What Happens When Women

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What Happens When Womens Preventive Care Is
Undervalued? Lessons from Romania

• Adriana Baban, PhD
• Babes-Bolyai University
• Cluj-Napoca, ROMANIA

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1990 the year of a new start
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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 18relative poverty

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ROMANIANS 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

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Life expectancy at birth (women, 2002)
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Standardised death rates per 100,000
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Maternal Mortality (2002)
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Cervical Cancer Mortality Rates in Selected
Countries (2000)(Levi, Lucchini, Negri et al,
2001)
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Trends in mortality from cervical cancer
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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

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PROJECT AIMS

• Estimate the prevalence of cervical cancer
  screening among Romanian women
• Identify demographic and socio-economic
  correlates of screening behavior
• Assess womens 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

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Study Methods

• KAP structured survey
• Semi-structured interviews
• In-depth interviews
• Focus groups

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Study Participants

• National representative sample (1053 women)
• 30 women
• 35 key informants
• 50 health care providers

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Cervical screening history
 
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Cervical Screening Awareness and Knowledge
 
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Barriers frequency
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Womens Beliefs about Cervical Cancer and
Screening
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Predictors of Screening Behavior
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Womens Constructions of Prevention

• My body is resistant and it hasnt created me
• any problems so far, at 49, so Ive never had to
• go to the doctor, except when I was pregnant.
• I dont even know my GP. I have registered with
• him but Ive never been there.
• I am not the type of woman who goes to
• the doctor for any little thing.

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Womens Constructions of Prevention(cont)  

• I did not go to ask for the Pap smear because I
• cant have cancer. Im feeling okay. Cancer is
• one of those diseases where you cant feel
• Healthy.
•  
• I feel that nothing is wrong with me, so why
• should I have the test?
•  

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Womens 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.
•  

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Womens 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 Gods name you
• bother them, that your problem is not something
• they should be wasting their time with.
•  

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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 womans body. This is why hes called a
• specialist, while the GP is a generalist, he
• knows a little of everything.
•  

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Health Professionals Perceptions of Cervical
Cancer Prevention Program

• Legal 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).

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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 dont 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).

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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

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Practice Regulations

• Regulations in accordance with EU norms
• Target groups (25 65 years of age)
• Interval for Screening (3 years)
• Active screening
• GPs involved in screening
• We know all too well what we have to do!
• (gynecologist)

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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).

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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
•  

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Final Comments

• An urgent need for interventions to reorganize
• cervical cancer screening in Romania through
• influencing womens 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.