Implementation of Gastric Cancer Screening in Vulnerable Populations: A Comprehensive Analysis of the TOGAS Qualitative Study in the Romanian Roma Community

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BACKGROUND AND AIMS: Gastric cancer (GC) remains a formidable global health burden. While incidence rates have declined in Europe, substantial differences between countries exist. In Romania, GC remains the sixth most prevalent cancer. This epidemiological divide is driven largely by the high prevalence of Helicobacter pylori (H. pylori), a class I carcinogen. Despite the proven efficacy of "screen-and-treat" strategies in high-incidence Asian cohorts, the European Union currently lacks organized, population-based GC screening programs. The Romanian Roma community experiences profound socioeconomic marginalization, resulting in starkly unequal access to preventative screening opportunities. METHODS: A qualitative, co-creative focus-group study was conducted in Cluj County, Romania, to assess the perception and the acceptability of GC screening among Roma adults. Utilizing a convenience sampling strategy, 36 participants (aged 18-75) were recruited. The study employed a sequential, two-stage design comprising an initial educational session to establish foundational health literacy regarding gastric anatomy and H. pylori, followed by a semi-structured focus group discussion. Data were analyzed using a modified grounded theory approach to identify core themes regarding screening knowledge, diagnostic preferences, and communication barriers. RESULTS: The analysis revealed a significant "concept gap," with the term "screening" being unrecognizable to most participants. While theoretical willingness to participate in the program was high, it was heavily stratified by testing modality. The majority of participants demonstrated a decisive preference for serology and urea breath test due to familiarity of serology and perceived non-invasiveness of the breath test. Conversely, stool antigen testing was viewed with reluctance due to logistical barriers related to sanitation and dignity. Acceptance of invasive gastroscopy was conditional, dependent entirely on the recommendation of a trusted general practitioner (GP). CONCLUSIONS: Implementing organized GC screening in the Roma community requires a paradigm shift from population invitation models to flexible, community-centered approaches. Successful implementation will require reframing "screening" as a "stomach health check," utilizing GPs as the primary recruitment node, and deploying Roma health mediators to bridge the literacy and trust gap. These findings underscore the necessity of precision in public health that adapts clinical guidelines to the social realities.

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