Perceived state of health
The sample gave a positive assessment of health status. 79.8% of the respondents declared their health to be either good or very good whereas only 4.6% considered they were in a bad or very bad state of health.
Positive self-assessment of health status is a common trend in quantitative studies focusing on the Roma population. Similar previous research conducted in Romania (Cace şi Vlădescu 2004:26, UNDP 2002:63), Bul- garia, Czech Republic, Hungary, Slovakia (UNDP 2002:63), and Greece (Trichopolou 2009:4) are consistent with our study in this respect. However, qualitative studies (in Romania, Fleck and Rughiniş 2008:88-103), as well as the analysis of objective indicators of health status such as life expectancy and infant mortality, contradict these self-assessments (UNDP 2002:64) and point to a series of structural problems preventing access to quality health services (OSI 2005).
The prevalence of optimism regarding health status in Roma communities from several geographical and cultural areas suggests a diff erent cultural concept of health and disease. A report published in Spain re- vealed that “a large percentage of Roma conceive health as the absence of disease, and disease as an inca- pacitating phenomenon linked to death” (FSG 2005:13). A disease is not considered to exist unless it shows some clear symptoms that prevent the individual from undertaking daily activities or endanger his/her very physical existence. Once symptoms have vanished the person considers himself/herself healthy again. The World Health Organization takes a completely diff erent approach to health based on Western thought. The WHO considers that “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infi rmity.”1 Therefore, it is safe to say that a large percentage of the Roma respondents who claimed good overall state of health do not consider asymptomatic problems or ailments which do not interfere with the performance of daily activities as disease.
The health status identifi ed by the respondents should be understood within the cultural context of the Roma population and compared with other indicators. Our research found that over half of the popula- tion age 45 and over, with no gender diff erence, suff ers from disabilities or chronic disease; over 60% of adult men and women have cavities; one out of every two adults is either overweight or obese. Diet is unbalanced with consumption of meat, eggs and fi sh below the recommended levels, and most subjects perform little if any physical activity outside work. On the other hand, the study shows that the incidence of
1 Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19- 22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Offi cial Records of the World Health Organization, no. 2,
disabilities and chronic diseases in the population age 5 to 29 is less than 4.2%; fewer than one out of every ten subjects suff ered an accident in the preceding 12 months; medicines are widely used once a disease has been identifi ed; and 96.5% of those surveyed made at least one visit to the doctor. In conclusion, re- spondents’ optimism regarding their health status is partially justifi ed; however, there are some important problems that need to be addressed in order to improve Roma health.
Lack of information
The study did not assess Roma access to healthcare information. Nonetheless, the answers given to some questions indicate a widespread lack of knowledge concerning the rights Roma people are entitled to with- in the National Health System, regardless of insurance. For example, 45.7% of the minors in the sample did not receive all the vaccines required by the National Immunization Program in spite of the fact that they are mandatory and provided free of charge. Moreover, half of them did not receive even one single vaccination.
Children living in neighborhoods and areas isolated from towns were particularly at risk of not complet- ing the required immunization program. In 9.1% of the cases, parents claimed they were not been aware of the immunization program. That percentage is likely to be higher if we consider that a further 9.4% of the minors didn’t get the mandatory vaccines due to lack of economic resources. While there is an indirect cost associated with vaccinations (including transportation to and from the healthcare center and, in some cases, informal payments), it is safe to say that at least some of the parents in this category had not been correctly informed about the rights they are entitled to under the Romanian healthcare system. The parents of 47.9% of the children who failed to receive mandatory vaccinations claimed they forgot to go to the doc- tor’s offi ce. The high number of people in this category suggests that at least part of the responsibility lies with the authorities. The National Immunization Program was unsuccessful in publicizing the usefulness of the vaccination program, the optimal period for completing it or the existence of mandatory vaccines provided free of charge.
Concern over health
Concern over health is diffi cult to defi ne given the diff erent concepts people have of health. For communi- ties where traditions play an important role in the social life of the group, assessing concern over health should cover not only the attitudes and behavior of the subjects regarding modern methods of prevention, control and disease treatment, but also attitudes and behavior regarding traditional ways to stay healthy. It was beyond the scope of this study to look into the ideas and practices surrounding health, the traditional preventive and curative measures, the use of medicinal plants and thaumaturgical practices aimed at heal- ing and avoiding disease (such as incantations and protection against the evil eye). This research project focused solely on the interest shown by members of the Roma community towards modern methods of prevention, control, and treatment of medical disorders. Concern for health was measured in terms of use of medicines, frequency of visits to the doctor and dentist and infant nutrition. Inevitably, we are dealing with an incomplete representation of interest taken in health.
62.8% of the sample had taken medicines in the two weeks prior to the interview and signifi cant diff erences were observed in terms of gender and age brackets. Among adults, three out of four women and one out of two men had taken medicines and consumption increases with age. Those over 45 consume the most medicines (83.5%). The medicines consumed correspond to the symptoms identifi ed by the subjects sug- gesting that in the Roma community health problems tend to be treated with drugs. As for minors who had to reduce their activity for medical reasons in the previous 12 months, 83% had sore throat, cough, cold, or fl u, and 52.9% had fever. In terms of medicines consumed, minors most frequently used cold and fl u rem- edies followed by antipyretics, vitamins, and minerals. One out of every fi ve minors had taken antibiotics.
The study also proved self-prescription of drugs to be a widespread practice among Roma. One out of every two users of cold or fl u remedies and six out of every seven antibiotic users take these drugs without ever consulting a doctor. The self-administration of drugs is practiced by minors as well as adults. Self pre- scription becomes prevalent at age 7. However, a methodological aspect should be mentioned here. The self-prescription rate was based on the use of medicines without a medical prescription but no information
was collected regarding the existence of a prescription obtained in the past for similar symptoms. From the information collected in the study, it was impossible to identify the mechanism underlying the self- administration of drugs, the types of situations requiring visits to the doctor’s offi ce and the kind of situ- ations where self-treatment is considered more appropriate or the degree to which prescribed drugs are combined with self-administered drugs. Self-administration of drugs (especially antibiotics) is potentially dangers to users. The treatment could be inappropriate for the medical condition, the dosage could be wrong, it could interfere with the treatment of some other ailment and, in the case of antibiotics, can create bacteria resistant to treatment (Grigoryan et al. 2007:153).
Most subject make at least one visit to the doctor each year. Only 2.3% of minors and 3% of adults declared they had never been to the doctor’s offi ce whereas 47.6% of minors and 29.1% of adults made at least one visit in the month prior to the interview. Most subjects went to the doctor for diagnosis or treatment (50.4%) or follow-up (31.6%).
Fewer people go to the dentist as compared to the doctor. 44.3% of the subjects declared they had never been to the dentist. Persons living in areas or neighborhoods isolated from towns and with poor health are most likely to have never gone to the dentist whereas those living in integrated areas with good health are the most likely to have made a visit to the dentist. In the three months preceding the interview, a higher proportion of minors than adults had gone to the dentist but, on average, adults made more visits than the rest of the population during the same period.
Concerning nutritional habits, breastfeeding is the most common form of infant nutrition. 98% of the chil- dren in the 6 weeks to 3 months age group were given only breast milk. After that age nutrition diversifi es.
93,8% of the children 3 to 6 months old continue to rely on breastfeeding, but 54.7% are also given other foods. The World Health Organization recommends that “infants should be exclusively breastfed for the fi rst six months of life to achieve optimal growth, development and health” (WHO 2009).
Two conclusions can be drawn from the use of medicines, visits to doctors and dentists, and infant nutri- tion: fi rst, the Roma population displays a real concern for health; and second, this concern is not always expressed in medical terms.
Health problems
The study does not reveal any ethnic-specifi c pathology for the Roma population. Cardiovascular patholo- gies and nutrition-related diseases are the most common health problems among adults; children suff er from respiratory disorders. 4 out of 5 minors had to curtail their regular activities in the two weeks preced- ing the interview because they had throat troubles, cough, cold or fl u; 1 out of every 2 minors had fever. In the same period, 57.6% of adults had headaches, 52.3% experienced bone, spinal cord, or joint pain and 34% suff ered chest pain. Breakdown of symptoms by gender shows some diff erences. Bone, spinal cord, or joint pain was more frequently encountered among women; the same tendency was found for chest pain.
On the other hand, a smaller proportion of the women in the sample showed symptoms related to the respiratory system and nervousness, depression or sleep-related troubles.
Improper nutrition and its immediate consequences and overweight and obesity combined with insuf- fi cient physical activity are major risk factors for the health of Roma in Romania. Subjects have a relatively varied diet but it is calorically unbalanced. Bread, cereals, and similar products are consumed on a daily basis by 86.9% of the population; the second category of food products in the ranking is pasta and rice which are consumed daily by 63.3% of the population. The heavy consumption of cereal-based products accounts for excess weight. The study also showed relatively low consumption of fi sh, eggs and meat lead- ing to a defi cit in animal protein, saturated fatty acids and phosphorous. These nutrients are important for the normal development of children.
Access to and use of healthcare services and facilities
The World Health Organization identifi ed three dimensions characterising an effi cient healthcare system:
access, utilization, and effi ciency. Access was defi ned in terms of availability, accessibility, aff ordability and acceptability. Utilization was the combination of access and personal health behaviour. Eff ectiveness was considered a function of several variables including effi cacy, inputs (amount and quality of resources), quality assurance mechanisms (process of service delivery, provider performance), patient compliance and health behaviour, and external factors (environmental, biological, social, etc).” (HSPA: 126)
Our research focuses especially on access to and use of health services. To this end, the following indicators were used: the existence of medical centers serving the population included in the study; the time it takes to get to and from healthcare centers; and the likelihood of getting an appointment. The existence of medi- cal insurance or access to the services it provides (for those receiving benefi ts without having to pay the cost of the insurance such as children, the unemployed and the retired) is a meaningful way of assessing access to healthcare. However, the way the question related to insurance was posed makes it impossible to use in the case of Romania. The use of medical services is estimated based on the number and frequency of visits made to doctors’ and dentists’ offi ces, the use of emergency services and the rate of hospitalization.
The existence of healthcare centres to serve the population was assessed through the combination of two indicators: the number of persons who made visits to the doctor and the average time it takes to get from one’s home to the medical center. Only 2.8% of the population had never been to the doctor, the percent- age being higher in the case of people living in shanty towns. The average access time to a medical facility is about 30 minutes and the most common response from subjects was 20 minutes.
Regarding appointments, out of the 178 subjects who did not receive medical care in the previous 12 months despite needing it, only 6.7% mentioned the diffi culty of obtaining an appointment as the cause.
Another 10.7% mentioned that the waiting list was too long. It is worth noting that the absence of insur- ance and insurance benefi ts as well as lack of transportation have also been mentioned as obstacles in gaining access to medical services.
Based on subjects’ responses, the medical infrastructure serving Roma communities is generally adequate and accessible. Despite this, the use of medical services is unbalanced, dental care facilities being used sig- nifi cantly less than general medicine services. 44.3% of those surveyed had never gone to the dentist and here an important distinction can be made according to housing. 78.5% of those living in neighborhoods and areas isolated from towns and with a poor state of health had never been to the dentist compared to only 35.5% of those living in integrated areas with a good state of health. The limited use of dental care facilities may be due to cost; most dentist offi ces are private and insurance only rarely covers dental work.
The economic barrier
It is impossible to measure the impact of economic level on access to medical services given that the ques- tionnaire did not cover the economic status of the households and individuals. However, it is likely that scant economic resources translates into limited access to medical care. One out of every fi ve subjects who needed health treatment in the twelve months preceding the interview but could not obtain it considered that either medical services were too expensive or they could not aff ord them. Another 47% did not go to the doctor because they lacked insurance or the insurance did not cover the services they needed. Moreo- ver, the parents of 9.4% of the minors who failed to complete the immunization program claimed poor fi nancial situation as the reason.