The decade of Roma Inclusion: did it make a difference to health and use of health care services?

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Abstract

Objectives

We investigated whether the severely disadvantaged health of Hungarian Roma adults living in segregated settlements changed by the Decade of Roma Inclusion program.

Methods

We compared the results of two paired health interview surveys that we carried out using the same methodology before and after the Decade, on the general Hungarian and Roma populations.

Results

Self-perceived health status of younger Roma worsened, while it improved among older Roma. Reported experience of discrimination reduced considerably and health care utilization improved in general. Positive changes in smoking and nutrition, and negative changes in alcohol consumption and overweight were observed. Many of observed changes can plausibly be linked to various government policies, including a quadrupling of public works expenditure, banning smoking in public places, restricting marketing of tobacco products, increasing cigarette prices, and a new tax on unhealthy foods. Liberalization of rules on alcohol distillation coincided with worsening alcohol consumption.

Conclusions

We have shown that Roma remain severely disadvantaged and present an innovative sampling method which can be used to monitor changes in groups where identification is a challenge.

Electronic supplementary material

The online version of this article (doi:10.1007/s00038-017-0954-9) contains supplementary material, which is available to authorized users.

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Most cited references 14

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The health of the Roma people: a review of the published literature.

S Hajioff, Anna McKee (2000)

The Roma people originated in northern India and have been known in Europe for nearly a thousand years. For much of that time they have been the subjects of discrimination and oppression, culminating in the extermination of half a million Roma in the Nazi death camps. While it is widely believed that the health of Roma people is often poorer than the majority population, these inequalities remain largely unresearched. Published literature on the health of the Roma people was identified using Medline. Opinion pieces were excluded, as were papers relating to anthropometry and to genetic markers. The resultant papers were analysed by country of study and by disease type or care group. Some 70% of papers identified related to just three countries; Spain and the Czech and Slovak Republics. Much literature concentrates upon communicable disease or reproductive health. The limited evidence suggests increased morbidity from non-communicable disease, but there is little published on this topic. Evidence on health care, though fragmentary, suggests poorer access to health services and uptake of preventative care. Published research on the health needs of the Roma population is sparse. The topics that have received attention suggest a focus on concepts of contagion or social Darwinism, indicating a greater concern with the health needs of the majority populations with which they live. There is a need for both further research into the health of Roma people; with particular emphasis on non-communicable disease; and also for interventions that improve Roma health. Such research must, however, be handled with sensitivity, recognising the social and political context of the society concerned.

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Does socioeconomic status fully mediate the effect of ethnicity on the health of Roma people in Hungary?

Z Kósa, R. Adány, Paul R Nemeth … (2009)

Several models have been proposed to explain the association between ethnicity and health. It was investigated whether the association between Roma ethnicity and health is fully mediated by socioeconomic status in Hungary. Comparative health interview surveys were performed in 2003-04 on representative samples of the Hungarian population and inhabitants of Roma settlements. Logistic regression models were applied to study whether the relationship between Roma ethnicity and health is fully mediated by socioeconomic status, and whether Roma ethnicity modifies the association between socioeconomic status and health. The health status of people living in Roma settlements was poorer than that of the general population (odds ratio of severe functional limitation after adjustment for age and gender 1.8 (95% confidence interval 1.4 to 2.3)). The difference in self-reported health and in functionality was fully explained by the socioeconomic status. The less healthy behaviours of people living in Roma settlements was also related very strongly to their socioeconomic status, but remained significantly different from the general population when differences in the socioeconomic status were taken into account, (eg odds ratio of daily smoking 1.6 (95% confidence interval 1.3 to 2.0) after adjustment for age, gender, education, income and employment). Socioeconomic status is a strong determinant of health of people living in Roma settlements in Hungary. It fully explains their worse health status but only partially determines their less healthy behaviours. Efforts to improve the health of Roma people should include a focus on socioeconomic status, but it is important to note that cultural differences must be taken into account in developing public health interventions.

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Research on Roma health and access to healthcare: state of the art and future challenges

Maria Földes, Alina Covaci (2011)

Introduction Health inequalities experienced by Roma people living in Europe presents a persisting challenge for health research and practice. Available literature on Roma and health agrees that: (1) Roma people suffer from poorer health and unhealthier living conditions compared to majority populations, (2) better data are needed to explain the Roma health gap and design better interventions to reduce this gap and (3) the poor health of Roma is closely linked to the social determinants of health. This editorial discusses the lessons to be learnt from recent research findings and outlines a number of challenges in exploring and addressing the various mechanisms that contribute to the health gap between Roma and majority populations. The Roma health gap: understanding the underlying mechanisms During recent years we have been witnessing two notable developments in research on Roma health. First, the focus has been gradually extended from communicable diseases, child health and genetic disorders that constituted the dominant topics a decade ago (Hajioff and McKee 2000; Zeman et al. 2003) to non-communicable diseases, chronic illnesses and associated risk factors (Mladovsky 2007; Masseria et al. 2010). Second, research has moved from predominantly descriptive studies on Roma health status towards more analytical studies exploring the factors that determine the health inequalities faced by Roma. Recent evidence shows that Roma people experience specific health inequalities that cannot be traced back fully to socioeconomic factors (Masseria et al. 2010; Paulik et al. 2011; Kolarcik et al. 2009, 2010; Rosicova et al. 2011). The importance of assessing the explanatory power of socioeconomic status versus other factors has been highlighted in the context of exploring the pathways leading to ethnic differences in health (Reijneveld 2010). Evidence demonstrates that Roma people face serious barriers in access to healthcare. Such barriers include lack of health insurance and other official documentation leading to exclusion of Roma from health services, geographic isolation from quality care, lack of information, language and communication obstacles, direct discrimination, degrading treatment and human rights violations in the provision of care (European Roma Rights Centre 2006; Council of Europe and EUMC 2003). Roma children are particularly affected by a range of barriers in obtaining health services (Rechel et al. 2009). Better evidence for better interventions There is a need to explore further how the specific barriers impact on the use of different types of care in Roma. Available studies suggest that Roma people overuse emergency care and underuse prevention services such as mandatory immunization for children (Fundación Secretariado Gitano 2009). Furthermore, the effects of health system reforms on access to healthcare for Roma require systematic and comparative research. A few studies are available from Bulgaria with focus on Roma children (Rechel et al. 2009) and Macedonia (Milevska-Kostova 2010). More research is needed to enable learning from cross-country experience. Despite their crucial role as primary caregivers in Roma families and mediators between Roma communities and health systems (Open Society Institute 2005), Roma women are often overlooked in health-related research. Dual discrimination (ethnic and gender) against Roma women in the healthcare setting has been documented by researchers (Surdu and Surdu 2006) and NGOs working in Central and East-European countries to advance the health rights of Roma women (European Roma Rights Centre 2006). Systematic research and comparable data are needed to design tailored responses minimizing the effects of specific barriers met by Roma women in accessing to healthcare. Several programs have been initiated at national and international levels to reduce the Roma health gap. Various measures have been launched under the Decade of Roma Inclusion 2005–2015 and action is also urged under the recently adopted EU Framework for National Roma Integration Strategies up to 2020 (European Commission 2011). Assessing the impact of programs implemented so far and providing evidence-based input for the development of further innovative actions is an upcoming challenge that requires the contribution of the public health research community. Research on Roma health and access to healthcare: the way forward Research on Roma and health is challenging. Such research must be methodologically sound, and findings must be compared to the majority populations. Obstacles to data collection and methodological challenges have been discussed repeatedly (Kósa and Ádány 2007, Hajioff and McKee 2000; Vokó et al. 2009). Often fragmented research is based on rather inadequate samples. Yet, experience has shown that the Roma communities across Europe present cultural differences that have health implications making it difficult to generalize fragmented research (Krumova and Ilieva 2008). Research of Roma health and access to healthcare should take into account such cultural differences. Last but not least, it is important to pursue research agendas that reflect better the needs of the Roma minority itself. Involvement of Roma people in the design and implementation of such research agendas contribute to a better understanding of their needs. Cooperation with Roma civil society helps in bringing the insider’s perspective, reaching out to the most marginalized communities whose health needs require urgent attention but remain overlooked often.

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Author and article information

Contributors

János Sándor: sandor.janos@sph.unideb.hu

Journal

Journal ID (nlm-ta): Int J Public Health

Journal ID (iso-abbrev): Int J Public Health

Title: International Journal of Public Health

Publisher: Springer International Publishing (Cham )

ISSN (Print): 1661-8556

ISSN (Electronic): 1661-8564

Publication date (Electronic): 29 March 2017

Publication date PMC-release: 29 March 2017

Publication date (Print): 2017

Volume: 62

Issue: 7

Pages: 803-815

Affiliations

[1 ]ISNI 0000 0001 1088 8582, GRID grid.7122.6, Department of Preventive Medicine, Faculty of Public Health, , University of Debrecen, ; Kassai str 26/B, 4028 Debrecen, Hungary

[2 ]ISNI 0000 0001 1088 8582, GRID grid.7122.6, Department of Preventive Medicine, Faculty of Public Health, WHO Collaborating Centre on Vulnerability and Health, , University of Debrecen, ; Debrecen, Hungary

[3 ]ISNI 0000 0001 1088 8582, GRID grid.7122.6, Department of Methodology for Health Visitors and Public Health, Faculty of Health, , University of Debrecen, ; Nyíregyháza, Hungary

[4 ]ISNI 0000 0001 1088 8582, GRID grid.7122.6, Department of Health Systems Management and Quality Management in Health Care, Faculty of Public Health, , University of Debrecen, ; Debrecen, Hungary

[5 ]Central Statistical Office, Budapest, Hungary

[6 ]ISNI 0000 0004 0425 469X, GRID grid.8991.9, ECOHOST, , London School of Hygiene and Tropical Medicine, ; London, UK

[7 ]ISNI 0000 0001 1088 8582, GRID grid.7122.6, MTA-DE Public Health Research Group, , University of Debrecen, ; Debrecen, Hungary

Article

Publisher ID: 954

DOI: 10.1007/s00038-017-0954-9

PMC ID: 5585300

PubMed ID: 28357445

SO-VID: e825cb1a-d402-49ae-90f2-225f7fd7a823

License:

Open AccessThis is an open access article distributed under the terms of the Creative Commons Attribution IGO License ( http://creativecommons.org/licenses/by/3.0/igo/legalcode), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. In any reproduction of this article there should not be any suggestion that WHO or this article endorse any specific organization or products. The use of the WHO logo is not permitted. This notice should be preserved along with the article's original URL.

History

Date received : 12 October 2016

Date revision received : 3 January 2017

Date accepted : 24 January 2017

Funding

Funded by: National Research and Development Grant

Award ID: NKFP-1B/0013/2002

Funded by: Ministry of Environment (Hungary)

Award ID: KvH-96/167/2000

Funded by: National Scientific Council on Health

Award ID: ETT: 445/2003

Funded by: European Union and the European Social Fund

Award ID: TÁMOP-4.1.2.E-15/1/KONV-2015-0001

Funded by: Hungarian Academy of Sciences

Award ID: MTA-TKI: 2011TKI473

Funded by: FundRef http://dx.doi.org/10.13039/100004423, World Health Organization;

Award ID: 2015/580661-1)

Custom metadata

ScienceOpen disciplines: Public health

Keywords: roma,decade of roma inclusion,health behaviour survey,public policy

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ScienceOpen disciplines: Public health

Keywords: roma, decade of roma inclusion, health behaviour survey, public policy

The decade of Roma Inclusion: did it make a difference to health and use of health care services?

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Abstract

Objectives

Methods

Results

Conclusions

Electronic supplementary material

Related collections

Global Health Next Generation Network

Most cited references 14

The health of the Roma people: a review of the published literature.

Does socioeconomic status fully mediate the effect of ethnicity on the health of Roma people in Hungary?

Research on Roma health and access to healthcare: state of the art and future challenges

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Contributors

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History

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