Social Structure in a Roma Settlement: Comparison over Time.

The objective of the present study was to compare the social structure and internal establishment of a Roma community in two historical periods: in the 18th century and the present. We analysed Samuel Augustini ab Hortis's work, "Von dem Heutigen Zustände, Sonderbaren Sitten und Lebensart, Wie Auch von Denen Übrigen Eigenschaften und Umständen der Zigeuner in Ungarn" (On the Contemporary Situation, Distinctive Manners and Way of Life, as Well as the Other Characteristics and Circumstances of Gypsies in Greater Hungary), written in 1775-1776. Using content analysis, we subsequently compared his findings with our recent data from analogous qualitative research in a geographically-defined area of north-eastern Slovakia, the same region in which Augustini lived. Data collection was intensely conducted in 2012-2013 and once more in 2017-2019. The qualitative methods included direct observation, semi-structured interviews and focus groups. Four key informants and more than 70 participants collaborated in the study. The greatest difference we observed compared to the 18th century was the absence of a leader of the community, a "vajda", whose status was taken over by a new social class of "entrepreneurs". The most vulnerable group of the segregated and separated Roma communities are the "degesa", the lowest social class. They face a phenomenon consisting of so-called triple marginalization: they live in one of the most underdeveloped regions of the country, they inhabit segregated settlements and they are excluded by their own ethnic group. The socioeconomic status of the richest classes has changed faces, while the socioeconomic status of the lowest has not. We found a misconception among helping professionals (e.g., social workers) regarding the homogeneity of the Roma community. This calls for more attention to the erroneous use of the ethnic-based approach in the helping professions.

The Framework Convention on Tobacco Control in Slovakia and in Finland: one law, two different practices?

BACKGROUND: The Framework Convention on Tobacco Control (FCTC) was ratified in 2004 in Slovakia and in 2005 in Finland. The aim of this study was to compare the implementation of the FCTC in the national laws and policies regarding smoking in Finland and Slovakia. METHODS: In this case study the following areas are compared: the legal framework; the monitoring system and health promotion; treatment; and policies aimed at reducing tobacco consumption. We report on these in this order after a short historical introduction. RESULTS: The legal frameworks are similar in Slovakia and in Finland. Finland far exceeds the minimum legal requirements. Slovakian regulations reflect the FCTC requirements; however, social tolerance is very high. In Finland the monitoring system and health promotion are aimed more at tobacco consumption. Slovakia does not follow the surveillance plans recommended by WHO so strictly; often there are no current data available. No additional documents regarding the FCTC have been adopted in Slovakia. The financial contribution to treatment is very low. Slovakian tobacco control policy is more focused on repression than on prevention, in contrast to Finland. Smoking bans meet European standards. Excise duties rise regularly in both countries. CONCLUSION: Implementation of the FCTC is at different levels in the compared countries. Finland has a clear plan for achieving the goal of a smoking-free country. Slovakia meets only the minimum standard required for fulfillment of its international obligations. Its policy should become more transparent by making more up-to-date data available.

To Comply or Not to Comply: Roma Approach to Health Laws.

According to the general public in Slovakia, compliance with the law is problematic when it comes to Roma and health. Roma compliance with laws has not yet been studied. The aim of this is study was to explore the determinants of Roma behavior in the field of health laws. We used the concept of a semi-autonomous field proposed by Moore (1973) and the theory of planned behavior by Ajzen (1985). We found that Roma (non-)compliance with health laws was influenced by many different factors, such as beliefs, traditions, living conditions and culture. Group beliefs overrule national laws and also individual preferences, which tend to be subordinate to the group view. The less contact Roma from settlements have with non-Roma, the stronger their own rules are in the field of health. Roma health status is influenced by many factors: group beliefs and community traditions are stronger and overrule individual and state behavioral influence. A community-based participatory approach together with improvement of living conditions in cooperation with Roma is desirable.

Availability, prices, and affordability of selected essential cancer medicines in a middle-income country - the case of Mexico.

BACKGROUND: More alternatives have become available for the diagnosis and treatment of cancer in low- and middle-income countries. Because of increasing demands, governments are now facing a problem of limited affordability and availability of essential cancer medicines. Yet, precise information about the access to these medicines is limited, and the methodology is not very well developed. We assessed the availability and affordability of essential cancer medicines in Mexico, and compared their prices against those in other countries of the region. METHODS: We surveyed 21 public hospitals and 19 private pharmacies in 8 states of Mexico. Data were collected on the availability and prices of 49 essential cancer medicines. Prices were compared against those in Chile, Peru, Brazil, Colombia and PAHO's Strategic Fund. RESULTS: Of the various medicines, mean availability in public and private sector outlets was 61.2 and 67.5%, respectively. In the public sector, medicines covered by the public health insurance "People's Health Insurance" were more available. Only seven (public sector) and five (private sector) out of the 49 medicines were considered affordable. Public sector procurement prices were 41% lower than in other countries of the region. CONCLUSIONS: The availability of essential cancer medicines, in the public and private sector, falls below World Health Organization's 80% target. The affordability remains suboptimal as well. A national health insurance scheme could serve as a mechanism to improve access to cancer medicines in the public sector. Comprehensive pricing policies are warranted to improve the affordability of cancer medicines in the private sector.

Access to cancer medication in public hospitals in a middle-income country: The view of stakeholder.

BACKGROUND: Access to cancer medicines is a core component of comprehensive cancer care; as such, it is included in Mexico's public health insurance: Seguro Popular de Salud (SPS). Learning about stakeholders' experiences on processes and barriers influencing access to essential cancer medicines within healthcare facilities allows identifying needed policies to improve access to cancer care. OBJECTIVE: The aim of this study was to obtain the insights of health professionals in public hospitals in Mexico on how SPS influences access to cancer medicines regarding medicine selection, financing, and procurement and supply systems. The purpose is to identify policy areas that need strengthening to improve access to cancer medicines. METHODS: Semi-structured interviews were conducted with 67 health professionals from 21 public hospitals accredited by SPS across Mexico. A framework analysis was used with categories of analysis derived from the World Health Organization's Access framework. RESULTS: Most stakeholders reported that the availability of listed cancer medicines was sufficient. However, cancer specialists reported that medicines coverage by SPS was restrictive covering only basic cancer care. Public hospitals followed SPS treatment protocols in selecting and prescribing cancer medicines but used different procurement procedures. When essential cancer medicines were unavailable (not listed or stocked-out), hospitals reported several strategies such as prescribing alternative therapies, resorting to direct purchases, and assisting patients in obtaining medicines elsewhere. Other reported barriers to access to treatment were: distance to health facilities, poor insurance coverage, and financial restrictions. CONCLUSIONS: Health professionals have encountered benefits and challenges from the implementation of SPS influencing access to cancer medicines and care in Mexico, pointing to areas in which action is necessary. Finding the right balance between expanding the range and cost of cancer treatments covered by insurance and making basic cancer care available to all is a challenge faced by Mexico and other middle-income countries.

Why don't health care frontline professionals do more for segregated Roma? Exploring mechanisms supporting unequal care practices.

RATIONALE: Unequal provision of health care contributes to the poor health status of segregated Roma in Central and Eastern Europe. Studies on the drivers and mechanisms behind this are lacking. OBJECTIVE: We explored what kinds of substandard practices health care frontline professionals engage in regarding segregated Roma and what mechanisms support such practices during the professionals' careers in care services. METHODS: Over a three-month period at five different locations in Slovakia we interviewed and observed 43 frontline professionals serving segregated Roma. Next, through qualitative content analysis we identified in the data three themes regarding kinds of substandard practices and 22 themes regarding supporting mechanisms. We organized these themes into an explanatory framework, drawing on psychological models of discrimination and intergroup contact. RESULTS: The frontline staff's substandard practices mostly involved substandard communication and commitment to care, but also some overt ethnic discrimination. These practices were supported by five mechanisms: the staff's negative experiences with people labelled "problematic Roma patients"; the staff's negative attitudes regarding segregated Roma; adverse organizational aspects; adverse residential-segregation aspects; and poor state governance regarding racism. In the course of their careers, many professionals first felt obliged and diligent regarding segregated Roma patients, then failing, unequipped and abandoned, and ultimately frustrated and resigned regarding the equal standard of care towards the group. CONCLUSIONS: Health care frontline staff's practices towards segregated Roma are frequently substandard. The psychological processes underlying this substandard care are supported by specific personal, organizational and governance features. These mechanisms cause many frontline professionals gradually to become cynical regarding segregated Roma over the course of their careers. Health care staff should be supported with skills and tools for effectively handling their own and others' racism, the culturebound and structural vulnerabilities of patients as well as related professional expectations regarding equity.

Does Life Satisfaction Mediate the Association between Socioeconomic Status and Excessive Internet Use?

Excessive Internet use is becoming a rapidly increasing problem in today's society. Our aim was to assess the association between socioeconomic status (SES) of the family and excessive Internet use (EIU), and whether life satisfaction mediates this association. We analyzed data from a representative sample of 2844 Slovak adolescents (mean age 14.34, 50.5% boys) from the 2014 Health Behavior in School aged Children (HBSC) study, based on self-report questionnaires. We assessed the association of SES, measured by several indicators, such as perceived family wealth, parental education, and (un)employment, and adolescent EIU using linear regression, adding life satisfaction as a mediator. Adolescents whose father was unemployed and whose perceived family wealth was low tended to score higher on EIU. Neither gender nor age affected this relationship. Life satisfaction mediated a part of the association between SES and EIU in the case of low perceived family wealth and father's (un)employment. Adolescents with a low SES are more likely to become excessive Internet users, and life satisfaction mediates this association. Prevention of EIU among adolescents should be targeted at those with low SES, with life satisfaction being the topic to address.

How adults and children perceive the impact of social policies connected to unemployment on well-being in the household: a concept mapping approach.

OBJECTIVES: Social policies help people to overcome various unfavourable living situations, such as unemployment, which may lead to health inequalities. The aim of this study is to examine how adults and children perceive the impact of social policies connected to unemployment on well-being in the household, and whether their views differ. METHODS: We obtained data from 123 stakeholders in Slovakia, 96 adults and 27 children aged 11-15 years. We used concept mapping, based on qualitative data collection and quantitative data analysis. RESULTS: We obtained four clusters related to: children and education; current workforce; disadvantaged groups; labour office support. Adults rated the current workforce as the most important and urgent, and children the disadvantaged groups. Contrasts were largest on the disadvantaged groups and on combining family life and working abroad which children rated as very important and urgent but adults less so. CONCLUSIONS: Stakeholders had many perceptions, which may help to improve social policies. Adults were more concerned about work, and children were more so about inequalities. In general, adults were more practical and individualistic, and children, more emphatic and idealistic.

The Impact of Price Negotiations on Public Procurement Prices and Access to 8 Innovative Cancer Medicines in a Middle-Income Country: The Case of Mexico.

BACKGROUND: To mitigate the effect of high prices, in 2008 Mexico established a commission that negotiates single procurement prices for patented medicines in the public sector. OBJECTIVES: We assessed the possible effect of price negotiations on the prices of new essential cancer medicines in Mexico between 2010 and 2016 and on access to these new cancer medicines. METHODS: We retrieved the public procurement prices and volume of 8 selected innovative cancer medicines in Mexico in addition to their maximum retail prices in the private sector. We calculated the median, interquartile (25%-75%) range, and maximum and minimum public procurement prices to analyze price changes and trends. We assessed changes between the maximum retail prices and the public procurement prices and changes in the volume procured from 2010 to 2016. RESULTS: Between 2010 and 2016, the prices of selected patented cancer medicines in the public sector decreased by 40% to 85%, expressed in US dollars. When expressed in Mexican pesos, public prices for 5 medicines reduced and others remained stable, whereas prices increased in the private sector over the same period. Procurement prices were not uniform between and within public institutions. The volumes of selected cancer medicines supplied in the public sector increased over the years, suggesting better access. CONCLUSION: Although direct causality is difficult to prove, the establishment of the negotiating commission seems to have led to reduced prices and possibly better access in the public sector. Medicine procurement by public hospitals should be monitored to ensure that negotiated prices benefit all institutions.

Increased Employment for Segregated Roma May Improve Their Health: Outcomes of a Public-Private Partnership Project.

Increasing employment opportunities for segregated Roma might prevent major economic losses and improve their health. Involvement of the private sector in Roma employment, on top of intensified governmental actions, is likely to be a key to sustainable improvement, but evidence on this is scarce. Our aim was to determine the potential outcomes of such a partnership regarding increased employability and the resulting improved well-being and health. We therefore investigated a Roma employment project called Equality of Opportunity, run since 2002 by a private company, U.S. Steel Kosice, in eastern Slovakia. We conducted a multi-perspective qualitative study to obtain the perspectives of key stakeholders on the outcomes of this project. We found that they expected the employability of segregated Roma to increase in particular via improvements in their work ethic and working habits, education, skills acquisition, self-confidence, courage and social inclusion. They further expected as the main health effects of increased employability an improvement in Roma well-being and health via a stable income, better housing, crime reduction, improved hygienic standards, access to prevention and improved mental resilience. Social policies regarding segregated Roma could thus be best directed at increasing employment and at these topics in particular to increase their effects on Roma health.

"I am spiritual, but not religious": Does one without the other protect against adolescent health-risk behaviour?

OBJECTIVES: Spirituality and religious attendance (RA) have been suggested to protect against adolescent health-risk behaviour (HRB). The aim of this study was to explore the interrelatedness of these two concepts in a secular environment. METHODS: A nationally representative sample (n = 4566, 14.4 ± 1.1 years, 48.8% boys) of adolescents participated in the 2014 Health Behaviour in School-aged Children cross-sectional study. RA, spirituality (modified version of the Spiritual Well-Being Scale), tobacco, alcohol, cannabis and drug use and the prevalence of sexual intercourse were measured. RESULTS: RA and spirituality were associated with a lower chance of weekly smoking, with odds ratios (OR) 0.57 [95% confidence interval (CI) 0.36-0.88] for RA and 0.88 (0.80-0.97) for spirituality. Higher spirituality was also associated with a lower risk of weekly drinking [OR (95% CI) 0.91 (0.83-0.995)]. The multiplicative interaction of RA and spirituality was associated with less risky behaviour for four of five explored HRB. RA was not a significant mediator for the association of spirituality with HRB. CONCLUSIONS: Our findings suggest that high spirituality only protects adolescents from HRB if combined with RA.

Why don't segregated Roma do more for their health? An explanatory framework from an ethnographic study in Slovakia.

OBJECTIVES: The health status of segregated Roma is poor. To understand why segregated Roma engage in health-endangering practices, we explored their nonadherence to clinical and public health recommendations. METHODS: We examined one segregated Roma settlement of 260 inhabitants in Slovakia. To obtain qualitative data on local-level mechanisms supporting Roma nonadherence, we combined ethnography and systematic interviewing over 10 years. We then performed a qualitative content analysis based on sociological and public health theories. RESULTS: Our explanatory framework summarizes how the nonadherence of local Roma was supported by an interlocked system of seven mechanisms, controlled by and operating through both local Roma and non-Roma. These regard the Roma situation of poverty, segregation and substandard infrastructure; the Roma socialization into their situation; the Roma-perceived value of Roma alternative practices; the exclusionary non-Roma and self-exclusionary Roma ideologies; the discrimination, racism and dysfunctional support towards Roma by non-Roma; and drawbacks in adherence. CONCLUSIONS: Non-Roma ideologies, internalized by Roma into a racialized ethnic identity through socialization, and drawbacks in adherence might present powerful, yet neglected, mechanisms supporting segregated Roma nonadherence.

Curbing the lifestyle disease pandemic: making progress on an interdisciplinary research agenda for law and policy interventions.

By 2030, noncommunicable diseases (NCDs) will be the leading cause of death in every region in the world. While law and policy have an important role to play in curbing this pandemic, our current understanding of how they can most effectively be used is still limited. This contribution identifies a number of gaps in current research and insists on an interdisciplinary research agenda between law, health science and international relations aimed at designing concrete proposals for laws and policies to curb the NCD pandemic, both globally and domestically.

Policy approaches to improve availability and affordability of medicines in Mexico - an example of a middle income country.

BACKGROUND: The World Health Organization recommends establishing and implementing a national pharmaceutical policy (NPP) to guarantee effective and equitable access to medicines. Mexico has implemented several policy approaches to regulate the pharmaceutical sector, but it has no formal NPP. This article describes the approach that the Mexican government has taken to improve availability and affordability of essential medicines. METHODS: Descriptive policy analysis of public pharmaceutical policy proposals and health action plans on the basis of publicly available data and health progress reports, with a focus on availability and affordability of medicines. RESULTS: The government has implemented pooled procurement, price negotiations, and an information platform in the public sector to improve affordability and availability. The government mainly reports on the savings that these strategies have generated in the public expenditure but their full impact on availability and affordability has not been assessed. CONCLUSIONS: To increase availability and affordability of medicines in the public sector, the Mexican government has resorted on isolated strategies. In addition to efficient procurement, price negotiations and price information, other policy components and pricing interventions are needed. All these strategies should be included in a comprehensive NPP.

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.

Is a Perceived Activity-Friendly Environment Associated with More Physical Activity and Fewer Screen-Based Activities in Adolescents?

Background: The aim of this study is to explore if perception of an activity-friendly environment is associated with more physical activity and fewer screen-based activities among adolescents. Methods: We collected self-reported data in 2014 via the Health Behavior in School-aged Children cross-sectional study from four European countries (n = 13,800, mean age = 14.4, 49.4% boys). We explored the association of perceived environment (e.g., "There are other children nearby home to go out and play with") with physical activity and screen-based activities using a binary logistic regression model adjusted for age, gender, family affluence and country. Results: An environment perceived as activity-friendly was associated with higher odds that adolescents meet recommendations for physical activity (odds ratio (OR) for one standard deviation (SD) change = 1.11, 95% confidence interval (CI) 1.05-1.18) and lower odds for excessive screen-based activities (OR for 1 SD better = 0.93, 95% CI 0.88-0.98). Conclusions: Investment into an activity-friendly environment may support the promotion of active life styles in adolescence.

Are area-level and individual-level socioeconomic factors associated with self-rated health in adult urban citizens? Evidence from Slovak and Dutch cities.

Background: Evidence shows that living in disadvantaged areas is associated with poor health. This may be due to the socioeconomic (SE) characteristics of both these residents and the areas where they live. Evidence regarding this on Central European (CE) countries is scarce. Our aim was to assess whether the prevalence of poor self-rated health (SRH) was higher in deprived urban areas, whether this can be explained by individual SE status (SES) and whether this differed between Slovakia and the Netherlands per age group. We examined the association of urban-level data and individual-level SE factors from different urban areas in different countries (Slovakia, the Netherlands) using comparable urban health indicators and area indicators. We also obtained unique data from the EU-FP7 EURO-URHIS 2 project. Multilevel logistic regression showed that poor SRH was associated with area deprivation in both countries. Regarding age by country, poor SRH occurred more frequently in the more deprived areas for the younger age group (≤64) in the Netherlands but for the older age group (≥65 years) in Slovakia. Moreover, Slovak citizens reported poor SRH significantly more often than Dutch residents. Individual SES was significantly associated with poor SRH in both age groups and both countries for most area-level SE measures. Individual SES is associated with SRH more strongly than area deprivation. Therefore, it is important to account for relative deprivation at an individual level when considering health-enhancing activities. Moreover, the effect of urban-area deprivation seems to differ between CE and WE countries.

Regional mortality by socioeconomic factors in Slovakia: a comparison of 15 years of changes.

BACKGROUND: Like most Central European countries Slovakia has experienced a period of socioeconomic changes and at the same time a decline in the mortality rate. Therefore, the aim is to study socioeconomic factors that changed over time and simultaneously contributed to regional differences in mortality. METHODS: The associations between selected socioeconomic indicators and the standardised mortality rate in the population aged 20-64 years in the districts of the Slovak Republic in the periods 1997-1998 and 2012-2013 were analysed using linear regression models. RESULTS: A higher proportion of inhabitants in material need, and among males also lower income, significantly contributed to higher standardised mortality in both periods. The unemployment rate did not contribute to this prediction. Between the two periods no significant changes in regional mortality differences by the selected socioeconomic factors were found. CONCLUSIONS: Despite the fact that economic growth combined with investments of European structural funds contributed to the improvement of the socioeconomic situation in many districts of Slovakia, there are still districts which remain "poor" and which maintain regional mortality differences.

Social participation in early and established rheumatoid arthritis patients.

PURPOSE: The aim of the study was to examine whether rheumatoid arthritis (RA) patients with different levels of restriction in social participation differ in disease related as well as psychosocial variables and whether a similar pattern can be found among early and established RA patients. METHOD: Two samples of RA patients with early (n = 97; age = 53 ± 12.3 years; disease duration = 2.8 ± 1.2 years; 76% women) and established (n = 143; age = 58 ± 10.3 years; disease duration = 16.1 ± 3.6 years; 86% women) were collected. The pattern of differences for the patients with different level of participation restriction (no restriction, mild, moderate or high restriction) was explored by the Jonckheere-Terpstra test. RESULTS: Significant differences were found between patients with different levels of social participation restrictions in both samples in pain, fatigue, functional disability, anxiety, depression and mastery. Generally, it was found that patients with higher restrictions experienced more pain and fatigue, more anxiety and depression and reported lower mastery. Similar pattern of differences concerning disease activity and self-esteem was found mainly in the established group. CONCLUSIONS: The study shows that the level of perceived restrictions in social participation are highly relevant regarding the disease related variables such as pain, fatigue and functional disability as well as psychological status and personal resources in both early and established RA. IMPLICATIONS FOR REHABILITATION: Supporting involvement and participation of individuals with rheumatoid arthritis is important for decreasing the impact of RA symptoms on everyday life. Recognition and empowerment of individual resources such a mastery and self-esteem of RA patients could be beneficial for overcoming restrictions in participation.

Test-retest reliability of the scale of participation in organized activities among adolescents in the Czech Republic and Slovakia.

OBJECTIVES: Participation in organized activities is related with a range of positive outcomes, but the way such participation is measured has not been scrutinized. Test-retest reliability as an important indicator of a scale's reliability has been assessed rarely and for "The scale of participation in organized activities" lacks completely. This test-retest study is based on the Health Behaviour in School-aged Children study and is consistent with its methodology. METHODS: We obtained data from 353 Czech (51.9 % boys) and 227 Slovak (52.9 % boys) primary school pupils, grades five and nine, who participated in this study in 2013. We used Cohen's kappa statistic and single measures of the intraclass correlation coefficient to estimate the test-retest reliability of all selected items in the sample, stratified by gender, age and country. RESULTS: We mostly observed a large correlation between the test and retest in all of the examined variables (κ ranged from 0.46 to 0.68). Test-retest reliability of the sum score of individual items showed substantial agreement (ICC = 0.64). CONCLUSIONS: The scale of participation in organized activities has an acceptable level of agreement, indicating good reliability.