Social Determinants of Health Inequalities among Roma People: A Systematic Review

Social Determinants of Health Inequalities among

Roma People: A Systematic Review

Thesis

NOHA Masters in Humanitarian Action

Submitted by

Hector Pradhan

Department of International Relations and International Organization Faculty of Arts Rijksuniversiteit Groningen Groningen The Netherlands Co-Supervisor Dr. David Shim Assistant Professor

Department of International Relations and International Organization Faculty of Arts Rijksuniversiteit Groningen Groningen The Netherlands August 2019

Abbreviations 03

1. Background 05

2. Research Question and Sub-Questions 08 3. Theoretical and Conceptual Frameworks 08 4. Methods 4.1. Design 11 4.2. Sample 11 4.3. Analysis 12 5. Results 12 6. Discussion 6.1. Child Health 35

6.2. Maternal and Reproductive Health 39

6.3. Nutrition 42 6.4. Common Diseases 6.4.1. Communicable Diseases 44 6.4.2. Non-Communicable Diseases 46 6.4.3. Mental Health 48 6.4.4. Genetic Disorders 50

6.5. Hygiene and Sanitation 50

6.6. Generic Health Status 52

6.7. Health Care Access and Utilization 55

6.8. Health Beliefs and Health Behaviours

6.8.1. Substance Abuse 59

6.8.2. Traditional and Cultural Beliefs and Behaviours 63

6.8.3. Societal and Structural Discrimination and Exclusion 70

7. Strengths and Limitations 74

8. Conclusion and Recommendations 76

ACR Albumin/Creatinine Ratio

AIDS Acquired Immunodeficiency Syndrome

ANC Antenatal Care

BDS Beck Depression Scale

BMI Body Mass Index

DPT Diphtheria, Pertussis and Tetanus (Vaccine)

ETS Environmental Tobacco Smoke

EU European Union

EUMIDIS European Union Minorities and Discrimination Survey

FGD Focused Group Discussion

FP Family Planning

GP General Practitioner

HAV Hepatitis A Virus

HepA Hepatitis A

HepB Hepatitis B

HepC Hepatitis C

HepE Hepatitis E

HIA Health Impact Assessment

HIV Human Immunodeficiency Virus

IDU Intravenous Drug User

IMR Infant Mortality Rate

MMR Measles, Mumps and Rubella (Vaccine)

PHC Primary Health Care

PHCU Primary Health Care Unit

PNC Postnatal Care

PV I Poliovirus I

PV II Poliovirus II

PV III Poliovirus III

RH Reproductive Health

RTI Respiratory Tract Infection

SES Socio-Economic Status

SMR Standardized Mortality Ratio

SRH Self-Reported/Rated Health

STD Sexually Transmitted Disease

T2DM Type 2 Diabetes Mellitus

TB Tuberculosis

UK United Kingdom

US United States (of America)

Vit.B2 Vitamin B2

Vit.B6 Vitamin B6

Vit.C Vitamin C

Vit.E Vitamin E

WHO World Health Organization

WHR Waist to Hip Ratio

The concept of health and wellbeing varies from society to society and individual to individual. Societal perception of health has its cultural and psychological connotations of the group and each individual of that group. Therefore, health or its gap in any community can not only be measured in mere economical terms, but has to be broadly envisioned in terms of its multidimensional social determinants. Health inequity is not only an economic case, but is rather a case of social justice (Marmot, 2009). It requires health equity as its key principle in all health policies in order to collectively fight the inequality which is running across the society as a whole (Marmot, 2009).

Roma are Europe’s largest ethnic group with an estimated population around 5 to 10 million (Kosa et al., 2007). They migrated from Northern India between the 9th and 14th century and are mainly residing in central and eastern European countries such as Romania, Bulgaria, Hungary, Slovakia and the Czech Republic (Hajioff et al., 2000; Kosa et al., 2007; Voko et al., 2009). Since the historical times, they were oppressed, discriminated and excluded from the mainstream social facilities (Hajioff et al., 2000; Kosa et al., 2007). According to EU Minorities and Discrimination Survey (EUMIDIS, 2008) conducted in 27 EU member states, Roma are the most vulnerable group to overall discrimination in education, employment, social security, housing, healthcare and access to goods and services as well as racist crime against them among all the minority groups surveyed, with half of the Roma respondents reported to have been discriminated in the previous 12 months. The survey estimated 12 million Roma people living in EU.

Roma people in general are seen to suffer from poor living conditions, discrimination and inaccessibility to health care services as compared to average population (Hajioff et al., 2000; Kosa et al., 2007; Voko et al., 2009). The low educational status of Roma people reduces their chance of better employment which leads to increase their poverty and ultimately put them into poor living conditions (Kolarcik et al., 2009). All these factors contributing together to low socio-economic status (SES) of Roma people may have direct associations with their poor health conditions (Hajioff et al., 2000; Kolarcik et al., 2009). In addition, the health behaviours of Roma people also contribute to their poor health status, and these behaviours are not

al., 2009).

A comparative study conducted by Kolarcik et al. (2009) among Roma and non-Roma adolescent population in Eastern part of Slovakia revealed that non-Roma adolescents have lower rates of substance abuse, more specifically among girls. However, those girls were found to have higher physical inactivity rates. On the other hand, Roma boys are not significantly different from non-Roma boys on these issues. This study suggested that the less endangering health behaviours among Roma adolescents may have arisen from the health beliefs and perceptions of Roma people about fate, spirituality, purity of the body, rituals and traditional healing as well as their own traditional social norms and values, which guided their lifestyle and affected their attitude towards their health practices such as substance use and physical activities among girls in this case. Mackenbach et al. (2002) as cited in the same article of Kolarcik et al. (2009) mentioned that individuals do not choose their health behaviours independently, but rather different social circumstances determine these behaviours to a certain extent. These social circumstances are ultimately governed by social norms and values. Roma people also have some distinct health beliefs and behaviours determined and controlled by their cultural traditions which are an important part of their social life such as concept of pollution and cleanliness, role of family and age hierarchy, concept of illness and disease, ideal body weight, practices at death, views on medical procedures and alternative Roma remedies (Vivian et al., 2004).

It is culturally difficult to access a Roma population for any kind of study (Kosa et al., 2007). Besides, there are difficulties in defining the Roma population (Hajioff et al., 2000; Kolarcik et al., 2009) and because of the strict regulations in many European states on research about ethnic issues, it is legally challenging too (Kosa et al., 2007; Voko et al., 2009). Despite these challenges, there have been many studies carried out about health of Roma people in different countries (Kosa et al., 2007). However, very few studies have tried to compare their results with non-Roma population (Kosa et al., 2007) which could have given better insight in the differences between health status and health beliefs of ethnic minorities with those of the majority population and also in the discrimination in health care delivery to these ethnic groups, if any.

10 years less in Roma population as compared to the majority population (Hajioff et al., 2000). In another study conducted in the 79 districts of Slovakia, socio-economic factors such as educational level and employment rate, and proportion of the population living in Roma settlements individually demonstrated a significant effect on peri-natal mortality, infant mortality and mortality rate in weeks 2 to 52 when the factors were analysed separately, however in another model, when all socio-economic factors and ethnicity were included together, the result verified a significant effect of only the proportion of people living in Roma settlements on peri-natal mortality, infant mortality and mortality rate in weeks 2 to 52 (Rosicova et al., 2010). The model observed the variance of 34.9% for peri-natal mortality rate, 36.4% for infant mortality rate and 30.3% for mortality rate in weeks 2 to 52 (Rosicova et al., 2010). These data are just an example of the huge disparity between Roma and non-Roma populations, where various socio-economic, psycho-cultural and geo-political factors are associated to their prevailing health conditions. Rosicova et al. (2010) suggested different hypotheses to explain the low health status of Roma population compared to the majority population such as different socio-economic characteristics, cultural differences, psycho-social conditions and conditions in early childhood having cumulative effects over life time despite free access to health care guaranteed by state law.

Access to health care is influenced by cultural factors within the Roma community as well as negative attitudes of health workers towards them (Hajioff et al., 2000). Not only their unique beliefs about treatment and care, but also their migratory lifestyles lead health workers to make misconceptions about Roma which lead to their discrimination or refusal to provide health services to Roma people (Vivian et al., 2004). On the other hand, the re-emerging nationalist discrimination and racist attacks on Roma people is also in rise in central and east European countries after the end of cold war (Hajioff et al., 2000; Vivian et al., 2004). Therefore, some sort of locally and culturally sensitive mechanism must be developed in order to understand the health needs and accommodate the health care to ethnic minorities (Hajioff et al., 2000; Vivian et al., 2004).

From the above introduction, several questions arise which social determinants lead to inequalities in health and which factors are responsible with regard to Roma population in their lower status of health as compared to other population. In an attempt to discuss these issues, this study aims to find an answer to the following research question:

To what extent the social determinants regarding health mentioned in the literature are associated with the different health status between Roma people and non-Roma people?

To make the study more specific and systematic to collect data and analyse them, the research question is further divided into following sub-questions:

1. What is the difference in health status between Roma and non-Roma people? 2. What are the factors associated with health of Roma people?

3. What is the role of health beliefs of Roma people in determining their health status?

3. Theoretical and Conceptual Frameworks

The issue of health inequality is not only confined to the problem of poverty, but rather has a social grading, requiring due consideration on the agenda of social determinants of health (Marmot, 2009). Poor social and economic conditions result into shorter life expectancy and more exposure to diseases among people gradually down the social ladder than people on the top (Wilkinson et al., 2003). This social gradient runs across society where both material and psychosocial status cause differences among different hierarchical strata of people and the more disadvantaged groups experience a higher frequency and degree of illnesses and premature deaths (Wilkinson et al., 2003). The longer people live in such a disadvantaged situation as having little family property, poorer education, reduced security and social support, unemployment or insecure employment, stress and addiction, low food intake, poor housing standards and running a family in those circumstances, the greater the deteriorating impact on their physical and mental wellbeing (Wilkinson et al., 2003).

the lowest strata of the social grading and thus are extremely affected by those social determinants of health throughout their life. The unemployed, ethnic minorities, guest workers, disabled, refugees and homeless are the people who face relative poverty, deprivation and social exclusion, and they are the most vulnerable to different diseases and premature deaths (Wilkinson et al., 2003). Social exclusion which results from racism, discrimination, stigmatization, hostility and unemployment socially isolates people, treats them as less than equal, prevents them from participating in social, economic and cultural life of their society, denies them access to basic and vital services and ignores them of their social justice and human rights (Wilkinson et al., 2003).

Social exclusion is a dynamic and multidimensional process that excludes people or groups from social systems and social relations whereby the status of the people or groups is associated with poverty and disadvantage (Popey et al., 2008). Exclusion consists of four dimensions viz., political, economic, social and cultural and can be studied at the individual, household, community, national or global level; exclusion is characterized by unequal power relationships, unequal distribution of resources and unequal rights and capabilities (Popey et al., 2008).

There are two pathways viz., constitutive and instrumental, which make the links between the processes of social exclusion. The constitutive pathway restricts participation in political, economic, social and cultural relationships and has a negative impact on health (Popey et al., 2008). Such constitutive restrictions cause instrumental deprivations like poor work conditions, exclusion from labour market, low income, poor nutrition, poor living conditions and poor health conditions (Popey et al., 2008).

The concept of social exclusion helps to understand poverty and disadvantage, and to develop appropriate and effective ways of tackling deprivations and inequities (Popey et al., 2008). The political, economic, social and cultural dimensions are the relation with the interactions among these four dimensions generating different power structures leading to inequalities in health, which are explained in the following conceptual framework.

Political dimension

Political rights, Legal rights, Human rights, Rights to basic needs and access to services,

Rights to express and participate, Rights to education Economic dimension Housing, Land, Livelihoods, Employment, Income, Working conditions Social dimension Family, Clan, Kinship, Friendship, Neighbourhood, Community, Society, Social networks Cultural dimension Norms, Values, Beliefs, Diversity in living

Figure 1. Conceptual Framework of the Main Dimensions Contributing to Inequalities in Health (Source: Popey et al., 2008)

Hierarchical system of social stratification Gender, Ethnicity, Class, Caste, Ability, Age

Unequal access to power and resources

Differential exposure and vulnerability

Environmental, Biological, Social, Psychological, Economic capacities

4.1. Design

This study is a systematic literature review aiming to highlight the underlying determinants associated with the health status of Roma people as compared to average population.

4.2. Sample

This research design is based upon a systematic literature review. An extensive search was performed on Web of Science, SocLit, PubMed, MEDLINE, ScienceDirect, PsycInfo, PiCarta, EMBASE, CINAHAL and Google Scholar online web sources. Key terms ‘health AND inequalities AND Roma (OR Romani OR Gypsy OR Gypsies)’, ‘social AND determinants AND health AND Roma (OR Romani OR Gypsy OR Gypsies)’, ‘social AND exclusion AND Roma (OR Romani OR Gypsy OR Gypsies)’, ‘health AND Roma (OR Romani OR Gypsy OR Gypsies)’, ‘health AND beliefs (OR behaviour) AND Roma (OR Romani OR Gypsy OR Gypsies)’, ‘maternal (OR mothers) AND health AND Roma (OR Romani OR Gypsy OR Gypsies)’, ‘children AND health AND Roma (OR Romani OR Gypsy OR Gypsies)’, ‘reproductive AND health AND Roma (OR Romani OR Gypsy OR Gypsies)’, ‘nutrition (OR malnutrition) AND Roma (OR Romani OR Gypsy OR Gypsies)’ were used to search the studies from 2000 to 2010 in the English language.

Published articles and books in English describing theories of health inequality, social determinants of health and social exclusion as well as those describing health behaviour and health status of Roma people related to key health indicators such as morbidity, mortality, life expectancy, disease pattern, health services utilization, child health, maternal health, reproductive health and nutritional status were included in this study. Cited articles of the selected studies were also reviewed.

Both kinds of studies either focusing only on Roma population or those comparing Roma with the Non-Roma population were included as long as they were related to social determinants of health of Roma people, their social exclusion, health beliefs and behaviours, and the existing health inequalities. Studies containing a quantitative data analysis regarding morbidity, mortality, life expectancy, disease pattern,

nutritional status in the selected studies were included and those studies or data analyses done beyond the scope of these key indicators were excluded from this study.

4.3. Analysis

The initial literature search was scanned by titles. Studies with relevant titles were then selected for the review of their abstracts. Articles deemed relevant for the study were selected for full-text review from the screening of abstracts. After the full-text review, only those articles fulfilling the above-mentioned inclusion criteria were selected as final sample for the study. The final selected articles were categorized according to the research sub-questions and related data to each sub-question were extracted from them. Besides, information on the study design, sampling method, independent and dependent variables, statistical analysis, results and findings of the final listed articles were also analysed. For purpose of the analysis, each of the three sub-question areas was further classified according to different attributes used in the data.

5. Results

Figure 2. Flow-Chart Diagram of the Literature Search Performed

Retrieved hits (N = 130)

Excluded because of abstract (N = 21) No abstract available (N = 2), No Roma health (N = 19) Remaining publications (N = 106)

Remaining publications (N = 85)

Excluded because of full paper (N = 48) Not available in English language (N = 11); No full text

available online (N = 20); Only presentation notes, reviews, letters to editor and news analysis (N = 17)

Excluded because of title (N = 24) No Roma (N = 24)

Remaining publications (N = 37) for review

their social determinants which were published between 2000 and 2010. This study aimed to compare differences in health status and the associated factors of those differences between Roma and non-Roma general populations. This study also aimed to find out health believes of Roma and their role in determining their health positioning. A total of 37 scientific research papers were included to explore social discrimination and exclusion of Roma and its historical institutionalization, traditional and cultural beliefs and attitudes of Roma and their health behaviours and practices, access to health care facilities and its utilization by Roma, availability of culture sensitive health care services and experience of Roma, and the longstanding socio-economic status of Roma and its impact on their health status in the backdrop of centuries long persecution of Roma people.

Table 1. Synopsis of the Studies Reviewed Author Year N / n Design Roma / non-Roma

Difference in Health Status Associated Factors Health Beliefs

Hajioff and McKee 2000

Review of

literature Roma * Roma children had higher rates of low birth weight and premature births. * Roma children had lower immunization coverage.

* Roma children had higher rates of recessive syndrome.

* Roma children had higher incidence of secretory otitis media.

* Roma children had higher incidence of lead poisoning and burns.

* Roma children had lower rates of chromosomal and autosomal disorders, and brain tumours.

* Roma adolescents had lower rates of substance use.

* Roma women had higher rates of early age pregnancies, abortions and live births than majority population.

* Low level of education among Roma women.

* Higher rates of consanguinity among Roma population.

* Lower SES of Roma.

* Higher exposure of Roma children to hazardous environmental conditions. * Roma adults have higher rates of smoking and obesity.

* Poverty, overcrowded living conditions and lack of proper sanitation in Roma settlements.

* Cultural insensitivity towards Roma. * Misunderstanding between health care providers and Roma people, and negative attitudes towards each other.

* Low support from authorities and discrimination against Roma population.

* Cultural belief of Roma on community management of ill-health and folk-healing.

* Roma believe on fate and pre-destiny. * Roma believe that staying in hospital will bring death except for childbirth.

Year Design non-Roma

* Roma women had lower level of knowledge about contraception, seeking contraceptive advice and using

contraception methods.

* Roma pregnant women were found to have high rates of HepA and HepB. * Very high seroprevalence rate of HAV antibodies was found in Roma children compared to non-Roma children. * Higher seroprevalence of HepC was found in Roma prisoners than in other prisoners.

* Higher seroprevalence of HepE antibodies was found in Roma STD clinic attenders than in non-Roma attenders. * Roma prisoners and IDUs had lower seroprevalence of HIV than non-Roma. * Roma adults had higher rates of hypertension, diabetes, occlusive vascular disease, chronic renal failure, triglyceride and cholesterol.

* Roma people had inequality in access to dental care and low utilization of preventive dental services than majority population. * Roma people had higher rates of suicide than majority population.

* Mycobacterial infection was found to be more common in Roma.

* Roma did not seek health care for all health problems, and they rejected hospitalization except for childbirth. * Roma faced negative attitudes of health care providers due to cultural ignorance. Van Cleemput 2000 Descriptive Cross-sectional study (General Roma (Adults; UK)

* Low life expectancy, high perinatal and infant mortality, high rates of accidents among children, high mortality from

* Enforced housing on isolated sites or in houses with little privacy and separated from extended families.

* Belief that the change of traditional lifestyle is the major cause of increased physical and mental ill-health.

Year Design non-Roma Population; Generic health and morbidity, living conditions, hygiene and sanitation, access to health care, health care provision)

cardiovascular disease, high incidence of asthma among Roma.

* High stress related physical and mental health problems, and substance use among Roma.

* High prevalence of congenital anomalies and metabolic conditions with autosomal recessive inheritance.

* Low level of immunization uptake among Roma.

* Fear of eviction and alienation of local people.

* Legal bindings against nomadic life. * Poverty and deprivation.

* Hostile living environments.

* Lack of adequate basic facilities and local amenities.

* Lack of playing facility for children. * High incidence of first cousin marriage among Roma.

* Lack of education and low school attendance among Roma.

* Difficulty in access and inequality in availability and use of health services among Roma.

* Lack of information and clear explanations about medical matters from health staff. * Lack of access to medical records of Roma.

* Lack of registration with GP.

* Missed appointments to medical care. * Experience of humiliation and rejection to obtain health care.

* Prevalence of prejudice about Roma among health staff.

* Lack of continuity of care.

* Nomadic mindset of Roma.

* Tradition of taking up family roles and responsibilities from the age of about 12 years.

* Fear of assimilation of own culture. * Beliefs on herbal home remedies, traditional healers, spiritual cure, pilgrimages and prayers.

Ginter et al.

2001 Review of literature Roma / non-Roma * Higher prevalence of infectious diseases, injuries, poisoning and burns in Roma children.

* High fertility rates and prevalence of premature births in Roma women. * Shorter life expectancy of Roma. * Higher neonatal mortality rates, lower birth weight, lower head length and lower breast circumference in Roma new-borns. * Lower body height and weight

* Higher environmental hazards in Roma settlements.

* Bad economic situation of Roma. * Lower level of education of Roma. * Incorrect lifestyle of Roma.

* Early age marriage of Roma women. * Consanguinity in Roma.

* Higher prevalence of smoking, alcohol consumption, animal fat consumption and obesity in Roma.

Year Design non-Roma

development in Roma children. * Higher prevalence of congenital anomalies and recessive genetic diseases such as glaucoma, hypothyroidism, diabetes mellitus and phenylketonuria in Roma.

* Higher prevalence of mental retardation in Roma children of 6-14 years.

* Higher prevalence of infectious diseases such as STDs, active pulmonary TB, enteritis, salmonellosis, scabies, smallpox, viral HepA, B and C, and lues in Roma population.

* Increased rate of suicide among Roma. * Higher prevalence of cardiovascular diseases, hypertension, diabetes, hypertriglyceridemia,

hypercholesterolaemia, atherogenic index, occlusive vascular disease and chronic renal failure among Roma.

* Lower prevalence of vegetables and fruits consumption in Roma.

Koupilova et al.

2001

Review of

literature Roma / non-Roma * Roma people had lower life expectancy. * IMR and perinatal death rates were higher in Roma children than in non-Roma. * Roma children had lower birth weight and higher rates of premature births than in non-Roma.

* Roma children had lower vaccination coverage.

* Childhood mortality rates were higher in Roma.

* Roma children had slower rate of growth and development, and late appearance of menarche in girls.

* Rates of abortion were higher in Roma women than in non-Roma.

* Use of contraception is much lower in

* Financial benefit of child bearing (social benefit) from the state demotivated the use of contraception among Roma.

* Roma had poor hygiene and sanitation conditions, crowded living, poverty, lower social status and lower educational level. * High prevalence of inbreeding within Roma population.

* Roma had high consumption of animal fat, low consumption of fruits and vegetables, obesity, high smoking from early age, high alcohol consumption and lack of physical activities.

* Roma were unwilling to participate in disease prevention and health promotion activities.

* Roma sexual behaviour was conservative such as rejection of homosexuality and high value placed on faithfulness in marriage.

* Prostitution and drugs abuse are new risk behaviours in Roma society.

Year Design non-Roma

Roma women than in non-Roma. * Communicable diseases such as HepA and E, shigellosis, giardiasis, lice infestation and RTI were common among Roma.

* Roma were highly exposed to parasites, bacteria and viruses, and had

splenomegaly.

* TB was prevalent among old Roma. * Roma children had higher prevalence of RTI, skin and gastrointestinal diseases, and accidents than non-Roma.

* Hospitalized Roma children were mostly diagnosed with RTI and middle-ear infections, anaemia and diarrhoea. * Roma children had higher prevalence of congenital anomalies and genetic diseases such as hypothyroidism, craniostenosis, glaucoma and phenylketonuria than non-Roma.

* Cardiovascular diseases were the most common cause of death in Roma. * Roma suffered from RTI, liver and digestive tract diseases.

* Old Roma had problems of neurological, joint and bone, and airway diseases. * Roma mothers breast fed their children for shorter periods of time, and smoked a lot. * Roma women had a lower incidence of cervical cancer than non-Roma.

* Roma children were found to consume inadequate RDA of dietary food, but more snack food containing high fat and sugar. * Roma children had low daily intake of Vit.C, Vit.E, Vit.B2, Vit.B6, calcium and iron.

Lehti and Mattson 2001 N = 4 Cross-sectional qualitative study (Women aged from 31 to 40 years; Women’s Roma (Adult women; Sweden)

* Gypsy women and youth had low ranking in their families whereas elderly was given respect and taken care by the younger ones.

* Gypsy women had more rules to follow than men.

* Gypsy women visit health centres with one or more relatives or friends. * Gypsy women show acute symptoms and demand urgent access to doctors. * Gypsy women visit health centres very frequently for some period and were not

Year Design non-Roma health and morbidity, health beliefs and behaviours, health care utilization)

* Collective system of Gypsies was a good supporting network for Gypsy women to share their troubles and happiness.

seen then after for months.

* Stress, pain and depression created by social tension within gypsy community caused Gypsy women immediate to visit health centres.

* Gypsy women and their accompanying relatives and friends tended to visit a health centre in chronological order closely following one after another showing same types of symptoms and were given same diagnosis and treatment.

* Demarcation between purity and contamination, and purification rituals were sharply followed in Gypsies. * Women were considered impure because they menstruate and bear children, and could not touch anything at home during those periods.

* At least one relative should be together with the patient when a family member was hospitalized.

* It was considered dishonoured if a Gypsy woman shows her body or talks about her illness to men or elderly women.

* The collective punishment system of Gypsies caused ill-health to those who ended up outside the collective. Van Cleemput and Parry 2001 N = 87 n = 87 cross-sectional study (General population aged 17 years and Roma / non-Roma (Adults; UK)

* Gypsy travellers have poorer health status than the lowest socio-economic class of the UK population, but no remarkable

difference from socially deprived non-Roma urban resident neighbourhood.

* Gypsy travellers have unequal access to health services.

* Social deprivation

* Forced changes to travelling lifestyle * Lack of basic amenities

* Lack of permanent address

* Exclusion from health plans and programs * GPs not accepting gypsy travellers onto their practice list.

Year Design non-Roma over; Generic health, mental health, substance use) Ekuklu et al. 2003 N = 235 n = 654 Cross-sectional study (General population aged 17 years and over; health care utilization)

Roma / non-Roma (Adults; Turkey)

* Gypsies used PHC services more

frequently than non-Gypsies. * Lower social security coverage of Gypsies.

* Higher rates of unemployment among Gypsies.

* Lower levels of education among Gypsies.

* Poorer economic situations of Gypsies. Smart et al.

2003 Review of Literature Roma * Roma had one of the highest birth rates in EU.

* Roma had high IMR, still birth and low birth weight.

* There was evidence of some hereditary conditions among Roma.

* Roma were more likely to suffer from asthma, chest infections, heart disease, chronic disability, accidents, injuries and conditions linked to poor sanitation. * Roma had low uptake of FP services, cervical cytology, and ANC and PNC. * Roma had high prevalence of

miscarriages, still births and injuries during pregnancies.

* Roma mothers are reluctant to immunize their child.

* Hazardous environmental conditions in and around Roma camp sites.

* Lack of water and sanitation facilities in Roma camp sites.

* Use of landfill sites and industrial wastelands tolerated as official Roma camp sites by local authorities.

* Open fire, faulty wiring, proximity of overhead power lines, road traffic and lack of safe play area for children increase the risk of hazards in Roma.

* Poverty among Roma people.

* Feeling of powerlessness and intimidation in Roma in dealing with health staff. * Discrimination against Roma on the basis of gender, class and community.

* Discriminatory, offensive and derogatory attitudes of health workers towards Roma. * Harassment and eviction of Roma women by authorities during pregnancy.

* Young age of Roma women at marriage. * Roma mothers are concerned about the potential side-effects of vaccination.

* Roma had tendency to seek help when only direct need arises.

* Roma women did not consider themselves to be ‘sick’ and see no reason to attend pregnancy care services.

Year Design non-Roma

* Lack of access to FP services and health education to Roma.

* Lack of updated and transferable medical records of Roma people.

* GPs’ reluctance to accept Roma patients. * Lack of access to preventive treatment and screening programs of certain diseases for Roma.

* Administrative mismatch with the nomadic lifestyle of Roma such as difficulties with making and keeping appointments, transport problems, lack of postal address. Vozarova de Courten et al. 2003 N = 156 n = 501 Cross-sectional study (General population aged 30 years and over; T2DM, metabolic syndrome and cardiovascular diseases) Roma / non-Roma (Adults; Slovakia)

* Gypsies had higher prevalence of T2DM, obesity, hypercholesterolemia,

hypertriglyceridemia, hypertension, hyperinsulinemia, insulin resistance, elevated ACR, metabolic syndrome and cardiovascular disease.

* Gypsies were younger, heavier, and had higher BMI and WHR.

* Gypsies had higher smoking rate. * Gypsies had lower prevalence of physical activities.

* Gypsies had lower levels of education. * More gypsies were unemployed and had low monthly income.

* Gypsy ethnicity.

Zeman et al.

2003 Review of literature Roma / non-Roma * High rates of genetic conversion and congenital anomalies found in Hungarian, Czech, Romanian and Spanish Roma. * Blood and blood clotting disorders found in German and Hungarian Roma.

* High prevalence of asthma found in Roma in Northern Spain.

* Congenital cataract found in Bulgarian and Slovakian Roma.

* Neuromuscular disorders found in Hungarian, Bulgarian and Spanish Roma. * Congenital hypothyroidism found in

* High prevalence of consanguinity among Roma.

* Reduced access due to high mobility and poverty of Roma.

* Social concern motivated for personal dental hygiene than health concern in UK travellers.

* UK Travellers preferred whole foods than processed food, and in winter children were given sweets and sugary foods.

* Crowded living conditions in Roma settlements.

* Cultural beliefs against immunization among Roma.

* Culture of family cohesiveness in Roma. * Beliefs about purity or ‘Marime’ of top half and impurity of bottom half of the body, and concept about internal and external cleanliness and contamination in Roma.

* Beliefs about good luck or ‘Baxt’ and bad luck or ‘Prikaza’ are associated with purity and contamination.

Year Design non-Roma

Slovakian Roma.

* Low child immunization rates were observed in UK and Italian Roma. * Low utilization of preventive dentistry services in UK Travellers.

* High rates of seropositive antibodies for HepA, HepB, HepC and HepE found in Spanish, Czech, Bulgarian, Italian and UK Roma.

* Lower rates of HIV infection found in Spanish Roma prisoners than non-Roma prisoners.

* Higher IMR, and slower childhood growth and development found in UK, Hungarian, Czech and Slovakian Roma.

* Higher still birth rate, lower birth weight and lower life expectancy found in UK Travellers.

* Early age of marriage, early age of pregnancy, high rates of abortions and low use of contraceptives reported in Bulgarian Roma women.

* Earlier onset of lactogenesis after birth and larger volume of milk production reported in Italian Roma women. * Higher rate of attempted suicides with lower rate of completed attempts found in Hungarian and Czech Roma.

* Higher cardiovascular diseases rates found in Czech Roma than non-Roma. * Lower rates of multiple sclerosis and Parkinson’s disease found in Bulgarian Roma than non-Roma.

* High prevalence of smoking found in Greek Roma.

* Opiate-addicted Spanish Roma had lower

* Lack of running water and waste management in Roma settlements. * Discrimination against Roma. * Making fire for cooking and warming house from scavenged materials in Roma settlements.

* Cultural misunderstanding, conflict, resistance and reluctance between Roma population and health care providers. * Legal restrictions on traditional lifestyles in the UK put Travellers in isolation and hostility from general population and health care.

* Higher parity per Roma women, lower literacy rates and activities, lower intake of milk, fruits and vegetables, higher intake of alcohol, lower positive view on economic opportunities, lower socio-economic status and lower SRH status among Slovakian Roma was reported.

spiritual basis of illnesses in Roma. * Use of spittle to treat wounds. * Roma value systems prevent women from gynaecological treatments. * Mistrust of outsiders or ‘Gadje’. * Large numbers of visitors come to see Roma patients in hospitals.

Year Design non-Roma

compliance to drug treatment programs than non-Roma.

* Spanish Roma children had higher risk of increased blood lead level than non-Roma. * Czech Roma mothers lower Vit.C intake than non-Roma mothers.

Vivian and Dundes 2004

Review of

literature Roma * Discrimination in hospitals. * Health providers’ misconception and suspicion towards Roma. * Roma believe the more a person weigh, the healthier s/he is.

* Diseases are caused by spirits or devils due to impurities and filthiness at home. * Faith on folk and herbal remedies. * Concept of purity and cleanliness of the body.

* Importance of family support networks and hierarchy of age and sex.

* Importance of birth and death rituals. * Avoidance of immunization, anaesthesia and surgery. Kelly et al.

2006 N = 286 Longitudinal study

Randomized controlled trial (Young men with mean age 19.7 years; prevention of HIV and STDs) Roma (Adults; Bulgaria) Intervention:

* Behavioural intervention for HIV and STD prevention in high risk social networks of young Roma

Follow up 3 and 12 months:

* Intervention showed positive effects: * Reduction in reported prevalence of unprotected intercourse in intervention groups than in control groups in 3 months and in 12 months.

* Changes were more pronounced among men having casual partners.

* Changes had long-term and consistent effects.

* Increase in knowledge of risk of AIDS, positive attitudes towards condom use, and intention to reduce risk behaviour in

* Behavioural intervention done through social network leaders to their members was effective

* Increased conversation about AIDS and safe sex on close social networks

* Significant change occurred in knowledge related to AIDS, attitudes and motivations to change sexual behaviours

Year Design non-Roma

intervention groups from baseline to 3 months and to 12 months.

* Less contraction of STDs in intervention groups than in control groups by 12 months. Kraigher et al. 2006 N = 987 Cross-sectional retrospective study (Preschool aged children of 6 years and school aged adolescents of 16 years; Vaccination coverage of polio, DPT and MMR) Roma (Children, adolescents; Slovenia)

* Preschool-aged Roma children showed higher vaccination coverage than school-aged Roma children.

* Coverage for two doses of MMR vaccine in school-aged Roma children was only 33%.

* Vaccine coverage of preschool-aged Roma children for polio, DPT and MMR was lower than that of the Slovenian national coverage for preschool-aged children.

* Proportion of fully vaccinated children in both preschool-aged and school-aged Roma generations was low.

* Roma school-age generation was highly susceptible to infections and epidemics. * New-born Roma babies were at risk of neonatal tetanus.

* Improvement in immunization status of preschool-aged Roma children relative to previous generations

* Improved awareness of Roma parents about immunization and taking care of their children receive prescribed vaccination than Roma parents of previous generations * High dropout rate in Roma children * Vaccine coverage in Roma children was not high enough to ensure adequate herd immunity

* Low coverage of tetanus vaccine among Roma women of child-bearing age

Petek et al. 2006 N = 12 Cross-sectional qualitative content analysis (General population aged from 17 to 74 years; attitude towards smoking) Roma (Adults; Slovenia)

* Attempts at quitting smoking were

unsuccessful among Roma. * Roma have knowledge about harmful effects of smoking, but no attitude about quitting.

* Roma do not associate smoking-related illness with their habit.

* Roma do not care about passive smoking. * Financial situation has no association with motive for quitting smoking.

* Physician’s advice to quit smoking were not taken seriously.

* Low education level, low income and low level of acculturation.

* Smoking as a part of cultural, ethnic and individual identity.

* Smoking is accepted for all men, women and children.

* Smoking habit is introduced by older to younger ones as a part of growing-up. * Smoking is a hobby, a part of family and social life and a source of pleasure. * Belief that harmful effects of smoking are in the hands of destiny.

* Belief that bad effects of smoking go with older age.

bed-Year Design non-Roma

al. 2007

descriptive study (Male and female population aged 0 to 75+ years grouped in 5-year age categories; mortality) Roma (Children, adolescents, Adults; Serbia)

decreased from 2002 to 2005, but was still higher than in non-Roma.

* Most common causes of death in Roma were cardiovascular diseases, neoplasm and respiratory system diseases. * Morbidity due to respiratory system diseases was higher in Roma than in non-Roma.

* Morbidity due to cardiovascular diseases was lower in Roma than in non-Roma. * Mean age of death in Roma men decreased from 57.8 years in 2002 to 56.8 years in 2005, and were 10 and 12 years lower respectively than non-Roma men. * Mean age of death in Roma women increased from 61 years in 2002 to 61.9 years in 2005, but remained 12 years lower than non-Roma women.

compared to non-Roma.

* Roma had low living conditions such as lack of electricity, sewage, water supply, and overcrowded homes.

* Roma children had lower school attendance and missed compulsory medical examination in schools.

* Roma lacked family doctors and access to health care institutions near their

settlements.

* Pregnancy at young age in Roma women. * Roma did not use contraceptives. * Roma women did not visit doctors during pregnancy.

* Roma did not visit counselling offices for children.

* Roma lack health insurance. * Roma have low level of education. * Roma go to doctors at late stages of illnesses.

ridden person is ‘sick’.

Kosa, K et al. 2007 N = 70 Quantitative and qualitative health impact assessment (General population; Hygiene and sanitation, living condition, substance use, mental health, generic health) Roma (Adults; Hungary)

* Health of the Roma community under study was poorer than the majority population and other Roma settlements. * High rates of illnesses of respiratory, gastrointestinal and skin infections among Roma children.

* High rates of injuries, smoking and depression among Roma adults.

* Lack of basic facilities like paved roads, enough and well-maintained rooms, insulation, electricity supply, running water, sewage systems and rubbish collection.

Kosa, Z et al. 2007 N = 936 n = 4121 cross-sectional Roma / non-Roma (Adults;

* Lower self-reported health (SRH) status and self-initiative for good health among Roma.

* Discrimination against Roma. * Low education level of Roma. * Low employment status of Roma.

Year Design non-Roma

study (General population aged18 years and over; Generic health, SRH, health care utilization, substance use)

Hungary) * Higher intake of unhealthy diet, smoking

rate and starting smoking at early age among Roma.

* Low utilization of health services among Roma.

* Higher prevalence of functional limitations among Roma women.

* Less obesity among Roma women.

* Low income level of Roma. * Low social status of Roma. * Low living conditions of Roma. * Decreased social support within Roma due to housing settlement.

* Ethnicity of Roma. * Skin colour of Roma. * Lack of services and staff. Niksic and Kurspahic-Mujcic 2007 N = 1100 n = 383 Cross-sectional descriptive quantitative study (Parents and children up to 3 years of age; Health behaviour, child health) Roma/ non-Roma (Children, adults; Bosnia and Herzegovina)

* Roma parents seek medical care for their children only in emergency cases such as high fever and diarrhoea.

* Domestic violence was accepted in Roma families with children having physical and emotional effects most severely.

* Roma parents were very young. * Roma parents had lower level of education.

* Roma children live with foster parents more than non-Roma children. * Roma had low quality of family environment and living conditions. * Roma parents physically punished their children more often than non-Roma parents. Parry et al. 2007 N = 260 n = 293 Cross-sectional quantitative study (General population and pregnant women aged 16 years and over; Generic health and morbidity, SRH, substance use, mental health, maternal and reproductive health) Roma / non-Roma (Adults; UK)

* Gypsies and Travellers had poorer SRH status over past one year than other ethnic groups.

* Gypsies and Travellers had more chronic illnesses, health problems or disabilities limiting their daily work.

* Gypsies and Travellers had more accidents over past six months. * Gypsies and Travellers had more problems with mobility, self-care, usual activities, pain or discomfort, and anxiety and depression than other ethnic groups. * Gypsy and Traveller women had more pregnancies, more deliveries and more children than other ethnic groups. * Gypsy and Traveller women had more miscarriages, stillbirths and neonatal

* Lower education level of Gypsies and Travellers.

* Higher smoking rate in Gypsies and Travellers.

* Gypsies and Travellers were main caretaker of chronically ill or disabled relatives.

Year Design non-Roma

deaths.

* Gypsy and Traveller women reported less hypertension than other ethnic groups. * Gypsies and Travellers who had chronic illnesses were more prone to live in trailers on council sites or houses than on private sites or empty lands and had lower health status.

* Gypsies and Travellers who rarely travelled had poorer health status. * Gypsies and Travellers had more self-reported chest pain, respiratory problems and arthritis. Van Cleemput et al. 2007 N = 27 Cross-sectional descriptive qualitative study (General population; Health beliefs and generic health) Roma

(Adults; UK) * Limited accommodation, lack of basic amenities, difficult access to education and

health care were the perceived negative effects of travelling lifestyle by Gypsies and Travellers.

* Freedom, outdoor fresh air, living with extended family, security and support, and escape from troubles, hostilities and victimizations from the external world were the perceived positive effects of travelling lifestyle by Gypsies and Travellers. * Official sites for Gypsies and Travellers housing often had hazardous

environments, and they viewed it as the reflection of society’s perception of them. * Gypsies and Travellers had feeling of ‘imprisonment’ in settled housing. * Forced move of Gypsies and Travellers into official sites created psychological effects to them.

* Gypsies and Travellers had seen threat to their culture and identity by perceived policy of social assimilation via housing and

* Low level of health status was expected and accepted by Gypsies and Travellers. * Health status was described by gypsies and Travellers in terms of ability to perform daily tasks.

* Chronic illnesses were accepted as long as its daily management was possible. * Elderly Gypsies and Travellers believed that years of living on wet and damp roadsides had caused health problems to them such as arthritis and chest

complaints.

* Gypsies and Travellers lacked knowledge and understanding about some disease symptoms.

* Gypsies and Travellers had beliefs on stoicism and self-reliance.

* Roma expressed themselves as being tough and not admitting to minor health complaints and underestimating chronic ill health.

* Roma take care of their elderly parents and sick members of their extended

Year Design non-Roma

education.

* Roma had lack of access to health care in need.

* Roma perceived lack of control over their destiny and self-determination due to restrictive policies and exclusion from authorities.

* Roma lacked trust on outsiders.

family rather than sending them to care homes.

* Roma believed on fatalism and avoided life-threatening diagnoses.

* Cancer was feared as death sentence. * Close family members never left bereaved relatives alone and sense of loss was severe when death occurred. * Grief of bereavement perceived as cause of illness or even death, and alcohol and substance use as coping strategy. Jesper et al. 2008 N = 7 Cross-sectional qualitative study (Women; Terminal illness, cancer, health beliefs, health care utilization) Roma

(Adults; UK) * Roma have less access to health care. * Roma prefer to go to accidents and emergency departments than to a new GP. * Roma are more likely to fail to go for follow-up services.

* Mobile life-style of Roma. * Lack of registration with GP.

* Lack of knowledge about cancer among Roma.

* Little awareness about hospices among Roma.

* Conflict between Roma and hospital staff about care and patient visit.

* Health care given less attention as compared to other priority social problems. * Experience of difficulty in dealing with health staff.

* Reluctance to visit new GP while away from home.

* Illiteracy among Roma.

* Mistrust of outsiders and authorities. * Lack of understanding of Roma culture among health staff.

* Importance of care by extended family during illness.

* Gender defined roles within family. * Dealing of sensitive medial issues from man to man and woman to woman. * Importance of independence, self-reliance and pride, and less doctor-dependency.

* Importance of physical cleanliness. * Preference to be cared at home by family during last days of life.

* Large family members visit sick relative in hospital.

* Preference not to tell the patient about the diagnosis.

* Incorrect beliefs and understandings about cancer.

* Feeling of containment in hospital environment.

* Feeling of distress in hospital

environment from being unable to follow usual hygiene practices.

Monasta et al. 2008 N = 737 Cross-sectional Roma (Children;

* Roma mothers reported diarrhoea, coughing and respiratory difficulties in their

* Poor environment, inadequate insulation of shacks, lack of hot water, lack of proper

Year Design non-Roma

mixed method study

(Muslim children aged from birth to 5 years; Generic health complaints, living conditions, hygiene and sanitation)

Italy) children. toilets, lack of drainage, presence of

stagnant water, presence of rodents, use of wood-burning stove, overcrowding and lack of playing space for children in Roma settlements.

* The more years the Roma families spent living in the settlements, the more was the risk of ill-health of their children.

Kanapeckiene et al. 2009 N = 90 n = 640 cross-sectional descriptive study (School children and adolescents aged from 9 to 19 years; SRH, chronic conditions, generic health complaints, mental health, substance use, health care utilization) Roma / non-Roma (Children, adolescents; Lithuania and Latvia)

* Lower prevalence of chronic diseases (bronchitis, neurodermatitis, heart diseases and diseases of immune system) among Roma children.

* Perception of poorer self-health condition by Roma children.

* Higher prevalence of alcohol use, smoking and drugs use on daily basis among Roma children.

* Somatic symptoms (dizziness, nausea and vomiting, abdominal pain, headache) were higher among Latvian Roma except backache in non-Roma.

* Emotional symptoms (loneliness, helplessness, self-dissatisfaction, depression) were higher in Latvian Roma except fear and tiredness in non-Roma.

* Underdiagnosis due to less consultation with doctors.

* Preconceptions about Roma life styles, housing, health and future perspectives. * Influence of Roma parents’ life style on their children. Kolarcik et al. 2009 N = 330 n = 722 cross-sectional study (Elementary school students aged from 12 to 17 years; SRH, generic health complaints, health Roma / non-Roma (Adolescents; Slovakia)

* Poorer self-rated health (SRH), more accidents and injuries, and more frequent use of health care, but fewer health complaints among Roma adolescents.

* Roma ethnicity.

* Lower educational status of Roma parents.

* Lower employment status of Roma parents.

* Crude ethnic difference partially can be explained by educational difference.

Year Design non-Roma care utilization, accidents and injuries, mental health) Peters et al. 2009 N = 260 n = 256 Cross-sectional quantitative study (General population aged 16 and over; Generic health status, health care utilization) Roma / non-Roma (Adults; UK)

* Gypsies and Travellers had poorer health status than other ethnic minorities and these in turn had poorer health status than majority population.

* Gypsies and Travellers had a higher rate of use of medication, however a lower rate of use of tonics and vitamins.

* Gypsies and Travellers visited social workers and accident and emergency departments more than other health care services.

* Gypsies and Travellers visited dentists, opticians and chemists less.

* Registration with a GP was less in Gypsies and Travellers than in other ethnic groups.

* Higher rates of smoking in Gypsies and Travellers.

* Lower level of education in Gypsies and Travellers.

* Increasing age, smoking and Roma ethnicity were contributing to poorer health status. Rambouskova et al. 2009 N = 76 n = 151 Cross-sectional study (Mothers and Infants; Health behaviours, nutrition, anthropometry, substance use, maternal and reproductive health) Roma / non-Roma (Children, Adults; Czech Republic)

* Short gestation period, low birth weight, short length of new-born, high smoking rate prior to and during pregnancy, less frequent use of food supplement during pregnancy, and low blood concentration of folate, β-carotene, retinol and α-tocopherol among Roma women.

* Differing socio-cultural patterns in Roma. * Poorer SES of Roma.

* Lack of cooperation between gynaecologists and Roma mothers.

Rechel et al. 2009 N = 12 n = 38 Longitudinal, Roma (Adults; Bulgaria)

* High IMR among Roma. * Poverty in Roma.

* Administrative and geographical obstacles for Roma.

* Fear among Roma that immunization cause sterilization to their children. * Use of traditional healer, magic, prayer

Year Design non-Roma qualitative study (Parents, caretakers and service providers to children; Child health, access to health care, health behaviours)

* Low level of parental education and restricted access to education in Roma. * Lack of ways to accommodate cultural, linguistic and religious differences of Roma. * Lack of trust between Roma and health care providers.

or herbal remedies.

* Belief that health care providers want to harm Roma patients.

Rosicova et al. 2009 Population of Slovakia in 2002 Ecological study (General population aged from 20 to 64 years; Mortality) Roma / non-Roma (Adults; Slovakia)

* Socioeconomic differences in regional mortality were found among males, but not among females.

* Education and unemployment rate significantly contributed to mortality differences between regions. * Income and the proportion of Roma population did not contribute to mortality differences between regions.

* The model explained over 30% of the variance in SMR among districts for males and some 7% for females.

Voko et al. 2009 N = 936 n = 4121 Cross-sectional quantitative study (General population aged from 18 to 64 years; SRH, generic health, health behaviour) Roma / non-Roma (Adults; Hungary)

* SRH status was lower in Roma than in non-Roma.

* SRH status of Roma was strongly associated to socio-economic factors, which gradually disappeared after adjustment for income and education. * Functional limitation in Roma was strongly associated to socio-economic factors, which gradually disappeared after adjustment for income.

* Daily smoking, consumption of fresh fruits less than weekly and using lard as fat for cooking were higher in Roma.

* Health behaviour of Roma was strongly associated to socio-economic factors,

* Lower income level of Roma. * Lower education level of Roma. * Lower employment status of Roma. * Roma ethnicity was associated with different health behaviours.

Year Design non-Roma

which although slightly reduced after adjustment for income, education and employment, remained high.

* Income of Roma was strongly associated with smoking daily and not consuming fresh fruits and vegetables, an increment in income reduced daily smoking and consumption of fresh fruits and vegetables less than weekly.

Carrasco-Garrido et al. 2010 N = 527 n = 1054 Cross-sectional descriptive study (Women aged 16 years and over; Women’s health, substance use, SRH, mental health, health care utilization) Roma / non-Roma (Adults; Spain)

* Higher rates of obesity, depression and migraine among Roma women.

* Higher alcohol consumption rates among Roma women.

* Lower rates of visiting doctors, using drugs and using preventive measures like smear test and mammography among Roma.

* Low physical exercise and low perception of their health among Roma women. * Higher rates of self-medication in Roma.

* Lower education level of Roma. * Lower employment status of Roma. * Ethnicity of Roma people.

* Lower SES of Roma.

* No custom of sports/exercise in Roma. * Sex was seen as a taboo in Roma. * Myth, ignorance, anguish and fear in Roma about gynaecological check-ups. * Less importance was given to prevention and health education in Roma community. * More important role of mothers and grandmothers in self-care.

* Attitude of solving problems immediately in Roma. Dostal et al. 2010 N = 66 n = 466 Longitudinal study (Children aged from birth to 6 years; Childhood morbidities, allergies, ETS) Roma / non-Roma (Children; Czech Republic)

* Higher incidence rates of influenza, otitis media, intestinal infectious diseases, viral infections, acute bronchitis and pneumonia among Roma children of 0-2 years of age. * Early age of pregnancy, short gestation period, low birth weight, more siblings under 14 years of age, high smoking rate among mothers during and after

pregnancy, and high smoking rate in family among Roma people.

* Low rates of allergic diseases in Roma children.

* Heavy exposure of Roma children to ETS.

* Ethnicity of Roma.

Year Design non-Roma Gerevich et al. 2010 N = 225 n = 182 Cross-sectional quantitative study (School students aged from 13 to 16 years; Substance use) Roma / non-Roma (Adolescents; Hungary)

* Roma had higher lifetime prevalence of tobacco use, alcohol intoxication and illicit drug use.

* Roma girls had a disproportionately higher prevalence of smoking than non-Roma girls as compared to the difference between Roma and non-Roma boys. * Roma boys had a disproportionately higher increase in prevalence of illicit drug use than Roma girls as compared to the difference between non-Roma boys and girls.

* Ethnicity

* Roma parents had a more tolerant attitude to smoking.

* Roma parents had lower parental education, employment and perceived family wealth. Janevic et al. 2010 N = 1192 Cross-sectional study (Children under 5 years of age; Malnutrition) Roma (Children; Serbia)

* Prevalence of stunting, wasting and underweight among Roma children was 20.1%, 4.3% and 8.0% respectively in Serbia.

* Regional differences between Roma. * Status of wealth of Roma.

* Lower education level of Roma mothers. * Practice of leaving child in care of another child in Roma.

* Many unregistered Roma children. Kolarcik et al. 2010 N = 330 n = 722 Cross-sectional study (Elementary school students aged from 12 to 17 years; Health behaviours, substance use) Roma / non-Roma (Adolescents; Slovakia)

* Lower rates of substance use (smoking, alcohol use, drugs use) among Roma adolescents, especially girls.

* Lower physical activities among Roma girls.

* Lower rate of drugs uses among Roma boys.

* Ethnicity of Roma.

* Social norms and values of Roma. * Educational differences had no effect on the ethnic differences in substance use.

* Purity of the body

Masseria et al. 2010 N = 4764 n = 3707 Cross-sectional quantitative study (General population aged 16 years and over; SRH, Roma / non-Roma (Adults; Bulgaria, Hungary and Romania)

* Roma had worse SRH status than majority population; however, in Bulgaria, the health conditions of other ethnic minorities were poorer than Roma. * At least one chronic illness was reported by Roma higher than by majority population except in Bulgaria; however, Roma suffered less from any chronic illness than majority

* Roma people were of younger age than the majority population.

* Roma had lower level of education. * Roma were less wealthy than the majority population and they spent less.

* In Romania, chronic illness was affected by age, gender, ethnic origin and education.

Year Design non-Roma chronic conditions, hygiene and sanitation) population.

* Other ethnic minorities had more chronic illness than Roma.

* Roma and other ethnic minorities felt more threatened than the majority population from diseases related to unhygienic living conditions.

* In Hungary, chronic illness was affected by expenditure, wealth and education. * In Bulgaria, none of the socio-economic factors affected chronic illness.

Molnar et al. 2010 N = 9 Longitudinal study retrospective HIA and outcome evaluation (General population; Generic health and morbidity, hygiene and sanitation, living conditions, access to health care) Roma (Adults; Hungary) Intervention:

* Retrospective HIA of Roma housing project compared to Outcome Evaluation of the project.

Follow up 2 and 4 years:

* No change in quantity and quality of nutrition due to the housing project. * No change in health risk behaviours such as smoking and alcohol consumption due to the housing project.

* No change in access to health and social care due to the housing project.

* No change in rates of infections and injuries due to the improved housing. * No sustained change in health status.

* Improvement in school attendance due to the housing project.

* Improvement in indoor and outdoor housing conditions in new housing. * Increase in housing rental, maintenance and overhead costs.

* No change in employment condition due to the housing project.

* No improved privacy and less crowd in new housing.

* Negative impact on social networks. * No neighbourhood satisfaction. Van Cleemput 2010 N = 27 Cross-sectional mixed method qualitative study (General population; Social exclusion, Health beliefs, Generic health, Communication barriers, health policies) Roma

(Adults; UK) * Poor community health among Roma. * Roma face more distressing psychological consequences.

* Delayed access to health care by Roma. * Failure to obtain health care by Roma. * Roma choose alternatives to primary care services.

* Experience of racism and hostility by Roma.

* Lack of trust of non-Roma people and institutions.

* Perceived discriminatory attitudes and cultural insensitivity of health staff towards Roma.

* Inability of Roma to register with GP. * Misunderstanding due to language. * Mutual suspicion between Roma and health care providers.

* Lack of health knowledge among Roma. * Preconceptions and stereotyping of Roma

* Belief in stoicism and self-reliance, and avoiding doctor

* Cultural belief to be seen as strong and tough, and fight with ill-health

* Stoical attitude of keeping hardship and suffering to oneself

* Fatalistic attitudes

* Fear of investigation, procedure and treatment

* Doubt about competence of health staff * Not tolerating uncertainty of a diagnosis * Lack of confidence about to be taken seriously by health staff

Year Design non-Roma

by health staff.

* Negative medial portrayal about Roma.

* Fear of inevitable fatal diagnosis like cancer

* Low expectations from health services Rosicova et al. 2010 Population of Slovakia in 2004 Ecological study (Children below 1st _{year of age;} Perinatal and infant mortality) Roma / non-Roma (Children; Slovakia)

* Districts in central and eastern Slovakia had higher perinatal mortality rate among Roma.

* Districts in eastern Slovakia had higher IMR among Roma.

* Roma ethnicity explained over 30% of the variance in perinatal mortality, in infant mortality rate, and in mortality in weeks 2 to 52; the SES variables (education,

unemployment, income) appeared to be not significant in the final model.

* High proportions of Roma settlements in south and central part of eastern Slovakia. * Low level of education in Roma. * Higher unemployment rate in Roma.

N = number of Roma in study n = number of non-Roma in study

6.1. Child Health

Child health was given attention by many studies done on the health of Roma particularly on new-born health, immunization, infectious diseases, infant mortality and congenital disorders. Higher prevalence of lower values of birth weight of Roma children compared to non-Roma children was evidenced from studies performed in the Czech Republic (Ginter et al., 2001; Koupilova et al., 2001; Rambouskova et al., 2009; Dostal et al., 2010), Hungary (Hajioff and McKee, 2000; Ginter et al., 2001), the UK (Smart et al., 2003; Zeman et al., 2003) and Slovakia (Ginter et al., 2001; Koupilova et al., 2001). Higher prevalence of premature births was also observed in Hungary (Hajioff and McKee, 2000; Ginter et al., 2001), the Czech Republic (Koupilova et al., 2001) and Slovakia (Koupilova et al., 2001). Premature births and low birth weight of Roma new-borns were attributed to low levels of maternal education of Roma (Hajioff and McKee, 2000), inadequate intake of dietary supplement by Roma mothers (Rambouskova et al., 2009), poorer SES of Roma (Rambouskova et al., 2009) and shorter gestation period of Roma mothers (Rambouskova et al., 2009; Dostal et al., 2010). The closed Roma culture prevented Roma women to access antenatal care (Smart et al., 2003; Zeman et al., 2003; Rambouskova et al., 2009), and lack of understanding about Roma by health care providers (Rambouskova et al., 2009) further increased this gap.

Vaccination coverage rate in Roma population was found to be lower than that of the majority population. In Slovenia, although immunization rates of DPT, polio and MMR vaccines of the preschool-aged generation of Roma children (between 50% to 72%) had improved compared with that of the school-aged generation of Roma children (between 33% to 66%), they were far below the national averages for Slovenian preschool-aged children (between 92% to 94%), and the proportion of full immunization was also very low among Roma children indicating high drop-out rates and absence of herd immunity (Kraigher et al., 2006). In Spain, the vaccination coverage rate of poliomyelitis, diphtheria and tetanus of Roma children was 41%, that of pertussis was 24% and of MMR was 36%, and the full vaccination coverage of Roma children was only 30% (Martinez-Camillo et at., 2003 cited in Kraigher et al., 2006). Low vaccination uptakes by Roma children were also reported in studies from the UK (Van Cleemput,