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

How Well Do Health-Mediation Programs Address the Determinants of the Poor Health Status of Roma? A Longitudinal Case Study

In Central and Eastern Europe (CEE), health-mediation programs (HMPs) have become central policy instruments targeting health inequities between segregated Roma and general populations. Social determinants of health (SDH) represent the root causes behind health inequities. We therefore evaluated how an HMP based in Slovakia addressed known SDH in its agenda and its everyday implementation. To produce descriptive data on the HMP's agenda and everyday implementation we observed and consulted 70 program participants across organizational levels and 30 program recipients over the long-term. We used a World Health Organization framework on SDH to direct data acquisition and consequent data content analysis, to structure the reporting of results, and to evaluate the program's merits. In its agenda, the HMP did not address most known SDH, except for healthcare access and health-related behaviours. In the HMP's everyday implementation, healthcare access facilitation activities were well received, performed as set out and effective. The opposite was true for most educational activities targeting health-related behaviours. The HMP fieldworkers were proactive and sometimes effective at addressing most other SDH domains beyond the HMP agenda, especially material conditions and psychosocial factors, but also selected local structural aspects. The HMP leaders supported such deliberate engagement only informally, considering the program inappropriate by definition and too unstable institutionally to handle such extensions. Reports indicate that the situation in other CEE HMPs is similar. To increase the HMPs' impact on SDH, their theories and procedures should be adapted according to the programs' more promising actual practice regarding SDH

The health of segregated Roma: first-line views and practices: a case study in Slovakia using ethnographic methods

This thesis assesses the views and practices first of segregated Roma, i.e. Roma living in separated communities, and then of health system professionals in Slovakia regarding the poor health status of segregated Roma in the country. It aims to contribute to the understanding of the health inequalities between segregated Roma and the general populations in Central and Eastern Europe (CEE). Based on four ethnographic studies, the thesis offers novel insights regarding three kinds of pathways. First, it adds that some CEE segregated Roma develop themselves ethnically framed racialized ideologies against the culture of local “non-Roma” standards of life, including care. Such social norms then shape health-endangering exposures of these Roma within the segregated enclaves in various ways, which vary by the household’s social level. Second, the thesis adds that frequently provided substandard healthcare to segregated Roma can be sustained by a poor understanding of their conditions and practices, and not-aligned organizational features. This can in turn lead to the Roma using healthcare services less effectively and to further exacerbation of specific health problems in this group. Lastly, the thesis adds that both pathways can be driven by an omnipresence of a specific form of racism targeting Roma: antigypsyism. In sum, the thesis suggests that to better understand and tackle inequalities concerning Roma, more focus is needed on the specific exposure pathways that we identified and on the fundamental underlying role of racism. Simultaneously, it shows that use of ethnographic tools within such research can be productive

Structures in the Area of Lauterhofen in BavariaStrukture v prostoru Lauterhofna na Bavarskem

Lauterhofen lies northwest of Regensburg in Germany. A necropolis dating to the second half of the 7th and the first half of the 8th centuries is situated here. The area of the cemetery is organized such that the place of burial could symbolize the gender, age and social status of the deceased. The measuring system of the necropolis corresponds with religious and astronomical foundations and furthermore, it repeats itself in the topography of the mythical surrounding landscape

Grobovi s Puščave nad Starim trgom pri Slovenj Gradcu

In 1911 and in 1995, a total of 138 graves from the late Roman and early medieval period were discovered at Puščava above Stari trg near Slovenj Gradec. The cemetery from the late Roman period originated first at the end of the 4th century and was in use throughout the entire 5th century. The inhabitants of Roman Colatio were probably buried in it. Graves that could be dated solely to the 6th or 7th centuries were not present. Burial again began at the earlier cult site at the beginning of the 8th century at the latest. All 8th century burials are in the northwestern half of the cemetery, and all 9th century graves in the southeastern half. The structural changes that occurred at the transition from the 8th to the 9th century were probably the result of the creation of Gradec - the residence of the župan (district head) of Slovenj Gradec next to the cemetery. At the end of the 9th century or at the beginning of the 10th century, burial ceased at Puščava.1911 in 1995 je bilo na Puščavi nad Starim trgom pri Slovenj Gradcu odkritih 138 grobov iz pozne antike in zgodnjega srednjega veka. Poznoantično grobišče je nastalo najprej konec 4. st. in bilo v uporabi v celem 5. st. V njem so najverjetneje pokopavali prebivalce antičnega Colatia. Grobov, ki bi jih lahko uvrstili samo v 6. ali 7. st., ni. Na starem kultnem mestu so ponovno pričeli pokopavati najkasneje na začetku 8. st. Vsi pokopi 8. st so na severozahodni polovici grobišča, vsi grobovi 9. st. na njegovi jugovzhodni polovici. Strukturne spremembe, ki so se zgodile pri prehodu iz 8. v 9. st. so verjetno posledica nastanka Gradca - bivališča slovenjegraškega župana, poleg grobišča. Konec 9. st. ali na začetku 10. st. pokopavanje na Puščavi preneha

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

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