Intestinal parasitic infections in children from marginalised Roma communities: prevalence and risk factors.

BACKGROUND: Intestinal parasitic infections remain a significant global health issue, particularly affecting poor and marginalised populations. These infections significantly contribute to children's diseases, malnutrition, poor school performance, cognitive disorders, and future economic losses. This study aimed to explore and compare the occurrence of intestinal parasites in early childhood among the group of infants from the Slovak majority population and from marginalised Roma communities (MRCs). Furthermore, it aimed to explore the health complaints of children with and without intestinal parasitic infection in the past month and assess the effect of various risk factors on the occurrence of intestinal parasitic infection in infants from MRCs. METHODS: We obtained cross-sectional data from mothers and stool samples of their children aged 13-21 months using the first wave of the longitudinal RomaREACH study. A total of 181 stools from infants were analysed: 105 infants from the Slovak majority population and 76 from MRCs. RESULTS: Infants from MRCs are significantly more often infected by Ascaris lumbricoides, Trichuris trichiura and Giardia duodenalis than their better-off peers from the majority population. Infection rates are 30% in infants from MRCs vs. 0% in the majority population (p < 0.001). Single and mixed infections were observed in children from MRCs. Infants with intestinal parasitic infections suffer significantly more often from various health complaints, particularly cough, stomach ache, irritability, and diarrhoea. Within MRCs, the risk of parasitic infections in infants is significantly increased by risk factors such as the absence of flushing toilets in households (OR = 4.17, p < 0.05) and contact with un-dewormed animals (OR = 3.61, p < 0.05). Together with the absence of running water in the household, these three factors combined increase the risk more than ten times (p < 0.01). CONCLUSION: Maintaining hygienic standards in conditions of socioeconomic deprivation in MRCs without running water and sewage in the presence of un-dewormed animals is problematic. These living conditions contribute to the higher prevalence of parasitic infections in children from MRCs, causing various health complaints and thus threatening their health and healthy development.

Association of socioeconomic disadvantage and ethnicity with perinatal neonatal, and infant mortality in Slovakia.

BACKGROUND: Infant mortality rates are reliable indices of the child and general population health status and health care delivery. The most critical factors affecting infant mortality are socioeconomic status and ethnicity. The aim of this study was to assess the association between socioeconomic disadvantage, ethnicity, and perinatal, neonatal, and infant mortality in Slovakia before and during the COVID-19 pandemic. METHODS: The associations between socioeconomic disadvantage (educational level, long-term unemployment rate), ethnicity (the proportion of the Roma population) and mortality (perinatal, neonatal, and infant) in the period 2017-2022 were explored, using linear regression models. RESULTS: The higher proportion of people with only elementary education and long-term unemployed, as well as the higher proportion of the Roma population, increases mortality rates. The proportion of the Roma population had the most significant impact on mortality in the selected period between 2017 and 2022, especially during the COVID-19 pandemic (2020-2022). CONCLUSIONS: Life in segregated Roma settlements is connected with the accumulation of socioeconomic disadvantage. Persistent inequities between Roma and the majority population in Slovakia exposed by mortality rates in children point to the vulnerabilities and exposures which should be adequately addressed by health and social policies.

Foot health among the Roma population of southern Spain according to the foot health status questionnaire.

BACKGROUND: Foot health of the Roma population is a challenge for the health professionals where this minority is significant, as is the case in Spain. At present, little is known about foot health of the Roma population and their knowledge would promote the training of these professionals at the community level. Foot pain is common and a reason for consulting podiatry services. The purpose of this study was to determine foot health among the Roma population according to the Foot Health Status Questionnaire. METHOD: An observational, cross-sectional and quantitative study conducted at the Roma population living in Spain in 2018. Self-reported data and the Foot Health Status Questionnaire were recorded. Examining the general health and foot health (foot pain, foot function, footwear and general health) and general (general health, social capacity, physical activity and vigour). This questionnaire is recommended as a valid and reliable patient-reported outcome. The obtained scores were compared. RESULTS: A sample made up of 624 men and women from the Roma population took part in this study. 45% were Roma men and 55% Roma women. In the first section of the FHSQ, a lower score of values was recorded in the footwear domain (62.5) and in the general foot health domain (60). Gypsy women obtained lower scores in all the domains. In the second section, lower scores were obtained in the vigour (56) domain and in the general health (60) domain. A large effect size (r-Rosenthal) was found by gender in the footwear domain (0.334) and in the vigour domain (0.195). Roma women showed higher values in cardiac disorders, serious illnesses, doctor visits and foot problems. 67.8% reported that they had never been assisted by a podiatrist. CONCLUSIONS: The studied Roma population has foot health problems, and these are more pronounced among women. They show lower values in the footwear and vigour domains. More professional training is required for health workers in this field to avoid cultural diversity stereotypes.

What do we know about the health of Spanish Roma people and what has been done to improve it? A scoping review.

Objectives: This study aims to review the published literature on the health of the Roma population in Spain, particularly that which describes health interventions and outcomes. Design: A scoping review of published articles/reports on Roma population health was carried out in Spain for publications between 2002 and 2014. Articles in Spanish or English were identified from Pubmed, Scopus, Science Direct, Web of Science, Scielo, IBECS, MEDES, Dialnet, Index Foundation, a database of theses and Google Scholar. After an initial assessment of the article title and summary, genetic studies, editorials, reviews and grey literature with incomplete data were excluded. Two independent researchers followed a protocol to analyze the selected papers in terms of general information, methodology, themes, and results or conclusions. Results: Forty studies were selected for inclusion, primarily located through PubMed and Google Scholar. Most of the papers were scientific articles, published after 2007 in Spanish scientific journals (70.0%) followed by institutional reports (20.0%). The main language was Spanish (84.2%). The studies were carried out mainly by public institutions (35.0%) or universities (22.5%). Most (67.5%) followed a descriptive design and nearly half (47.5%) were concerned only with the Roma population. The main thematic areas were: child health (25%), infectious diseases (25%), health and social education context (20%), perceived health and lifestyle (15%), sexual and reproductive health (7,5%) and health services use (7,5%). We found seven intervention studies related to health, educational environment, or social services. Conclusions: There are few publications related to the health of the Roma community in Spain and even fewer related to health interventions and outcomes. Those that are available have focused on areas such as child health or infectious disease outbreaks. It is important to promote health interventions in Roma communities and longitudinal studies that include a comprehensive vision and account for the social determinants of health.

Pregnancy experiences of women in rural Romania: understanding ethnic and socioeconomic disparities.

Women in rural Romania face significant health disadvantages. This qualitative pilot study describes the structural disadvantage experienced during pregnancy by women in rural Romania, focusing on the lived experiences of Roma women. We explore how women in rural communities experience pregnancy, their interactions with the healthcare system, and the role that ethnic and social factors play in pregnancy and childbearing. We conducted 42 semi-structured interviews with health and other professionals, seven narrative interviews with Roma and non-Roma women and a focus group with Roma women. Data were analysed using thematic analysis. We identified intersectional factors associated with women's pregnancy experiences: women perceiving pregnancy as both unplanned and wanted, joyful, and normal; women's and professionals' differing prenatal care perceptions; transport and cost related barriers to care; socioeconomic and ethnic discrimination; and facilitators to care such as social support, having a health mediator and having a doctor. Talking directly with professionals and Roma and non-Roma women helped us understand these many factors, how they are interconnected, and how we can work towards improving the pregnancy experiences of Roma women in rural Romania.

A high prevalence of viral hepatitis C in a socially excluded Roma community in Brno.

OBJECTIVES: To conduct a pilot study to assess the prevalence of blood-borne and sexually transmitted diseases (STDs) in a social-ly excluded Roma community engaging in risky behaviours in Brno, Czech Republic. METHODS: Fifty subjects engaging in risky behaviours, of whom 35 self-reported to belong to the Roma ethnicity, were recruited while receiving treatment in a newly established addiction centre in Brno between March and December 2017. All subjects were tested for blood-borne diseases and STDs. Epidemiological and demographic data were collected by means of assisted interview at the time of the first contact. RESULTS: Forty-three (86%) of 50 participants were anti-HCV positive. Of 35 subjects from the Roma subgroup, 32 (91.5%) tested anti-HCV positive. Among the 43 anti-HCV positive subjects, 35 (81.4%) also showed HCV RNA positivity. Of the 32 anti-HCV positive in the Roma subgroup, 26 (81.3%) were HCV RNA PCR positive. Only HCV (hepatitis C virus) genotypes 1 (a,b) and 3 were detected in the study group. Nine Roma subjects (25.9%)were newly diagnosed with syphilis of which none of them was aware. All study patients were negative for anti-HIV 1,2. CONCLUSION: As a proof of concept, this pilot study showed the importance of targeting epidemiological research and preventive care at excluded communities engaging in risky behaviours. The high anti-HCV seroprevalence in the Roma population in Brno who self-admitted intravenous drug use as well as the nine newly diagnosed cases of syphilis illustrate not only a high prevalence of risky behaviours in this excluded community but also the absence of systematic health care coverage in this population.  A positive point is that when an appropriate model of care is used, even the Roma clients are willing and able to comply with the therapy. This is true of both viral hepatitis C and syphilis: thanks to close cooperation with addictology services and opiate substitution treatment, all nine patients successfully completed 2 weeks of anti-treponemal antibiotic treatment. More systematic work with socially excluded communities including specific models of care tailored to the needs of poorly compliant patients is an essential prerequisite for controlling HCV epidemics in the Czech Republic. An additional effect in the surveillance of other infectious diseases linked to risky behaviours can be considered as an added value.

Socioeconomic status, health related behaviour, and self-rated health of children living in Roma settlements in Hungary.

OBJECTIVE: The poor health of Roma is well documented, but there is only limited data regarding the health of Roma children. The aim of this study was to describe the socioeconomic status, health related behaviour, and health of children living in segregated Roma settlements, and to compare the data with that of non-Roma children. METHODS: In March-April of 2011, a cross-sectional questionnaire-based survey among 11-year-old (211 boys and 252 girls) and 13-year-old (205 boys and 247 girls) children living in Roma settlements was performed (response rate: 91.5%). These data were compared with data from the Health Behaviour in School-Aged Children (HBSC) survey carried out in 2009/2010. RESULTS: The parents of Roma children were substantially less educated and less likely to be actively employed, and Roma children reported lower material welfare than non-Roma ones. The prevalence of consuming sweets and soft drinks at least 5 times per week was 1.5-2 times higher among Roma children. The prevalence of regular intense physical activity was higher at the age of 13 years among Roma boys, while physical inactivity was substantially higher in both age groups among Roma girls. Almost one quarter of Roma children and approximately 14% of non-Roma children had tried smoking at the age of 11. More Roma boys tried alcohol at the age of 11 than non-Roma ones. One in ten Roma children was obese in both age groups. The self-rated health status of Roma children was worse than that of non-Roma children. CONCLUSIONS: Children living in Roma settlements reported poorer socioeconomic conditions, higher consumption of sweets and soft drinks, earlier smoking and alcohol initiation, and worse self-rated health, but with some exceptions do not differ in fruit or vegetable consumption and BMI from general child population. To promote health of children living in Roma settlements, a multi-sector approach, special health education, plus social and health promotion programmes are needed.

The Differential Impact of Religion on Self-Reported Health Among Serbian Roma Women.

The present paper offers an account of how self-reported health varies with religious affiliation and reproductive effort among Serbian Roma women. Data were collected in 2014-2018 in two Roma semi-urban settlements in central Serbia. The sample consisted of 177 Christian and 127 Muslim women, averaging 54 years of age. In addition to religious affiliation (Christianity/Islam), demographic data, reproductive histories, data on self-reported and children's health were collected, along with height and weight, and smoking status. Christian and Muslim Roma women differed significantly on a number of variables, with Muslim women reporting poorer health and higher reproductive effort. Among Roma women religion may be an important determinant of reproductive and fertility patterns, largely because it may have formed an important foundation upon which identity is based. This study adds to the literature on the cross-cultural relevance of the ways religion shapes reproductive behaviors for understanding the health variations of women from the same ethnic group who profess different religions.

Gypsy, Roma and Traveller access to and engagement with health services: a systematic review.

Background: Gypsy, Roma and Traveller people represent the most disadvantaged minority groups in Europe, having the poorest health outcomes. This systematic review addressed the question of how Gypsy, Roma and Traveller people access healthcare and what are the best ways to enhance their engagement with health services. Methods: Searches were conducted in 21 electronic databases complemented by a focussed Google search. Studies were included if they had sufficient focus on Gypsy, Roma or Traveller populations; reported data pertinent to healthcare service use or engagement and were published in English from 2000 to 2015. Study findings were analyzed thematically and a narrative synthesis reported. Results: Ninety-nine studies from 32 countries were included, covering a range of health services. Nearly one-half of the presented findings related to primary healthcare services. Reported barriers to health service usage related to organisation of health systems, discrimination, culture and language, health literacy, service-user attributes and economic barriers. Promising engagement strategies included specialist roles, outreach services, dedicated services, raising health awareness, handheld records, training for staff and collaborative working. Conclusion: This review provides evidence that Gypsy, Roma and Traveller populations across Europe struggle to exercise their right to healthcare on account of multiple barriers; and related to other determinants of disadvantage such as low literacy levels and experiences of discrimination. Some promising strategies to overcome barriers were reported but the evidence is weak; therefore, rigorous evaluations of interventions to improve access to and engagement with health services for Gypsy, Roma and Traveller people are needed.

A modified chain binomial model to analyse the ongoing measles epidemic in Greece, July 2017 to February 2018.

Greece is currently experiencing a large measles outbreak, in the context of multiple similar outbreaks across Europe. We devised and applied a modified chain-binomial epidemic model, requiring very simple data, to estimate the transmission parameters of this outbreak. Model results indicate sustained measles transmission among the Greek Roma population, necessitating a targeted mass vaccination campaign to halt further spread of the epidemic. Our model may be useful for other countries facing similar measles outbreaks.

Improving equity and cultural responsiveness with marginalised communities: Understanding competing worldviews.

AIM: To explore the impact of culture on health, healthcare provision and its contribution towards health inequity experienced by some marginalised communities. BACKGROUND: Health inequity is a global issue, which occurs across and within countries, and is the greatest barrier to worldwide health and the development of the human race. In response to this challenge, there is an international commitment to ensure universal health coverage based on the fundamental principle that individuals should be able to access healthcare services they need. Despite this, there is clear evidence that indigenous and other cultural minorities such as New Zealand Maori and Gypsy Roma Travellers still experience far poorer health outcomes when compared to the majority population. Furthermore, when they do access health care, their experiences are often not positive and this in turn results in reluctance to access preventative health care, instead accessing health services much later, reducing treatment options and compounding higher mortality rates. What is often not explored or examined is the impact of the different cultural beliefs of individuals in these communities and the nurses caring for them. DESIGN: This is a position paper drawing upon research experience with New Zealand Maori and Gypsy Roma Travellers. We critically review the experiences of health inequity of marginalised communities. It does so by examining how these communities may have a different world view to the nurses caring for them, and it is this lack of understanding and valuing of alternative worldviews that contributes to the poorer health outcomes both communities face. CONCLUSION AND RELEVANCE TO CLINICAL PRACTICE: As nurses work with many different individuals and groups, we have to find ways of ensuring a more embracing, culturally responsive healthcare environment which respects and values the beliefs of others.

Low levels of modern contraceptive use and associated factors in the Western Balkans.

OBJECTIVES: The objective of this research was to determine modern contraceptive use (MCU) and explore factors associated with MCU in the Western Balkans. METHODS: Multiple Indicator Cluster Survey (MICS) data from Bosnia and Herzegovina, Kosovo, Macedonia, Montenegro and Serbia, including the datasets from Roma settlements, were merged. Bivariate and multivariate analyses were used to assess which factors were associated with MCU among married women aged 15-49 in the region. RESULTS: Among the 11,381 women surveyed, 13.75% reported MCU and 23.74% justified domestic violence. While bivariate analysis indicated that women who expressed justification of domestic violence were less likely to report MUC, this was not the case after adjusting for sociodemographic factors. Multivariate analysis showed that Roma were less likely than non-Roma to engage in MCU. Additionally, increased education, increased wealth, and urban residency were significantly associated with increased likelihood of MCU. CONCLUSION: The results highlight the need for more attention from research, programming and policy communities in order to better understand and address the overall problematically low level of MCU and factors associated with low MCU. More efforts are needed to address the disparities in MCU among Roma women and women of lower socioeconomic status.

Comparison of birthweight patterns in rural municipalities with and without a Roma community: a cross-sectional analysis in Slovakia 2009-2013.

OBJECTIVES: The health of the Roma population is relatively poor and indicators on municipal level are needed to inform authorities to improve it. The aim of this study was to compare the rate of low birthweights (LBW) and mean birthweight (BW) in municipalities with minor Roma population (MMR) and municipalities with large Roma population (MLR) in Slovakia. METHODS: A population-wide, ecological level, cross-sectional study was conducted using data from 2009-2013. Data on proportions of newborns with LBW, on mean birthweight of newborns and on mean ages of mothers at birth were obtained from the National Health Information Centre of Slovakia. Rates of LBW and mean BW were compared between the MMR and MLR groups. Mean age of mothers and rates of unemployment were considered possible confounders. RESULTS: The mean BW was by 183 g higher in the MMR group compared to MLR; the rates of LBW were 4.2% and 8.9%, respectively. Increasing proportions of Roma were significantly associated with increasing rates of LBW and decreasing mean BW, one percent increase in the proportion of Roma was associated with an increase in LBW rate of 0.15% and a decrease in mean LBW of -4.9 grams. CONCLUSIONS: Our findings could be used as a proxy for the purposes of policy making, replacing individual level studies with more resource-demanding design.

Risk factors of preterm birth and low birth weight neonates among Roma and non-Roma mothers.

OBJECTIVE: This study analyses the differences in birth outcomes between Roma and non-Roma mothers and investigates the potential causes of such differences. METHODS: We conducted a retrospective cohort study of 1,989 non-Roma and 799 Roma mothers who gave birth in 2014 and 2015 at the Gynaecology and Obstetrics Clinic of Louis Pasteur University Hospital in Kosice. Data on mothers and new-born infants have been obtained from the birth book and from the reports on mothers at childbirth. For low birth weight we considered the weight of a new-born weighing less than 2,500 grams and as for premature birth we referred to childbirth before pregnancy week 37. The file was split by ethnicity and statistically processed in IBM SPSS Statistics 21.0. RESULTS: Our results confirmed a lower birth weight among Roma children (-365.4 grams, p < 0.001). The shorter gestation age and higher risk of premature birth were not statistically significant regarding Roma children. Based on the characteristics of Roma mothers, they are at higher risk of giving birth as minor (OR = 23.64; 95% CI = 15.29-36.54; p < 0.001), as single mothers (OR = 7.13; 95% CI = 5.80-8.76; p < 0.001), with basic education or lack of education (OR = 141.31; 95% CI = 100.47-198.76; p < 0.001). They also have a higher risk of smoking during pregnancy (OR = 23.84; 95% CI = 18.06-31.49; p < 0.001); drinking alcohol (OR = 11.71; 95% CI = 3.36-40.90; p < 0.001) and taking drugs (OR = 8.70; 95% CI = 1.81-42.02; p < 0.001). Roma women attended gynaecologists more rarely. CONCLUSION: It is therefore important to support the work of community health workers and stimulate collaboration between community health professionals, paediatricians and gynaecologists to overcome institutional barriers in maternity and child care for mothers living in Roma settlement.

Differences in the prevalence of depression in older Spanish Romany and non-Romany people and associated factors.

AIM: Depression among older adults has serious implications, especially because suicide rates are higher in this group than in younger adults. Research has identified biological and social risk factors. However, studies addressing cultural and psychosocial factors associated with specific ethnic groups, such as Spanish Romani, are lacking. The objective of the present study was to establish the differential prevalence of depression among Romany and non-Romany people older than 55 years of age. It also aimed to explore how cultural, sociodemographic, and psychosocial factors predispose individuals to depression. METHODS: A total of 181 people were interviewed. The sample consisted of 95 self-adscribed Romany individuals and 86 non-Romany individuals over the age of 55; the latter group served as the control group. We performed bifactorial univariate anova, epidemiological analysis using Epi Info software, and analysis of correlations between Geriatric Depression Scale scores and the different factors analyzed. RESULTS: Significant differences in Geriatric Depression Scale score related to ethnicity and sex were found. Probable depression or depression in Romany men was four times higher than in non-Romany men. In Romany women, the risk was more than twice as high as in non-Romany women. Among the factors analyzed, income level, activity at home, and perception of being valued by family members showed significant differences between the groups. CONCLUSIONS: In short, we can state that Romany people develop symptoms of depression to a greater extent than non-Romany people, and although Romany women have a higher risk of depression, the differential effect of ethnicity is greater among Romany men. Income level, activity at home, and perception of being valued by family members are unambiguously related to ethnicity.

Vaccine uptake in the Irish Travelling community: an audit of general practice records.

Background: Compared to the general population, the Traveller community has substantial health inequalities. Vaccination coverage in Traveller children is estimated to be low and Travellers are at higher risk of vaccine-preventable diseases due to their social circumstances. Methods: Audit of vaccination history of Traveller (n = 214) and non-Traveller (n = 776) children registered at a general practice in England. The Green Book childhood immunization schedule was used as a reference standard. Results: There was significantly lower coverage for Traveller children compared to non-Traveller children for all vaccinations in the routine childhood immunization schedule. The percentage of children completing the schedule at all time points was significantly lower in the Traveller community. Conclusions: Traveller communities have significantly lower uptake of vaccinations, and therefore Travellers' children should be targeted by general practitioners for catch-up vaccination to improve outcomes for individuals and local herd immunity.

Predictors of prenatal smoking and attempted smoking cessation during pregnancy: a community-based study of Romani women in Southeastern Europe.

Background: The objective of this study was to examine predictors of prenatal smoking, and attempted smoking cessation during pregnancy among Romani women. Methods: A community-based, cross-sectional study (November 2012 to February 2013) of 410 Romani women in Roma settlements in Serbia and Macedonia was conducted. Logistic regression was used to identify predictors of prenatal smoking and attempted smoking cessation during pregnancy. Results: Romani women older than 30 years and those who were living with a man were over twice as likely (adjusted odds ratio (aOR) 2.48, 95% confidence interval (CI) 1.12-5.46; aOR 2.09, 95% CI 1.27-3.43) to smoke during pregnancy, compared to women <20 and married women, respectively. An inverse relationship between education and prenatal smoking was observed (for primary education versus no education, aOR 0.56, 95% CI 0.32-0.98; for secondary or higher education versus no education, aOR 0.38, 95% CI 0.16-0.90). Having a husband/partner who smokes was associated with significantly increased likelihood of prenatal smoking (aOR 3.71, 95% CI 2.20-6.25) and decreased likelihood of attempting to quit (aOR 0.51, 95% CI 0.24-1.06). Conclusions: Culturally sensitive and comprehensive prevention strategies and intervention programs are needed to reduce smoking during pregnancy among Romani women, including interventions targeting male partners.

Health-endangering everyday settings and practices in a rural segregated Roma settlement in Slovakia: A descriptive summary from an exploratory longitudinal case study.

BACKGROUND: Research into social root-causes of poor health within segregated Roma communities in Central and Eastern Europe, i.e. research into how, why and by whom high health-endangering settings and exposures are maintained here, is lacking. The aim of this study was to assess the local setup of health-endangering everyday settings and practices over the long-term in one such community. It is the initial part of a larger longitudinal study qualitatively exploring the social root-causes of poor Roma health status through the case of a particular settlement in Slovakia. METHODS: The study, spanning 10 years, comprised four methodologically distinct phases combining ethnography and applied medical-anthropological surveying. The acquired data consisted of field notes on participant observations and records of elicitations focusing on both the setup and the social root-causes of local everyday health-endangering settings and practices. To create the here-presented descriptive summary of the local setup, we performed a qualitative content analysis based on the latest World Health Organization classification of health exposures. RESULTS: Across all the examined dimensions - material circumstances, psychosocial factors, health-related behaviours, social cohesion and healthcare utilization - all the settlements' residents faced a wide range of health-endangering settings and practices. How the residents engaged in some of these exposures and how these exposures affected residents' health varied according to local social stratifications. Most of the patterns described prevailed over the 10-year period. Some local health-endangering settings and practices were praised by most inhabitants using racialized ethnic terms constructed in contrast or in direct opposition to alleged non-Roma norms and ways. CONCLUSIONS: Our summary provides a comprehensive and conveniently structured basis for grounded thinking about the intermediary social determinants of health within segregated Roma communities in Slovakia and beyond. It offers novel clues regarding how certain determinants might vary therein; how they might be contributing to health-deterioration; and how they might be causally inter-linked here. It also suggests racialized ethnically framed social counter-norms might be involved in the maintenance of analogous exposure setups.

Low vaccination coverage of Greek Roma children amid economic crisis: national survey using stratified cluster sampling.

Background: Research on Roma health is fragmentary as major methodological obstacles often exist. Reliable estimates on vaccination coverage of Roma children at a national level and identification of risk factors for low coverage could play an instrumental role in developing evidence-based policies to promote vaccination in this marginalized population group. Methods: We carried out a national vaccination coverage survey of Roma children. Thirty Roma settlements, stratified by geographical region and settlement type, were included; 7-10 children aged 24-77 months were selected from each settlement using systematic sampling. Information on children's vaccination coverage was collected from multiple sources. In the analysis we applied weights for each stratum, identified through a consensus process. Results: A total of 251 Roma children participated in the study. A vaccination document was presented for the large majority (86%). We found very low vaccination coverage for all vaccines. In 35-39% of children 'minimum vaccination' (DTP3 and IPV2 and MMR1) was administered, while 34-38% had received HepB3 and 31-35% Hib3; no child was vaccinated against tuberculosis in the first year of life. Better living conditions and primary care services close to Roma settlements were associated with higher vaccination indices. Conclusions: Our study showed inadequate vaccination coverage of Roma children in Greece, much lower than that of the non-minority child population. This serious public health challenge should be systematically addressed, or, amid continuing economic recession, the gap may widen. Valid national estimates on important characteristics of the Roma population can contribute to planning inclusion policies.

Associations between racial discrimination, smoking during pregnancy and low birthweight among Roma.

Background: Racial discrimination may increase the risk of low birthweight (LBW), but has not been studied among Roma, the largest minority population in Europe. Moreover, few studies test both institutional and interpersonal forms of racial discrimination on health. Our objective was to examine associations between institutional and interpersonal racial discrimination with LBW, and to test potential mediation by smoking during pregnancy. In 2012-2013, Romani women interviewers surveyed 410 Romani women in Serbia and Macedonia. We measured institutional discrimination (neighborhood segregation, legal status of housing and neighborhood socioeconomic status), interpersonal discrimination [Everyday Discrimination Scale (EDS)], birthweight and smoking by self-report or interviewer report. We estimated relative risks for discrimination on LBW and separately on smoking during pregnancy using log-binomial regression, adjusting for age, parity, years at residence and wealth. The indirect effect of high EDS via smoking on LBW was estimated using inverse odds weighting mediation. Living in a low SES neighborhood showed a 2-fold risk of LBW [adjusted risk ratio (aRR) = 2.4, 95% CI = 1.2, 5.0]; aRRs for segregation and illegal housing were weaker (aRR = 1.8, 95% CI = 0.7, 4.3; aRR = 1.3, 95% CI = 0.6, 2.6, respectively). Institutional measures were not associated with smoking. High EDS was associated with LBW (aRR = 2.4, 95% CI = 1.1, 5.2) and smoking during pregnancy (aRR = 1.4, 95% CI = 1.1, 1.8); the indirect effect of EDS on LBW via smoking was not significant. Interpersonal discrimination and living in a low SES neighborhood were associated with LBW among Roma. Interventions to improve Romani health may benefit from a human rights approach.