original article Wien Klin Wochenschr (Suppl) DOI 10.1007/s00508-015-0704-z

Attitudes of the Prekmurje Roma towards health and healthcare Erika Zelko · Igor Švab · Alem Maksuti · Zalika Klemenc-Ketiš

Received: 18 January 2013 / Accepted: 16 January 2015 © Springer-Verlag Wien 2015

Summary Background  Knowledge of the culture, traditions and values of the Roma is important for understanding their relationship to health and the health system. The Roma in Prekmurje, the far northeastern part of Slovenia, are a unique ethnic group and in many respects different from other Roma. The aim of the study was to determine their attitudes towards health and the healthcare system. Methods and materials  We conducted 25 interviews in Roma settlements. The participants were between 18 and 64 years of age, with the average age being 23.46 years old; 48 % were men and 52 % women. We used qualitative content analysis as the data analysis technique. As a tool to facilitate the qualitative data analysis, we used the software Atlas.ti. In the study, we used a data-driving coding scheme. Two independent coders carried out the coding. Results  We determined eight logical categories that explain the attitudes of the Roma towards health, satE. Zelko, MD, MSc () · Z. Klemenc-Ketiš, PhD Medical Faculty, Department of Family Medicine, University of Maribor, Taborska 8, 2000 Maribor, Slovenia e-mail: [email protected] E. Zelko, MD, MSc Otroska ulica 29, Crensovci, Slovenia I. Švab, MD, PhD · Z. Klemenc-Ketiš, PhD Medical Faculty, Department of Family Medicine, University of Ljubljana, Poljanski nasip 58, 1000 Ljubljana, Slovenia A. Maksuti Faculty of Social Sciences, University of Ljubljana, Kardeljeva ploscad 5, 1000 Ljubljana, Slovenia

13

isfaction, problems and prospects and the functioning of the health system at the local level. These are experiences with the healthcare system, personal healthcare, the perception of health and illness, suggestions for improvement, common diseases as perceived by the Roma, poverty and socioeconomic status of the Roma, discrimination and the need for a better understanding of the Roma. Conclusion  Roma culture and their customs affect the Roma’s relationship with health and the healthcare services in Prekmurje. The Roma are willing to participate in health status improvement, but require special attention within the national healthcare system. Keywords  Roma  · Health  · Healthcare system  · Prekmurje · Slovenia · Discrimination

Introduction The Roma (Gypsies) are a special ethnic community with multiple homelands, abundant cultural heritage and a certain way of life. They predominantly live in Central and Eastern Europe (CEE) (about 5.2 million Roma live in CEE countries). It is estimated that about 10,000 Roma live in Slovenia, of which 3000 live in Prekmurje [1, 2]. In Slovenia, the Roma are legally considered to be a minority at risk, and their status is partly regulated by the Slovenian Constitution [2, 3]. The Romani population in Slovenia is coarsely divided in two groups: the Roma in Prekmurje and other Romani groups [1]. The Roma in Prekmurje are a more organised group with their own denomination, Ciganje, which is still very much alive [1, 4]. In Prekmurje, the Roma have been part of the community for at least 40 years. Their integration into the community has primarily involved jobs and schooling (Roma and non-Roma children attend the same schools). Indeed, the majority of the Roma in Prekmurje have built

Attitudes of the Prekmurje Roma towards health and healthcare  

1

original article

good relations with the non-Roma population. They are also very active in protecting and developing their cultural and ethnic identity. They have their own radio and television programmes and publications in the Roma language, and they are active in investigating the needs and specificity of the Romani population [4–6]. The Roma have a unique material and spiritual culture including their health culture that determines their attitudes towards health, diseases and death. In the past, they were very superstitious and preferred to go to domestic healers rather than physicians and official healthcare providers [4–7], which is not unique to the Roma in Prekmurje [4, 5]. The Roma culture affects the decision to seek medical care [4, 7–10]. They equate health with happiness. They believe that certain diseases are outside the realm of their perception of health; thus, they visit special Romani practitioners and use homemade herbal medicines [4, 5, 11–13]. The latter is also typical of the Roma in Prekmurje, who believe that plants have supernatural powers and a soul [5]. However, in the last few decades, the Roma have abandoned most of these beliefs [3, 5, 9]. They began to trust official medical methods, but continued to lack confidence in the healthcare workers and institutions [5, 7, 11, 12, 14]. As they are mostly poorly educated, and they may not trust the non-Roma population, this often results in difficulties in communication with healthcare workers. They often do not understand medical protocols or the information that they receive in health centres. In some cases, they espouse cultural beliefs about health and healthcare with which health workers may not be familiar [12, 16, 17]. Vivian and Dundes [12] emphasised that healthcare workers frequently make the mistake of assuming that all Roma patients have basic medical knowledge and accept the standards of the medical system in the country. The hierarchy of the Roma family and the gender distinction are also significant in the communication between the Roma and medical workers. Usually, the eldest in the family makes conversation, handles the family decision-making and ensures that the younger family members cooperate with the physicians and other medical workers [12, 14, 18, 19]. Therefore, understanding the culture, traditions and values of the Roma is very important if health professionals want to understand and help these people. The general health of the Romani population is substantially worse than that of the total population [4, 20– 25]. Several studies in Slovenia have shown that within the Romani population, there is a disproportionately high prevalence of, for example, smoking, metabolic syndrome with type 2 diabetes, respiratory diseases and increased cardiovascular mortality [4, 20–27]. The health of the Roma is strongly dependent on their socioeconomic situation and related unsuitable living conditions and infrastructure where they reside [22, 28, 29]. Their health problems are also linked to inadequate hygiene and poverty, which lead to a shorter life expectancy and an increased risk of illness including chronic diseases [23–25, 30, 31].

2   Attitudes of the Prekmurje Roma towards health and healthcare

However, in general, the quality of life of the Roma has improved in the last few decades. Today, the main problems that the Roma in Slovenia encounter are socioeconomic conditions (mainly affected by education and employment), social exclusion and, in some cases, misunderstandings with the local people, which otherwise has never been typical of Prekmurje [4, 25]. Some obstacles for the Roma in Slovenia relate to some special medications and hospital-related fees, especially for those without compulsory health insurance. Like any special ethnic minority, the Roma need special attention from the social and health systems [6, 19, 29, 32–35]. It is important that the healthcare system recognises and deals with the requirements of this population [6]. However, this is difficult if the attitudes and beliefs of the Roma regarding healthcare are not taken into consideration. The aim of this study was to analyse the relation of the Prekmurje Roma to health and the Slovenian healthcare system to develop a health intervention tailored to this population. Numerous studies have taken into account ethnicity and culture as important variables in the exploration of a marginalised ethnic community’s relationship to health and healthcare [32, 33, 36–41]. Considering the inequality and special needs of such populations, this variable is important for analysing the attitudes of ethnic and racial minorities towards health and healthcare services [32, 33]. In the last few decades, numerous qualitative and quantitative studies have investigated the Roma population and its attitudes towards health and healthcare services in the USA and some West European countries [7, 9, 12, 16, 18, 20, 21, 24, 28], CEE countries [8, 15, 19, 23, 24] and the former Yugoslav republics, which include Slovenia [4, 5, 22, 26, 27, 42].

Methods This was a qualitative study conducted among the Roma in Prekmurje, Slovenia. One of the researchers (E.Z.) conducted semi-structured interviews with 25 Roma (Table 1) at a previously agreed-upon location, mostly in their settlements, where they feel comfortable and could talk more freely, which is important in qualitative research [43]. The participants were between 18 and 64 years of age (Table 1). We used purposeful sampling, typical for qualitative research [44, 45], taking care to cover women and men, and both rural and town residents from different settlements. The reasons for using a qualitative approach relate to the unique issues of the Roma in Slovenia, such as the physical or language-related inaccessibility of healthcare services, a lack of understanding of the Slovene language, and the distrust of physicians and other medical staff. All of the participants agreed to be interviewed. The questionnaire was developed in the following manner: after studying the literature (Slovenian and foreign literature) regarding the health of the Roma, the first set of questions was developed. This set was then discussed among the

13

original article

Table 1  Demographic characteristics of participants Participants n = 25

%

Male

12

48

Female

13

52

Married

18

72

Single

4

16

Gender

Marital status

Divorced

2

8

Widowed

1

4

5

20

Educational status Without educational qualifications Elementary school

14

56

Vocational school

4

16

High school

2

8

Faculty

1

4

Employed

6

24

Student

2

8

Housewife

6

24

Retired

3

12

Unemployed

8

32

Employment

the best conditions in which the interviewees could give us the most extensive and profound answers. All of the interviews were audio-recorded and transcribed verbatim by a trained administrator. For the systematic examination of the collected data, we used qualitative content analysis (QCA), a method derived from the communication sciences which is useful for systematic analysis in a wide range of scientific domains [45–47] as well as in the field of the Romani people and their attitudes towards health and healthcare services [5, 12, 15, 19, 27]. We used inductive content analysis including coding, creating categories and abstraction to formulate a general description of the research topic [47]. To facilitate the data analysis, we used the qualitative data analysis software Atlas.ti [48]. Two researchers (E.Z. and A.M.) independently coded the interviews, and the third researcher supervised the process. In the study, we used a data-driving coding scheme [46] and formed 181 codes sorted in 8 logical categories/themes (“families” in Atlas. ti) to detect patterns in the analysed data, and to explain the attitudes of the Roma from Prekmurje towards health and healthcare. During the coding process, the two researchers sought consensus. When this failed, we tried to achieve intercoder agreement [49] about differently perceived parts of an analysed text to fit the created category (also known as the “unitising process”) [46, 49].

Housing Wooden house Brick house With relatives Others

1

4

20

80

3

12

1

4

Tap water

24

96

Electricity

25

100

Sewerage

13

52

Medical insurance

24

96

Results We identified the following categories: experiences with the healthcare system, personal healthcare, the perception of health and illness, suggestions for improvement, common diseases as perceived by the Roma, poverty and socioeconomic status of Roma, discrimination and a need for better understanding of Roma.

Experiences with the healthcare system researchers in order to narrow down the topics. The exact wording of the questions was determined on the basis of consultation with local physicians and district nurses working in the area where the Roma live. We asked the following general questions: (1) How would you describe a healthy person? (2) What is health? (3) How would you describe being ill? (4) What do you think about the services offered by healthcare centres, especially family medicine? (5) What do you expect from healthcare (from society, self-care, healthcare in general)? (6) How could one improve the health of the Roma? (7) Do you or your relatives encounter any problems when you are seeking help from a physician? and (8) Have you ever experienced anything unpleasant in a healthcare centre because you are Roma? Besides those pre-formulated questions, during the research implementation, we asked additional sub-questions (like: Because you are Roma?) which are typical of semi-structured interviews [44]. In this manner, we tried to provide

13

Most of the interviewees reported very good experiences with the healthcare system and the services provided by the health centres. On this point, it should be noted that the answers and compliments given in the interviews refer to the interviewee’s personal physician and health centres in the local community. Likewise, there were no comments about the work of a physician, although some of the participants did comment on the organisation of the practice. Their main complaints related to long wait times and limited time for medical examinations, which is a result of the high demand for primary healthcare in Slovenia [50]. Some examples are as follows: It could be better, because we have to wait too long. (Participant 12) It depends on the day; if there are a lot of people, we have to wait. When you come, he accepts you, but if the waiting room is crowded, you have to wait. (Participant 9)

Attitudes of the Prekmurje Roma towards health and healthcare  

3

original article It depends on the physician, in general. In Murska Sobota, some physicians do their work well; sometimes the patient expects that the physician has time for him. (Participant 21)

Personal healthcare The interviewees mostly complained about many diseases and problems, but the majority of them believe that everyone is responsible for their own health. They emphasised the importance of prevention, a healthy lifestyle and good communication and trust with the personal physician. They also highlighted the importance of making a timely visit to the physician, and the risk of treatment rejection. Here are some interesting examples: In general, I have to take care of my health by myself. Everyone has to take care on his own. Today, they speak so much about preventive activities that everyone should know what the best is for himself. (Participant 2) First of all, I am responsible for my own health. If I don’t do it, others won’t, either. And so, I have to go to the physician. It doesn’t work without it. If the physician tells me that I have to have a healthy diet, or take medicine, and I won’t do it, if I don’t follow, I cannot be healthy. No way. (Participant 18) I personally think that you must do the most for your health yourself. Health is different things— food, social activities, work, living conditions and stress, not enough time for family, and so on. These things influence health. I think you must take care of your own health alone. (Participant 5)

Perception of health and illness The respondents explicitly stated that a healthy person is a happy person. In some responses, we could see that some of them were convinced that nobody is totally healthy. A healthy person is young, participates in sports, does not smoke and takes care of his/her lifestyle (food, air, water, living conditions). They also believe that a healthy person is someone who is not stressed and lives in a regular family situation, or someone who simply does not need medicine or a physician. For example, participant 24 said the following: For me, everyone is ill in some way—some psychically, others have heart diseases. In our country, mental illness is very common. Old people are more often ill than people aged 10–30. But from age 45 upwards, everybody is ill; everybody has something. Women reach menopause; that’s a problem, too. And sports—someone with heart disease can’t do sports, because they simply can’t. A woman in the change can work, too, but she has her own prob-

4   Attitudes of the Prekmurje Roma towards health and healthcare

lems—hot flushes or whatever it is called. My wife has them, and then she has to rest. (Participant 24) If health is a value and is key to happiness, then illness is the biggest problem and misfortune for the interviewed Roma. They mostly linked illness to pain, age, limited mobility and an inability to take care of themselves. According to the responses, the signs of illness include pain, redness in the face, increased body temperature, weakness, inability to work and problems with breathing. They also enumerated diseases that they mostly understood as personal problems. They connected illness with an unhealthy lifestyle and their bad socioeconomic status. Below are some interesting answers: Illness is pain; when you have a headache, you are ill. What is causing pain is illness. When there is pain, it is illness; when there’s no pain, it can’t be an illness. (Participant 7) Illness/disease is when a person feels bad, has pain. Sometimes the pain travels through the body. You can be ill and not even know that you are ill; you don’t feel it, but you are ill. You can’t walk, which means that you can’t do certain things. (Participant 5)

Suggestions for improvement The Roma gave many suggestions for how their health situation could be improved. They mostly recognised problems within themselves, because they rarely go to the physician, and if they do, it is generally when it is too late: The fact is, we do not go to the physician until it is sometimes too late. We then say that the physician isn’t qualified enough and is responsible for the bad situation. We wait till the end. And you can see that is our failure, a Roma failure. We don’t go to the physician often; we don’t have preventive checks, or radiology, or therapy. (Participant 11) A common suggestion for improvement was educational workshops and education in settlements. Here, the interviewees considered the knowledge of how to take medicine correctly to be very important. They expressed concern about the lack of information on the safe use of medicines and other preventive measures. Thus, the interviewees stated that workshops in the form of lectures, written and audio/video materials and other methods provided in Roma settlements or in their homes would be highly desirable. Further, they emphasised that physicians and other medical staff should provide these workshops. This would also be a way to improve the communication between the Roma and the healthcare staff. Some suggestions were as follows:

13

original article I think that Roma should be better informed about health. (Participant 10) Roma need more information, to see some films about health or some pictures, maybe some lectures. We would need a psychologist, because the use of alcohol is too high for all ages. I see it; under the influence of alcohol they get violent and aggressive. In the end, they are completely nervous and they end up in a psychiatric hospital. I wouldn’t recommend it. I would ask for help. (Participant 4) I would say so. First of all, we should educate Roma regarding health. But healthcare workers should also know how Roma settlements are organised and structured. That would be the first step. The second would be healthcare, which is closer to Roma people. For example, some preventive check-ups, measurements of blood pressure, sugar in the blood… Maybe consultation with Roma women about a healthy lifestyle. (Participant 5)

Common diseases as perceived by the Roma In the interviews, the Roma talked about the diseases that they have (or have had) and about the diseases that their family members and other relatives have. According to the interviewees, the most common diseases are respiratory diseases (asthma, laryngitis and tuberculosis), heart and blood vessel diseases (cholesterol, blood pressure, heart attack and stroke), diabetes, epilepsy and different psychological problems (mental illness, depression, etc.). In my home, there are a lot of diseases. I’ve got high cholesterol. Many others have diabetes, high blood pressure, depression, and psychological problems. (Participant 21) The Roma mainly attributed these diseases to an unhealthy lifestyle including, for example, smoking, eating greasy food and inadequate hygiene habits. We see a lot of asthma, because children are smoking. They need to be told that smoking causes cancer and lung problems. You should speak about hygiene; some people do not wash their hands, and that can cause disease. (Participant 18) Fox example, my father got diabetes. He says that in the past, he did not eat well. And my mother, she has epilepsy. This is a real disease! (Participant 3)

ture and basic hygiene needs) and poor education. These issues influence the lack of responsibility that the Roma take towards their own health. The Roma population is still living without basic essentials, such as heating, water, and electricity— not everybody, but most of them. Most of them are unemployed, and if they work, they do arduous (dirty) work. Many of them handle scrap metal, which is useful, but on the other hand, unhealthy. (Participant 4) I would say they couldn’t afford healthy food. Then there are problems with heating the houses, because there is no money. We are poor. If houses are cold, children get ill, there is no hot water, no hygiene. (Participant 16) Poverty, a high unemployment rate, a low level of education, social delinquency and illness together form a vicious cycle which creates a fertile environment for the emergence of numerous stereotypes and different types of discrimination and contemptuous views on the Roma in different societies [12, 17, 22, 37–41]. The next category that we created refers to this problem.

Discrimination Most of the interviewed Roma did not report experiencing any discrimination in health centres. In other words, in the health centres in Prekmurje, they never feel deprived or disadvantaged because of their ethnicity. For those who did, their definition of discrimination included some serious racial public discrimination, fear of physicians and neglect of the Roma patient’s problems: Roma are sometimes discriminated against by nonRoma. Even if they have a better education, they don’t get a job. (Participant 4) My friend went to the physician. It was the same person who worked yesterday. And then he shouted at him, ‘what are you doing here?’ My friend was scared because he still had a fever from the day before. And then he said that he will never go to the physician again, even if it means he will die. (Participant 3) If you do not have acquaintances, you need to wait. Because you are Roma? Yes. It happens often. Also, we are not informed about options regarding our disease. They [the physicians] have nothing to say until problems arise. (Participant 11)

Poverty and socioeconomic status of Roma The socioeconomic status of the Romani population in Prekmurje has been identified as a very important reason for bad health. Dependence on social help is an important issue, as are low income, difficult manual jobs, bad conditions in Roma settlements (e.g. lack of infrastruc-

13

Less serious, but not insignificant, occurrences of discrimination were identified in the unkindness of medical workers in the healthcare centres. Some Roma expressed concern about such attitudes.

Attitudes of the Prekmurje Roma towards health and healthcare  

5

original article Yes, I was [aware of discrimination]. Not with my relatives, but there was a Roma woman with her daughter, a teenager. They were waiting a very long time. They didn’t know what to do, so the mother went to the nurse, to ask what she should do. And the nurse was very impolite and told her to get out. Maybe she had her own problems, but it wasn’t nice to hear it. I wouldn’t feel good if someone did that to me. Everything depends on understanding. That is very low between medical workers and Roma. (Participant 2) Some interviewees also recognised the unkindness of medical workers in the cases of queues and long wait times. Some of the interviewees emphasised that they had come before others and then they had to wait. It is important to highlight that some of them characterised this as a minor conflict or as a misunderstanding. I asked the lady how come I was here first, and have an appointment at this time, but now she is putting me at the end of the list. And she said that I had time. And I said, ‘Lady, then you shouldn’t make appointments at this hour, but two hours later’. A lot of work and a lot of nervousness. Not big but small conflicts. (Participant 18)

Need for better understanding of the Roma The interviewees stressed the importance of good communication, education and an understanding of the Roma to foster trust between them and the medical workers. Some of them said explicitly that Roma are cautious. They do not trust non-Roma, and they will stop medical treatment if they feel undertreated. They also emphasised the importance of the family, and they expect kind attention and care from medical workers, who are sensitive to this. If this nurse better understood this mother, she would know that Roma mothers react in another way. They are much more sensitive; they need more often to be about one thing. Maybe then she would react in another way. But I am a nurse myself; I know that we do not have much time for one person. It’s a need of trust. (Participant 2) We Roma are in some ways very cautious, and if nobody is cooling us down, we panic. We wait for a kind person, who is nice to us and accepts us for who we are, and gives us advice… Others, hmm, if you go to the physician with children, and there are no kind nurses, you get resistance, and you don’t go there anymore. Maybe we are too sensitive, and if we go, we are too cautious. If we don’t know what is wrong with us, we want them to listen to us, and we want to get good information. The Roma are sensitive; we don’t know about some things. This you can see through our history. They [the medical

6   Attitudes of the Prekmurje Roma towards health and healthcare

workers] have to know our culture and our habits. (Participant 23)

Discussion The results of our study have shown that the Roma are a special group requiring special attention within the national healthcare system. We can confirm that Roma culture and customs definitely affect the Roma’s relationship to health and healthcare services in Prekmurje. Another important conclusion of our study is that the Roma are willing and ready to participate in improving their health status. Most of them are aware that Roma culture is the important determinant of their health. According to the respondents, while the health of their community is good overall, some changes are needed to improve the health status of the Romani population in Prekmurje. They are convinced that they are responsible for their own health status (e.g. unhealthy lifestyle, inadequate hygiene, etc.), but they also expect more engagement from physicians and other medical workers with the aim of improving their relationship with the Roma patients. Therefore, it is necessary to improve relations between the Roma and the medical workers. The latter should be more sensitive to the Roma culture including their habits, fears and beliefs. The only way for this to happen is through ongoing education about ethnic diversity and initiatives to facilitate the deeper integration of the small Roma community into the majority population. In most cases, the Roma themselves are satisfied with the health protection they are offered, but the same cannot be said for all health workers’ attitudes in Prekmurje. Most of the respondents reported discriminatory factors in the forms of the unkindness of medical staff and long waiting lists. As some of them talked about discrimination in general, it is very difficult to provide conclusions about the degree of discrimination against the Roma in Prekmurje. As this was beyond the scope of the present study, further research should investigate other forms of discrimination that the Roma face [41]. In the context of the healthcare system, the respondents suggested that medical workers should know the Roma population better and that the medical care should be adjusted to better suit their needs. Therefore, it is crucial that medical workers in health centres in Prekmurje establish positive communication with the Roma in the future, to prevent misunderstandings that can affect the quality of the Roma people’s health management, taking into account their culture and diversity. In a comparative view, our study confirmed the findings of other researchers who studied the attitudes of the Roma towards health and healthcare. Indeed, almost all issues represented in the categories that we created were reported in other studies [5–8, 10, 12, 14–24, 28, 42]. We can see that these eight elements reflect the four main problems regarding the health of the Roma in Slovenia: low education level, unemployment, bad housing conditions and poverty. It is widely accepted that an unhealthy

13

original article

lifestyle and low socioeconomic status strongly influence the health status of the Roma population [17, 22, 24, 25, 31]. The attitude of the Roma towards health upon which our study shed light was described in previous studies in different countries [7, 9, 12]. According to the participants, the problems regarding self-healthcare are mostly seeking of medical help late and the rejection of treatment. These elements are commonly recognised attitudes of the Roma towards their own health that previous studies also showed [5, 12, 14, 18, 19]. The present study offers important insight into the health status of the Roma in one region of Slovenia. It reflects the opinions and beliefs of this particular group of Roma, and should not be generalised to other Roma groups in Slovenia or elsewhere. We exploited the advantages of QCA and inductive coding and further category formation to determine as accurately as possible how the Roma perceive their health and healthcare. We used a data-driving coding scheme [46] where saturation is met by definition (during the first stage of coding, we created only meaningful codes that were summarised into the umbrella categories in the second phase). Some methodological limitations of our study may relate to our open research question, and the explanatory character of the study may have been hampered by the inductive creation of codes and categories [45]. In the context of the latter, a potential criticism would be that the study was subjective, which is the most frequent criticism of qualitative research [44, 45]. However, all co-authors relied on a careful, deliberate research strategy and respect for the basic characteristics of qualitative research during the data collection and analysis stages. Our qualitative study is the first step in a process of developing an intervention programme for improving the health of the Roma in Prekmurje that would address their specific needs, interests and cultural and socioeconomic characteristics. The second step is to prepare interesting workshops in the Roma settlements about topics including diabetes mellitus, arterial hypertension, urgent medicine, respiratory diseases and the correct administration of medication. Some of these workshops have already been implemented, like urgent medicine and home visit, respiratory diseases and the correct administration of medicine. We also prepared a website, playing cards for children and a Roma medical dictionary of frequently used medical terms in communication about illnesses. We will also develop some radio and television shows in the Roma language. These measures may be insufficient to be classified as a solution to the problem, but they are definitely important steps in the direction of solving some of the problems of the Roma ethnic community which are, unfortunately, too often neglected. Acknowledgements The authors would like to thank all of the Roma who participated in the study for their help. Without them, it would not have been possible to complete the research. They would also like to thank the community nurses for helping them establish contacts in the Roma settlement.

13

Conflict of interest  The authors declare that there are no actual or potential conflicts of interest in relation to this article.

References  1. Josipovič D, Repolusk P. Demographic characteristics of the Romany in Prekmurje. Acta Geographica Slovenica. 2003;3(1):127–40.   2. Urad Vlade Republike Slovenije za narodnosti. Bivalne razmere Romov po občinah v Sloveniji. http:// w w w . u n . g o v. s i / s i / m a n j s i n e / r o m s k a _ s k u p n o s t / statisticni_in_osnovni_podatki/.  3. Statistični urad RS  -  Popis 2002. http://www.stat.si/ popis2002/si/default.htm.   4. Zadravec J. Zdravstvena kultura Romov v Prekmurju. Murska Sobota: Pomurska Založba; 1989.   5. Maksuti N. Samozdravljenje Romov v Prekmurju: specialistićna naloga. Univ.Ljubljana; Medicinska Fakulteta. Ljubljana; 2009.  6. Jagodic D. Javnozdravstveni vidiki obravnave ogroženih in ranljivih skupin prebivalstva. Ljubljana: Ministrstvo za zdravje; 2007.   7. Van Cleemput P, Parry G, Thomas K, Peters J, Cooper C. Health-related beliefs and experiences of Gypsies and travellers: a qualitative study. J Epidemiol Community Health. 2007;61:205–10.   8. Koupilová I, Epstein H, Holcík J, Haijoff S, McKee M. Health needs of the Roma population in the Czech and Slovak republics. Soc Sci Med. 2001;53:1191–204.   9. Zeman CL, Depken DE, Senchina DS. Roma health issues: a review of the literature and discussion. Ethn Health. 2003;8(3):223–49. 10. Goulet D, Walshok M. Values among underdeveloped marginals: the case of Spanish Gypsies. Comparative Stud Soc Hist. 1971;13(4):452–72. 11. Niksić D, Kurspahić-Mujcić A. The presence of healthrisk behaviour in Roma families. Bosn J Basic Med Sci. 2007;7:144–9. 12. Vivian C, Dundes L. The crossroads of culture and health among the Roma (Gypsies). J Nurs Scholarsh. 2004;36(1):86–91. 13. Pavlić D, Zelko E, Kersnik J, Lolić V. Health beliefs and practices among Slovenian Roma and their response to febrile illnesses: a qualitative study. Zdrav Var. 2011;503:169–74. 14. Hajoff S, McKee M. The health of the Roma people: a review of published literature. J Epidemiol Community Health. 2000;54:864–9. 15. Kósa Z, Széles G, Kardos L, Kosa K, Nemeth R, Orszagh S. A comparative health survey of the inhabitants of Roma settlements in Hungary. Am J Public Health. 2007;97(5):853–9. 16. Peters J, Parry GD, Van Cleemput P, Moore J, Cooper Cl, Walters SJ. Health and use of health services: a comparison between Gypsies and travellers and other ethnic groups. Ethn Health. 2009;14(4):359–77. 17. Ringold D. Roma and the transition in Central and Eastern Europe: trends and challenges. Washington D.C.: The World Bank; 2000. 18. Parry G, Van Cleemput P, Peters J, Walters S, Thomas K, Cooper C. Health status of Gypsies and travellers in England. J Epidemiol Commun Health. 2007;61:198–204. 19. Colombini M, Rechel B, Mayhew HS. Access of Roma to sexual and reproductive health services: qualitative findings from Albania, Bulgaria and Macedonia. Global Public Health. 2012;7(5):522–34.

Attitudes of the Prekmurje Roma towards health and healthcare  

7

original article 20. Goward P, Repper J, Appleton L, Hagan T. Crossing boundaries. Identifying and meeting the mental health needs of Gypsies and travellers. J Mental Health. 2006;15(3):315–27. 21. Binni GAC, Ginter E. The health of Gypsies. BJM. 1998;316(7147):1824–5. 22. Jakšić B, Bašić G. Umetnost preživljavanja: gde i kako žive Romi u Srbiji. Beograd: Institut za filozofiju I društvenu teoriju; 2005. 23. Filadelfiová J, Gerbery D, Škobla D. Report on the living conditions of Roma in Slovakia. Bratislava: FriedrichEbert-Stiftung; 2007. 24. Serrano Rodriguez N, Rodriguez Derecho N. Health and the Roma community, analysis of the situation in Europe: Bulgaria, Czech Republic, Greece, Portugal, Romania, Slovakia, Spain. http://ec.europa.eu/justice/discrimination/ files/roma_health_en.pdf. 25. Belović B, Buzeti Verban Z, Copot M, Kranjc Nikolić T. Determinants affecting the health of Roma in Pomurje. Murska Sobota: Institute of Public Health; 2011. 26. Bogdanović D, Nikić D. Mortality of Roma population in Serbia, 2002–2005. Croat Med J. 2007;48:720–6. 27. Petek D, Rotar-Pavlič D, Švab I, Lolić D. Attitudes of Roma toward smoking: qualitative study in Slovenia. Croat Med J. 2006;47(2):344–7. 28. McKee M. The health of Gypsies: lack of understanding exemplifies wider disregard of the health of minorities in Europe. BJM. 1997;315(7117):1172–3. 29. Urad vlade Republike Slovenije za narodnosti. Nacionalni program ukrepov za Rome Vlade Republike Slovenije za obdobje 2010–2015. http://www.un.gov.si/fileadmin/ un.gov.si/pageuploads/Program_ukrepov.pdf. 30. Žagar M, Komac M, Medvešek M, Bešter M. The aspect of culture in the social inclusion of ethnic minorities. MEU Programme. Minorities in the EU. Ljubljana: The Institute for Ethnic Studies; 2006. 31. Posavec K. Sociokulturna obilježja Roma u Europi—od izgona do integracije. Društvena iztraživanja. 2000;9:229–50. 32. Pfeffer N. Theories in health care and research: theories of race, ethnicity and culture. BJM. 1998;317(7169):1381–4. 33. Kelleher S, Hillier S, editors. Researching cultural differences in health. London: Routledge; 2002.

8   Attitudes of the Prekmurje Roma towards health and healthcare

34. Kronenfeld JJ, editor. Health care services, racial and ethnic minorities and underserved populations: patient and provider perspectives. Amsterdam: Elsevier; 2005. 35. Kutalek R. Diversity competence in medicine: equality, culture and practice. Wien Klin Wochenschr. 2012; 124(Suppl 3):3–9. 36. Anderson G, Tighe B. Gypsy culture and health care. Am J Nurs. 1973;73(2):282–5. 37. Zoon I. On the margins. Roma and public services in Slovakia. New York: Open Society Institute; 2001. 38. Anstead A. Litigating discrimination in access to health care. Roma Rights Quarterly. 2004;9(1):75–7. 39. Dobrushi A. Litigating discrimination in access to social services. Roma Rights Quarterly. 2007;12(1–2):59–62. 40. Iszak R. “Gypsy rooms” and other discriminatory treatment against Romani women in Hungarian hospitals. Roma Rights Q. 2004;3–4:7–11. 41. Kravchuk N. Discrimination of Roma in Russia: an update. Roma Rights Quarterly. 2008;13(2):47–9. 42. Čvorović J. Sexual and reproductive strategies among Serbian Gypsies. Popul Environ. 2004; 25(3):217–42. 43. Herzog H. Interview location and its social meaning. The Sage handbook of interview research: the complexity of the craft. 2nd ed. Los Angeles: Sage; 2012. pp. 207–17. 44. Flick U, Kardorff EV, Steinke I. Qualitative interviews: an overview. A companion to qualitative research. London: Sage; 2004. pp. 203–8. 45. Flick U, Kardorff EV, Steinke I. Qualitative content analysis. A companion to qualitative research. London: Sage; 2004. pp. 266–9. 46. Schreier M. Qualitative content analysis in practice. Los Angeles: Sage; 2012. 47. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nursing. 2008;62(1):107–15. 48. Saldaña J. The coding manuals for qualitative researchers. Los Angeles: Sage; 2009. 49. Krippendorff KH. Content analysis: an introduction to its methodology. Thousand Oaks: Sage; 1980. 50. Švab I, Petek Šter M, Kersnik J, Živec-Kalan G, Car J. Presečna študija o delu zdravnikov splošne medicine v Sloveniji. Zdrav Var. 2005;44(4):183–92.

13