
Maternal Mortality (2002)Maternal Mortality (2002)
Country/Country/
RegionRegion
RomaniaRomania EUEU USAUSA
Maternal morta...
Cervical Cancer Mortality Rates inCervical Cancer Mortality Rates in
Selected Countries (2000)Selected Countries (2000)
((...
Trends in mortality from cervical cancerTrends in mortality from cervical cancer
0
3
6
9
12
15
1970 1975 1980 1985 1990 19...
Psychosocial and Health System
Dimensions of Cervical Cancer
Screening In Romania* (2004-2005)
 Babes-Bolyai University, ...
PROJECT AIMS
 Estimate the prevalence of cervical cancer screening
among Romanian women
 Identify demographic and socio-...
Study Methods
KAP structured survey
Semi-structured interviews
In-depth interviews
Focus groups
Perceived
susceptibility
Perceived
susceptibility
Perceived severity
Perceived severity
Perceived barriers
costs
Perceived...
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't
know
Cervical screening...
  
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
Ce...
Barriers frequency
Barriers Frequency (N=1053)
My doctor never suggested it 31.8 %
Gynecological visits are unpleasant 30....
Women’s Beliefs about Cervical Cancer and Screening
Ever had
smear test
(Mean, SD)
Never had
smear test
(Mean, SD)
tt pp
S...
Predictors of Screening Behavior
Dimension Model 4
Residence*Residence* 1.90 [1.13-3.20]
KnowledgeKnowledge 1.58 [1.37-1.8...
Women’s Constructions of Prevention
“My body is resistant and it hasn’t created me
any problems so far, at 49, so I’ve nev...
WWomen’s Constructions of Prevention
(cont)
“I did not go to ask for the Pap smear because I
can’t have cancer. I’m feelin...
Women’s Perceptions of Health Services
“As a young and healthy woman, I would feel
really bad to take up the time of a doc...
Women’s Perceptions of Health Services
“When you go to doctors you get the impression
that you bother them, they give you ...
Locating Responsibility for Cervical
Cancer Prevention
“The Pap test should only be performed by the
gynecologist; no way ...
Health Professional’s Perceptions of Cervical
Cancer Prevention Program
Legal and Policy FrameworkLegal and Policy Framewo...
Financing Cervical Cancer Prevention
 NCCPP: low, fluctuating, uncertain budget
 The National House for Health Insurance...
System Capacity: Infrastructure and
Human Resources
“What national screening program could there be? With
whom and what?” ...
Practice Regulations
Regulations in accordance with EU norms
 Target groups (25 –65 years of age)(25 –65 years of age)
 ...
Information, Education and Communication
No training for medical doctors and nurses on
counseling information and skills.
...
Providers’ Constructions of the Role of
Women in Cervical Cancer Screening
Blaming the “victim”
 Women as irresponsible
...
Final Comments
An urgent need for interventions to reorganize
cervical cancer screening in Romania through:
 influencing ...
What Happens When Women's Preventive Care is Undervalued? Lessons from Romania
What Happens When Women's Preventive Care is Undervalued? Lessons from Romania
Upcoming SlideShare
Loading in …5
×

What Happens When Women's Preventive Care is Undervalued? Lessons from Romania

213 views

Published on

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

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
213
On SlideShare
0
From Embeds
0
Number of Embeds
19
Actions
Shares
0
Downloads
3
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide

What Happens When Women's Preventive Care is Undervalued? Lessons from Romania

  1. 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
  2. 2. 1990 the year of a new start1990 the year of a new start
  3. 3. 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
  4. 4. 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
  5. 5. 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
  6. 6. 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
  7. 7. 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
  8. 8. 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
  9. 9. 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
  10. 10. 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
  11. 11. 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
  12. 12. Study Methods KAP structured survey Semi-structured interviews In-depth interviews Focus groups
  13. 13. 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
  14. 14. Study Participants  National representative sample (1053 women)  30 women  35 key informants  50 health care providers
  15. 15. 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
  16. 16.    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
  17. 17. 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 %
  18. 18. 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
  19. 19. 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
  20. 20. 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”.
  21. 21. 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?”
  22. 22. 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”.
  23. 23. 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”.
  24. 24. 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.”
  25. 25. 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).
  26. 26. 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).
  27. 27. 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
  28. 28. 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)
  29. 29. 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).
  30. 30. 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
  31. 31. 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.

×