As confidence in institutions falls in the wake of the COVID-19 pandemic and within the current social, political and economic climate, a shift in screening for cervical cancer in Slovenia stands out as an example of the transformative impact of trust. The country has demonstrated that eliminating cervical cancer relies on understanding how people on the front lines – patients and health workers – tackle these challenges.
If people do not trust that health services will deliver for them when needed, they are less likely to participate in the health system. As many examples from across the WHO European Region show, trust and transformation go hand in hand.
Moving from opportunistic to organized screening
Slovenia has seen cases of cervical cancer drop by almost half over the last 20 years, with the number of deaths from the disease also falling. Today, it is proud to have one of the lowest incidences of cervical cancer in Europe thanks to its screening programme ZORA.
The country has one of the oldest population-based cancer registries in Europe, meaning it can closely monitor cancer rates and easily track the effects of any cancer prevention programme. When data in the 1990s revealed an increase in the incidence of cervical cancer, authorities recognized the need for action.
Until then, the country had used opportunistic screening, which relies on women to come in for annual checkups or actively request Pap smear tests from their gynaecologists. Not everyone was convinced of the need for a transition to organized screening, especially as the testing interval was to increase from 1 year to 3 years under ZORA.
However, Urška Ivanuš, Head of ZORA, says that having gynaecologists on board who were already highly trusted by their female patients made a big difference. “The ZORA project was co-created with gynaecologists,” she explains, “so having their input and trust meant that the women soon followed.”
Building trust and consensus through collaboration
Introducing ZORA involved overcoming scepticism. This was achieved by bringing together all stakeholders to agree on the best ways to manage the new scheme. Public health experts, clinicians, policy-makers, insurance providers and patient representatives co-designed the legislation, clinical guidance and monitoring framework, and worked together to set the rules and standardize data.
Finland has also successfully reduced cervical cancer incidence and mortality by almost 80% since it began organized screening programmes covered by the public health-care system, reducing out-of-pocket payments for women. Still, it can be challenging to reach some populations. Doing so requires engaging with civil society to build trust, and ensuring that women feel confident that if screening detects something abnormal, they will be able to access follow-up care and treatment.
Taru Koivisto, Deputy Director General of the Department for Communities and Functional Capacity at the Ministry of Social Affairs and Health in Finland, attributes Finland’s high screening rates to the high level of trust in public health-care services and screening programmes. She says, “Women know that if something is found they will get diagnosed quickly and treated.”
WHO/Europe’s Tallinn Charter 15th Anniversary Health Systems Conference examined the effect that trust and transformation have on health care. The Conference focused on the growing sentiment that health services will not deliver for people when they are needed, and the erosion of trust between patients and health workers.
Co-creation and ownership
Human papillomavirus (HPV) vaccination is another key pillar in the prevention and elimination of cervical cancer. In 2023 France introduced a safe, efficient and free school-based HPV vaccination programme for girls and boys during the second year of middle school. Yet vaccine hesitancy and anti-vaccine movements have hindered progress towards attaining 80% coverage in target populations by 2030.
To build trust, France has focused on communication with parents through radio and digital media to address the safety and efficacy of the vaccine, and on educational packages for children.
The importance of trust is paramount, says Jérôme Weinbach, Deputy Director for European and International Affairs of the French Ministry for Labour, Health and Solidarities. “You cannot build trust if you do not have knowledge underlying the trust.”
In all these cases, the importance of co-creation and engagement of a broad range of stakeholders have been key to nurturing population trust in the health system and to changing perceptions. “Trust was also built over time,” says Urška Ivanuš, adding, “Codesign leads to ownership, and ownership leads to trust.”
The road to elimination
The “Roadmap to accelerate the elimination of cervical cancer as a public health problem in the WHO European Region 2022–2030”, adopted by Member States at the 72nd session of the WHO Regional Committee for Europe, outlines core principles, strategic shifts and priority actions to guide countries in reaching the 2030 targets.
Set by the Global Strategy to Accelerate the Elimination of Cervical Cancer as a Public Health Problem, these are known as the 90–70–90 targets:
- 90% of girls fully vaccinated with the HPV vaccine by age 15;
- 70% of women screened using a high-performance test by age 35, and again by age 45; and
- 90% of women identified with cervical disease receive treatment (90% of women with precancer treated, and 90% of women with invasive cancer managed).
Achieving these targets requires strong political commitment from Member States and appropriate investment in care pathways, workforce training, communications and monitoring.