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

1. What Happens When Women’s Preventive Care Is Undervalued? Lessons from Romania Adriana Baban, PhD Babes-Bolyai University Cluj-Napoca, ROMANIA

3. 1990 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, 2002)

7. Rank Group of diseases Romania 2000 EU 2000 1. Cardiovascular667.8 257.8 2. Malignant tumours172.2 184.7 3. Respiratory system67.3 60.4 4. Digestive system diseases65.2 61.5 5. Accidents, poisonings64.039.8 6. Infectious diseases 15.8 7.3 7. TB10.6 0.8 Standardised death rates per 100,000

8. Maternal Mortality (2002)

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

10. Trends in mortality from cervical cancer

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. FACTORS PSYCHOSOCIAL FACTORS SOCIOECONOMIC FACTORS Knowledge/ Perceived stress/ well-being DEMOGRAPHIC FACTORS Perceived severity Social support HEALTH CARE SYSTEM: Access; pathways; organization of screening; structural barriers, doctor-patient relations Perceived barriers costs Normative beliefs Perceived benefits EMOTIONS (Fear/ Worry) Perceived susceptibility Health Locus of Control BEHAVIORAL INTENTIONS SCREENING BEHAVIOR

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

17. Cervical screening history

18. Cervical Screening Awareness and Knowledge

19. Barriers frequency

20. Women’s Beliefs about Cervical Cancer and Screening

21. Predictors of Screening Behavior

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. Women’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 problemis 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 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) • Interval for Screening (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.