In a study of maternal health care amongst Roma women in Serbia and Macedonia, Janevic et al. (2011) identify three categories of racism affecting Roma women’s experiences of health services: 1) personally mediated racism, which refers to individual perceptions of discrimination; 2) internalised racism, which refers to patients’ low self-esteem and fear in accessing services; and 3) institutional racism, which refers to the environments in which Roma live and the ways in which their relative disadvantage can impact on access to health services. Studies addressing systemic barriers to health services further reveal how administrative procedures and providers’ attitudes towards Roma can limit Roma individuals’ health service use. Access to health services can be restricted at the point of contact, with barriers to registration arising from lack of identification documents, physical distance from services, lack of transport and lack of funds to purchase insurance (Council of Europe, 2012; Idzerda et al., 2011;
Kuehlbrandt et al., 2014; McFadden et al., 2018; Rechel et al., 2009; FRA, 2018c). While restrictions on access sometimes have a legal basis (the requirement to purchase insurance, for example), they can also
result from miscommunications between Roma individuals and health professionals about entitlement to services and requirements for registration. Fear of intrapersonal discrimination and poor past experiences of health services can also lead Roma to choose not to access services, as was reported by Roma surveyed in Slovakia (Jarcuska et al., 2013).
There is also a body of evidence indicating that Roma women across Europe face particular barriers and challenges in accessing health services, leading to poorer health outcomes and poorer self-reported health (FRA, 2003; Carrasco-Garrido et al., 2010; Sedlecky & Rašević, 2014; Logar et al., 2015). According to FRA survey data, Roma women are often the primary caregivers for their families, which may lead them to de-prioritise their own health needs. Community expectations and cultural stigmas related to sexual and reproductive health may also lead Roma women to view family planning services as inapplicable to their particular life situations (FRA, 2003). When Roma women in Slovenia were asked about their views on reproductive health, respondents revealed how transmission of health information amongst female family members forms the basis of their reproductive health knowledge, though they reported increasing levels of professional input (Logar et al., 2015). Survey data from Spain further reports that Roma women experience higher rates of anxiety and depression and poorer self-reported health than population averages, as well as lower rates of accessing preventive services such as mammograms and smear tests (Carrasco-Garrido et al., 2010). Focusing specifically on sexual and reproductive health amongst Roma women, questionnaires collected from Roma settlements in Serbia reported higher fertility rates, adolescent birth rates and poorer overall levels of sexual and reproductive health, which were likely linked to socioeconomic disaparities between Roma and the general population (Sedlecky & Rašević, 2014).
After Roma patients establish initial contact with health services, they may encounter segregated facilities, as well as ‘hostile, patronising, judgemental, unsympathetic and even abusive attitudes of healthcare staff’, leading them to feel that health professionals do not take their needs seriously (McFadden et al., 2018, pg. 78). Despite reports of discrimination and restricted access, however, there are also key examples of programmes that have effectively enabled Roma to access health services.
Health mediator programmes in Romania, Bulgaria and Slovakia – in which members of the Roma community actively assist their fellow Roma in establishing meaningful contact with health services – have led to increases in use of health services, vaccination uptake and patient satisfaction (European Commission, 2014; Roman et al., 2013; FRA, 2018b). Additionally, peer education programmes based on
active outreach by community members have brought about increased knowledge of tobacco risks and safe sex (Carr et al., 2014). While such enablers can be effective in building community health literacy and actively involving community members in taking charge of their health situations, they also run the risk of over-emphasising behavioural factors and individual choice as key health determinants, thus minimising health services’ and policy makers’ accountability in promoting minority community health (Aboud & Singla, 2012; Schrecker, 2013).
Barriers to health care access have been linked to poorer self-rated health, and the greater the perceived barriers, the lower an individual’s overall self-reported health (Janevic et al. 2012; Jarcuska et al., 2013; Masseria et al., 2010). The Roma tend to report poorer self-rated health than population averages, which is associated with discrimination, lower levels of education, higher levels of poverty and higher unemployment rates (though levels of self-rated health improved between 2011 and 2016 FRA surveys) (Janevic et al. 2012; Ringold et al., 2005; FRA, 2018b). Masseria et al. (2010) note, however, that self-reported health is not always a reliable indicator of an individual’s precise health situation:
‘the self-reported worsening in health status indicator does not tell anything about the actual health condition of an individual. It is, therefore, possible that Roma are still less healthy than the national majority population even if their self-reported health status did not deteriorate more than for the latter, simply because their initial health was worse. Moreover, the Roma may have a different perception of what worsening health is than the non-Roma’ (p. 553).
What self-reported health can indicate, however, are levels of access, perceptions of discrimination and the psychological impact of barriers to care (Janevic et al., 2012).
Particularly in the area of mental health, external stigmatisation of mental illness can also have a pronounced impact on Roma individuals’ decisions to disclose issues and to seek out support. While the tight-knit nature of Roma communities can from one side be seen as an asset to community members’
wellbeing, close community bonds can also contribute to increased feelings of shame in disclosing mental distress (Lee et al., 2014). In this sense, Roma may be reluctant to disclose mental health issues out of fear that other community members will perceive mental ill health to be a sign of weakness. This can bring shame not only on the person experiencing mental illness, but also on that person’s family (Roma Support Group, 2012; Warwick-Booth et al., 2017; Tobi et al., 2010). Yet mental health stigma also transcends community boundaries, and can be seen in Roma community members’ fears to seek
out formal support for mental health issues out of fear that this will further damage the wider society’s perception of Roma and bring about greater discrimination (Lee et al., 2014).