Romania has one of the highest rates of cervical cancer incidence and mortality in the Eastern European region.
It is likely this is partly due to the legacy of the pro-natalist policies introduced between 1966 and 1989.
There is considerable stigma around cervical cancer screening and HPV vaccine due to associations with promiscuity.
Part of the solution could be ensuring fully informed consent for cervical cancer screening and engaging with communities when developing health promotion efforts.
Cervical cancer is the second most common form of cancer among European women aged 15–44. In recent years, many countries have seen a decline in incidence. However, it continues to remain high within Eastern Europe and in particular in Romania, which has the highest rates of cervical cancer incidence and mortality across the region. While attempts to introduce effective nationwide screening programmes have been made, take up and outcomes have remained poor.
Contributing factors to the negative outcomes of screening programmes include a lack of economic resources at individual and health provider level as well as inconsistent programme management and implementation.
However, qualitative studies demonstrate that the socio-cultural context similarly plays an important role in determining the effectiveness of the screening programmes. These studies place considerable emphasis on the politicisation of women’s bodies. Within the context of dramatic shifts in Romanian family planning policy and service provision over the past six decades, women’s bodies have often metaphorically been associated with the notion of a viable nation state.
During the Ceausescu regime from 1966–1989, women were routinely subjected to gynaecological exams at their workplace in an effort to bar any potential attempts to illegally abort unwanted pregnancies. This and the long-standing culture of surveillance and regulation have brought about an inherent mistrust towards the medical system which causes women to avoid screening. This legacy is also thought to be the reason why many parents refuse to allow their daughters to have the HPV vaccination, introduced in 2008.
Discussions of introducing mandates for compulsory screening are embedded in this historical context. However, the attitude toward screening is not only reflective of the legacy of the Romanian communist regime but also of the wider cultural and social perceptions of women’s health and behaviour in Romania.
For instance, one study showed that sexual health care clinicians, to a large extent, perceive women as ‘irresponsible’ and in need of monitoring and sanctioning in order to follow procedures for prevention. In addition, cervical cancer is associated with promiscuity which serves to stigmatise screening and shifts attention away from the needs of older women. And lastly, some practitioners consider themselves responsible for medical treatment rather than education and prevention.
These culturally and historically shaped attitudes toward sexual health could explain why Romania is one of the only European countries not to have introduced population based screening. According to one report from the European Commission, countries without population based screening have lower response rates than countries inviting all women from the target age groups.
All countries with population-based programmes send written invitations to the eligible women through the screening registry. In Romania, these are disseminated through the primary health care or through the general practitioners. Additionally, whilst informed consent for cervical cancer screening is required in several European countries, Romanian practitioners need only obtain verbal consent. This could further enhance the mistrust towards health practitioners.
In order to earn the trust of the women, practitioners would need to focus on obtaining fully informed consent. This necessitates spending time talking to the women in a non-judgemental way about what the screening entails. Health promotion efforts should also focus on the benefits of regular screening and include educational material on HPV prevalence and transmission in order to destigmatise the procedure.
However, education alone may not be enough to change people’s behaviour when there is such a strong negative legacy around screening. Therefore, it could be useful for health practitioners to engage with communities, build advocacy among community leaders and develop ways to promote screening together with people in the communities.
Links for further reading
- European Commission (2017). Cancer Screening in the European Union. Report on the implementation of the Council. [online] Available at: https://ec.europa.eu/health/sites/health/files/major_chronic_diseases/docs/2017_cancerscreening_2ndreportimplementation_en.pdf
- International Agency for Research on Cancer (2015) Cervical cancer. Available online: http://eco.iarc.fr/EUCAN/CancerOne.aspx?Cancer=25&Gender=2 (accessed 25/11/15).
- Johnson, B. R., Horga, M., and Andronache, L. (1996) Women’s perspectives on abortion in Romania, Social Science and Medicine, 42(4): 521-530.
- Kirkham, J. (2011) Sexual and reproductive health in Romania and Moldova: contexts, actors, challenges, PhD thesis, University of Glasgow.
- Nicula, F. A., Antilla, A., Neamtju, L., Zakelj, M. P., Tachezy, R., Chil, A., Grce, M. and Kesic, V. (2009) Challenges in starting organised screening programmes for cervical cancer in the new member states of the European Union, European Journal of Cancer, 45(15): 2679-2684.
- Rada, C. (2014) Sexual behaviour and sexual and reproductive health education: a cross-sectional study in Romania, Reproductive Health, 11: 48.
- Sen A. (1976) ‘Real national income’, Review of Economic Studies, 43 (1), 19–39.
- Todorova, I., Baban, A., Alexandrova-Karamanova, A. and Bradley, J. (2009) Inequalities in cervical cancer screening in Eastern Europe: perspectives from Bulgaria and Romania, International Journal of Public Health, 54: 222-232.
- Todorova, I. L. G., Baban, A., Balabanova, D., Panayotova, Y. and Bradley, J. (2006) Providers’ constructions of the role of women in cervical cancer screening in Bulgaria and Romania. Social Science and Medicine, 63: 776-87.