Transcript Qualitative Methods in Outcomes Research

What Happens When Women’s
Preventive Care Is Undervalued?
Lessons from Romania
Adriana Baban, PhD
Babes-Bolyai University
Cluj-Napoca, ROMANIA
1990 the year of a new start
Romania: demographics & socioeconomic 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
(women, 2002)
Country/
Region
Life expectancy
Romania
EU
USA
75.1
82.1
79.9
Standardised 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
6. Infectious diseases
15.8
7.3
7. TB
10.6
0.8
Maternal Mortality (2002)
Country/
Region
Romania
EU
USA
Maternal mortality/
100,000 live births
33.9
9.8
8.9
Cervical Cancer Mortality Rates in
Selected Countries (2000)
(Levi, Lucchini, Negri et al, 2001)
Country
Mortality Rates (100,000)
USA
3.3
Canada
2.8
UK
3.9
Sweden
2.9
Finland
1.3
Romania
11.2
Trends in mortality from cervical cancer
15
12
Romania
Lithuania
Poland
Czeh R.
Slovenia
EU average
9
6
3
0
1970
1975
1980
1985
1990
1995
2000
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
 In-depth
 Focus
interviews
interviews
groups
FACTORS
PSYCHOSOCIAL
FACTORS
Knowledge/
Perceived stress/
well-being
Perceived severity
Social support
Perceived barriers
costs
Normative beliefs
Perceived benefits
EMOTIONS (Fear/
Worry)
SOCIOECONOMIC
FACTORS
DEMOGRAPHIC
FACTORS
HEALTH CARE SYSTEM:
Access; pathways; organization
of screening; structural barriers,
doctor-patient relations
Perceived
susceptibility
Health Locus of
Control
BEHAVIORAL
INTENTIONS
SCREENING
BEHAVIOR
Study Participants
 National
representative sample (1053 women)
 30
women
 35
key informants
 50
health care providers
Cervical screening history
Figure 6. Have you ever had a cervical smear?
(N=1053)
73,3%
Yes
80
No
60
40
20
0
20,2%
Don't
know
6,5%
Cervical Screening Awareness and Knowledge
Figure 10. Have you ever heard about cervical
smear? (N=1053)
53,5%
60
46,3%
50
Yes
40
No
30
Don't know
20
0,2%
10
0
Barriers frequency
Barriers
My doctor never suggested it
Gynecological visits are unpleasant
I fear a bad diagnosis
The costs of services and tests
Long lines and waiting
I don't think smears are necessary
I am too exhausted
I do not have time
Doctors might say I am complaining
Frequency (N=1053)
31.8 %
30.6 %
25.8 %
25.5 %
24.9 %
18.2 %
16 %
15.9 %
13.4 %
Women’s Beliefs about Cervical Cancer and Screening
Ever had
smear test
Never had
smear test
(Mean, SD)
(Mean, SD)
Severity
Benefits
Costs
Self-efficacy
13.74 (3.32)
26.29 (3.71)
10.87 (4.29)
4.34 (1.01)
14.20 (3.08)
24.08 (3.79)
14.43 (4.22)
3.8 (1.41)
-1.88 .05
7.63 .000
-10.94 .000
6.32 .001
Normative
beliefs
3.4 (1.12)
2.87 (1.06)
6.45
.001
Positive
attitudes
20.83 (2.3)
19.55 (2.73)
6.29
.001
t
p
Predictors of Screening Behavior
Dimension
Model 4
Residence*
1.90 [1.13-3.20]
Knowledge
1.58 [1.37-1.83]
Normative beliefs
1.27 [1-1.61]
Age
1.03 [1.00-1.05]
Perceived psychological costs
.88 [.83-.94]
.71 [.56-.90]
Frequency of gynecological
exams
Marital status (married)
Nagelkerke R2
.35 [.14-.82]
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”.
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?”
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 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.”
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).
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)
 Interval
 Active
 GPs
for Screening (3 years)
screening
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
attitudes
education;
 reducing
women’s awareness, knowledge,
and practices through public
barriers created by the health care
system;
 creating
a new environment for the delivery of
this preventive health care service.