HPV Testing for Cervical Cancer in Romania: High-Risk HPV Prevalence among Ethnic Subpopulations and Regions

The effect of the music-supported education program on the awareness and health beliefs of Roma women about cervical cancer and screening

BACKGROUND

Roma women, who have low education, are one of the risk groups for cervical cancer as it has proven that they marry and give birth at an early age and have limited access to preventive health services.

AIM

This study aims to reveal the effect of a music-supported education program based on the Health Belief Model on the awareness and health beliefs of Roma women about cervical cancer and screening.

METHODS

This study was conducted between June 2021- January 2022 with 40 Roma women in the experimental group and 40 in the control group. Data were collected using the Personal Information Form and the Health Belief Model Scale for Cervical Cancer and Pap Smear Test. The experimental group received a four-week training and a two-week music-supported training.

RESULTS

It was revealed that 27.5% of the Roma women in the experimental group had the pap smear test after the intervention, and there was a significant difference in the mean scores of the awareness of cervical cancer and screening and the factors of the Health Belief Model Scale for Cervical Cancer and Pap Smear Test compared to the pre-intervention. It was found that the intervention had a significant effect at the level of 77.9% in reducing the perceived barriers to the pap smear test (p < 0.001).

CONCLUSION

It was found that the music-supported education program based on the Health Belief Model positively affected the awareness and health beliefs of Roma women about cervical cancer and screening.

TRIAL REGISTRATION

The study was registered with the U.S.National of Medicine Clinical Trials Registry (NCT04756440 -15.08.2020).

Beyond Vaccination: Exploring Young Adults' Awareness, Knowledge, and Attitudes Related to Sexually Transmitted Infections in Romania

BACKGROUND AND OBJECTIVES

Romania has the highest rate of cervical cancer in Europe. The aim of this study is to measure the level of sexual health knowledge among participants and determine the extent to which factors such as age, gender, education level, access to sexual health resources, and cultural background influence their knowledge.

MATERIALS AND METHODS

A cross-sectional study was conducted on 1089 Romanian youth participants aged 18-35 years. A self-administered online questionnaire was used concerning the level of knowledge relating to STIs, contraception methods, and preventive attitudes during the 2023-2024 academic year.

RESULTS

Most of the participants (93,8%) scored a "good-to-excellent" STI level of knowledge. Despite this, 71.9% of the responders had never taken an HIV test, and 63.5% had never been tested for other STIs. Logistic regression analysis revealed a direct association between higher STI knowledge levels among respondents with age (p < 0.001), underage sexual debuts (p = 0.018), greater parental education (p = 0.016), and those who studied health sciences (p < 0.001).

CONCLUSIONS

This study highlights the critical need for health communication campaigns to enhance STI knowledge and vaccine literacy to improve the vaccination rates among young people in Romania. The identified knowledge gaps, frequent misconceptions, and barriers to STI testing underscore the importance of comprehensive sexual health education, public health initiatives for reducing the stigma associated with STIs, and improved access to healthcare services for young people.

Understanding Cervical Cancer Screening Attendance: Barriers and Facilitators in a Representative Population Survey

Background/Objectives: Cervical cancer causes high mortality rates globally despite the existence of cervical cancer screening. The purpose of this study is to investigate the factors limiting Romanian women's participation in cervical cancer screening, focusing on socio-demographic characteristics, health practices, sexual history, and personal health views. Methods: A cross-sectional study was conducted with a representative sample of 1605 women aged 25 to 64 from all regions of Romania. Computer-Assisted Telephone Interviewing was performed in February and March 2020. Logistic regression models assessed the impact of socio-demographic characteristics, psychosocial factors, sexual health history, and personal beliefs on non-participation, which were quantified using the odds ratio. Results: A percentage of 25.1% of women had never been screened for cervical cancer. Higher education and income levels were linked to higher screening rates. The adjusted odds for a lack of HPV awareness were significantly high (aOR: 2.45, 95% CI: 1.85-3.25), highlighting a gap in health knowledge affecting screening behavior. Not receiving a referral to a specialist from the primary care physician (aOR: 2.96, 95% CI: 2.09-4.19) was strongly associated with increased odds of non-participation. Personal beliefs about cancer prevention, health misconceptions, perceived costs, and stigma emerged as significant contributors to cervical cancer screening participation. Conclusions: Analyzing predictors influencing participation in cervical screening is crucial for public health in Romania, which has high cervical cancer mortality and low participation rates in cervical cancer screening. To improve participation, we recommend enhanced physician referrals, HPV awareness campaigns, addressing social stigma, and widespread communication about screening availability.

Educational inequalities in cervical cancer screening participation in 24 European countries

OBJECTIVES

Cervical cancer screening (CCS) is an important public health measure for early detection of cervical cancer and prevents a large proportion of cervical cancer deaths. However, participation in CCS is relatively low and varies substantially by country and socio-economic position. This study aimed to provide up-to-date participation rates and estimates on educational inequalities in CCS participation in 24 European countries with population-based CCS programmes.

STUDY DESIGN

This was a cross-sectional study.

METHODS

Using data from the European Health Interview Survey (EHIS) conducted in 2019, 80,479 women aged 25-64 years were included in the analyses. First, standardized participation rates and standardized participation rates by educational attainment were calculated for all 24 countries based on each country-specific screening programme organization. Second, a series of generalized logistic models was applied to assess the effect of education on CCS participation.

RESULTS

Screening participation rates ranged from 34.1% among low-educated women in Romania to 97.1% among high-educated women in Finland. We observed that lower-educated women were less likely to attend CCS than their higher-educated counterparts. Largest educational gaps were found in Sweden (odds ratio [OR] = 6.36, 95% confidence interval [CI] = 3.89-10.35) and Poland (odds ratio = 5.80, 95% CI = 4.34-7.75).

CONCLUSION

Population-based screening initiatives have successfully reduced participation differences between women with medium and high educational attainment in some countries; however, persistent disparities still exist between women with low and high levels of education. There is an urgent need to increase participation rates of CCS, especially among lower-educated women.

Status of Healthy Choices, Attitudes and Health Education of Children and Young People in Romania-A Literature Review

Background and Objectives: This study aims to assess the health status and factors influencing healthy choices among children and young people in Romania, as well as the efficacy of related health education programs. Through understanding these dynamics, the study seeks to provide insights that can shape targeted interventions, policies, and educational strategies to improve this demographic's overall health and well-being. Materials and Methods: For this study, we performed a literature review of original published papers on the health status, healthy habits, health education, predisposition to making healthy choices in the future, and accessibility to the paediatric health system of Romanian children and young people, as well as the effects of different types of educational interventions on this demographic in Romania. Results: The prevalence of dental caries is high in Romania. In terms of eating habits and nutritional status, a worrying proportion of children are overweight or obese, which can lead to a variety of future physical and psychological problems. In terms of physical activity, few adolescents demonstrate regular fitness practices. Romania presents an increase in alcohol and tobacco consumption among adolescents. The mental health of students has become a pressing public health concern, exacerbated by the COVID-19 pandemic. The use of social networks is linked to mental health issues among young people. Romania still has one of the highest rates of sexually transmitted diseases and faces a high incidence of cervical cancer, with a mortality rate three times higher than the EU average. High rates of teenage pregnancies are linked to limited information about sexuality and a lack of access to family planning at a young age. There are large discrepancies in the accessibility of medical services between urban and rural areas. Conclusions: Romania faces significant obstacles to providing high-quality healthcare to children and young people. Improving nutrition, immunisation rates, and access to medical services represent essential areas for enhancing the health of children and young people in Romania.

Prevalence and sociodemographic predictors of high-risk vaginal human papillomavirus infection: findings from a public cervical cancer screening registry

INTRODUCTION

High-risk human papillomavirus (HPV) screening is vital for early cervical cancer detection and treatment. With the introduction of the national cervical cancer screening programme and screening registry in Malaysia, there is a need to monitor population-based HPV screening uptake and high-risk HPV prevalence as part of cervical cancer surveillance.

OBJECTIVE

To determine the prevalence and sociodemographic factors predicting high-risk HPV infection in Malaysia based on a public, community-based cervical cancer screening registry targeting women at risk of getting HPV infection.

METHODS

The study used data from the Malaysian cervical cancer screening registry established by the Family Health Development Division from 2019 to 2021. The registry recorded sociodemographic data, HPV test details and results of eligible women who underwent HPV screening at public primary healthcare facilities. A vaginal sample (via self-sampling or assisted by a healthcare provider) was used for DNA extraction for HPV detection and genotyping. Registry data were extracted and analysed to determine prevalence estimates of high-risk HPV infection. Multifactorial logistic regression analysis was conducted to determine predictors of high-risk HPV infection. All analyses were performed using Stata version 14.

RESULTS

The programme screened a total of 36,738 women during the study period. Women who attended the screening programme were mainly from urban areas, aged 30-39 years, and of Malay ethnicity. The prevalence of high-risk HPV infection was 4.53% among women screened, with the yearly prevalence ranging from 4.27 to 4.80%. A higher prevalence was observed among urban settling women, those aged 30-49 years, those of Indian ethnicity, and those without children. The results from logistic regression showed that women from urban areas, lower age groups, of Indian or Chinese ethnicity, and who are self-employed were more likely to be infected with high-risk HPV.

CONCLUSION

Targeted and robust strategies to reach identified high-risk groups are needed in Malaysia. In addition, the registry has the potential to be expanded for an improved cervical cancer elimination plan.

TRIAL REGISTRATION

Trial registration number: NMRR ID-22-00187-DJU.

Assessing the Level of Knowledge and Experience Regarding Cervical Cancer Prevention and Screening among Roma Women in Romania

Background and Objectives: Romania ranks among the countries with a particularly high rate of mortality that can be prevented through prevention programs, screening, early detection, and prompt care. Cervical cancer (CC) is a major cause of these preventable deaths, affecting individuals from marginalized and rural regions, as well as the Roma population. The purpose of this article was to identify accurate and consistent information about the Roma population on the risk of CC, as well as the importance of understanding the causes of the disease and awareness of the available prevention methods. Materials and Methods: A cross-sectional study was conducted using a self-administered questionnaire applied only to Roma women in Romania. Results: We enrolled 759 patients in this study. These were divided into two groups: Group 1 comprised 289 (38.1%) women who had been tested for HPV infection, while Group 2 included 470 (61.9%) women who had never been tested for HPV infection. Characterization of women in Group 1: mostly aged between 25 and 54 years, with high school education, married, who started sexual activity under the age of 18 years, with only one sexual partner, and had over five pregnancies. Regarding contraceptive methods, 35.7% of women do not know or use any contraceptive method, and 32.2% use hormonal contraceptives. Two thirds of the women tested had heard of HPV, and 19.7% were vaccinated against HPV with at least 2-3 doses. A percentage of 8.7 had a diagnosis of CC, compared to those who were not tested (p-0.0001), whereas 63% of the tested women did not know much about CC, as opposed to 85.7% of the group of untested women. Conclusions: Cervical cancer (CC) continues to be a public health concern in Romania, particularly among vulnerable groups. Promoting campaigns to raise awareness for HPV vaccination and CC screening are necessary to reduce the associated mortality and morbidity.

Inequities in Screening and HPV Vaccination Programs and Their Impact on Cervical Cancer Statistics in Romania

(1) Introduction: A Romanian woman is diagnosed with cervical cancer every two hours; the country ranks second in Europe in terms of the mortality and incidence rate of this disease. This paper aims to identify the main reasons that have led to this situation, focusing on the measures taken by the Romanian Ministry of Health for the prevention of this type of cancer-national programs for cervical cancer screening and HPV vaccination. (2) Materials and methods: We performed a study based on the available secondary data from the National Statistics Institute, World Health Organization and Bucharest Institute of Oncology in order to assess the burden associated with cervical cancer and place it in the context of known global and European incidence and mortality rates, thus evaluating the importance of this health issue in Romania. The second component of our study was a cross-sectional study. Here, we used a 14-question questionnaire applied to the women participating in the National Screening Program for Cervical Cancer and aimed to evaluate the women's level of knowledge about screening and HPV vaccination and their access cervical-cancer-specific healthcare services. (3) Results: The results of this research show that a high percentage of women postpone routine checks due to a lack of time and financial resources and indicate that a low level of knowledge about the disease and the specific preventive methods determines the low participation in screening and HPV vaccination programs implemented in Romania, contributing to the country's cervical cancer situation. (4) Conclusions: The national programs have complicated procedures, are underfunded and do not motivate healthcare workers enough. This, combined with the lack of information for the eligible population, adds up to an extremely low number of women screened and vaccinated. Our conclusion is that the Romanian Ministry of Health must take immediate action by conducting major awareness campaigns, implementing measures to make the programs functional and ensuring coherent funding.

The Hybrid Capture 2 Results in Correlation with the Pap Test, Sexual Behavior, and Characteristics of Romanian Women

BACKGROUND

Human papillomavirus (HPV) infection is the major cause of cervical cancer (CC); hence, it is critical to understand the processes by which HPV infection causes squamous intraepithelial lesions, as well as the proper diagnostic tools. The objective of this study was to establish the correlations between Pap test results and Hybrid Capture 2 (HC2) tests findings.

MATERIALS AND METHODS

This study included 169 women between the ages of 30 and 64, who presented for consultation in gynecological clinics in both the public and the private sectors. These women reported symptoms, such as abnormal vaginal discharge and genital irritation, as well as early onset of sexual activity, multiple sexual partners, history of other sexually transmitted infections or high-risk sexual partners, immunosuppression, or tobacco smoking. Pap tests and HPV testing, using the HC2 method, were performed for the women enrolled in the study, including data gathered after patients completed questionnaires concerning their sexual behavior.

RESULTS

The HC2 method revealed that 66 patients (39.1%) tested positive for high-risk HPV types. Of the patients with positive results, 14 (21.2%) presented Atypical Squamous Cells of Undetermined Significance (ASC-US) compared to 10 (9.7%) patients in the negative group (p = 0.042). Atypical Squamous Cells for which a high-grade lesion cannot be excluded (ASC-H) were identified primarily in women with positive HC2 (6.1%). HR-HPV positivity was substantially more associated with low-grade ASC-US or low-grade squamous intraepithelial lesion (LSIL) and high-grade ASC-H cytology (OR = 2.53; 95% CI: 1.10-5.80, respectively, OR = 14.9; 95%CI: 1.006-34.59). Unmarried women (31.8%; p = 0.004) and women with multiple partners (over four partners, 10.6%; p = 0.03) were more likely to have an HPV infection when compared to married women and those with fewer sexual partners.

CONCLUSIONS

Understanding the epidemiology of HPV genital infections is essential for developing preventive measures against this infection and CC. Identifying the most prevalent HPV types, and determining the incidence of HPV oncogenic infections, in conjunction with Pap test results and sexual behavior information, can constitute part of an algorithm for the efficient management of cervical intraepithelial lesions.

The Prevalence of High-Risk Human Papillomavirus in Hungary—A Geographically Representative, Cross-Sectional Study

Background: The estimated age-standardized incidence and mortality rates of cervical cancer in Hungary are substantially higher than the European average. In many countries, human papillomavirus (HPV) testing is the first-line method of cervical cancer screening in women >30 years. According to the European guidelines, evidence-based improvement of a national prevention strategy requires the monitoring of representative data.

Methods: ThinPrep cervical samples were collected over a period of 8 months at 84 sampling sites, including 4,000 eligible samples with valid laboratory results from the screening target population of females aged 25–65 years, with addresses in the representative geographic area (19 counties and four major settlement types). Genotyping of high-risk HPV (hrHPV) was performed using the Confidence HPV-X (Neumann Diagnostics) and Linear Array HPV Genotyping (Roche) tests. Demographic data were collected using a questionnaire, enabling the analysis of hrHPV genotype distribution by age, geography, education, and HPV vaccination.

Results: Overall, 446 samples were hrHPV-positive, showing a prevalence of 11.15% (9.73% age-representative), similar to the world average, higher than the European average, and lower than the Eastern-European average. After age standardization, no significant geographic differences were found, except for low hrHPV prevalence in villages (p = 0.036) and in those with elementary education (p = 0.013). Following genotypes 16 and 31, in order of frequency, certain non-vaccine hrHPV genotypes (HPV51, 66, 56) showed unexpectedly higher prevalence than international data.

Conclusion: Our study provides the first geographically representative genotype-specific hrHPV prevalence baseline database in Hungary to support policy-making efforts. Significant correlations with demographic data have transferable conclusions.

Assessing the Level of Knowledge, Beliefs and Acceptance of HPV Vaccine: A Cross-Sectional Study in Romania

(1) Background: The infection with Human papilloma virus (HPV) is the most common sexually transmitted infection and it has been associated with cervical cancer (CC) in 99.7% of the cases. In Romania, CC is the second most common, with incidence (22.6%000) and mortality rates (9.6%000) three times higher than any other European country. Our aim was to assess the level of knowledge regarding HPV infection among parents, highschool students, medical students and doctors, with an emphasis on their main source of information-the Internet. (2) Methods: We applied five questionnaires to six categories of respondents: parents of pupils in the 6th-8th grades, medical students, doctors, boys in the 11th-12th grades, girls in the 11th-12th grades and their mothers. (3) Results: We included a total of 3108 respondents. 83.83% of all respondents had known about HPV infection. The level of information about HPV infection and vaccination was either satisfactory, poor or very poor. Their main source of information varied depending on the respondent profile and professional activity. Medical students were informed by doctors and healthcare professionals (53.0%), doctors gathered their information from books, journals and specialized brochures (61.6%). For the other categories of respondents, the Internet was the main source of information. Most respondents answered that doctors and healthcare professionals should provide information on HPV infection and vaccination, but very few of them actually seeked information from their general practitioner. (4) Conclusions: Population adherence to the appropriate preventative programs, as well as relevant information disseminated by the medical staff are key elements towards reducing the risk of HPV-associated cancers. An important role could also be played by schools, where teachers and school doctors could provide relevant information on the general aspects of HPV infection. Additionally, sex education classes and parent-teacher meetings should cover the main characteristics of HPV infection and what preventative measures can be employed against it.

Predicting cervical screening and HPV vaccination attendance of Roma women in Hungary: community nurse contribution is key

BACKGROUND

HPV screening/vaccination has been observed lower for ethic minorities. Understanding factors that predict and can improve attendance is therefore key. Hence, the aim was to identify causes, especially concerning the quality of the patient-provider relationship, that predict past HPV screening and vaccination turnout of Roma women in Hungary.

METHODS

Cross-sectional research design with self-developed, culturally sensitive questionnaire. A final, female Roma sample of 368 participants was randomly selected from census register. Community nurses contacted participants and distributed surveys. Surveys were mailed-in by participants. Bivariate logistic regression was used to predict former participation in HPV screening/vaccination.

RESULTS

Of the total sample, 17.4% of women attended at least one cervical screening and HPV vaccination in the past. Bad screening experience was positively associated with racially unfair behaviors of physicians. The odds of past attendance were 4.5 times greater if 'no negative earlier experience' occurred, 3.3 times likelier if community nurse performed screening/immunization and 1.6 times more probable if respondent felt 'no shame'. Evaluating the screening/vaccination process painful, being only financially motivated and attendance involving a lot of travel decreased the odds of 'no show' by 50%, 40% and 41%, respectively.

CONCLUSIONS

When considering the ratio of past cervical screening attendance, we conclude that our female Roma sample did not behave differently from the general population. We saw no evidence that racial mistreatment made any contribution to explaining cervical screening participation. Past positive screening experience and the quality of patient-provider relationship increased the odds of participation the most. Cancer of friends, pain, financial motivation and travel distance decreased odds of participation to a lesser extent. In order to improve future screening and immunization, community nurses should play more central and advanced role in the organization and implementation of such services specifically targeting Roma populations.

Cervical Cancer Mortality in Romania: Trends, Regional and Rural-Urban Inequalities, and Policy Implications

Background and Objectives: Despite being largely preventable, cervical cancer mortality still remains an important public health problem globally, in Europe, and in Romania. The European Union member states are urged to implement systematic, population-based screenings for cervical cancer, but the programs developed by the countries remain very heterogeneous. This study aimed to investigate the differences in cervix cancer mortality between Romania and EU and within Romania over the last two decades and to reveal the major sources of inequalities and the policy implications. Materials and Methods: We analyzed the number of deaths and the mortality rates by cervical cancer, standardized using the direct method, over two decades (2001-2016 for the EU, and 2001-2019 for the national and sub-national analyses). Trends, mortality reduction over the years, and mortality differences at the beginning and end of the time interval have been calculated for the EU and Romania, at national and sub-national levels (rural-urban and regions). Results: Our results revealed differences in cervical cancer mortality between Romania and EU and within Romania (among regions and rural-urban areas). These differences used to be very high in the past and are still persisting. Conclusions: The country should revisit its national cervical cancer screening program, which has been implemented for many years, but with a very limited participation rate. Due to the similar problems existing in Central-Eastern Europe, targeted support from the EU for the members from this geographical area could contribute to the minimization of differences in cervical cancer mortality among the EU members.

Challenges in the Prevention of Cervical Cancer in Romania

Approximately every two hours, a Romanian woman is diagnosed with cervical cancer as the country ranks first in the EU in terms of its mortality rate. This paper aims to identify the main reasons that have led to this situation. First, a study based on secondary data was conducted in order to identify measures taken by the Romanian Ministry of Health for the prevention of this type of cancer. Second, a quantitative study was conducted to evaluate the impact that exposure to information and awareness campaigns has on women's behavior regarding cervical cancer prevention through screening. The results of the research show an increased percentage of the women understanding the importance of screening and the benefits of early diagnosis, but also shows that a high percentage of women postpone the routine checks due to lack of time and financial resources. The research results also indicate that the only free screening program implemented in Romania during 2012-2017 was a failure due to poor procedures, low number of women tested, underfunding and the lack of promotion. Our conclusion is that the Romanian Ministry of Health has to take immediate action by conducting major awareness campaigns and also by implementing functional screening programs.

Roma Health: An Overview of Communicable Diseases in Eastern and Central Europe

The Roma are Europe’s largest minority. They are also one of its most disadvantaged, with low levels of education and health and high levels of poverty. Research on Roma health often reveals higher burdens of disease in the communities studied. This paper aims to review the literature on communicable diseases among Roma across Eastern and Central Europe. A PubMed search was carried out for communicable diseases among Roma in these parts of Europe, specifically in Romania, Bulgaria, Hungary, Serbia, Slovakia, the Czech Republic and North Macedonia. The papers were then screened for relevance and utility. Nineteen papers were selected for review; most of them from Slovakia. Roma continue to have a higher prevalence of communicable diseases and are at higher risk of infection than the majority populations of the countries they live in. Roma children in particular have a particularly high prevalence of parasitic disease. However, these differences in disease prevalence are not present across all diseases and all populations. For example, when Roma are compared to non-Roma living in close proximity to them, these differences are often no longer significant.